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Chapter18.docx18 Personality Disorders
Disorders
The diagnoses in this chapter had in the past been listed on Axis II, but as the DSM-5 shifts from a multiaxial system (as discussed in Chapter 1 ) all mental disorders will be assessed on a single axis. In addition, pilot research has been conducted on an alternate dimensional model for personality disorder diagnoses, and it is included for further study in Section III of The DSM-5 ( APA, 2013 ).
The personality disorders refer to pervasive, persistent, and relatively inflexible personality traits that lead to functional impairment or subjective distress. In this sense, departures from expectations of the individual's culture may include the cognitive approaches to viewing the self or others, emotional range, intensity, stability and/or appropriateness, interpersonal functioning, and/or impulse control. The pattern in question should be stable across a broad range of situations, be established by early adulthood, and not be due to another mental disorder, a general medical condition, or substance usage ( APA, 2013 ).
Although the criteria for the specific personality disorders do not preclude their use with children or adolescents (with the exception of antisocial personality disorder), clinicians are encouraged to be extremely circumspect in applying these labels with young people. Usually, problematic personality traits exhibited in early years will often not persist into adulthood. In any event, for these diagnoses to be applied to persons under the age of 18, the specified behavior needs to have been present for at least 1 year. Antisocial and Borderline types of personality disorders tend to lessen and abate with age, but this is not typical for the remaining personality types ( APA, 2013 ).
The specific diagnoses in this section are divided into three “clusters” or subgroupings based on similarities in symptom presentation. Often, an individual warranting a diagnosis of a particular personality disorder will exhibit traits related to other diagnoses within the same cluster. Less frequently, an individual may exhibit a grouping of traits related to a particular cluster of personality disorders without fully meeting any specific diagnosis; this may be diagnosed as either “other specified personality disorder” and/or “unspecified personality disorder.” Additionally, clients can be diagnosed with a personality change due to another medical condition (e.g., temporal lobe epilepsy). For greater detail please see the DSM-5 ( APA, 2013 ).
Cluster A personality disorders, refer to those with a pattern of behavior that is generally viewed as odd or eccentric. Commonly, clients with one of these disorders tend to isolate themselves and/or be suspicious. Frequently, a pattern of social isolation can be traced into childhood. People with cluster A personality disorders seldom seek treatment ( APA, 2013 ).
The first cluster A diagnosis is Paranoid Personality Disorder. A pervasive distrust and/or suspiciousness of others characterize clients with this diagnosis. More specifically, they may suspect others of having malevolent motives, be preoccupied with concerns about others, be reluctant to confide in others, be extremely sensitive to perceived criticisms, and/or bear grudges against others ( APA, 2013 ).
The next cluster A diagnosis is Schizoid Personality Disorder. Clients with this diagnosis are characterized by avoidance and lack of desire for social relationships. In addition, clients with Schizoid Personality Disorder show emotional coldness, lack of empathy, and a narrow range of affect. More particularly, they consistently prefer technical occupations and activities that involve little social contact. They are often described as loners who derive little pleasure in leisure time activities. The person with schizoid personality disorder, however, does not have distorted perceptions or cognitions. ( APA, 2013 ).
The diagnosis of Schizotypal Personality Disorder completes cluster A and is characterized by a general detachment from social relationships and a restricted range of emotional expression. Essential features include social and interpersonal deficits that are expressed by clients who consistently prefer isolation to social relations, generally have few interests or hobbies, seldom engage in intimate relationships, seem indifferent to others' opinions of them, and/or are described as cold or emotionless ( APA, 2013 ). Clients with this diagnosis typically have restricted interpersonal relationships and evidence marked peculiarities in thinking and perception. More specifically, they show thinking and perceptual processes similar to, but not as severe as, those in persons diagnosed with schizophrenia or other psychotic disorders. In this matter, symptoms mirror those seen in schizophrenia except individuals can usually distinguish between their distorted ideas and reality. For example, someone with this personality disorder may have ideas of reference but not so pervasively as to be considered delusions of reference ( APA, 2013 ).
The cluster B personality disorders refer to a pattern of behavior that is generally viewed as dramatic or emotional. In particular, clients with one of these disorders often display erratic or impulsive behaviors. Further, there is generally a marked self-absorption that results in a diminished capacity for empathy ( APA, 2013 ).
The first cluster B personality diagnosis is Antisocial Personality Disorder. It should be noted that for diagnosis, clients must be aged 18 or older (who have shown symptoms of conduct disorder with onset before the age of 15). Clients with this diagnosis usually engage in illegal activities, routinely practice deceit, are often aggressive or violent, are typically irresponsible, and generally ignore the rights and feelings of others. Further, these clients rarely show remorse for their behavior. Typically, they do not seek treatment but may be referred because of interactions with the legal system or in conjunction with substance-abuse treatment ( APA, 2013 ).
The next cluster B diagnosis is Borderline Personality Disorder. Clients with this diagnosis typically evidence erratic interpersonal relationships, fluctuating self-image and/or affect, and marked impulsivity. They frequently engage in suicidal or self-mutilating behaviors. They are noted for extremes in affect and in judgment; people diagnosed with this disorder rarely see themselves or others in a balanced way. These clients are the most likely of people with personality disorders to seek treatment ( APA, 2013 ).
Another cluster B diagnosis is Histrionic Personality Disorder. Clients with this diagnosis evidence emotionality and attention seeking. They generally are only comfortable when they are the “center of attention” and will use physical appearance, speech, and emotions to command others' attention ( APA, 2013 ).
The final cluster B diagnosis is Narcissistic Personality Disorder. A grandiose sense of self-importance, a need for attention, and a reduced capacity for empathy characterize clients with this diagnosis. They often seem to have an exaggerated sense of entitlement and expect to be admired and obeyed by others. With these last two personality disorders, clients usually seek treatment to address their frustration with other people ( APA, 2013 ).
The cluster C personality disorders include patterns of behavior that are essentially fearful and/or anxious. Clients with these disorders tend toward being perfectionistic or rigid in standards or expectations for themselves or others. Like people with cluster A diagnoses, clients with cluster C disorders are relatively unlikely to seek treatment ( APA, 2013 ).
The first of the cluster C diagnoses is Avoidant Personality Disorder. Clients with this diagnosis show marked feelings of inadequacy that are associated with hypersensitivity to negative feedback and/or social inhibition. More specifically, these clients seldom put themselves in “risky” or even new situations in which they may perform poorly. They seldom develop intimate interpersonal relationships and may even constrain occupational choices based on fear of negative judgments and/or a demand for high levels of social interaction ( APA, 2013 ).
The next diagnosis in cluster C is Dependent Personality Disorder. Clients with this disorder seek someone to take care of them, even to the extent of being submissive, clinging, and fearful of separation. These clients avoid decisive action and encourage others to make decisions for them. The characteristic subservience makes it quite difficult to express disagreement, even when asked to undertake unpleasant activities. These clients fear being alone and quickly substitute a new relationship if an old one is lost. They systematically underestimate themselves and their ability to function independently ( APA, 2013 ).
The final cluster C diagnosis is Obsessive-Compulsive Personality Disorder. Clients with this diagnosis have well-controlled, perfectionistic patterns of behavior at the expense of spontaneity, flexibility, and even efficiency. More particularly, there is often such preoccupation with planning and details that tasks are not completed. These clients have difficulty delegating responsibilities and, in fact, tend to work long hours in order to meet their own standards regarding productivity. Also, they tend to collect and hoard things even when those things have little value. Unlike persons with obsessive-compulsive disorder, individuals with Obsessive-Compulsive Personality Disorder do not necessarily have obsessions or compulsions. Rather, they tend to be rigid in their actions and thinking, adhering to strict and controlled patterns of thought and behaviors ( APA, 2013 ).
Assessment
Detailed and thorough histories are necessary for the diagnosis of a personality disorder. Assessment of the characteristics of a personality disorder must be consistent over time and across circumstances. Diagnosis is often complicated by the fact that many individuals with personality disorders often do not seek out treatment on their own, have overlapping symptoms as well as coexisting disorders. It is worth mentioning, that caution should be used when employing many self-report scales due to the possibility of built-in gender and/or ethno-cultural bias.
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997 ) is the recognized benchmark for the diagnosis of the 10 personality disorders currently in the DSM-5 ( APA, 2013 ). This semistructured instrument can make a diagnosis by either the presence/absence of symptoms or by counting (sum scores) the number of criteria needed to meet diagnosis. Additionally, the personality questionnaire (SCID-II PQ; First et al., 1997 ) consists of 119 items and can be used as a self-report screening tool. Training on both the administration and scoring of this instrument is recommended. The inter-rater reliability for this instrument ranges from fair to excellent. For a listing of the numerous reliability studies, see instrument website ( www.scid4.org ) under psychometric reliability. Of note, the more dimensionally the SCID-II pathology is indexed, the higher inter-rater reliability ( Lobbestael, Leurgans, & Arntz, 2011 ). As pointed out by Ryder, Costa, and Bagby ( 2007 ) as well as others, the major concern with this instrument is comorbidity across diagnoses due to overlap in symptoms within the clusters.
Another comprehensive measure, the MMPI-2 (see Chapter 1 for details) can be useful in assessing the presence of the various personality disorders, particularly as the clinical and validity scales are included in its administration. Due to the target age range of the MMPI-A, there is much less emphasis on the possibility of personality disorders in its interpretation. The MMPI-2 is a widely used instrument with years of supportive research and requires training in the administration and scoring of this instrument.
Two other broad-based assessment instruments have been designed to address the presence of a personality disorder more directly. The Millon Clinical Multiaxial Inventory (MCMI-III; Millon & Davis, 1997 ) consists of 175 true-false items designed primarily to detect a variety of personality disorders as well as additional subscales for detecting some of the more common co-occurring mental disorders. In its third edition, this instrument reflects the diagnostic constructs for the 10 personality disorders currently found in the DSM-5 ( APA, 2013 ) as well as the addition of 42 Grossman Facet Scales. Similar to other NCS Pearson products, the MCMI has been well researched and validated in its various versions. Details and psychometrics can be found in the author's test manual ( Millon, Millon, Davis, & Grossman, 2006 ).
Another set of instruments designed to detect personality disorders has been developed by Coolidge and associates. The Coolidge Axis II Inventory (CATI; Coolidge, 2005 ; Coolidge & Merwin, 1992 ) consists of 250 questions self-rated on a 4-point scale, ranging from “strongly false” to “strongly true” designed to measure personality disorders based on current diagnostic criteria. There are 14 personality disorder scales in the CATI, including the 10 personality disorders included in this chapter as well as 4 others (e.g., passive-aggressive, depressive, sadistic, and self-defeating). Additionally, some scales may help when determining the possible presence of a personality change due to another medical condition (e.g., General Medical Condition scale). Three other companion instruments are available. The short-form of the Coolidge Axis II inventory (SCATI; Coolidge, 2001 ); which is a shorter, 70-item version with similar psychometrics ( Coolidge, Segal, Cahill, & Simenson, 2010 ); The CATI—Significant Other Form ( Coolidge, Burns, & Mooney, 1995 ), which is designed for completion by a person familiar with the client; and, the Kids' Coolidge Axis II Inventory (KCATI; Coolidge et al., 1990 ), which is designed to assess personality disorders or their precursors in children and adolescents (ages 5–17). All of these instruments have demonstrated reasonable psychometric properties. For further information on use and psychometrics see author references.
For screening purposes, the self-report Standardized Assessment of Personality Abbreviated Scale (SAPAS-SR; Moran et al., 2003 ) is an 8-item, dichotomously rated measure for personality disorders (further validated by Hesse & Moran, 2010 ). When a response indicates pathology, the interviewer must administer additional questions (up to 8 more). This tool screens for the presence of a general personality disorder versus diagnosing which disorder may be present. Summing items produces a total score ranging from (0–8) with higher scores indicating greater likelihood for the presence of a personality disorder. During validation, a cutoff score of 3 correctly identified the presence of a DSM- IV personality disorder in 90% of participants. The sensitivity (.94) and specificity (.85) were reported in the original validation study ( Moran, et al., 2003 ). This brief instrument takes less than 5 minutes to complete. Limitations have been reported for some personality disorders (e.g., antisocial, histrionic, and obsessive-compulsive) and with the trait narcissism ( Hesse & Moran, 2010 ).
Additionally, the DSM-5 ( APA, 2013 ) contains new disorder specific assessment measures (e.g., Personality Inventory for DSM-5—Brief Form; PID-5-BF) for both adults and children, which can be found under online assessment measures, for examples please see www.psychiatry.org .
Cultural Considerations
Judgments about persistent and pervasive personality traits cannot be made without consideration of a person's cultural background. Caution should be exercised when evaluating clients whose culture of origin is unfamiliar to the assessor. Particular care should be exercised in diagnosing members of minority groups with paranoid personality disorder. There is a tendency to underestimate the existence of prejudice and discrimination by people who are not members of the group in question.
In a study of personality disorders and ethnicity, Chavira et al., ( 2003 ) found that of four targeted personality disorder categories (schizotypal, borderline, obsessive-compulsive, and avoidant), Hispanic men and women (primarily Puerto Rican) were more likely to be diagnosed with borderline personality disorder than Caucasians or African Americans. The authors clearly state that the explanations for such findings are inconclusive. Hispanic men and women may display borderline type symptoms due to the stress of acculturation to a majority society. On the other hand, a diagnosis of borderline personality disorder may be a misdiagnosis due to cultural bias by Western clinicians. For example, in Puerto Rican culture, men are expected to display emotions openly, to shout and cry during crises, and have physical and verbal outbursts of aggression. These symptoms would be considered an ataque de nervios in Hispanic culture. The authors suggest that there are major problems with the categorization of personality disorders among diverse ethnic groups due to a lack of understanding on the part of Western society regarding the cultural nuances and upbringing of non-Western populations. Lin ( 1997 ) argues that the diagnosis of “borderline” is extremely rare in some non-Western societies calling the universality of the diagnosis into question. He states that in China, for example, this diagnosis is rarely utilized. Other personality disorder diagnoses may be overused due to a lack of cultural competence on the part of clinicians. Schizotypal personality disorder, for example, has been overdiagnosed among African and African-American groups.
The incidence of certain personality disorders seems sharply divided along gender lines. For example, men are much more likely to be diagnosed with antisocial personality disorder, whereas women predominate in diagnoses of borderline, histrionic, and dependent personality disorders. Even though this may, in fact, reflect an actual difference in prevalence, clinicians should be cautious about over- or underdiagnosing these disorders based on gender role stereotypes.
Social Support Systems
The impact of personality disorders on both social relationships and occupational functioning is both “constraining” and “disrupting.” Because these are persistent patterns of behavior established by early adulthood, the characteristics directly influence both social and vocational choices. For example, individuals with a diagnosis of dependent personality disorder would not likely seek or be comfortable with an egalitarian relationship. Similarly, people with a cluster A personality disorder are not likely to become salespeople.
These constraints are also evidenced in patterns of seeking treatment. As has been indicated, few people with personality disorders actively seek treatment. Those who do are frequently “motivated” by circumstances that prevent them from comfortably continuing their pattern of behavior. For example, someone with antisocial personality disorder may seek intervention only to minimize the intrusion of the legal system into his or her life. People with a cluster A personality disorder may be “forced” into treatment when changing circumstances force them to interact more broadly with the world (e.g., when their parents die).
With these characteristics in mind, it is not surprising that most community resources and Internet sites are devoted to “explaining” personality disorders to those who may be associated with the client. Some resources are as follows:
· www.nami.org : The National Alliance on Mental Illness is a grassroots mental health organization dedicated to the advocacy and support of people living with mental illness, including personality disorders.
· www.nimh.nih.gov : The National Institute of Mental Health seeks to transform the understanding and treatment of mental illnesses through research and education. For information on some personality disorders see the “Health & Education” section of their website.
Case 18.1
Identifying Information
Client Name: Natalie Loftin
Age: 29 years old
Ethnicity: Caucasian
Educational Level: College graduate
Occupation: Administrative assistant
Intake Information
Natalie Loftin contacted the Marriage and Family Counseling Center due to concerns about her relationship with her boyfriend, Larry Watkins, over the past 6 months. She reported that she has been so upset that she hasn't been able to function at work, and her coworkers told her she needs to get some help.
When the intake worker asked her what she meant by “upset,” Natalie stated that she felt so depressed and empty that she didn't think she could stand it. A friend of hers gave her the name of this agency since it has a sliding-scale fee structure. Natalie said she also was having financial difficulties and hoped her insurance would cover the cost of counseling. The intake worker assured her that the cost of sessions was based on the client's ability to pay and that if Natalie had insurance coverage, the cost would be minimal. Natalie agreed to come in for an initial interview the following week. Her case was assigned to you.
Initial Interview
You find Natalie restlessly moving around in the waiting area chewing on her fingernail and flipping through a magazine while she walks. She is a petite, well-groomed woman wearing a dark blue suit, a yellow blouse, and small heels. Her long, brown, curly hair is pulled back in a large clip, and she has applied a considerable amount of makeup.
You introduce yourself as the counselor and ask her to come with you to your office. Natalie readily agrees and begins talking as you walk down the hall.
“My friend, Denise, told me that this was a good place to come to talk to someone. Do you know Denise?” she asks.
“No, I'm afraid I don't, but even if I did, I couldn't tell you because everything we discuss here is confidential. We don't even tell anyone that someone is being seen by a counselor at this agency,” you reply. “Won't you come in and have a seat?”
“Oh, I see. Well, I guess that's a good thing,” Natalie responds. “What is your degree? I have a bachelor's degree in math and computer science.”
“That's impressive,” you respond. “My degree is in mental health counseling. All the counselors at this agency are master's level counselors, and we work with people who are attempting to cope with a variety of emotional issues. Everything we talk about is confidential, but I must tell you that if you tell me that you may harm yourself or someone else, I cannot keep that confidential and I must report that information to either the police or my supervisor. Do you understand that?” you ask.
Natalie thinks for a minute and then replies, “Yes, that makes sense. I haven't really thought about suicide this week. That's what you're talking about, isn't it?”
You decide to note that Natalie inferred that she has thought about suicide in the past but to wait before delving into that issue since it might be too much divulgence too fast for Natalie to handle. “Yes, maybe we could begin by you telling me why you decided to make an appointment.”
“Okay. Well, I've been dating this guy, Larry— Larry Watkins—for about the last 6 months. He and I just seemed to have a whole lot in common, and I really thought this was going to turn into a permanent relationship. We just seemed to get along so well and, you know, after seeing each other for about a month, he moved in with me and it just seemed to be great. I just don't know what happened.” Tears well up in Natalie's eyes, and she looks as if she's about to burst into tears.
“I see. You were living together for the past 5 months and everything seemed to be going well. Then what happened?” you inquire.
“Well, we got into this big argument about my parents. I mean it was a huge argument one night. We stayed up all night arguing, and in the morning, he just said he couldn't take it anymore and packed a bag and left.”
“Okay. Did you ever argue before this?” you ask.
“Well, sometimes, usually over little things. One time I remember thinking I had some kind of love-hate relationship with Larry, but then things got better, and I just felt like this guy could really take care of me. But since the other night, I'm wondering what's wrong with me. This has been the sixth time I've been involved with someone and had the relationship just blow up in my face. I hate it and I hate myself when this happens.” Natalie slumps down in her chair, and tears well up in her eyes again, but she doesn't actually cry.
“Okay, so you've had other relationships that have ended abruptly,” you suggest.
“Yes, five other relationships that were serious. I guess I dated other boys in high school, but those don't really count. I just don't understand it.”
“Can you tell me what you and Larry were arguing about the other night? You said it was about your parents,” you acknowledge.
“Yes, you see, Larry doesn't like my parents or, at least, he thinks I'm too involved with my family. He got mad because I talked to my mother on the phone about the car accident I had a few weeks ago, and she just infuriated me because she refused to help me out. My car was totaled, and I really need to get another car, but I don't have enough money to get the one I want. My parents have plenty of money and could help me if they wanted, but my mother can be a real ‘witch’ sometimes. She said that they had already bought me two other cars, and they weren't going to buy me another one. I couldn't believe what a witch she was being. She can be crazy, I'm telling you. She had the nerve to suggest I need to get a better job where I could use my college education, but she doesn't realize how hard it is to get a job in the computer industry, and besides, I think she just hates me. Sometimes I think I hate her, too.”
She continues, “So, I'm just telling Larry about this conversation, and he gets really angry and says I'm too dependent on my parents and that I still act like I'm a teenager and should let go of them since they always make me furious. He knows that the whole subject of my parents is a ‘hot button’ for me. I think he said that just to make me mad and he did. He knows what a temper I have! He made me so angry I thought I was going to explode. Actually, I did explode. I told him what an idiot I thought he was. Just because he doesn't have a relationship with his parents doesn't mean I shouldn't have one with my parents. It's weird—sometimes I am so in love with Larry and other times I hate his guts. Is that the way it is for most people?” Natalie curiously inquires.
“I don't think it's unusual to have disagreements with people you love,” you suggest. “How did the argument end?”
Natalie stares out the window for a moment and then says matter-of-factly, “He just said he couldn't take it anymore and went to the bedroom and packed a suitcase and left. I actually thought he was joking. I told him if he walked out the door, he'd be a stupid fool. And then when I realized he was serious, I begged him not to leave me, and he just shrugged his shoulders and said, ‘Life is too short, Natalie; you are always running hot and cold. I just can't take it anymore.’”
“What do you think he meant by that statement?” you ask.
“Well, I think he's referring to the fact that I sometimes hate him and then, other times, I love him. It just seems too empty inside when he's not around. I wonder if it's all really worth it,” Natalie responds.
“So, sometimes you feel really empty when you're not involved in a relationship. Is that right?” you ask.
“Maybe that's why I've had so many,” Natalie ponders. “It seems like the times in between relationships are awful, like sitting in the bottom of a black hole. Nothing, there's just nothing worth living for. And I hate everyone and everything. But sometimes, I feel that way when I'm in a relationship, too. I don't know. It's very confusing to me.” Natalie rubs her forehead and pulls her legs underneath her.
“How do you feel about yourself when you're in or out of a relationship?” you ask.
“That's simple. I usually hate myself when I'm not in a relationship. I think I'm stupid and ugly and can't do anything right. I feel that way when I'm in a relationship sometimes, too, but it comes and goes. Initially, when I first meet someone, I feel really good about myself, but then it gradually disappears.”
“And when you're thinking you hate yourself, how does that make you feel?” you ask Natalie.
“Very down in the dumps and worthless and hopeless,” Natalie replies. “Like I said before, sometimes I've been so depressed I've felt suicidal. Like I just want to end it all.”
“Have you ever actually tried to hurt yourself?” you ask.
“A couple of times when I was a teenager, I scratched my wrists and a couple of times after I broke up with a boyfriend, but I haven't done anything serious lately,” Natalie replies.
“Okay, can you make a contract with me that if you start feeling suicidal, you will not do anything before talking to me?” you inquire seriously.
“I think so,” Natalie states. “I'm sort of feeling more hopeful about things now that I've talked to you. Do you think you can help me figure all this stuff out?” Natalie asks pleadingly. “I'm just scared to death I'm going to be left alone for the rest of my life.”
“Natalie, I think I may be able to help you, but you have to make a commitment to counseling, and sometimes it may feel uncomfortable for you. I'd like you to think about whether or not you really want to get involved in counseling, and if you decide this is a good idea, call and make another appointment. Okay?”
“I'm pretty sure I need to get some help,” Natalie considers.
“Okay, but why don't you think about it overnight, and if you are still sure tomorrow, you can call and make an appointment.”
“Okay, that will be all right,” Natalie sighs. “I guess this isn't going to be easy.”
· 18.1–1 Describe Natalie's presenting problem. Do you think this is her primary problem? Why or why not?
· 18.1–2 What are some of Natalie's strengths?
· 18.1–3 What potential diagnoses would you want to rule out in this case?
· 18.1–4 What resources might be helpful for Natalie to access?
· 18.1–5 What is your preliminary diagnosis for Natalie?
Case 18.2
Identifying Information
Client Name: Jack Keller
Age: 40 years old
Ethnicity: Caucasian
Marital Status: Married
Occupation: Corporate accountant
Intake Information
Jack Keller has been referred to you, a counselor at a large corporation's employee assistance program (EAP), due to recent problems he has had with coworkers. His boss, Chris, strongly recommended that Jack contact the EAP because of several complaints he had received concerning Jack's interactions with other employees.
Jack is a hardworking employee whom Chris values. He is a competent accountant who always completes his work on time and often works overtime in order to make deadlines. His work is always accurate and detailed.
Chris suggested Jack talk to a counselor since Chris has received several complaints from assistants and coworkers over the past 2 months. Although Jack stated that he “had things under control,” Chris insisted that Jack make an appointment with a counselor. Chris suggested that perhaps Jack was under a lot of stress, but Jack maintained that there was nothing wrong with him other than working long hours on several big projects recently.
He told Chris, “I don't know why you want me to see a counselor. My work is flawless; I get things in on time; and I work harder than anyone else in this department. Just because I expect others to do their jobs doesn't make me crazy.”
Chris told Jack that he (Jack) expected perfection and was being overly critical of others when they did not measure up to his expectations. “You've got to stop berating others when they aren't as perfect as you, Jack,” Chris told him in exasperation. This comment made Jack wonder what he was doing that bothered people so much, and he decided to make the appointment with a counselor to get a better handle on the situation.
Initial Interview
You meet Jack in the waiting room and observe that he is an immaculately dressed man about 6 feet tall and of average weight. He is wearing a white shirt, a blue-and-white tie, and black pants. His black shoes are polished so they shine, and his wire-rimmed glasses give him a studious appearance. Jack glances at his watch as you walk into the waiting room.
You introduce yourself as a counselor at the EAP and escort him to your office. Jack questions the time of the appointment, suggesting you are late (it's 3 minutes past the hour). You explain that sometimes you are running a minute or two behind in order to get messages or make a phone call between clients.
Jack responds matter-of-factly, “Well, it did seem like you must be running behind today.” You note the fastidiousness of this comment.
“Well, first, I want to tell you that everything we talk about in these sessions is confidential. It is important for you to know that, especially since we are a counseling center within this larger corporation. Unless you tell me you are going to hurt yourself or someone else, the information we share in this room will not be discussed with anyone other than my direct supervisor. Do you have any questions concerning confidentiality?”
“No, that's pretty clear. I've never actually seen a counselor before,” Jack says hesitantly. “I'm only here because my boss thought I should come for a session.”
“I see. So, you aren't sure you really need counseling,” you reply.
“Well, it might be a good idea to talk to an expert about some things that have been going on in my department as long as it's confidential,” Jack states.
“Okay, tell me what's been going on,” you say.
“Well, you see I'm the senior CPA in my division, and I report to the head of the finance department. I have 10 people working under me and am responsible for all their work. Sometimes it seems like I'm the only one in my division that takes work seriously. I work very hard to see that everything is running smoothly and that all the figures are accurate. Sometimes that means I work late at night and on weekends, double-checking everyone else's work to make sure it's correct. I shouldn't have to do that, but I've found that if I don't, mistakes are made and I get called on the carpet because other people aren't doing their jobs. So, I tell people that they must be precise and accurate when it comes to these figures and they can't be lazy about doing it right. If they'd do it right the first time, then I wouldn't have to be on their backs all the time to get the numbers correct.”
“And how do they respond to what you tell them?” you inquire.
“Well,” Jack throws his hands in the air, “they just get irritated and angry with me. Apparently, they are running to my boss and telling him that I'm hard to get along with or something like that. I can't understand it. No one works as hard as I do in that department, and if they'd take a little more pride in being accurate, then I wouldn't have to be on their cases all the time. I don't really see it as my problem.” Jack leans back in his chair and shrugs his shoulders. “So, that's why I'm here, I guess.”
“Let me see if I understand what you're saying. You are telling me that people who work for you are getting upset because you are correcting their mistakes and telling them they should be more careful about their work. Does that more or less sum it up?” you ask Jack.
“More or less,” Jack replies. “From what my boss tells me, they think I'm being overly critical of their work. He told me that I needed to learn how to control my anger.”
“Do you get angry when your employees don't do the work the way you want them to?” you ask.
“Well, it's very frustrating to me. I go over and over pages of figures to make sure they are accurate, and no one else seems to care. It just infuriates me that they don't take their jobs seriously. These numbers are either right or wrong. It's all very black and white. When I tell them that they need to check their work again, they get angry and say that if they spent all their time rechecking every number the way I did, they'd never accomplish anything. Sometimes, they even leave work early and say they've finished for the day. I don't understand how they can do that when they've rushed through their work and done a sloppy job. I've told them that according to their job descriptions they are supposed to be at their desk from 8 A.M. until 5 P.M., Monday through Friday. Recently, I had to tell them that they had to stick by the rules and only take 1 hour for lunch since they were coming back 15, or sometimes 20, minutes late. No wonder they don't get their work done right the first time! They just don't care. I've told my boss that I can't get the spreadsheets to him on time since I've got to check everything that other people are doing three or four times.”
“Okay, I can see that this issue is a very upsetting one for you,” you respond. “Do you have similar experiences with people outside work?”
“Well, it's not the same thing, but if you mean do people get under my skin because of their slovenly behavior, you bet!” Jack replies. “I have a 12-year-old son who just refuses to follow the rules in my house.”
“What exactly do you mean?” you ask.
“Well, he plays sports at school, and when he gets home from soccer practice, he just drops his muddy soccer shoes at the foot of the stairs even though I've told him a hundred times that his dirty shoes belong on the back porch. He just doesn't listen to me. And that's just one example. There are numerous times when he disobeys my orders. He'll walk out of the house without making his bed, or he'll leave the toothpaste tube open on the sink. He knows that he's breaking the rules, but he does it anyway. My wife will take his side sometimes, which makes me even more angry.”
“What happens when your son breaks the rules?” you ask seriously.
“Well, I tell him he's grounded, or he can't do something he wanted to do until he straightens up his act. I slave away at this job all week long in order to buy him $80 soccer shoes, and then he drags those muddy things into the house and I have to clean up after him. The last time I bought myself a new pair of shoes was 10 years ago. Look at the soles of these shoes I have on.” Jack throws his foot up in the air so that you can see the bottom of his shoe.
“Wow, it looks like you've really worn a hole in that shoe,” you comment. “Have you thought about buying another pair?”
“I can't afford to buy another pair when I have an irresponsible son who needs expensive shoes and apparel all the time,” Jack says mournfully.
“Okay, what I hear you telling me is that your 12-year-old son can get on your nerves at times. I guess most 12-year-olds are not always neat. Are there other people that you run into problems with in a similar way?” you ask.
“No, not really,” Jack says. He looks tired and discouraged. “I just can't understand why people don't have the same values as I do. My wife and I argue about these issues all the time, but she knows who pays the bills and is head of our household,” Jack states unequivocally. “I've told her when she starts making more money than I do, then she can make the rules in my house.”
“Wow, how does she respond to that?” you ask.
“She usually just gets quiet and walks away,” Jack states. “She knows I'm right.”
“Okay, I think I've got a fairly good picture of what you're talking about,” you respond. “I'm just wondering if you think that counseling could be beneficial to you in working on some of these issues.”
“You mean so that people will listen to me and do what they're supposed to do?” Jack inquires.
“No, actually, I meant to help you be more effective in dealing with other people,” you reply as convincingly as you can. “You see, Jack, people come to counseling to obtain help with something they want to change about themselves. As I'm sure you know, we really can't make other people change. We can only work to change things about ourselves. And what I do is assist people in making those changes about themselves that they would like to work on. Does that make sense to you?”
“Well, I guess I see what you're saying. I'm going to have to think it over. I'm not really sure how you could help me since I think it's other people who have the problem, but I'll think it over and talk to my wife.”
“Good idea. Give it some thought, and if you would like to come back for another session, call the office and schedule an appointment. So, that will be our plan?” you ask.
“Sounds fine with me,” Jack says. “Thank you for your time.”
· 18.2–1 As the counselor interviewing Jack, how did you feel?
· 18.2–2 Do you think Jack will agree to counseling? Why or why not?
· 18.2–3 What other resources might be useful to Jack?
· 18.2–4 What diagnosis would you give Jack?
Case 18.3
Identifying Information
Client Names: Sherry Black and Kyle Monroe
Ages: Sherry, 25 years old; Kyle, 28 years old
Ethnicity: Caucasian
Marital Status: Cohabiting couple
Occupations: Sherry, airline flight attendant; Kyle, operating room technician
Intake Information
Sherry Black contacted the Marriage and Family Counseling Center for assistance with a relationship that she is having with Kyle Monroe, her livein boyfriend. Sherry is a flight attendant, and Kyle is an operating room (OR) technician at the local hospital.
Sherry told the intake worker that she and Kyle have been having increasing difficulty with their relationship due to Kyle's suspicious nature and constant questions about Sherry's loyalty to him. Sherry feels that Kyle has become overly possessive, and when she tries to talk to him about this issue, he states that her desire to be more independent is evidence that she can't be trusted and that she must be seeing someone else.
Sherry states that Kyle has become more and more suspicious of her whereabouts while she is flying and every phone call that she receives. Even though she has told Kyle he can listen in on the phone conversations, Kyle resents her accepting phone calls from anyone he doesn't personally know. In addition, he has told Sherry that her desire to get some help is just a way for her to get support when she leaves him.
Sherry states that his suspiciousness has “spilled over” to his job and is causing Kyle problems at work. For example, he feels that the OR nurses can't be trusted and that they may be trying to get him fired. He told Sherry that his friend Arnold at the hospital told him that the head OR nurse thought he was an excellent OR technician. Kyle felt that the comment meant that he wasn't as good as the nurses and he had to be careful about what he told the head nurse. The intake worker scheduled an appointment for the couple to come to the first interview together.
Initial Interview
Sherry and Kyle sit together on the couch in your office. You introduce yourself and explain to them that you provide counseling to couples who may be experiencing difficulties in their relationship. Kyle is very concerned about how this appointment will be reported on insurance forms and about issues of confidentiality. You explain that the appointment is confidential and that the agency operates on a sliding-scale fee. Kyle appears to be assessing you.
“What made you both decide to make an appointment for counseling?” you ask.
Sherry looks at Kyle and begins. “Kyle and I have been having some problems in our relationship,” Sherry comments. “I think we care a lot about each other, but we've been getting into some big arguments lately.” Kyle appears to be inspecting the office and your desk. You realize he's staring at the file with Sherry's name on it.
“Can you tell me what the arguments are about?” you ask. Kyle remains fixated on the file folder on your desk.
“Kyle seems to be having a hard time trusting me while I'm away at work,” Sherry states. “You see, I am a flight attendant for Southern Light Airlines, but I fly locally and I'm always back in town each evening. So, I'm a little confused about why he thinks I'm playing around on him when I'm home every night.”
Kyle grunts and continues to stare at the folder. Pointing to the folder on your desk, he asks, “What's that folder got in it?”
“Just the information that the intake worker got when Sherry called to make the appointment,” you say.
“Wait a minute. Before we can go any further, you need to show me that folder.”
“I'll be happy to show it to you at the end of the session,” you remark. “Right now, I'd like to find out what you have been arguing about.”
“Oh, no. I'm not giving you anything until I see what's in that folder,” he insists.
Sherry blushes and says, “Kyle, I'm sure it's just basic information. Don't worry about it. It's nothing.”
“Nothing? My personal life may be nothing to you, but it's my life, okay? It's bad enough that you tell everyone our business. Now it's in print!”
“Is this how the arguments go at home?” you comment. Sherry and Kyle both look at you and appear taken aback by your comment. You decide to gently reframe by stating, “Privacy seems to be a tense issue for you, Kyle, and Sherry doesn't seem to be so concerned.”
Sherry quickly responds despite Kyle's glaring, “This is exactly the problem at home, only at home he's suspicious about my whereabouts and what I say to anyone.”
Kyle leans back in the chair, nods, and says, “You've both already talked about this, haven't you? You don't even need me here, do you?”
Sherry sighs in resignation. “Do you see what I mean? Kyle doesn't trust anyone about anything!”
You realize that you have to establish some rapport or Kyle will leave. You say, “Kyle, this is the first time I've had the opportunity to talk with either of you, and I'd really like to get your perspective on how things are at home.”
Kyle eyes you and then Sherry.
Sherry says, “Come on, Kyle. She's a counselor and wants to help.”
Kyle looks pensive and begins hesitantly to discuss the relationship. “Well, as anybody can see, Sherry is a very attractive woman and flirty by nature. She's on that plane every day with all those businessmen and you can't tell me that they don't make moves on her. It all started when I picked her up after her Houston trip …”
“Oh, God. Here we go again!” Sherry says with disdain.
“Will this help me understand the situation?” you comment.
“It sure will. It explains everything. Let me finish. I go to pick her up, and there she is bending over her purse at the baggage claim, and this idiot guy is standing there with her bags in his hands. It's quite obvious what's going on. Makes me sick to think about it.”
Sherry says, “It was just a nice man trying to help me with my bags while I took out my claim stubs. I didn't even know his name. It was a 30-second interaction.”
Kyle exclaims, “Bull! I saw how you looked at each other, and you were giggling away. It sure didn't look like ‘nothing’ to me.”
Sherry sighs and throws her hands in the air in utter frustration. “This was one of our worst arguments, and he brings it up every time we try to deal with things. He's so jealous of everything I do. He can't let it go!”
“Have your arguments ever become physical?” you question.
“No, except he once threw my carry-on bag out the door of the house, telling me never to come back.”
You respond, “Okay, so the arguments focus on Kyle's worries about your commitment to the relationship, and you feel these worries are unfounded. Is that correct?”
They both nod. Sherry urges Kyle to tell you about the work situation. Kyle glares at you again and says, “That's not what we're here for. We're here to figure out what's wrong with our relationship. If you weren't messing around on me, we wouldn't have any problems. Then I wouldn't have to be so concerned about my job.”
Sherry in utter exasperation stands up and says she's going out for some water. “Maybe this is enough for today.” She leaves the room, with Kyle glaring after her.
In one last attempt to establish some rapport with Kyle, you say, “How is all of this making you feel, Kyle? It's pretty hard to talk about personal stuff with a stranger.”
He says, “Sherry just needs to get her ducks in a row, and everything will be fine. How about giving me a look at that chart?”
You hand him the chart and say, “Really, Kyle, this just contains your names and address.”
Sherry returns with a cup of water. “Where do we go from here?” she asks you.
“I'd like you to consider becoming involved with some counseling. I think it could be beneficial to you at this time. I'd like to start with six sessions and see if you feel your relationship is improving. How do you feel about coming in for six sessions?” you inquire of both of them.
Kyle shrugs his shoulders and says, “If you think it will help, I'm willing to do it.”
Sherry nods her head enthusiastically and agrees.
“Okay, so we'll schedule an appointment for next week,” you reply. “If you need to talk before the next appointment, here is my card. Call me and if I'm not available, I'll call you back as soon as possible.”
· 18.3–1 Describe your perceptions of the presenting problem.
· 18.3–2 Do you think Kyle and Sherry will be able to maintain this relationship? Why or why not?
· 18.3–3 What other information would you like to gather about Kyle? Include additional questions you might like to pose to him as well as collateral information.
· 18.3–4 What is your preliminary diagnosis for Kyle?
· 18.3–5 What, if any, diagnoses are you considering for Sherry?
Case 18.4
Identifying Information
Client Names: Filipo and Kim Garrett
Ages: Filipo, 40 years old; Kim, 36 years old
Ethnicity: Kim: Caucasian; Filipo: Hispanic- Puerto Rican
Marital Status: Married
Occupations: Filipo, high school principal; Kim, middle school teacher
Children: Gary, age 5
Intake Information
Kim Garrett contacted the Family Counseling Center for assistance with her 5-year-old child, Gary, who has been having some conduct problems in his first year of kindergarten. She stated that the school counselor suggested that they contact the Family Counseling Center for help since there have been multiple incidents at school with Gary hitting and fighting with other children.
Kim stated that she and her husband, Filipo, have tried everything to get Gary's behavior under control and have not been successful. The intake worker suggested that both Kim and Filipo come to the agency for the initial interview with the counselor without their son. Another interview will be scheduled for Gary. Kim stated that it would have to be after 5 P.M. because her husband is a school principal and wouldn't be able to come earlier in the day.
Initial Interview with Kim and Filipo Garrett
You meet the Garretts in the waiting room and notice that both parents are dressed in professionallooking clothes. They are seated beside each other and are both looking at separate magazines when you enter. You introduce yourself, shake their hands, and escort them back to your office. They sit beside each other in chairs next to your desk.
You begin by explaining the purpose of the agency and the issue of confidentiality. You explain that your agency works with families and that when children are experiencing difficulties, it is very important for the parents to be involved in the child's counseling.
Filipo begins the discussion by stating that he is the principal at the largest high school in the city and that he has a very important position that requires a tremendous amount of time and effort. “Despite the fact that I hold a very important job, I always make time for my wife and son.”
“Okay, good, can you tell me what's been going on with Gary recently?” you inquire.
“Well, to be perfectly honest, I'm not sure anything is wrong with Gary,” Filipo replies. “Kim and I don't experience any of the problems they are talking about at school when Gary is at home with us. I think we're just trying to get an assessment done so that we can have some evidence that perhaps it's the teacher, not Gary, who has the problem. Of course, we'll leave the evaluation to you, but I have many years of experience working with children, and I just don't see Gary as having a problem. What kinds of problems would a 5-yearold have anyway? In my position, I work with teens with lots of problems. But, we're talking about a little boy who has good parents who care about him,” Filipo states.
“Okay, so you don't really see this as Gary's problem. You think that it may be the teacher who is not able to cope with Gary. Is that correct?” you ask Filipo.
“Exactly. Kim and I are very educated and intelligent professionals, and we have excellent parenting skills. Kim leads a parenting workshop every year at her middle school, and I'd say parenting is a real strength of mine. Gary always behaves when he's around me. I make myself clear, so of course he obeys.” Filipo straightens the lapels of his jacket.
“I see,” you reply. “Have you been feeling that the school is blaming you for Gary's behavior?”
“Well, not exactly,” Filipo replies. “However, they are saying that Gary's behavior is the problem, and we just don't believe that is the case. There may be some jealousy involved. After all, this is the same school district, and I'm a ‘star.’ It's possible that this teacher wants to try to embarrass me.”
“Okay, I understand,” you respond. “So, as you said, my job is to do an assessment of Gary. In order to do that, I'm going to need to ask you some questions that you may find unimportant, but I need to ask them anyway. Is that okay with you?”
“That's fine with us,” Filipo states.
“Is Gary your only child?” you ask.
“Yes,” Filipo states. “We don't plan on having more than one child because of our professions.”
“How long have you been the principal at Southside High?” you ask.
“It will be 3 years in September,” Filipo states. “I am in charge of 200 teachers and 2,000 students. It's quite a large responsibility. Not to mention all the other duties I have with the school district. It's a great school, though. I've really turned it around, and the administration has suggested there may be other positions in the district open for me to move into as time goes on. I've really been quite successful in my career, so far.”
“Yes, he has,” Kim states. “Everyone thinks Filipo is the greatest principal Southside has ever had. He has quite a loyal following of teachers that really appreciate his management style.”
You note that Kim's comment about her husband was the first time she has spoken since the session started. “Wow, that's impressive,” you state. “What about you, Kim? How do you see Gary's behavior?”
“Kim feels the same way I do,” Filipo answers. “We both feel that this kindergarten teacher is just not very competent. We've talked to her about Gary's behavior, and I just think she's really clueless about children. We may just need to move Gary to a different class.”
“Okay, and how do you experience Gary's behavior, Kim?” you say directly to Kim.
“Well, Filipo really knows a lot about children. He took courses in child psychology in his doctoral program,” Kim states. “Gary really isn't a behavior problem at home.”
“Just to summarize, both of you feel that Gary's behavior may be a result of the teacher's interaction with him and that you see no problems with Gary's behavior at home. Is that correct?”
Filipo nods his head and adds, “Just make a note that Gary's parents are experts in working with children.”
“All right,” you acknowledge Filipo's remarks. You decide to get some information about Filipo and Kim's relationship. It is clear to you that Filipo does not believe Gary has a behavioral problem.
“Let me ask you about your relationship with each other. How long have you been married, and how would you characterize your relationship with each other?” you ask.
Kim begins to answer but is interrupted by Filipo. “Go ahead,” Kim tells her husband.
“Well, Kim and I met in college when I was a senior and she was a freshman. We dated for 3 years before we got married. Kim began teaching and I was in graduate school. Then I taught and enrolled in a part-time doctoral program in order to get my PhD. Even though I had a full scholarship to complete the PhD. program, we both worked very hard for a number of years before we decided to have a child.”
“Kim, how would you describe your relationship with Filipo?” you inquire.
Kim looks at Filipo and smiles, “Well, Filipo was everything I was looking for in a life partner. He is so bright and ambitious. I was so impressed by his intellect and his being 4 years older than I was. I thought he ‘walked on water.’ He was president of the student teachers' association and had a whole following of female undergraduate students who thought he was fantastic. I didn't think I stood a chance of dating him. Filipo asked me to go out for dinner one night after we finished working on a project for the student teachers' organization, and I couldn't believe he was interested in me. He could have had any girl he wanted.”
Filipo looks very pleased with Kim's response. He laughs and adds, “Well, Kim was fairly outgoing herself. Even though she didn't excel in school the way I did, she was a good team player. I think we complemented each other.”
You glance at Kim to see her reaction to Filipo's comment. She smiles and says, “Filipo has never had a problem with his ego.”
You're surprised that Kim would so clearly state the obvious, but Filipo appears unconcerned about the comment.
Filipo responds with a smile on his face, “I just know my strengths and weaknesses.”
“Okay, so you met in college and married after Kim finished her degree, when Filipo was still in graduate school. How was that time for you in your relationship?”
“It was great. Kim was teaching and I was going to school and teaching, and we both enjoyed what we were doing. Probably the most difficult time was when I was trying to finish my dissertation and I ran into some trouble with the chair of my dissertation,” Filipo stated.
“What kind of trouble?” you query.
“Well, I just think he was an incompetent fool, if you want to know the truth. We had a disagreement about my research design, and he just decided he didn't like me or something. It was a real nightmare. Eventually, I had to fire him and get another chair for my dissertation committee, but it was not an easy time. He could have prevented me from completing my doctorate that I had aspired all my life to have.” Filipo leaned back in his chair and sighed.
Kim added, “Yes, that probably was the most difficult time in our marriage, thus far. Filipo was really questioning himself and his career and felt like he wasn't being treated fairly. It was a difficult time for both of us.”
“But you eventually got it worked out and then decided to have a baby?” you ask.
“Yes, after I finished my degree, we decided we wanted a baby,” Filipo stated.
“And how was it for you, having been working professionals for a long period of time, to have an infant at home?” you ask.
“Well, Kim took a leave of absence from her job for a year and stayed home with Gary, and then we found a good day care so that Kim could go back to work,” Filipo states.
“And how was that time for you, Kim?” you ask.
“Oh, it was great. Gary was a dream come true. I thought he was the cutest baby on earth. I guess all mothers think that about their babies, but Gary was a good infant who never really caused us much trouble. He seemed to be happy at the day-care center and always was happy to see me when I went to pick him up in the afternoons. Honestly, other than the normal stuff that infants go through, Gary was a fairly content little baby.”
“How old was he when he began walking and talking?” you ask.
Filipo chimes, “Oh, he was really talking early, around 9 months. I think it's because Kim and I exposed him to books at a very young age, as well as classical music. He began walking early, too, as I recall. He was about 13 months when he started to walk. You know, now that we're talking about all of this, maybe the problem Gary is having in kindergarten is that he's just too advanced for the class and he's bored stiff!”
“What do you think, Kim?” you inquire.
“Well, I never thought of Gary as being advanced. He seemed to go through the normal developmental milestones about on time and always seems to blend in with the crowd until recently.” Kim sighs, “I'm just not sure what the problem is right now.”
“Has anything changed in your family's life this year?” you ask.
Filipo looks puzzled for a moment and then quite suddenly blurts out, “Well, I've had a lot of speaking engagements to attend now that I'm in such a prominent position in the community, and maybe Gary is angry that I'm not at home as much as I used to be.”
Kim looks at Filipo and says, “Filipo, you are so brilliant. You may have just discovered the problem. You've been gone two or three nights a week for the past year, and Gary asks me all the time, ‘When is Dad coming home?'”
“Okay, well I'm glad we at least uncovered one possible reason why Gary may be having some difficulties in school. Can you think of anything else?” you inquire.
Both parents look at each other and shake their heads. You decide to schedule an appointment to meet Gary, but you feel your assessment of the parents has yielded some valuable information. You will meet with them again following your interview with Gary.
· 18.4–1 What are some of the strengths of these parents?
· 18.4–2 How would you characterize Filipo?
· 18.4–3 What would be your preliminary diagnosis for Filipo?
· 18.4–4 List the psychosocial and cultural factors that might impact this diagnosis.
Case 18.5
Identifying Information:
Client Name: Zachary Michaels
Age: 20
Occupation: College Student—Sophomore year
Ethnicity: Caucasian
Relationship status: Single
Intake Information
Zachary Michaels is referred to you by a computer science professor, Dr. Hodge, who has noticed that Zachary has not been attending classes and has not responded to his attempts to engage him in conversation by phone or email. The professor stated that he has tried on several occasions to get Zachary to come to his office to no avail. His roommate told the professor that he sometimes spends days never leaving his room and only has minimal conversations with him. In a final attempt to make contact, the professor went to Zach's room and told him he had to go with the professor to the student health center in order to stay in school. Zachary reluctantly agreed to walk to your office with Dr. Hodge. When you meet Zachary he is sitting slouched on the couch in the waiting room staring at the floor. Dr. Hodge introduces you to Zachary and then leaves the center. Zachary follows you to your office and shuffles to a chair.
“Zachary, it seems like Dr. Hodge has been very concerned about you missing class lately and is worried that you won't pass this semester,” you say while attempting to get Zachary's attention.
With no expression on his face, Zachary stares at the floor and says, “Yeah, well.”
“Have you been going to your other classes, or have you quit going to classes all together?” you ask.
“I've got more important things to do than to sit in a boring class,” Zachary says without changing his gaze.
“OK, so what have you been doing lately?” you query moving your chair closer to Zachary's chair. Zachary looks up with a completely blank face.
“I've been connecting with others in the Third Flight,” he responds. “You probably don't possess the capacity to understand the importance of the work I'm doing but it's highly significant in terms of the military defense system in this country and internationally. I may be the only one that truly understands their goals. In fact, I think they will offer me a position once they get to know me.” Zachary finally looks at you with a very cool expression on his face.
“Is this Third Flight a company or organization?” you ask.
Zachary scratches his unkempt hair. “It's more like a group of scientists that are involved in top secret work for the government. I discovered them through the Internet gaming world. My goal is to become the Commander in Chief.”
“Zachary, you say you found them through online games. Is Third Flight a game you've been playing on the Internet?” you wonder.
“I'm really not sure I should be discussing this with you,” replied Zachary. “I don't have official clearance and you may be trying to sabotage me in some way.”
“Believe me, Zachary, I'm only here to help. Our conversation is strictly confidential. The only exception to that rule is in the event that you tell me you want to harm yourself or others and then I have to tell someone about our conversation. Otherwise, our conversation is just between you and me,” you reply. At this point, you wonder what Zachary is trying to tell you. It's not making a lot of sense to you and you realize you need to get more information.
“Zachary, do you mind if I change the subject?” you ask. Zachary shrugs.
“Tell me a little about yourself, where you are from and your family,” you venture. Zachary leans back and looks at the ceiling.
“I'm from Wisconsin. I have two parents, divorced, and two sisters, one younger and one older. They live with my mother and, before I came to college, I lived with my father. He works for the state government. We don't talk; just email or text. I don't really care. They are all morons.”
“What about friends?” you ask. “Do you have friends here at college?”
“My friends are on the web and in the Third Flight,” Zachary suggests. “I don't have much to do with the people here. They can be very tricky and give me strange vibes sometimes.”
“Like what kind of strange vibes?” you respond.
“They just don't get it. They are so superficial and uninformed. I have no interest in wasting my time in mindless prattle,” Zach tells you emphatically. “I have more important things to do and people to see.”
“O.K., so your friends are primarily participants of the Third Flight,” you state. You decide to take another tactic by assuming that this is an internet game. “If I wanted to play this game, could I just join? How does it work and what are the objectives?”
Zach looks at you with a steely gaze, “You're kidding, right? You have to be invited by a member and have to have certain mental abilities. For example, if you're a member of the MENSA society then you might meet the criteria. This isn't Pokeman.” Zach continues to stare at you without flinching.
“So, it's a game that requires a high degree of intelligence. Correct? But it's still a web-based game. Do you have to pay for a membership to this exclusive game club?” you probe.
“Well, perhaps it's a game in your opinion, but it parallels reality and as we both know, if you can't beat them, then join them.” Zach studies the diploma on the wall.
“I'm not sure I'm following you, Zach,” you tender. How does the game parallel reality,” you ask cocking your head to one side with a curious look on your face.
“We must prepare ourselves for any disaster whether it's terrorism or natural. We must be ready to defend this country with a strong military. Do unto others as the saying goes.”
“OK, so the game has something to do with the country's military and defense systems? Is that correct?” you query.
“Hmmm, if you say so,” Zach states vaguely.
“So, you've been spending a great deal of time in your room, playing this game, Third Flight on the Internet and have pretty much decided it's more important than going to class,” you suggest.
“Oh, it's a tangled web we weave when first we practice to deceive,” Zach replies.
You are really struggling to understand Zach at this point and begin wondering if he is experiencing psychotic symptoms.
“Zach, Have you ever experienced hearing voices when no one is around or when you are alone?” you ask.
“You think I'm crazy, don't you,” Zach retorts. “Are you trying to get me thrown out of school? Of course, I don't hear voices and I don't see little green people either,” Zach spits out with complete distaste. He eyes you suspiciously. “Who do you think I am? Just because I prefer being alone doesn't make a psycho, does it? I've always been this way. My parents call me a loner and I call them losers. What's the point?” Zach exhibits no emotion but an isolated and cold stare as he talks. “I'm better off on my own. Other people just don't get me.”
“Zach, I'm not trying to get you thrown out of school. In fact, just the opposite. I want to help you stay in school by attending classes and handing in assignments. If you are unable to do those things for some reason, maybe I can help you get back on track so you won't fail the semester. If you don't go to class, there's a good chance you'll fail and will be put on academic probation. Is that what you want?” you respond. You decide to confront Zach with the reality of his situation. “For example, if you are experiencing problems in class, maybe I can help you resolve the issues. Or if you're having problems with assignments, we can talk to the professors. I want you to understand I'm here to help you. My job is to help students be successful in college and I want to assist you in accomplishing your goals and graduating.”
Zachary stares out the window on silence.
You decide that if you try to continue the interview, it may distance you even further from establishing rapport with Zachary. “Zachary, let me ask you just one more question. Do you really want to stay in school or do you think it's just too distracting to be in class and do assignments right now? If that's the case, you can withdraw from your courses without getting a failing grade, which would allow you to return when and if you think a degree is something you want to pursue.”
Zachary stares at you coldly. “I'll have to think about it.”
“Okay,” you respond. “Why don't we get together again in a few days after you've had some time to consider your options. Zachary, I want you to be aware of that fact that you will need to make a decision soon since the deadline for dropping courses is close. So, the next time we meet, you need to tell me how you want to proceed. Do you understand?”
“Yeah, I get it.” Zachary gets up and walks out of your office without saying a word.
· 18.5–1 What are the prominent symptoms and behaviors you observe in Zachary?
· 18.5–2 What differential diagnosis are you considering in this case?
· 18.5–3 What other information would you like to obtain concerning Zachary's situation?
· 18.5–4 What is your primary diagnosis for Zachary?
· 18.5–5 What are some psychosocial or cultural factors that might impact this diagnosis?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
“Author; 2001.” After “Colorado Springs, CO:” Should be: Coolidge, F. L. (2001). Short-form of the Coolidge Axis II Inventory (SCATI): Manual. Colorado Springs, CO: Author; 2001.
Chavira, D., Grilo, C., Shea, M., Yen, S., Gunderson, J., Morey, L., et al. (2003). Ethnicity and four personality disorders. Comprehensive Psychiatry, 44(6), 483–491.
Coolidge, F. L. (2001). Short-form of the Coolidge Axis II Inventory (SCATI): Manual. Colorado Springs, CO:.
Coolidge, F. L. (2005). The Coolidge Axis II Inventory Manual– Revised. Colorado Springs, CO: Author. Retrieved February 10, 2014, from www.uccs.edu/Documents/fcoolidg/CATI%20Manual%20(1).doc
Coolidge, F. L., Burns, E. M., & Mooney, J. A. (1995). Reliability of observer ratings in the assessment of personality disorders: A preliminary study. Journal of Clinical Psychology, 51(1), 22–28.
Coolidge, F. L., & Merwin, M. M. (1992). Reliability and validity of the Coolidge Axis Two Inventory: A new inventory for the assessment of personality disorders. Journal of Personality Assessment, 59, 223–238.
Coolidge, F. L., Philbrick, P. B., Wooley, M. J., Bunting, E. K., Hyman, J. N., & Stager, M. A. (1990). The KCATI: Development of an inventory for the assessment of personality disorders in children. Journal of Personality and Clinical Studies, 6, 225–232.
Coolidge, F. L., Segal, D. L., Cahill, B. S., & Simenson, J. T. (2010). Psychometric properties of a brief inventory for the screening of personality disorders: The SCATI. Psychology & Psychotherapy: Theory, Research & Practice, 83(4), 395–405. doi:10.1348/147608310X48636
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Press.
Hesse, M., & Moran, P. (2010). Screening for personality disorder with the Standardised Assessment of Personality: Abbreviated scale (SAPAS): Further evidence of concurrent validity. BMC Psychiatry, 101–106. doi:10.1186/1471- 244X-10-10
Lin, K. M. (1997). Personality and personality disorder in the context of culture. Transcultural Psychiatry, 34, 480–488.
Lobbestael, J., Leurgans, M., & Arntz, A. (2011). Inter-rater reliability of the structured clinical interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II). Clinical Psychology & Psychotherapy, 18(1), 75–79. doi:10.1002/cpp.693
Millon, T., & Davis, R. D. (1997). The MCMI-III: Present and future directions. Journal of Counseling & Development, 68, 69–85.
Millon, T., Millon, C., Davis, R., & Grossman, S. (2006). MCMI-III manual (3rd ed.). Minneapolis, MN: Pearson Education, Inc.
Moran, P., Leese, M., Lee, T., Walter, P., Thornicroft, G., & Mann, A. (2003). Standardised Assessment of Personality- Abbreviated Scale (SAPAS): Preliminary validation of a brief screen for personality disorder. British Journal of Psychiatry, 183, 228–232.
Ryder, A., Costa, P., & Bagby, R. (2007). Evaluation of the SCID-II personality disorder traits for DSM-IV: Coherence, discrimination, relations with general personality traits, and functional impairment. Journal of Personality Disorders, 21(6), 626–637.
