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.
You are working as a forensic psychologist—that is, a psychologist who works for the court system. You receive the following referral paperwork, in which a judge is asking you to evaluate a man named Randy who is in jail due to some strange behavior that resulted in his arrest. Select the button below to review the paperwork before you begin the interview.
New Client
Randy: Case #10114
Forensic Psychological Clinic, District Court
Referral Paperwork
Client Name: Randy
Age: 32 years old
Gender: Male
Ethnicity: Caucasian
Occupation: Unemployed
Current living situation: Lives alone in a cabin in the mountains, 25 miles outside of town
Why are you referring this person for an evaluation?
Randy needs a psychological evaluation to see if he is suffering from a mental disorder. His odd, disruptive behavior caused him to be arrested and charged with the misdemeanors of assault and battery following a physical attack on a waitress in a local diner and several patrons who tried to intervene. His odd behavior has continued in jail, where he bangs on the bars of his cell constantly. He has also damaged jail property—he threw his metal dinner tray at the closed-circuit television, denting it. The jail superintendent wants him charged with destruction of jail property. We are requesting that Randy be evaluated to see if he should be referred for mandatory psychiatric treatment, rather than remanding him to the penal system where he may not get adequate care.
- Judge Judith Ginsberg, District Court
You will now ask Randy a number of questions you would typically ask during the intake interview. As you conduct the interview with Randy, 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 Randy’s responses to your questions. To read the transcript for these answers, select the “transcript button.”
“Randy, do you understand why you’ve been referred for a psychological evaluation?”
Transcript
Randy: [sounding distracted] Sure, I told that judge woman already. They – you – want to get inside my head. But I told her – I told her – I’ll tell you, they won’t find anything. My brain is missing, and I don’t know who took it.
“Okay. It’s important for me to explain that, since Judge Ginsberg referred you to me for an evaluation, the court is technically my client, not you. Therefore, nothing you tell me is confidential—it can all end up in my report to the judge. That being said, I will strive to use that information to make recommendations that are both in your best interest and in the interest of public safety. What we are doing today is called an intake interview. I’m going to ask you some questions that I ask everyone who I see. This information will tell me how best to help you. This may mean having you continue to see me for therapy, or it may involve referring you to another mental health professional. Let’s start. Do you remember how you ended up in jail?”
Transcript
Randy: I came – I come down from my cabin to town, 25 miles by the crow flies. The crows and the game and the other birds and my vegetable garden are how I get food. I collect rainwater or get my water from streams. I live off the land. I heat my house with trees. I’m a survivor – I’m a survivalist …revival survivalist. No electricity – you have to watch out for that. Very tricksty. But I come – I came to town to get a few supplies. Some groceries – I don’t have chickens, I don’t have cows, so I have to buy their by-products. What they leave behind. I buy coffee – can’t grow that in Colorado not on the mountain not on the plains. I stop by the library – such a nice lady, she gets me such nice books. Philosophy and history, none of those trash novels and hunting books. She orders them from the booksitorium, just for me. Then I always end with the diner, always the diner.
Hint
Focus specifically on the words that Randy seems to be making up and which of the symptoms these words match.
“Okay, Randy, but what happened the other day? How did you end up in jail?”
Transcript
Randy: The other day? The day of others? Oh! The diner. Have to watch out for the TV at the diner. The one waitress – she knows. She will turn it off, the infernal box, the TV. But she wasn’t there. I needed something to stop the noise! I asked the girl waitressing to help me stop the noise. “What noise?” she says, as if she didn’t know. What noise, what noise? The noise in my head! [smacks hands on ears] I can’t stop it, it won’t stop ever since the TV stole my brain. She tried to be funny oh she tried to be clever and told me to tell them [gesturing as if to entire room] about the noise, said she might want to listen, too. She knows better. That’s what the noise wants! So I reached over and I grabbed her – grabbed her front – grabbed her shirt and told her, I warned her “Kill the noise or I’ll kill you.” Then they were on me! So many people grabbing and shoving. So I kicked, I bit, I threatened, I fought. Then they called the police – never trust ‘em! I tried to trust ‘em years ago, the boys in blue, they just ignored me and the TV got worse and now my brain is gone. [suddenly quieter, somewhat fearful] But when I saw them I knew – I knew it was THEM. And so I said to them, I told them, "So, it's you. You’ve been after me for years – putting arsenic in my garden, taking money out of my bank account. And stealing my brain – don’t think I forgot that. But you will pay for this. The Chief is looking for you."
“How long have you felt like the TV was stealing your brain? When did you first start having these experiences?”
Transcript
Randy: They’ve been there. They’ve been there and I didn’t even know it. Ohhh yes, they’ve been there. Really noticed it in college. Oh that man, the Dean. He tried to hide it, but oh no, he was the problem. He stole her, my girlfriend. She broke up with me – it had to be him. And the probation, for academics! 3.8 GPA my first year, straight A’s in high school. And he tries to say “probation.” [raising his voice] For what? For majoring in history? For trying to learn from the past? For sleeping and eating junk food when he stole her – stole her? He said I didn’t go to class! Class didn’t need me to go. So he expelled – expelled me! I think he was threatened by me. [quieter] But I was glad, because then I got to live at home with the TV and then I realized they were there. I would yell at them, in the TV! When they – the parents – when they were gone for the weekend, I fixed it. I pulled out the box, the cable box, the brain-sucking box, and I hammered that TV. Smashed it good. They – the parents – they didn’t understand. I explained it so clearly that the box was taking thoughts from my brain and sending them to the TV and I didn’t want everyone to hear the thoughts – they’re mine! [becoming upset, more emphatic.] My thoughts belong to me, and to no one else. Whoever tries to take them is going to have to pay. So I talk to them, all the time, I have to tell them. One, two at a time, I talk to them. They’re so clever ... others say they can’t hear them.
Based on his initial report of his symptoms, which of the following psychotic disorders could Randy be suffering from? Select all that are possible diagnoses for Randy. To review the definition for each term, select the term.
Schizophrenia
wCfH0QtRgXJ8o+c+Brief Psychotic Disorder
wCfH0QtRgXJ8o+c+Schizophreniform Disorder
bI0LPa9lfHQ+dYqkSchizoaffective Disorder
wCfH0QtRgXJ8o+c+Delusional Disorder
Hint
Think about how long Randy has had his symptoms, as well as which symptoms he is experiencing.
“Randy, what happened in jail? The judge told me you had some difficulties while you were there.”
Transcript
Randy: They took me and they locked me up in over overnight – overnight. And there was a TV right there, right outside the bars. Like they knew, like they were taunting me or trying to get information. So I tossed ... I threw my plate at the thing ... the TV thing. I asked them: Why are you doing this to me? You stole my brain, what else do you want? What else does it want?
That sounds very upsetting, Randy. I can understand why you might react the way you did, even though I recognize that it is not necessarily an appropriate reaction. I’d like to change gears here for a minute and learn more about you. Tell me about your childhood. What was it like growing up in your family?
Transcript
Randy: Three boys – one older, one younger. My big brother, the older, he left us ... he shot himself when he was only 30 – 30! So much to live for ... He had a good job – all supposed to have ... [lecturing self] “Son, get a good job!” said the parents. He could live among the people. He didn’t have to live off the grid, like me. So why did he shoot? My dad is an electrician, he was strange, always strange, I think because of the electricity – tricksty. Paranoid, he was, always watching – he knew. My mom taught kids, elementary kids. She learned, she learned how to deal with dad. [As if lecturing himself] Be quiet, be passive, appease him. Otherwise ... the bad side. They – the parents ... didn’t talk, not much, and when they talked, only arguing.
Hint
Think about how both genes and the behavior of others might have influenced Randy, and consider the details of his childhood that he has shared.
“It sounds like you have had quite a bit to deal with in your life, Randy. Have you ever seen a mental health professional, like a psychiatrist, a psychologist, or a counselor?”
Transcript
Randy: No, never did. Dad said no, no way. A neighbor said it would be good, would help, after I smashed the box, smashed the infernal TV. But dad said no, “no son of mine is going to a shrink, we take care of our own. Shrinks are not to be trusted.” So the neighbor asks me, do I want help? I want to keep dad happy and so I say, “I don’t need help. I’m okay now the TV is gone.”
“Randy, have you ever been in trouble with the law previously—ever been arrested or convicted of a crime?”
Transcript
Randy: [emphatic] No, never trouble on my part, only on their part. Tried to get help. Went to them, asked to file a criminal complaint. Against who? They say. Like they don’t know. So I tell them, I make it clear, against KBDI-TV. They ask what they did – as if the cops don’t know. So I tell them, real slow so they understand [speaking very slowly and deliberately] “Larceny – grand larceny. They stole my brain, and I want it back.” They let me think I could fill out a report, so I did, and when I left, I heard them laughing. “Boy, it takes all kinds,” they said, and I saw them throw it in the trash. So I left. I left the station and I left home.
Hint
Think about how you might react if Randy told you what he told the police.
“You said you left home. Do you have any contact with your parents now? Who do you go to for help or if you need support?”
Transcript
Randy: [agitated and almost shouting] I left – can’t you see? I was just telling you, aren’t you listening? [Calming down] I left them – the parents – 10 years ago. That woman – my aunt, she died and left me some money. 50,000 clams. Have to keep them clams safe … them clams … so I put them in the bank. Bought my old truck – not new, can’t trust the new ones, they have TVs. Wrote them a note, the parents, “Thanks for nothing.” Packed and drove and found the cabin, where it’s safe. No parents, no contact. Off the grid. I’m surviving, I’m a survivalist revivalist ... Safer that way.
Which of the following symptoms is Randy currently experiencing? Select all that apply.
Delusions
wCfH0QtRgXJ8o+c+Catatonia
bI0LPa9lfHQ+dYqkHallucinations
wCfH0QtRgXJ8o+c+Negative symptoms
wCfH0QtRgXJ8o+c+Engaging in risky behaviors
bI0LPa9lfHQ+dYqkDisorganized speech
wCfH0QtRgXJ8o+c+Feeling the need for less sleep
bI0LPa9lfHQ+dYqkImpairment in self-care
bI0LPa9lfHQ+dYqkImpairment in interpersonal functioning
wCfH0QtRgXJ8o+c+Feeling the need for more sleep
wCfH0QtRgXJ8o+c+Feeling depressed or down
Hint
Think about not only the symptoms Randy is describing but also the ones you observed during your interview with him.
From the File. You remember a former patient, Steve, who experienced symptoms similar to Randy’s. You review this case to help you diagnose Randy.
Transcript
REPORTER: Do you think you've had a difficult life?
STEVE: Oh yeah. I've had a lot of suffering in my life. I've had a lot of suffering, yeah.
REPORTER: Do you think your life has been harder than other people?
STEVE: Much harder than most people I know. How can you ask that question when I've had 71 psychiatric institutionalization?
REPORTER: Steve, can you describe the transition when you started feeling psychotic?
STEVE: Oh, yes. It's like going to sleep in a penthouse in Manhattan and somehow waking up on the suburbs of Nairobi in the jungle. It's just as dramatic as that, yeah.
REPORTER: In 1969, Steve had graduated from MIT and just finished his first year of medical school. At age 21, he suffered the first of many psychotic attacks. A world full of promise was flooded with fear and paranoia.
STEVE: How do you describe paranoia? Paranoia becomes just so incredibly intense that the feeling that everybody in the room knows what you're thinking, the feeling that everybody in the room wants to control you and get you to act in a certain way, either socially, emotionally, psychologically, spiritually, or sexually-- they're all trying to force you to do certain things and act and think in a certain way.
Hint
In making your decision, think about Randy’s symptoms and their duration.
Hint
Think about the definition of each term.
Hint
Think about the definition of hallucination.
Hint
In making your choice, think about which model best explains schizophrenia.
Hint
Think about what the therapists’ advice says to patients about their symptoms.
EPILOGUE
As the psychologist, you write a report diagnosing Randy with schizophrenia and explaining why his symptoms may have led to his outbursts in the diner and in jail. Upon reading your report, Judge Ginsberg orders Randy to receive treatment, rather than than sentencing him to jail. This mandated treatment comes with conditions: If Randy does not follow through with the judge’s orders, he can be called back into court and can potentially still end up in the penal system. After considering several treatment options—such as inpatient hospitalization, an intensive outpatient program, and family therapy—the psychiatrist, Dr. Samuelson, prescribes an antipsychotic medication because she believes Randy is high-functioning enough to receive treatment on an outpatient basis.
Once his body adjusts to the medication, Randy stops hearing voices and feels like he has his brain back; he no longer believes the delusion that the television has stolen it. However, Randy is still struggling with how to integrate socially rather than staying isolated in his cabin. Dr. Samuelson refers Randy to a therapy trial of cognitive-behavioral therapy (CBT) for schizophrenia that is being conducted by psychologist Dr. Melek. Randy is fortunate to live near a city where a variety of mental health options are available to him. Randy finds that with the combined help of medication and CBT he is able to control his symptoms, and eventually he moves to a small apartment near the library in town.
At the encouragement of his doctors, Randy contacts his parents, who are extremely relieved to learn that he is still alive, and they eagerly reestablish contact with him. Randy’s father begrudgingly admits that mental health services have helped his son. His mother and younger brother visit regularly. Randy discovers a love of and talent for gardening based on his success with his own vegetable garden, and he starts working at a local nursery to earn income to pay his rent.
Real World Application
Watch the following clip, which shows CNN anchor Anderson Cooper trying to complete a series of tasks while undergoing a schizophrenia simulation in which he hears recordings of voices by wearing ear buds.
Transcript
ANDERSON COOPER: So I'm going to put these earphones in. They're going to try to do a series of tests. So I'm now hearing sort of whispers and voices in my head. And the first test is some number puzzles.
FEMALE VOICE: You suck and they know it. Can't you get this right?
ANDERSON COOPER: OK. So I did this test for three minutes. And I did not get a single one. It's very hard to concentrate when-- if it's like music or something constant, it's easy. But people talking to you is very difficult.
So now I'm going to be asked a series of questions by our producer, Susan. And these are basically a series of questions that a person would be asked if they were being admitted to a hospital.
SUSAN: Can you tell me what day it is?
ANDERSON COOPER: Yeah. It's Sunday, June-- I don't know, 7th?
SUSAN: So I'm going to say five numbers. And I want you to repeat them back to me after I'm done. 5, 23, 67, 2, 76.
ANDERSON COOPER: 5, 23, 67, something, 76.
SUSAN: I'm going to say five words. You don't have to repeat them, but just listen to them.
SUSAN: Cat. Book. Cigar. Damage. And rain.
BACKGROUND VOICE: Make you OK.
SUSAN: Can you name the last four Presidents of the United States?
BACKGROUND VOICE: OK for you to be--
ANDERSON COOPER: Barack Obama. George Bush. Bill Clinton. And George Bush.
SUSAN: So those five words I said before, can you remember any of them?
ANDERSON COOPER: No. It's hard when-- because sometimes voices are like whispering, and sometimes they're aggressive, and sometimes they're kind of comforting. And again, with people kind of talking to you all the time, it's--
BACKGROUND VOICE: It's OK.
ANDERSON COOPER: It's hard.
It's really-- it's incredibly distracting on the street to have somebody talk in your head. And it makes you feel completely isolated from everyone else around you. And you don't want to engage in conversation with other people. You're kind of finding yourself wanting to engage in conversation with a voice in your head. Because they're constantly being really negative and talking to you.
And everything they're saying relates to things that you're actually doing. They're criticizing things you're doing. It's like somebody is-- it's like you have a chorus watching you and commenting on what you're doing. And you can't help but-- I literally find myself wanting to respond to them, tell them to be quiet.
And it's incredibly unpleasant. This is a very, very unpleasant experiment. It's eye opening, because it really shows you what other people must be going through who deal with this on a regular basis.
But also, I cannot wait to take these headphones off. Because it's really depressing. It's very, very negative. It makes you feel very, very negative.
It's very creepy. I want it to stop.