Many ethical, legal, forensic, and diagnostic issues arise in clinical practices. As well as implications. As professionals, we must uphold our obligations of moral nature that govern the practice of medicine, therapeutic assessments, tools, and techniques. Ethics is about judgement and making the appropriate decisions when faced with dilemmas. Legal regulations in clinical practices must carried out in daily practices so that both the therapist and the patient are protected. Mental health disorders have a wide range of mental health conditions. These disorders can affect thinking patterns, behavior, mood, and the way an individual function in their day-to-day life. In this paper we will discuss the ethical, legal, forensic, and diagnostic issues that can arise in clinical practices when treating someone with a mental illness disorder. This paper will also explore behavioral observations, background information, the DSM-5 diagnoses, treatment recommendations, and a prognosis pertaining to the individuals that were evaluated.
What about Bob
In the movie What About Bob, the main character Bob Wiley is one of Dr. Leo Marvin’s newest patients. Dr. Marvin is currently married to his wife Fay and they have two children. A son, Siggy, and a daughter Anna and they reside in New York City. Leo Marvin is a psychotherapist and has a successful Manhattan practice. Dr. Marvin currently wrote a book called “Baby Steps” that is about emotional disorder theories in which he details his philosophy of treating patients and their phobias. Dr. Marvin is also scheduled to appear on Good Morning America to discuss his new book. Dr. Marvin has a PhD. and is considered to be triumphant in his successes. After Bob is pawned off on Dr. Marvin by a colleague, Dr. Marvin feels like he’s in over his head with this patient. When Dr. Marvin leaves for a month to go on vacation with his family, Bob tricks the doctor’s answering service into telling him where the doctor went and his location. When Bob shows up at Lake Winnipesaukee, he turns Leo’s vacation into a nightmare. Soon, Bob wins over Leo’s wife and kids which drives his psychiatrist to the brink of psychosis, and he starts spinning out of control. Leo attempts several times to get rid of Bob. He drops him off at an insane asylum, leaves him in the woods, and even kicks him out of his car but to no avail.
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Watching Leo interact with others and his family is when you see him somewhat nice, and a little easy going although you can see his relationship with his family is somewhat strained while on vacation during summer at Lake Winnipesaukee. Leo comes off as an egotistical, uptight, overbearing man when he interacts with others. Leo thinks he’s a brilliant husband and remarkable father who knows all there is to know about everything, or at least he thinks he does. He also has a huge ego and thinks that he has a grip on everything, never getting angry or upset and is in full control. He believes he handles each situation that arises with clarity and ease, but his family seems to disagree. When first observing Dr. Marvin’s appearance, he is very well put together. He dresses in nice clothing that seems to fit what a typical psychotherapist would wear. He is very well kempt and looks like he practices good hygiene and self -care routines. Based on Dr. Marvin’s education one would assume that he has a high level of intelligence, and an extensive educational background but very little insight into his own problems. His mood seems to change rapidly when he gets upset someone says or does something he may not like. He gets upset and he is easily angered by others.
Based on Dr. Marvin’s mood, attitude, and behaviors he comes off as being very egotistical and narcissistic. I would diagnosis Dr. Marvin with a 301.81 (F60.81) Narcissistic Personality Disorder. Dr. Marvin fits the diagnostic criteria for a Narcissistic Personality Disorder. He lacks empathy and he is unwilling to recognize the feelings and needs of others (i.e., Bob), he displays arrogant and haughty behaviors, he shows signs that he feels he has a sense of entitlement, and believes that he can only be understood by those who are high-status, or special people (Black & Grant, 2014). Narcissistic behaviors are manifested by traits related to dominance and aggression. He tends to overestimate his accomplishments while underestimating the accomplishments or the abilities of others. “People with narcissistic personalities also share another central trait—they are unwilling or unable to take the perspective of others, to see things other than “through their own eyes” (Hooley & Butler, 2017, p.355). Dr. Marvin also displays behaviors that portray grandiosity. Another disorder I would diagnosis Dr. Marvin with is possibly with a brief psychotic disorder 298.8 (F23). Dr. Marvin shows signs of briefs episode of psychosis that are brought on by stressful situations and acute mood changes (Black & Grant, 2014). With Bob tagging along on his vacation, Leo seems to struggle with his moods, anger, strange behavior and outbursts. The psychosocial stressors that contribute to Leo’s behaviors include Bob bonding with his family, everyone loving Bob, Leo not being able to get rid of Bob so that he can enjoy his vacation, and Bob simply showing up to Lake Winnipesaukee.
Treating Dr. Marvin entails a couple different tools and techniques. Each disorder must be treated and addressed. Transference-focused psychotherapy (TFP) is a highly structured modified psychodynamic treatment for a narcissistic personality disorder. This therapy targets distorted interpersonal representations of one’s self as underlying pathological narcissism. This therapy promotes mentalization which is the ability to think about complex mental states by reflecting on the patient’s internal experience within a correctively secure therapeutic relationship (Kealy, Goodman, Rasmussen, Weideman & Ogrodniczuk, 2017). Distorted perceptions of others and themselves are associated with this type of treatment and it focuses on the integration of object representations and parts of themselves. Narcissists display behaviors that include self-inflation, callousness behavior, fragile self-representations, and they are overtly avoidant. TFP therapy works on inner aspects of experience in the transference relationship with the therapist in order to foster greater identity stability. Another treatment I would recommend for a narcissistic personality disorder is Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy highlights self-schemas that include beliefs about entitlement and specialness. CBT includes modifying behaviors and schemas while treatment goals are based on the patient’s agreement regarding the costs of narcissistic attitudes and behaviors (Kealy, Goodman, Rasmussen, Weideman & Ogrodniczuk, 2017). CBT is used to treat many different mental health conditions. This therapy aims to change behaviors, cognitive distortions, it targets solving current problems, and helps in developing coping strategies for the patient. CBT will also help change Dr. Marvin’s destructive patterns of behavior. The great thing about CBT is that it is a combination of two therapeutic approaches, behavioral therapy and cognitive therapy. Some antidepressants are also be implemented into a treatment plan in an attempt to relieve depression and anxiety in people with personality disorders. Some of these antidepressants include Paroxetine, Escitalopram, Alprazolam and Clonazepam. When treating personality disorders, psychotherapy should be the first line of treatment before turning to any medications.
The prognosis for Dr. Marvin seems good, yet it depends on his commitment to working towards changing his behaviors into positive ones. His motivation to move on seems to be positive. Considering the severity of his prognosis, I think working on his narcissism and ego are crucial in Leo’s road to recovery. Unfortunately like many other personality disorders, narcissistic personality disorders are lifelong but with the appropriate treatments patients such as Leo can improve. Individuals with narcissistic personality disorders who experience overtly poor functioning in a wide range of areas seek treatment when they feel vulnerable (Dashineau, Edershile, Simms & Wright, 2019). Foe Leo, seeking treatment tells me that he wants to receive treatment in order to regain control of his behaviors.
When considering any ethical or legal considerations in regard to Leo, I do not feel that he is a harm to himself or others. Although he does get mad and agitated quite fast, I do not feel that he would physically harm anyone. At this time no hospitalization would be considered for the patient because with proper therapy I feel that he would be safe residing at his home with his family. Leo is not a threat to himself or others and therefore would not be required to stay in a hospital. The patient’s behavior does not warrant filing any report or to government agencies because he is not a threat to society. Some ethical concerns that I would make sure that I addressed when treating Leo is (3.04 Avoiding Harm). I would make sure that I would take reasonable steps to avoid harming my patient and making sure I provide him with a safe, supportive environment. I would also stay within the boundaries of my competence (2.01 Boundaries of Competence). By doing so I provide Leo service based on my training, education, and professional experience.
Bob is single and lives alone and adores his goldfish Gil, which is the only relationship he really has. He is a sweet, good natured man who has a great work ethic. He can be somewhat neurotic and manipulative. He was married but is now divorced. Bob has no children but has a lengthy history with seeing multiple therapists for his multitude of psychological disorders. Bob is an intelligent man. Bob Wiley is Dr. Leo Marvin’s newest patient. Bob was pawned off of Dr. Marvin by his last psychologist who simply could not stand him anymore. Bob seems pretty dependent on having a psychologist and believes he has every disorder that is known to man. He is seen as somewhat of a recluse, afraid to leave his apartment due to his numerous paralyzing phobias. Bob has a multi phobic personality, which is a constant state of panic that is characterized by acute separation anxiety. Bob also has a fear of germs (hypochondria) because he worries about diseases or catching something. Hypochondriasis is fear of illness. He struggles to open doors or push elevator buttons without the use of a handkerchief due to the germs. He also has agoraphobia. Public places scar him because they give him anxiety. He starts to feel dizzy; he gets cold & hot sweats, involuntary trembling and difficulty swallowing. Bob also suffers from an obsessive-compulsive disorder and a dependent personality disorder. Bob becomes so dependent on his new therapist, Dr. Marvin, that when his Doctor leaves for summer vacation Bob makes it his mission to track him down which he does successfully. Bob has a history of clinging onto each therapist he has.
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Bob seems a little messy when first observing how he dresses and when looking at his appearance. Bob is actually very smart, but his phobias prevent him from interacting with others the way he would like too. Due to his fear of germs, Bob is unable to go out in public and have those real interactions with others. Even though he has a list of phobias, he is a pretty happy guy considering what he deals with on a daily basis. Bob has a lot of insight into his own problems and that is probably because he has seen so many therapists in the past. He is very open and honest about each of his phobia’s.
When referencing the DSM-5 manual in regard to Bob’s disorders, the first one we will discuss is Agoraphobia -300.22 (F40.00). Bob meets the diagnostic criteria for agoraphobia when looking at his symptoms. Bob has a fear of transportation, being outside of his home, fear and anxiety are provoked, he avoids public places, he shows signs of significant distress when in public places, and he does not like being in open spaces (Black & Grant, 2014). Another disorder Bob has is a Separation Anxiety Disorder 309.21 (F93.0). Bob also meets the diagnostic criteria for this disorder. When Dr. Marvin leaves for vacation, we that Bob cannot handle his therapist being away for an extended amount of time, so Bob finds him. This plays into Bob’s separation anxiety disorder because he needs to have his therapist close to him. Bob shows signs of distress when separated from major attachment figures (e.g., Dr. Marvin), and becoming separated from that attachment figure (Black & Grant, 2014). Another disorder is a Dependent Personality Disorder 301.6 (F60.7). Bob depends on his therapist for emotional support and when making everyday decisions. Bob meets a lot of the diagnostic criteria for this disorder. He feels helpless when he’s alone due to his exaggerated fears, he goes to extensive lengths to obtain nurturance from others (Black & Grant, 2014). Dependent Personality Disorders are known to be comorbid with other disorders and dependent personality disorders are associated with high levels of neuroticism (Hooley & Butler, 2017).
The findings justify each of the diagnoses that I made such as Agoraphobia -300.22 (F40.00) because Bob has issues when it comes to being out in public. As we can see Bob also spends a lot of time at home and rarely leaves his house due to the symptoms brought on by doing so. A rapid heartbeat, feeling nauseous, and having hot and cold flashes seem to plague Bob whenever he steps outside of his house (Black & Grant, 2014). A Separation Anxiety Disorder in Bob’s case also justifies my finding’s. This is because when Dr. Marvin leaves for vacation Bob cannot seem to function without him. Bob has become very dependent on Leo. Bob becomes more stressed and overwhelmed at the thought of Leo not being close. Individuals with Dependent Personality Disorders are known to be very clingy and show submissive behaviors. People such as Bob see themselves as being inept and because they lack self -confidence, they tend to build their lives around others (Hooley & Butler, 2017).
The issues that need to addressed in Bob’s treatment plan include all three of his disorders. To treat his Agoraphobia, I would use Exposure-based therapy. This type of therapy gradually and systematically exposes the client to different agoraphobic situations. It’s a hierarchy of activities that is done at the client’s own pace. Once the client successfully completes a level, then they move onto the next level. Exposure therapy also implements interoceptive exposure, which brings about feared physical symptoms such as hot and cold sweats, dizziness, and a rapid heartbeat. Feared sensations are they paired with feared situations. Medication in some cases may also be implemented to help prevent or reduce symptoms. For Bob’s Separation Anxiety Disorder, I would use Selective serotonin reuptake inhibitors (SSRIs). These appear to be strong candidates for efficacy in ASAD (adult separation anxiety disorders) for several reasons (Schneier, Moskow, Choo, Galfalvy, Campeas & Sanchez, 2017). The quality of life along with symptoms seemed to improve. Another treatment I would use is Dialectical behavioral therapy (DBT) which is a type of cognitive behavioral therapy. This type of therapy helps in identifying and changing negative/destructive thinking patterns by pushing for positive behavioral changes. DBT also helps patients to improve their ability in regulating their emotions, tolerating negative emotions and stress, and helps them cope with difficult emotions. To treat Bob’s Dependent Personality Disorder I would use Psychotherapy. Cognitive therapy emphasizes on changing distorted beliefs a person has about themselves and focuses on restructuring cognitions of the self. Changing Bob’s long standing, damaging beliefs about himself can help him become more independent and also rebuild his self-confidence.
My prognosis for Bob is good. I feel that as long as Bob continues his therapy along with treatment he can have a successful outcome. Bob has had a lengthy history in terms of his illnesses and the severity of each one. His past treatments have not seemed to do much considering I have seen no current improvement in his behaviors or thought process and symptoms. If we can get Bob out of his comfort zone by trying new treatments I have faith that at some point his prognosis will be excellent.
I do not feel that Bob is a danger to himself or others. He his competent to make some decisions for himself but that depends. He does not need to be hospitalized and his behavior does not warrant contacting any local authorities. Some ethical concerns that I would need to address if I was treating this patient include
- American Psychological Association (2019). Ethical Principles of Psychologists and Code of Conduct.
- Black, D. W., & Grant, J. E. (2014). DSM-5® Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Vol. Fifth edition). [Washington, DC]: American Psychiatric Association Publishing.
- Dashineau, S. C., Edershile, E. A., Simms, L. J., & Wright, A. G. C. (2019). Pathological narcissism and psychosocial functioning. Personality Disorders: Theory, Research, and Treatment, 10(5), 473–478. https://doi.org/10.1037/per0000347.supp (Supplemental)
- Hooley, J.M., Butler, J.N., Nock, M.K. & Mineka, S. (2017). Abnormal psychology. (17th ed). Boston: MA. Pearson Education, Inc.
- Kealy, D., Goodman, G., Rasmussen, B., Weideman, R., & Ogrodniczuk, J. S. (2017). Therapists’ perspectives on optimal treatment for pathological narcissism. Personality Disorders: Theory, Research, and Treatment, 8(1), 35–45. https://doi.org/10.1037/per0000164
- Schneier, F. R., Moskow, D. M., Choo, T., Galfalvy, H., Campeas, R., & Sanchez, L. A. (2017). A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder. Depression & Anxiety (1091-4269), 34(12), 1085.
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