Week 8 Discussion – Challenging Practice

Conditions

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There are a wide variety of challenging practice conditions that you will encounter which

can be difficult at times, particularly for those that are not comfortable or practiced in

dealing with confrontation and the unknown.

Review Cases 9.1 and 9.2 and consider some of the strategies discussed in the text.

In a clinical setting, there are additional challenging practice conditions to consider. Using

information from the text as well as information from additional research (i.e., journals,

texts, .edu/.gov/.org) answer the questions below from the vignette listed.

Cite/support your responses in APA format.

1) What psychotic symptoms is the patient exhibiting?

2) What strategies or methods could be utilized in this situation?

3) What safety concerns should be considered for you and the client?

4) Give one other student feedback on their strategies or safety concerns.

Case Vignette: Emotionally Disturbed

 

Alicia Lewis was a 36-year-old woman brought to the emergency room by police after she

apparently tried to steal a bus. Because she appeared to be an “emotionally disturbed

person,” a psychiatry consultation was requested.

According to the police report, Ms. Lewis threatened the driver with a knife, took control

of the almost empty city bus, and crashed it. She appeared to be talking to herself with

active delusions. A more complete story was elicited from a friend of Ms. Lewis’s who had

been on the bus but not arrested. According to her, they had boarded the bus on their way

to the nearby shopping mall. Ms. Lewis became frustrated when the driver refused her

dollar bills. She began yelling at the driver “why are you trying to kill me?” She looked in

her purse, but instead of finding the exact change, she pulled a kitchen knife that she

carried for protection. The driver fled, so she got into the empty seat and drove the bus

across the street into a nearby parked car.

On examination, Ms. Lewis was handcuffed, disheveled appearance, a heavyset young

woman with a bandage on her forehead. She was fidgeting, rocking back and forth in her

chair, and appeared to be mumbling to herself.  When asked what she was saying, the

patient made momentary eye contact and just repeated, “Sorry, sorry, sorry.” She would

not respond or answer any other questions.  

 

More information was elicited from a psychiatrist who came to the ER after the accident.

He said that Ms. Lewis and her friend were longtime residents at the state psychiatric

hospital where he worked. They had just begun to take passes every week as part of an

effort toward social remediation, and deinstitutionalization with hopes of community

placement. This was Ms. Lewis’s first bus ride without a staff member.

According to the psychiatrist, Ms. Lewis had received a diagnosis of “childhood-onset,

treatment-resistant paranoid schizophrenia. She had started hearing voices by age 5 and

continued throughout her life. Ms. Lewis is very strong, intrusive, and easily triggered by

others, with hospitalization constantly since age 11. Her auditory hallucinations generally

consist of critical voice, commenting on her behavior. Her thinking is very concrete, but

when relaxed she can be self-reflective. She was very motivated to please and recurrently

said her biggest goal was to “have my own room in my own house with my own friends.”

The psychiatrist said that he was not sure what had caused her to pull out the knife. She

had not been hallucinating lately and been feeling less paranoid but wondered if she had

been more psychotic than she had let on. It was possible that she was just impatient and

irritated. The psychiatrist also believed that she had almost no period of her life

developing normally and so had very little experience with the real world.

Ms. Lewis had been taking clozapine for one year with a good resolution of her auditory

hallucinations. She had gained 45 pounds during that time, but she had less trouble getting

out of bed in the morning. She was hoping that she could eventually get a job and live more

independently and had insisted on continuing to take the clozapine. The bus trip to the

shopping mall was intended to be a step in the direction of reintegration into the

community setting.