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As a clinical therapist, I’ve recently received a call from a woman who had been concerned with her husband’s deranged delusions and hallucinations, and sought help to determine what she could do to help him. She explained to me that she has noticed he has been suffering from a disconnect from reality, along with withdrawal from other individuals. The following day, she brought her husband, a man with the name John Nash, into the psychological center to receive aid for him. He initially showed no interest in talking with me, and mentioned that he didn’t think he needed therapy. After he agreed to visit me for a few sessions, I was able to discover a lot about him and his underlying problems.
I was able to assess some of the client’s main problems through his wife’s description of some of John’s atypical behaviors and by analyzing his behaviors and cognitive notions in session. Before therapy had begun, Alicia (John’s wife) discussed that she often found Nash talking to imaginary people, even yelling at the fictional figures. While in session with Nash, he revealed other issues in his life, such as social anxiety and awkwardness and having a lack of concern about what others about him (especially his fellow graduate students). As Alicia too had mentioned, he pointed out that he often talked to people that were merely his hallucinations and that he has been dealing with a prevalence of false delusions that continually impact his cognitive thoughts.
Sidenote from film: In the movie “A Beautiful Mind” (2001), John Nash experiences both delusions of grandeur and delusions of persecution. When chatting with a character only existing inside of John’s head (Charles), John yells off the balcony to a group of graduate students at Princeton University and voices “I cannot waste time with these classes and books, memorizing the weak assumptions of lesser mortals” (A Beautiful Mind, 2001). People responded by laughing, as it appeared to them that he was only talking to himself. This scene was of significance as it underlined the idea that delusions of grandeur can make a social barrier between affected and unaffected individuals, along with a disconnection from reality that John encountered. Later in the film, John undergoes yet another episode of delusional thinking when he states to Alicia that someone is out to get him. She is greeted by John aggressively demanding that she shuts the lights off, as he is convinced he and his wife are in danger. He goes ballistic, yelling at yet another one of his hallucinated characters as she frantically demands to know who he is talking to. John’s paranoia is very evident in this scene, as it became noticeable to Alicia, in which she perceived as abnormal and deviant from the norm).
With the insight I have on John, I used the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to diagnose him with paranoid schizophrenia. Schizophrenia can be described as a chronic psychotic disorder that disrupts an individual’s thought processes and affect. Nash showed clear evidence of a serious distortion in his cognitive thinking as he disclosed to me his paranoid ideas that people were out to harm him. In support of this diagnosis, the DSM-5 states that “the diagnostic criteria [for schizophrenia] includes the persistence of two or more of the following active phase symptoms, each lasting for a significant portion of at least a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. John exhibited experiences of false underlying delusions, hallucinations of imaginal characters he recently learned were not actually real, and disorganized speech during our sessions, as he often changed notions rather rapidly and spoke about ideas in loose association with each other. He described particular experiences of social withdrawal from other graduates at school, in addition to his lack of care what others thought about him, which both represent common negative symptoms of schizophrenia. Furthermore, the DSM-5 includes that to authorize a diagnosis of schizophrenia, the patient must exhibit impaired functioning of interpersonal relationships, self-care, or decreased function in the workplace. In John’s sessions with me, he mentioned that he often had interpersonal conflicts with his wife due to his delusional thought processes and hallucinations. He has recognized this as a serious problem and doesn’t want to argue with his wife, but his delusions are so strongly held that he cannot change his underlying perceptions in the moment of the arguments. Lastly, the DSM-5 requires that there must be continuous signs of schizophrenia for a least 6 months. John verified in session that he has been experiencing his symptoms for most of his life. Moreover, I chose to diagnose Nash with paranoid schizophrenia due to the frequent discussions about his intense worry about someone constantly being after him.
As I was developing notions about some of his possible treatment options, I asked him to identify if he has had any psychosocial triggers that could have potentially sparked more intense episodes of unrealistic thinking. A straining aspect of his life he described was his feelings of intense distress and extreme pressure to publish his own original idea, but he doesn’t know what to write about. (Sidenote from film: In the movie, Nash was socially outcasted on multiple occasions from the other graduate students, and this could’ve been a trigger for schizophrenic symptoms as well). He even uncovers that he feels a significant amount of pressure during social interactions with others. Moreover, he enclosed to me that when he gets in a serious argument with his wife, he tends to see and hear three different individuals around the time of the argument. A pattern of psychotic symptoms follows with many of Nash’s socially challenging interventions, suggesting those are some feasible psychosocial triggers for his episodes.
John did not present with any current medical conditions at the time of the sessions, but he did inform me of a time at which he experienced an episode and his delusions and hallucinations lead him to self harm. This is a behavior commonly seen in schizophrenic individuals. John’s delusional thinking lead him to physically injure himself with a sharp objection, and although he did not admit any recent injuries, this created a great concern and I decided to refer him to some alternative therapy options that will fit to his individual needs.
Psychological treatment helps those with schizophrenia live with it and have the best possible quality of life. From my personal encounters and discussions with John, I have concluded that some form of cognitive psychotherapy (aka Cognitive Behavioral Therapy or CBT) would be most helpful to treat his symptoms. I’ve suggested that he try Ellis’ Rational Emotive Therapy. This type of goal-oriented therapy specializes in riding clients of negative philosophies and replacing pessimistic thinking with realistic and flexible thinking. By practicing rational and realistic thinking, individuals who utilize this therapy can find happiness and view negative life situations in a more sensible way. The techniques behind this therapy were developed by Albert Ellis in his A-B-C model. To further explain this prototype, the “A stands for ‘activating events,’ which are related to rational or irrational ‘beliefs’ (B). The beliefs involve ‘consequences’ (C), which, if the belief is irrational, may be emotional disturbances”. To elaborate, this model aims to help clients understand how their thoughts, feelings, and behaviors are related so that they can view the world rationally and increase their overall happiness. The underlying theory behind why RET works so well is due to the teachings of clients not to be disturbed by unfortunate events, along with informing them that nothing is good or bad, but the way we view a situation may make it so. Albert Ellis defends this idea and states “men are disturbed not by things, but by the views they take of them”. Moreover, I believe this form of therapy would be useful for John Nash to help teach him not to be disturbed by his delusions or hallucinations, and see things in a realistic sense. By changing some of his obstructive perceptions, he will be able to more successfully identify with optimistic considerations rather than negative ones.
A second form of cognitive psychotherapy that I would suggest is called Stress Inoculation Training (SIT). Developed by American psychologist Donald Meichenbaum, this model of therapy has its goals rooted in helping individuals strengthen current coping skills and introduce them to new and effective ways to cope with life disturbances and distress. Individuals in SIT will learn how to identify triggers and master how to handle situations rationally. The technique behind how SIT works is identified in the three phases: 1) conceptualization, 2) skill acquisition and rehearsal, and 3) application. The conceptualization phase is the step in which a therapist figures out any triggers that cause stress or anxiety. The second portion of this type of therapy focuses on cognitive restructuring and behavioral activation, along with the therapist making the patient feel better. The last step, application, is where the client actually practices the skills in session and may include role plays, practicing and applying learned skills. The theory as to why this method works is due to how SIT makes patients more resistant to stress. Moreover, SIT allows clients to better identify when stress is happening and how it affects their behavior so they can adjust to the situation accordingly. This form of psychotherapy could be beneficial to John Nash because when he is enduring his psychotic episodes, he can recognize his psychotic breaks and implement newly acquired coping mechanisms. Additionally, this treatment can help alleviate distress from his experiences delusions and hallucinations.
Due to key differences between each form of CBT, Rational Emotive Therapy would be most preferable for this client. RET involves continuous work on the troublesome notions that accompany schizophrenia. RET is more long term, and the constant fight to resolve the issue means that as more time passes, the stronger the effects. In comparison, SIT deals with stresses as they happen in the moment, and does not help as much to fix the underlying challenges of schizophrenia. Also, RET can have stress reducing results as the schizophrenic thoughts do not take hold of the client’s life because they are taught to question their irrationality, in this case Nash’s delusions.
John Nash is a man plagued with schizophrenic delusions and caused his once idyllic life to come crashing down around him for seemingly no reason from his perspective. After diagnosing him with paranoid schizophrenia, two cognitive psychotherapies stood out to me to help solve his mental degradation. Both RET and SIT are effective means to aid John, however RET has specific qualities that more closely fit to the needs of Nash including replacing negative thinking with realistic, rational thought pathways, teaching clients not to be disturbed by unfortunate life circumstances, and resolving emotional and behavioral issues due to positive schizophrenic symptoms. I see John Nash benefitting significantly from further sessions of therapy and with hard work he can overcome his debilitating condition.
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