Strange, false beliefs that a person firmly holds despite evidence to the contrary.
The cognitive model proposes that we can best understand abnormal functioning by looking at cognitive (thinking) processes. The cognitive perspective holds that abnormal functioning results from the person’s maladaptive, irrational, and inaccurate thoughts about and interpretation of a situation. Cognitive theorists and therapists believe that by substituting more realistic, rational thoughts for these irrational ones, clients can change their outlook on life and thus improve their symptoms.
The biological model adopts a medical disease perspective on psychological disorders. The main focus of this model is that psychological abnormality is an illness brought about by malfunctioning parts of the organism. Typically, the biological model focuses on genetic predispositions for disorders and abnormalities in brain anatomy or chemistry. To treat psychological disorders, the biological perspective argues that abnormalities in the brain must be addressed through medication or other treatments that act on brain chemistry or circuits.
The behavioral model argues that our actions are determined largely by our experiences in life. Behavioral theorists focus on principles of learning—in particular, how abnormal behavior might be learned by observing others or reinforced by contingencies in our lives such as avoiding discomfort. Behavioral theorists and therapists are more interested in observable behaviors and environmental factors than in the inner workings of the mind. To treat psychological disorders, the biological perspective argues that abnormalities in the brain must be addressed through medication or other treatments that act on brain chemistry or circuits.
The humanistic model believes in the inherent worth of every individual and believes that all people have the capacity to strive toward bettering themselves. Those who endorse the humanistic perspective argue that psychological disorders occur when people encounter “conditions of worth” in their lives—unrealistic expectations that others create as conditions that must be met in order to gain love and respect. To counteract this problem, humanistic or client-centered theorists and therapists focus on creating a supportive, genuine environment in which the therapist offers unconditional positive regard—that is, support no matter what the client does.
A conversational treatment used by psychodynamic therapists that includes such techniques as free association, or letting the client talk about whatever comes to mind, and therapist interpretation, or giving insight and offering an opinion on patterns noticed in the client’s free association and other indicators such as dreams. A psychoanalyst would treat Fred by seeing him 3–5 times per week for several years. Psychoanalysis is costly, and it requires a large time commitment.
Interpersonal therapy focuses on problems in significant relationships in the patient’s life. Interpersonal therapists treat patients by focusing on their current relationships with the most important people in their lives. These people include partners and spouses, parents, children, and other close relatives. For Fred, this is likely his wife.
Behavioral Therapy involves helping patients change maladaptive behaviors—by using learning principles from classical and operant conditioning, as well as modeling. Behavioral therapy would focus in changing Fred’s behaviors, likely with a series of rewards for desirable behaviors. This type of therapy is often used with the severely mentally ill.
Medication involves taking a chemical agent prescribed by a medical doctor to address physical problems such as infections, and to alter brain chemistry, which subsequently alleviates psychological symptoms. A physician or a psychiatrist, who has a medical degree (MD), would be able to prescribe medication to treat, respectively, their client’s physical and psychological symptoms. For Fred, this would involve medication to manage his current symptoms and medical care. Ideally, timely medical intervention would have stopped Fred’s symptoms much sooner and reversed his cognitive decline.
Author: Taryn A. Myers, PhD, Virginia Wesleyan University
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
The receptionist hands you the psychological consultation paperwork prior to your interview with your new client, Fred, who was referred to you by his attorney, George Roberts. Fred was hospitalized, and while he was there the hospital petitioned the court to appoint a guardian for him as a person unable to make decisions for himself. Fred’s attorney tells you that he thinks the hospital might have misdiagnosed Fred, making the guardianship unwarranted, and he wants your opinion. Fred is now a resident of a nursing home, where you visit with him. His wife, Angie, and his niece, Bernice, are present during the interview. Select the button to review the paperwork before you begin the interview.
Golden Years Retirement Community
Request for Psychological Consultation
Client Name: Fred
Age: 72 years old
Gender: Male
Ethnicity: African-American
Occupation: Worked part-time at the county health authority until hospitalization
Current living situation: Lives in nursing home with wife, Angie
Why are you seeking a psychological consultation?
Fred was hospitalized after experiencing abdominal pain. While in the hospital, he was diagnosed with neurocognitive disorder, possibly of the Alzheimer’s type. This may be a misdiagnosis, as he has been put on several different medications that may have increased his symptoms. Following a request by the hospital, Fred now has a court-appointed guardian who makes financial and medical decisions for him.
- George Roberts, JD, Attorney-at-Law, for my client, Fred
You will now ask Fred and his family a number of questions you would typically ask during a psychological consultation. As you conduct the interview with Fred, begin to think about his symptoms, what his diagnosis might be, and later, what type of treatment might be most helpful to him. Select the “play” button to hear Fred’s and his family’s responses to your questions. To read the transcript for these answers, select the “transcript” button.
“Hello, Fred, Angie, and Bernice. As you know, your attorney, Mr. Roberts, contacted me and asked me to evaluate Fred. I’m going to ask you a series of questions to try to determine what is going on with Fred’s health and his diagnosis. I hope to be able to answer all of our questions to determine how to best help Fred. Because Mr. Roberts hired me, I want to let you know up front that anything you share with me may also be shared with him and used in any legal action that you and your family decide to take in consultation with Mr. Roberts. Does that all make sense? Let’s start. Fred, can you tell me why you had to be hospitalized?”
Fred: [confused] Uh...I don’t remember ... Pain? ... Stomach pain?
Angie: [warmly, to Fred] That’s right, dear. [to the therapist] He went to work, same as usual. He worked there for 54 years, then went part-time – I don’t know ... 5–6 years ago? He didn’t take on as many jobs after he turned 65. He’s always been the healthy one, not like me, you know. They told me that he felt severe stomach pains after lunch. His supervisor first told him to go home, but then changed his mind and took Fred to the hospital. He’s a good man. The nurse called me from the hospital. I couldn’t go right then ... I don’t drive. [shakily] I was so scared not knowing what was happening to Fred! I wanted to be there with him!
Bernice: [indignant] After Uncle Fred got to the hospital, he had to wait hours before he was seen by anyone. The doctor first thought it was a urinary tract infection, but she wanted to make sure because of his age. That’s why she admitted him. They put him on an IV because they thought it might be an infection, and I guess they gave him some painkillers, too – for the stomach pain. Then they left him by himself. [angrily] Can you believe that? Then they told us Uncle Fred became confused and angry. He didn’t know what was going on and was worried because Auntie Angie wasn’t there. Who wouldn’t be? Apparently the nurses told the doctor. And she gave him Valium, on top of everything else they gave him. They told us it was to calm him down. Little good that did him.
Think about what the hospital staff did and did not do when Fred arrived.
“When was the first time one of you was able to join Fred at the hospital?”
Fred: [shakily] I was all alone ... I didn’t know what was going on. I couldn’t sleep. Every time someone came in they gave me more and more medicine. [muttering under his breath] ...doctors...nurses...doctors ... Ahh!
Angie: [reassuringly to Fred] It’s okay, sweetheart. It’s okay... I’m here now...I won’t leave you... [Distressed, tearful] Why is he like this now? Why?
Bernice: [annoyed] I talked to everybody who walked in that hospital room ... I did not get a straight answer about what happened from anybody.
Angie: I couldn’t get there that first day because I don’t drive. [guiltily] Bernice, I should’ve called you, but I … [sadly] I thought he might come home so I waited until the next day.
Bernice: You know you can always call me for help, Auntie!
Angie: I know. I know ... You’re working and the kids ... I didn’t want to bother you again, but ... [softly] I didn’t know who else to call.
Bernice: You know I love you two and I would do anything for you and Uncle Fred. [To the therapist] I went as soon as she told me the next morning. He was going into surgery. Auntie was so scared.
Think about what prevented Angie from getting to see Fred.
“Why did Fred have to undergo surgery?”
Fred: [trying to remember] Urr… urr… pros... pros... prostate. My prostate.
Bernice: The tests the doctor did showed he had an enlarged prostate. They said it came from the infection. They said it was minor surgery. They had to open up his urethra. Doesn’t sound minor to me! They said they gave him some general anesthesia, which put him out so he wouldn’t feel anything. When he woke up from surgery, he was so confused and angry. The nurses gave him more meds – painkillers, antibiotics, Valium, they just kept pumping it into him, and he kept getting more and more upset. He wanted to know where Auntie Angie was. He kept calling for her. He didn’t even know who I was. [distressed] Uncle Fred’s known me since I was born!
“How did Fred end up with a court-appointed guardian?”
Fred: [confused] I don’t know. What do you mean? Who? Why am I here?
Angie: That meddling social worker!
Bernice: Auntie Angie, she was just trying to do her job! But this really did happen because of her. I guess in those big hospitals they have a social worker come around before discharge to see what kind of help patients might need when they’re ready to leave.
Angie: And apparently her job is to coop people up and steal their money!
Bernice: Auntie!
Angie: Well! That’s what she did, isn’t it?
Bernice: I do think she had good intentions. I’m sure it was her job to see if Uncle Fred needed to go to a nursing home or rehab place before he went home. When she saw that he was confused, she thought he was suffering from some disorder. To her credit, she said she didn’t think it was Alzheimer’s.
Angie: But she did call in that psychiatrist.
Bernice: The social worker talked to me first. I explained that Uncle Fred lived with Auntie Angie, taking care of her and the house.
Angie: I love our home! Two bedrooms, my vegetable garden out back ... we’ve lived there for over 40 years. And Fred took good care of me. His health is [sadly] ... was ... better than mine, you know. He does ... did ... the cooking and the cleaning and all.
Bernice: Uncle Fred was confused, so the social worker called in the psychiatrist. She was worried that he couldn’t take care of the both of them.
Angie: But, she didn’t even tell us...
Review the transcript or listen to the interview on this screen again if you are uncertain.
“What happened when the psychiatrist evaluated Fred?”
Bernice: When he showed up, he made me leave the room. He was only in there for 5 minutes or so. I could hear him asking Uncle Fred questions about how old he is, what day it is, who the president is, the season, and things like that.
Angie: [sadly] Fred couldn’t answer any of their questions … he only got his name right. He said he was 68. He’s 72!
Bernice: The psychiatrist didn’t even look at his chart. If he looked, he would have seen that Uncle Fred had a fever since the surgery. And after those 5 minutes, he just diagnosed him with … [pause while she remembers the diagnosis] “neurocognitive disorder, probably of the Alzheimer’s type.” I guess he didn’t even listen to the social worker either. I have a copy of the chart right here.
Angie: That social worker called the hospital attorney and took it to court!
Bernice: I told her I could make sure they were taken care of, but she just ignored me. She told me I could “discuss it with the judge.” That Friday, we went to court. That judge had only read the psychiatrist’s report. The attorney for the hospital said they should declare Uncle Fred incompetent. The judge appointed a lawyer to be a guardian. I tried to tell all of them that I am looking out for my aunt and uncle, but the judge said I had to take it up with that attorney. This stranger makes all the decisions for my uncle, just like that!
Angie: [sadly] What do we do now?
How could the psychiatrist who examined Fred have made an accurate diagnosis? Select all that apply.
Think about what information the psychiatrist needs to make an accurate diagnosis.
“What happened next? How did you end up here at the nursing home, Fred?”
Fred: [confused] I don’t know. It all happened so fast. I … I … was still sick. Angie ... Angie ... but it was good to see you.
Angie: They sent him to this expensive nursing prison – I’m sorry, this is not a “home” it’s a prison! And what kind of money do they think we have? The judge sent another social worker, from the county I guess, to talk me into coming here too.
Bernice: This guardian has control of their bank account.
Angie: We’ve always been so careful with our money, and now ... there go our savings ... we worked so hard to save this. And once Fred got here, they had to turn right around and take him back to the hospital.
Bernice: He still had the infection. He was in the hospital for three more days. They kept giving him antibiotics and painkillers. And ... now because they say he has this “neurocognitive disorder,” they put him on a stronger antipsychotic medication.
Angie: That guardian, who doesn’t know the first thing about Fred, made all those decisions. At least when he got to this nursing prison, I was here. [sadly] At least we were together. We cried when we saw each other. And the nursing home said I can stay here with him until he’s stronger and ready to go home.
Bernice: [sadly, quietly so Angie cannot hear] It’s just killing me to see what they’ve done to my auntie and uncle. They’re like my second parents – they helped me go to college! They haven’t spent a night out of their home ever. They’ve been married 52 years – they were high school sweethearts. Now they’re stuck in this nursing home they can’t afford. [much quieter] I’m not going to tell Auntie Angie, but I don’t think they’re going home any time soon.
Which of the following symptoms is Fred currently experiencing? Select all that apply.
Think about the symptoms described by Fred’s family throughout your interview.
From the File. You remember a former patient who experienced symptoms similar to Fred’s. You review this case to help you diagnose Fred.
MAN 1: Hey.
SHAN: Hi.
MAN 1: What's going on here? What's going on? Herbie, I got a phone call from Shan--
HERBIE: Shan.
MAN 1: --that you refuse to go home.
HERBIE: That's why I booked-- at his-- on my mother.
SHAN: I don't know what happened. Once I parked, it was time for him to get out. He was just like switched.
MAN 1: Sweetheart, what do you want to do right now?
SHAN: Today is the worst.
MAN 1: Do you know where we are?
HERBIE: Yeah.
MAN 1: We're just three doors down from our house.
HERBIE: What do you call her here?
SHAN: Hm-mm.
MAN 1: Shan is her name.
HERBIE: Hm?
MAN 1: Shan is her name.
HERBIE: OK.
MAN 1: She's been taking care of you for two years, Herbie. Two years.
HERBIE: I've done nothing.
MAN 1: Well, nobody accused you of doing anything, Herbie.
HERBIE: Yeah. Yeah.
MAN 1: We just want to get you home.
HERBIE: You mean now?
MAN 1: Yeah.
HERBIE: Take me home? OK. Yeah.
- Problems orienting to the environment
- Condition developed over a short period of time
- Condition related to a health issue
In making your choice, think about the following symptoms that Fred exhibits:
- Problems orienting to the environment
- Condition developed over a short period of time
- Condition related to a health issue
Think about the differences and similarities between delirium and major neurocognitive disorder.
In making your choice, think about the type of treatments used on Fred and the main cause of his delirium.
In making your choice, think about what caused Fred’s problems.
EPILOGUE
You were very glad that Bernice thought to contact Fred’s attorney, who put the family in touch with you as well as a neurologist, Dr. Gunstad. You and Dr. Gunstad had to be particularly careful in your assessment procedures, reports, and diagnoses, because the legal system was already involved in this case—you were hired by Fred’s attorney and there was a court-appointed guardian. As a psychologist who often works closely with attorneys such as Mr. Roberts, you had to be aware of the relevant laws for this case. In addition, you made sure that you were up-to-date on the most recent literature and assessment techniques, so that if any of your findings were questioned in court, you would be able to back them up. Because Mr. Roberts hired you, you were very clear with Fred, Angie, and Bernice that anything they shared with you would also be shared with Mr. Roberts.
Collaborating, you and Dr. Gunstad determined that Fred did not have a neurocognitive disorder at the time of his hospitalization; he was suffering from delirium. Unfortunately, Fred had been compromised by the drugs, the hospitalization, and the removal from his home to a strange place. If left untreated in the elderly, delirium can also lead to a type of neurocognitive disorder, and sadly Fred would now be diagnosed with major neurocognitive disorder due to multiple etiologies. His disorder stemmed both from the untreated delirium and the consequences of the medications he was placed on while hospitalized.
By now, Fred was not able to manage his finances or make good decisions about his medical care. He was in no shape to go home. Bernice researched all of the available options for care for Fred and Angie, including in-home care with a live-in nurse or a healthcare worker who would make occasional home visits. After carefully weighing all the options, Bernice believed the best and only solution was for Fred and Angie to stay at the nursing home, where they had round-the-clock care, prepared meals, and engaging activities, for what would probably be the rest of their lives.
Mr. Roberts was able to get Bernice named as Fred and Angie’s guardian. Eventually, he won a malpractice lawsuit against the psychiatrist and the hospital, but it was too late for Fred and Angie. They would never return to their home. After several years, Fred died in the nursing home, and his beloved Angie passed away in her sleep a few months later. Fred never regained the mental or physical health he had on the day he last worked that nice fall day in September.
Think about the most severe of Fred’s symptoms.
Real World Application
Watch the following video about another disorder of aging: major neurocognitive disorder due to Alzheimer’s disease. Then answer the questions.
CYNTHIA MCFADDEN: Do you really feel you understand the world your mother now lives in?
BLANE WILSON: No. No.
CYNTHIA MCFADDEN: --what's going on in her head, her brain.
BLANE WILSON: I have no idea. I have no idea. I need to understand that then. I need to know what it's like.
CYNTHIA MCFADDEN: [voiceover] So I told Blane about an experiment developed by PK Beville and administered by her colleague, Laurie Labishak. The experiment helps families and caregivers actually experience what it's like to have Alzheimer's...[talking to Blane] I understand it is a pretty rough experience.
BLANE WILSON: It needs to be experienced. If it'll help me to understand, I would love to.
CYNTHIA MCFADDEN: I agreed to undergo the experiment with him.
TEST ADMINISTRATOR: Could you have a seat please?
CYNTHIA MCFADDEN: Our journey into another world begins here-- in this bedroom-- where Blane and I are suited up with some deceptively harmless looking devices-- goggles simulating macular degeneration, glaucoma, and cataracts-- conditions that older people with Alzheimer's often have. Likewise, latex gloves are placed on our hands, and our fingers are taped to make our hands feel arthritic, clumsy, hard to bend.
TEST ADMINISTRATOR: Remove your shoes.
CYNTHIA MCFADDEN: A substance is placed inside our shoes to make it harder for us to walk.
BLANE WILSON: Oh, that is uncomfortable.
CYNTHIA MCFADDEN: And on our heads, they place earphones, which emit an incessant jabbering, a clamor of noise that some Alzheimer's patient's say is constant.
TEST ADMINISTRATOR: Individuals with dementia say, we're hearing all this stuff. And they can't turn it off.
CYNTHIA MCFADDEN: Then we're each given five tasks to perform and only 12 minutes to accomplish them.
TEST ADMINISTRATOR: I'd like you to find the tie and put it on.
BLANE WILSON: I can't hear you.
CYNTHIA MCFADDEN: Blane has a hard time concentrating from the start.
TEST ADMINISTRATOR: Your time begins now.
CYNTHIA MCFADDEN: As he enters, Blane is immediately disoriented. He staggers, reminding us of the way his mother looked on our tapes. Blane tries to accomplish his first task-- clearing the dishes off the table-- but when he goes to put them away, he can't find the kitchen. So he gives up.
BLANE WILSON: Well, I don't know where to put them.
CYNTHIA MCFADDEN: Blane finally finds the kitchen, but he can't remember why he's there. And again, the similarities to his mother were astounding.
BLANE WILSON: She would open cabinets, and the she would shut them. Mother, what are you doing? Nothing?