Developing a Case Study
The clients name for this case study is John and he is an 21-year-old Caucasian male who lives in an upper-class neighborhood. John comes into counseling experiencing auditory hallucinations and delusions for the last 6 months. John also reports feeling paranoid on a regular basis saying that the devil is out to get him. John also reports social isolation and diminished family relationships.
John was brought into counseling by his parents after an incident where he tried to stab his brother because he thought he was Satan and out to get him. His parents report that he was hospitalized briefly and was diagnosed with schizophrenia but they want a second opinion. The mother does not believe that her son was diagnosed properly because she says that no one in their family is crazy and mental illness does not run on either side of their family.
John is close with his mother and turns to her to bail him out of trouble. John is estranged from his father and his brother, and does not see that changing any time soon. John’s brother perceives him as a mother’s boy, which adds more friction to their relationship. John has a 19-year-old girlfriend named Lindsey and reports that she is scare of John when he experiences hallucinations and delusions. She wants to end the relationship with John but does not know how John will react and is scared to end things with him unless a therapist is present. She is concerned about John’s wellbeing and wants him to get the help that he needs.
John has graduated with his high school diploma, but has not pursued a college education. John stated that he has never enjoyed school and prefers working with his hands or being creative. Both of his parents have college degrees and wanted John to become a doctor just like his father and his grandfather did. John states that he knows he is the black sheep of the family, but he does not care because the only person that loves him is his mother. His parents are willing to pay for him to go to community college but he has no desire to further his education.
John had one job when he was 20 years old but was fired for stealing money from the cash register. He has refused to seek steady employment because he feels like his bosses will hate him and either fire him for no reason or assign him menial tasks. John states that Lindsey is a source of support for him especially when he argues or gets into physical altercations with his father or his brother. His relationships with his family members is likely to be stressors, including his relationship with his mother. John’s mother constantly rationalizes and enables his behaviors which contributes to the presenting problem. She always says that he cannot help behaving that way or that John was provoked even when he is at fault. The precipitating event that lead John to seek counseling was when John attempted to stab his brother with a knife. He was arrested and hospitalized for 48 hours and issued a referral for counseling. He also has pending legal charges stemming from the event. His brother is pressing charges while his mother is begging him not to because John could not control himself from acting out.
Presenting Symptoms and Impact on Relationships
John was referred to counseling after being hospitalized for attempting to stab his brother with a knife. Josh says that he does not need help and it is his brother’s fault for provoking him and acting like Satan. John’s mother says that John often hears voices in his head that instigates his violent episodes.
Consequently, John experiences constant dysfunction in his relationships with his father and his brother. John’s violent episodes and hallucinations helps to contribute to their distant relationship. His father feels helpless to stop the negative dynamic between them, and would like John to have a closer relationship with his brother. John says that he does not need help and nothing is wrong with him. Wendt & Shafer (2015) states that men must conform within their gender role of being masculine and not showing weakness (Wendt & Shafer, 2015). Society equates showing emotion as being weak and this makes it difficult for men that need counseling.
The implications of the presenting symptoms are that they label John as the problem and burden him with an unfair stigma. Dickerson & Shafer, & Origoni, & Ringel, & Parente (2002) says that economic status can affect the amount of stigma a client might face (Dickerson, Sommerville, Origoni, Ringel, & Parente, 2002). Theoretically speaking, John could face more stigma with his parents being in a higher economic bracket. It is important to address this because these reasons provide a potential barrier for treatment. It is important to try to get John to willingly engage in treatment because more treatment goals can be met. The presenting symptoms of violent episodes and hallucinations must be addressed so that Josh’s quality of life is improved and wellness can be achieved.
Methods for Assessment and Preliminary Diagnosis
The learner would start by gathering whatever information she would get from John directly. Then, she would work to get John’s permission to speak with one of his family members or his girlfriend. She would explain to John why she needs to talk to them and what she plans to ask to help lessen any fear he might have. It would also be important to help John process his feelings about getting information from his family.
The learner plans to use a published assessment called The Scale for the Assessment of Positive Symptoms (SAPS). This assessment is useful in measuring the severity of certain symptoms of schizophrenia such as delusions and hallucinations. King (2014) states that SAPS is good at helping differentiate between clients with positive and negative symptoms (King, 2014). When she read about SAPS, she learned that reliability and validity for this assessment is decent. The learner would utilize the SAPS assessment in conjunction with the information collected from family members.
The learner would issue a provisional diagnosis of schizophrenia, with a diagnostic code of 295.90. She would specify even further and say John fits the criteria for multiple episodes, currently in acute episode (American Psychiatric Association, 2013). John suffers from both delusions and hallucinations and his quality of life is negatively affected. More specifically, John’s relationship with his relatives has been impacted due to the symptoms he has experienced. The most telling symptom is the constant paranoia John displays and his belief that his brother is out to get him. John stated that he believes his brother wants to murder him because he is “Bill Gates” type of rich.
Socio-Cultural Factors That Impact the Diagnostic Process
John is 21 years old, unemployed, lives with his parents, and they reside in an upper-class neighborhood. He is experiencing discord and toxicity with his father and his brother, but sees that as normal because that has always been a part of his environment. John has been hospitalized after a violent episode, and he said the quality of care was good at a private hospital. Horvitz-Lennon, & Volya, & Garfield, & Donohue, & Lave, & Normand (2015) declares that studies indicated the quality of care for African-American clients is lower than Caucasian clients that is diagnosed with schizophrenia (Horvitz-Lennon et al., 2015). While John might receive a better quality of care, he is likely to struggle with stigma or stereotypes due to his gender and parents’ economic state. His families’ perception of John’s symptoms might make John experience shame or view himself in a negative light. Horvitz-Lennon (2015) says that schizophrenia is known to have high levels of impairment (Horvitz-Lennon et al., 2015). This could possibly lead to a self-fulfilling prophecy for John.
The learner is half African-American and half Caucasian so racial factors could impact the assessment and diagnostic process. The learner must be aware of the possibility of misdiagnosis due to cultural factors, and gender should also be considered. Hays, & Prosek, & McLeod (2010) states that we need to be able to adapt decision making based on the population that we serve (Hays, Prosek, & McLeod, 2010). She can’t base decision-making on her cultural standards when they differ from John’s.
Limitations of Diagnostic Systems and Ethical Issues
A limitation of using the DSM-5 is it potentially places a label and stigma on the client. On the other hand, diagnosing can help provide a definitive answer for the symptoms the client is experiencing. Wykes & Callard (2010) states that while diagnosing can help with finding treatments, it can encourage stigma and encourage a narrow approach of prescribing medication to change behavior (Wykes & Callard, 2010).
The diagnostic label could make John resistant to treatment and that he does not need help because he does not want to be weak. Wendt (2015) emphasized how gender role expectations influence perceptions of seeking help for mental health disorders (Wendt & Shafer, 2015). John comes into counseling not seeing how his behavior is problematic and the label could increase his paranoia that others are out to get him. Diagnosing could harm the therapeutic alliance if it is not done respectfully or tactfully. The learner would want to help John process his diagnosis, and tell him that his diagnosis does not define who he is as a person. This is important to help increase self-esteem and help negate mental health stigma. Schizophrenia has a high amount of stigma associated with it and time for processing will be needed with John.
Misdiagnosis due to not addressing cultural factors is a common ethical issue. We must be sensitive to cultural factors and select assessments that are appropriate for the population we are serving (ACA, 2014). More specifically, the American Counseling Association (ACA) (2014) says in section E.8 that we must carefully select assessments especially if they haven’t been tested on that population (ACA, 2014). It is important to select assessments that fits John’s cultural dynamic and is appropriate for his gender. The learner also must be cognizant of the fact that she can only issue assessments that she is qualified to administer.
In this paper, the learner had the opportunity to develop a case study about John and provide a provisional diagnosis of schizophrenia. She discussed John’s symptoms and how they impacted his relationships. She learned a lot about the assessment and diagnostic process, and how important diversity is during this process. At the end of the paper, she acknowledged the possible limitations and ethical issues associated with diagnosing.
ACA (2014). ACA Code of Ethics. . Retrieved from Capella Library
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed ed.). : .
Dickerson, F., Sommerville, J., Origoni, A., Ringel, N., & Parente, F. (2002). Experiences of stigma among outpatients with schizophrenia. Schizophrenia Bulletin. Retrieved from Capella
Horvitz-Lennon, M., Volya, R., Garfield, R., Donohue, J., Lave, J., & Normand, S. (2015). Where you live matters: Quality and racial/ethnic disparities in schizophrenia care in 4 state medicaid programs. Health Services Research. Retrieved from Capella
King, S. (2014). Review of the Scale for the Assessment of Positive Symptoms. Mental Measurement Yearbook. Retrieved from Capella
Wendt, D., & Shafer, K. (2015). Gender and attitudes about mental health help seeking: Results from national data. Health & Social Work. Retrieved from Capella
Wykes, T., & Callard, F. (2010). Diagnosis, diagnosis, diagnosis: Towards DSM-5. . Journal of Mental Health. Retrieved from Capella