DSM-IV-TR Assessment of Parry in The Fisher King

Part I: Diagnostic Assessment. Using the 5 axes of the DSM IV-TR, please provide a full diagnosis of Parry and provide a brief explanation of how you arrived at each diagnosis.

Axis I

Diagnosis: Schizophrenia, Paranoid Type; Code: 295.30

Justification: Parry presents a lot of symptoms of PTSD, however, these symptoms have persisted over a very long period of time and now appear to be manifesting as schizophrenia. The DSM-IV-TR’s criterion for diagnosing schizophrenia requires at least two symptoms lasting for at least a month, impaired social or occupational dysfunction, and signs of continuous psychological disturbance for at least 6 months. Parry has auditory hallucinations, visual hallucinations in which he sees a red knight, and delusions of grandiose in which he believes that he is a knight on a quest to retrieve the holy grail. Additionally, his character reveals to Jack that he was catatonic for a year after his wife’s death, another classic symptom of schizophrenia. The fact that he is homeless and has been unable to keep a job reveals the significant impairment the disorder has had on his ability to take care of himself and relate to the social world.

Axis II

Diagnosis: Schizotypal Personality Disorder; Code: 301.22

Justification: Schizotypal Personality Disorder is marked by a reduced capacity for close relationships as well as various perceptual distortions and eccentricities of behavior. Additionally, it is often a comorbid disorder associated with schizophrenia. The DSM-IV-TR requires at least five symptoms for a diagnosis with this disorder. Parry presents delusions of reference as seen by his belief that God wants him to find the Holy Grail. He also exhibits many unusual perceptual experiences, odd thinking and speech, excessive social anxiety, and does not have many close friends.

Axis III

Diagnosis: Lack of symptoms

Justification: There are no known medical associations with schizophrenia, but a brain scan should be done to rule out other medical conditions that have similar symptoms

Axis IV

Diagnosis: Phase of Life Problem; Code: V62.89

Justification: Before his wife’s murder, Parry was a successful college professor. However, Parry is unable to cope with the guilt and trauma of her death, which causes him to start having PTSD flashbacks of the murder. The flashbacks intensify Parry’s psychological distress, making him need to reinvent his personality as a coping mechanism.

Axis V

Diagnosis: GARF score of 21-30

Justification: Parry’s behavior is primarily influenced by psychotic symptoms, such as delusions and hallucinations, and presents a serious impairment in his ability to function in most areas.

Part II: After diagnosing Parry from the Fisher King video, please address the following:

Assess and describe the client’s clinical problems that should be the focus of individual clinical treatment. Describe the problem in clinical terms—conceptually what are his clinical problems/issues? The most important clinical problem that should remain the focus of Parry’s clinical treatment should be his paralyzing feelings of guilt about his wife’s traumatic murder. His guilt is the underlying element to his illness and foundation upon which his entire fantasy world has been built upon. The reason he is seeking the holy grail can be traced back to this guilt. The Holy Grail is said to have held the wine at the last supper and also the blood of Christ, which makes it a source of ultimate grace and forgiveness.

What clinical theory will guide your individual work with this client? Describe the following:

1. Summarize the major concepts from the theory(ies) of human behavior that explain how the client develop the clinical problems. The Diathesis-Stress Theory would be the best clinical theory for guiding treatment of Parry. It adds to the characteristics of stress theory in order to explain more complex disorders such as schizophrenia. In order to cope with the stress of life events, an individual must have adequate social and personal resources available to them. Diathesis-Stress incorporates the idea that there is another factor in addition to stress, such as trauma, which causes more severe mental illness. For Parry, the stressing life event is the death of his wife. His subsequent trauma builds out of his guilt about not being able to protect her when he feels like it was his responsibility as her husband to protect her. In order to cope, Parry began dedicating his life to selfless and noble acts by coming to the aid of others. However, the need for Parry to rescue others eventually becomes so great that he starts hallucinating scenarios of people in danger. For example, in the park, Parry chases after an imaginary demon when he hears screaming. The benefit of these imagined scenarios is that Parry is in control of them, thus he has the ability to the perfect hero he wished he had been during the shooting in the restaurant.

2. What intervention theory (select 2) would guide your clinical work with this client? Compare and contrast each of the two theories that would guide your clinical work with this client? In other words, how are they different? How are they similar? How would they complement each other? Cognitive behavior therapy would be an effective intervention technique during Parry’s clinical treatment because it would help him weaken the connections between his troublesome thoughts of his wife’s murder and his reactions to current situations. Cognitive dissonance, as defined by Scott, Chant, Andrews, Martin, and McGrath (2007), occurs when thoughts, memories, and images of trauma cannot be reconciled with current meaning structures, which causes continuous distress. The cognitive system is driven by the psychological need for completion, in which new information matches an individual’s inner models based on older information (Scott et al., 2007).

Another intervention theory that would be useful in Parry’s treatment would be the stage-specific model of reconnection. According to Herman (1997), this model allows for clients to reconnect and come to terms with the trauma in addition to helping them create new selves. Parry has actually already done this on his own, but without the guidance of a professional social worker or psychologist. He chose to believe that he is a knight on a quest given to him by God to find the Holy Grail and begins to experience reality through a distorted lens. This was a misguided attempt for him to distance himself from the tragedy of his past and create a new persona since he cannot bear the pain of living as himself.

3. How and why would this specific theory(ies) and not another theory with this client drive your clinical treatment of this client? A reconnection intervention would help him make a more successful transition from being a victim to being a survivor and also restore his sense of power and control. Furthermore, it would encourage them to build their relationships with others back up again (Drake, O’Neal, & Wallach, 2008). Parry has purposefully distanced himself from others to keep himself from experiencing any further loss. However, increased interactions with others and building new friendships would help him realize that traumatic events are atypical rather than normal.

4. What specific techniques from this theory would you use with this client? Exposure therapy is a specific type of cognitive therapy that encourages clients to confront their fear-inducing thoughts and memories at increasing levels of exposure. The purpose of these exposures is to decrease emotional reactions through the process of habituation. This allows the client to face fear in a safe, controlled environment guided by a therapist, making the experience less overwhelming (Scott et al., 2000). This technique may specifically benefit Parry because he needs to accept the events of the past and realize that he is not responsible for his wife’s death. Parry needs to realize that he can only control his own actions, and needs to start interacting with others in normal social contexts, instead of focusing on saving everyone he can.

5. Describe how you would use the evidence based practice process in clinical assessment and intervention with this client? Evidence-Based Practice processes would first be used to assess the patient and formulate a clinical problem that is thoroughly researched. In Parry’s care, the clinical problem is his lingering fear and guilt causing him to be delusion and dysfunctional. Many treatments of schizophrenia involve medication, but this treatment seeks to first try exposure therapy in order see if eliminating the source of the adverse emotions eliminates the other symptoms of mental illness.

Use of self as a professional social worker

1. Describe how you would develop, manage and maintain a therapeutic relationship with Parry, keeping in mind the person-in-environment perspective and strengths perspective? In order to develop, manage, and maintain a therapeutic relationship with Parry, a social worker should do their best to make sure he is comfortable. It is hard for an individual to open up to a stranger. Therapeutic alliances are created through understanding, acceptance, and respect. Social workers may want to break the ice by sharing their own traumatic experiences. This would make them seem more human and instill a sense of companionship between Parry and the social worker where he feels more comfortable talking about his feelings and experiences. Additionally, it is important that the social worker maintains a sense of hope and optimism about their client and their progress, no matter how small. In many cases, people suffering from mental illness have already given up on themselves and lack motivation to try and improve their situation. Similarly, it is important for the client to perceive that the social worker supports their goals and has an interest in helping them succeed. Social workers can do this by periodically reviewing the client’s goals with them and explaining how treatment sessions are beneficial in achieving them. Additionally, adopting the person in environment perspective would help the social worker adopt a more adequate framework for assessing an individual by taking into account the various effects of their social, political, familial, temporal, economic, and spiritual environment. This perspective would allow the social worker to make use of more interventions since they can intervene with both the client and the environment.

2. What might be some ethical decisions that you as the social worker might face in working with this case? Some of the ethical implications of this case include the client's right to self-determination. Even though the social worker may know what is best for the client, the client still is ultimately in control of making their own decisions and finding solutions to their problems. This can be a very challenging frustration for social workers, who mean well and are only trying to help their client. In addition, the social worker may have many differences in morals and values from those of their clients. Parry’s fascination with the Holy Grail is based in religion, it may be hard for a social worker to work with him if they are an atheist. The most challenging issue concerns the dual relationship that exists between the social worker and the client. Often, clients may start to feel like their social workers are also their friends, forgetting that their relationship is strictly professional, and try to take the relationship too far. This may be especially difficult for clients like Parry, who desperately need to regain their social abilities and make new friends and will feel very close to a social worker if that is one of the few people they interact with.

3. How would you prepare yourself for working with the diverse population represented by the character Parry? To prepare for working with the diverse population represented by Parry’s character, the social worker should make sure to remember that each client is different and that not everyone will be responsive to the same intervention techniques.

4. As clinical social workers we must also address environmental stressors affecting our clients. Please describe in narrative form the client’s non-clinical problems that should also be included in his clinical treatment. According to Zuvekas and Hill (2000), many homeless people are eligible for benefits and do not receive any. Parry will need some assistance locating and obtaining housing as well as finding employment. Additionally, he will need some imperative personal care items such as clothing and hygiene products so that he is able to clean himself up so that he can apply for jobs. Case Management services advocate for a client’s needs, desires, and rights while continuously reviewing how they are progressing toward their goals. They will allow Parry to have access to a variety of health care and social services while he is recovering. Parry’s case manager should make sure he attends support groups for others who have survived traumatic events to make him feel like he is not alone and help him start interacting with new people (Zuekas & Hill, 2000).

References

Drake, R., Oneal, E., & Wallach, M. (2008). A Systematic Review Of Psychosocial Research On Psychosocial Interventions For People With Co-occurring Severe Mental And Substance Use Disorders. Journal of Substance Abuse Treatment, 34(1), 123-138.

Herman, J. L. (1997). Trauma and recovery. New York, N.Y.: BasicBooks.

Scott, J., Chant, D., Andrews, G., Martin, G., & McGRATH, J. (2007). Association Between Trauma Exposure And Delusional Experiences In A Large Community-based Sample. The British Journal of Psychiatry, 190(4), 339-343.

Zuvekas, S. H., & Hill, S. C. (2000). Income And Employment Among Homeless People: The Role Of Mental Health, Health And Substance Abuse. The Journal of Mental Health Policy and Economics, 3(3), 153-163.