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Recently, I watched a movie called “Sophie’s
Choice.” Two of the main characters are named Sophie and Nathan who live at a
boarding house in Brooklyn NY. Throughout the movie, these characters exhibit
several different behaviors that may be due to individual mental illness. These
behaviors also negatively affect how Sophie and Nathan interact within their
personal relationship and socially with others. Therefore, the overall purpose
of this work is to write a case evaluation that first diagnosis which mental
disorder each character may have. I will then provide all pertinent findings,
treatment recommendations and any ethical considerations that might apply during
their overall assessment and treatment plans.
Case
Name: Sophie Zawistowska
Background
Information
Sophie is a
polish catholic and survivor of the
Holocaust. During her time there she was also forced to give up her daughter to
be exterminated and her son was sent away never to be seen again. She doesn’t
have a college level education but is bilingual and possesses a high level of overall
writing and secretarial skills. These were acquired after working for her
father translating documents during the Second World War. She is currently
unemployed with no source of income so she relies on her boyfriend Nathan for
financial support. She also believes that he saved her life because she was
extremely ill after being released from the concentration camp and he provided her treatment. Sophie also has
scars on her wrists from an attempted suicide but she did not disclose whether
she received any psychological help to address the issues that may have caused
this behavior.
Behavioral
Observations
Sophie is an extremely intelligent woman who always wears
nice dresses and is well groomed. She interacts well with others but has a
slight issue trying to fully understand the English language and which words should be
used. Her mood is normally pleasant unless she experiences a psychological
and/or physical altercation with her boyfriend Nathan or discusses certain
remnants of her past. During these times she exhibits emotional behavior that
is associated with being a battered woman or guilt and anxiety from certain choices
that she made in her past.
Diagnoses
309.81 Posttraumatic
Stress Disorder (Chronic Type)
Other Conditions That May Be a Focus of Clinical Attention:
Physical Abuse of Adult (V61.1)
Findings
After considering Sophie’s background
information and current behavior, I would diagnose her with Post Traumatic
Stress Disorder (PTSD). The main reason for this diagnosis is because according
to (DSM-IV-TR. 1995-2013), “when an individual who has been exposed to a
traumatic event develops anxiety symptoms,
reexperiencing of the event, and avoidance of stimuli related to the event
lasting more than four weeks, they may be suffering from this particular Anxiety Disorder.”
Research has also shown that most people who suffer with this
disorder may have also experienced abandonment and/or severe neglect as children.
In
Sophie’s case, she was exposed to traumatic
events that were threatening to the lives of her and her children. This included
having to sacrifice the life of her only daughter to save her only son which caused
intense feelings of fear, helplessness, and horror at the time of occurrence.
Since, this increased level of trauma occurred I suspect that Sophie has continuously
recalled the events through cognition of distressing mental images,
perceptions or thoughts. However, since these may cause her great psychological
distress, she chooses to use total avoidance of the events as a major coping
mechanism. This includes continuously making a conscious effort to avoid all feelings,
thoughts, or conversations associated with the events.
Since, Sophie lives
her life trying to avoid these haunting aspects from her past, it has also
caused a feeling of being detached or estranged from many others. One example
of this is when she thinks about the "choice" that she made as a mother and it
makes her believe that she has less worth than all other mothers. She also exhibits a
slight restricted range of affect and high sense of a foreshortened future.
Some examples of this are when she always tells Nathan that she is going to die
and when telling Stingo that she’ll probably never be able to love him, live a
normal life in Virginia or be a good mother for his children.
She
also changes the room around at night because she can’t sleep and seems to
exhibit an exaggerated startle response during certain physical situations with
Nathan. I believe that she is exhibiting these behaviors because she doesn’t
want to have nightmares that are associated with her past trauma or experience
further physical abuse at the hands of her loving partner. Since, these issues
have occurred for several years Sophie also exhibits significant levels of
distress or impairment in other areas of functioning. Therefore, she has also become
majorly dependent on Nathan to meet her social, economic, psychological
and physical needs.
Furthermore, I also believe that Sophie has been a
repeated victim of physical abuse during the course of her relationship with
Nathan. This occurs because when he experiences certain symptoms associated
with his mental illness while abusing substances, he becomes physically violent and aggressive toward
her. There are also repeated scenes in the movie when she is crying and tries
to conceal visible bruises that he has left on her body.
Although, she says that his abusive behavior is okay and allows it to continue
due to her extreme level of overall dependency on him.
Treatment Recommendations
When reviewing
Sophie’s case, there are some major issues that would need to be addressed. The
first one is her psychological need to use avoidance to deal with her past.
This is a major issue because it’s preventing her from dealing with feelings of
guilt and shame in an appropriate and healthy manner. I would also treat this
issue by using one-on-one talk and exposure therapy. This way, she would be
able to verbally expose issues from her past in a safe environment and learn
coping skills that can be used to manage her overwhelming level of guilt and
shame.
Furthermore, I would also prescribe a selective serotonin reuptake
inhibitor to reduce the intensity of these negative feelings. This
is because according to (Jaffe & Schub. 2012), “selective
serotonin reuptake inhibitors (SSRIs) are the first-line medications used to
treat PTSD and are the only medications approved by the U.S. Food and Drug
Administration (FDA) for treatment of PTSD.” Finally,
I would refer Sophie to an agency that helps women who are victims of domestic
violence. This is because she may be able to receive beneficial services like
further counseling, a safer place to live and group therapy with other victims.
Prognosis
When reviewing
all of the details of Sophie’s case, I don’t believe that she would do well in
treatment and that her overall prognosis is less than fair. This is because if
she continues to live in her current environment, further abuse from Nathan
will most likely occur and she won’t have the positive support system that is
needed to fully recover from her severe level of long-term PTSD. Having a
positive support system and acquiring treatment are also major requirements for people who develop this disorder after experiencing
trauma because it can reduce symptoms and initiate a faster
recovery time. However, up to this point she has only received positive support
from their mutual friend Stingo who knows little about PTSD.
I am also
confident that she will never acquire the motivation that is needed to end her
relationship with Nathan due to her growing dependency and skewed belief that
he is her savior. Therefore, her feelings of guilt and shame will probably get
worse and she may also begin to experience issues like low self-esteem and
worthlessness due to ongoing occurrences of severe psychological and physical
abuse.
Ethical/Legal
Considerations
When conducting an assessment and
treatment plan for Sophie, I will also need to address any ethical concerns
that may apply. This is because following ethical standards will help ensure
that her rights are protected throughout the overall process. Four specific
ethical codes that may also apply to her individual case include:
1. Informed Consent – According to
this standard, professionals must inform participants of all features which
might affect his or her willingness to participate. This is important because
clients will be informed about the overall purpose and it gives them an option
to participate or withdraw. I will also implement this by having Sophie sign a
written document that identifies the overall content and purpose of the
assessment and treatment plan.
2. Debriefing – This states that
all professionals should debrief each client before, during and after the
process. This is important because it can ensure that clients are aware of all
beginning, ongoing, and final results that may be obtained. This can also allow
the opportunity to address any misconceptions that clients may have during the
overall process. I could also implement this by ensuring that Sophie was kept
informed about all important findings.
3. Protection From Harm – This means that I will need to get permission
from Sophie prior to treatment and if any aspects of
treatment may be harmful to her I will avoid using them.
4.
Confidentiality – This standard protects the rights of clients by mandating
that personal information can only be released under specific circumstances.
Following this law is important because it can ensure that no harm occurs to
the client due to personal information being released in a malicious or
damaging manner to third party members. However, according to (BACB Guidelines
For Responsible Conduct), a behavior analyst can “disclose confidential
information without the consent of the individual only as mandated by law, or
where permitted by
law for a valid purpose, such as (1) to provide needed professional services to
the individual or organizational client, (2) to obtain appropriate professional
consultations, (3) to protect the client or others from harm, or (4) to obtain
payment for services, in which instance disclosure is limited to the minimum
that is necessary to achieve the purpose” (p.4). Since, this is the case I may
be required to report some of Sophie’s personal information to specific third
parties that can further assist her. This is because she is a victim of
domestic violence which is a crime and she may also be a danger to herself due
to an unstable psychological state and/or mental disorder.
Client Name: Nathan
Background
Information
Nathan is 29
years of age and from a Jewish descent. He currently lives in Brooklyn with his girlfriend Sophie and states that
he is a biologist but his brother says that he actually works at a library. He
claims that he graduated from Harvard University but his brother dispels that
lie as well by saying that Nathan has no college education and is regularly abusing cocaine.
Furthermore, he was diagnosed with
Paranoid Schizophrenia at the age of 10 and has been in and out of mental
institutions. The symptoms that are associated with this particular disorder
are also still present.
Behavioral
Observations
Nathan is an
extremely intelligent man who often wears nice suits and is well groomed. He
interacts well with others unless he experiences a psychotic episode. This is
when his mood changes and he becomes extremely agitated, angry, paranoid, and
delusional. During this time, he also psychologically and physically abuses
Sophie on a severe level. Furthermore, he also has delusions of grandeur which
make him believe that he is a brilliant biologist and almost every aspect of
his daily life is consumed by this fabricated way of thinking.
Diagnosis
295.30
(Schizophrenia) Paranoid Type - This type of schizophrenia
involves a preoccupation with delusions or auditory hallucinations. In order to
diagnose a client with this disorder, he or she must also still have organized
speech and non-catatonic behavior.
Other
Conditions That May Be a Focus of Clinical Attention:
Substance Abuse and possible Bi-Polar
Disorder
Findings
After reviewing Nathan’s background information and long-term behavior, I
diagnosed him with Paranoid Schizophrenia because he meets the criteria for
that disorder. This is because he exhibits the following symptoms and/or
behavior:
1. Clinically
significant distress – He feels bad after he hurts Sophie due to his disorder.
2. Mood changes with
periodic hypomania – He becomes agitated and physically abuses Sophie.
3. Anger that is dealt
with by using repression, denial or paranoid projections – He often
psychologically attacks Sophie by calling her names and accusing her of
cheating on him.
4. Delusions of
grandeur or auditory hallucinations – He believes that he graduated from Harvard
University and is a brilliant biologist who is working on groundbreaking
research.
Treatment
Recommendations
When reviewing
Nathan’s case, there are major issues that need
to be immediately addressed. The first one will be to try and reduce the
overall level of symptoms that are related to Paranoid Schizophrenia. According
to (Butcher., Mineka & Hooley. 2010), an individual with this type of
schizophrenia “shows a history of increasing suspiciousness and of severe
difficulties in interpersonal relationships” (p. 463). The symptoms that seem to
be most relevant with Nathan are his mood changes with hypomania, paranoid
projections, anger, and delusions of grandeur.
The main reason that these
symptoms should be treated as soon as possible is because he is causing
psychological and physical harm to Sophie when they appear. These symptoms are
also preventing him from being able to live in a normal state of reality. I
would begin treating his disorder by verbally teaching him certain coping
skills that can be used to manage these symptoms and prescribe
an antipsychotic medication to try and reduce the intensity of symptoms and number
of episodes.
Furthermore, I would also refer Nathan for an additional assessment to address possible Bi-Polar Disorder and to agencies that help with domestic violence and substance abuse. This is because he may be able to receive
beneficial services like further counseling, a neutral place for discussion, and group therapy with others who are experiencing the same issues.
Prognosis
When reviewing
all of the details of Nathan’s case, I don’t believe that he will do well in treatment and that his overall prognosis is poor. This is because if he
continues to live in his current environment, further abuse to Sophie will most
likely occur when mood changes with hypomania and/or paranoia are present. Therefore, he
won’t have the positive support system that is needed to combat symptoms that
are associated with his severe level of long-term Paranoid Schizophrenia.
Having a positive support system and acquiring treatment are also major
requirements for people who develop this disorder because it may reduce these symptoms.
However,
up to this point he has been in and out of several mental institutions and has
not improved. I am also confident that he will never acquire the
motivation that is needed to end his relationship with Sophie due to his
growing obsession and skewed belief that he is her grand savior. Therefore, his
symptoms will probably only get worse and he may also begin to experience
issues like self-hate and depression due to his continuous psychologically
and physically abuse toward Sophie.
Ethical/Legal
Considerations
When conducting an assessment and
treatment plan for Nathan, I would also need to address any ethical concerns
that may apply. This is because following ethical standards would help ensure
that his rights were protected throughout the overall process. Five specific
ethical codes that may apply to her individual case include:
1. Informed Consent – This means
that I will need to inform Nathan about all features that might affect his
willingness to participate. I will also implement this by asking him to sign a document
that identifies the content and purpose of the assessment and treatment
plan.
3. Debriefing – This means that I
will need to debrief Nathan before, during and after the assessment and
treatment process. This is important because it will ensure that he’s aware of
all beginning, ongoing, and final results that are obtained. This will also
allow the opportunity to address any misconceptions that he may have during the
overall process.
4. Protection From Harm – This means that I will need to
acquire permission before treating Nathan and if any aspects of
treatment may harmful, I will avoid using them.
5.
Confidentiality – This states that personal information can only be released
under specific circumstances. The BACB Guidelines For Responsible Conduct also state
that a professional can disclose confidential information without a client’s consent
to protect the client or others from harm. In Nathan’s case, I would be forced
to release some of his personal information to third parties. This is because he
carries weapons, has threatened others safety and has already caused severe psychological
and physical harm to Sophie. Since he is experiencing delusions of grandeur
about who he is and what he has become, I also don’t believe that he is
competent enough to make important decisions so involuntary hospitalization may
be required in the future.
Summary
This was written after watching a movie called “Sophie’s Choice”
which includes two main characters named Sophie and Nathan. There are several scenes
in the movie that depict different behaviors which may be associated with
individualized mental illness. These behaviors and/or symptoms also negatively
affect how Sophie and Nathan are able to interact as a couple and with others in
various social settings. Therefore, the overall purpose of this work was to first
provide a case evaluation for each character that confirms which mental
disorder/s they may have. I then followed each diagnosis with any pertinent
findings, treatment recommendations and ethical considerations that may apply
to each case.
References:
American Psychiatric Association. (2000). BehaveNet: APA Diagnostic Classification DSM-IV-TR. Retrieved on February 1 2013 via the World Wide Web at http://behavenet.com/apa-diagnostic-classification-dsm-iv-tr
Behavior Analyst Certification Board. (2004). Guidelines for responsible conduct for behavior analysts. Retrieved on February 2 2012 via Kaplan Online at http://content-asc.kaplan.edu.edgesuite.net/PS502_1004A/images/product/Guidelines%20for%20Responsible%20Conduct.pdf
Butcher, J. N., Mineka, S., & Hooley, J. M. (2010). Abnormal Psychology (14th Ed.). Boston, MA. Allyn & Bacon, Pearson Higher Education.
Pakula, Alan (Director and Producer). (1982). Sophie’s Choice. (DVD). Lions Gate
Schub, T., Jaffe, S. (2012). Post-traumatic stress disorder. Retrieved on February
3 2013 via the Kaplan Library at http://ehis.ebscohost.com.lib.kaplan.edu/eds/pdfviewer/pdfviewer?sid=b008d357-ffce-4487-b4b6-7d2bd37572c9%40sessionmgr11&vid=9&hid=2