Please note that the following vignettes represent samples of the types of questions you will be asked to respond to on the comprehensive exam. You will NOT receive these questions on the comprehensive exam; they are for study purposes only.
Please compose a well-written and organized essay in response to each of the following questions. When writing your essays, please
- Use APA (6th edition) Style, with 1-inch margins, double-spaced, 12 font, with a reference list at the end.
- Write clearly and concisely.
- Cite appropriate, and especially current, literature (empirical and/or theoretical).
- Avoid all sexist idioms and allusions.
- Remember to demonstrate your multicultural competence where appropriate.
Vignette: Utilize this scenario for all of your responses
A 42-year-old African American woman was brought to the emergency room by police officers for evaluation prior to going to jail to await disposition. She reported that she had been shopping when “something happened.” She said that she had no recollection of events between the time she entered the store and an hour later, when she was arrested for shoplifting in a nearby department store with a considerable amount of stolen property on her person. She protested her innocence and became so agitated, belligerent, and profane that the arresting officers took her to the hospital for evaluation. At the hospital she reported that two years previously she had been arrested for shoplifting and had had amnesia for the act. The charges against her were then dropped because she explained that both the shoplifting and the amnesia resulted from her forgetting to eat after taking her insulin. Of note, her blood-sugar level on testing in the emergency room was elevated.
The patient calmed down appearing asymptomatic after the evaluation and was transferred to jail pending a preliminary hearing. When she learned that her release was planned for the next day and that the charges against her would not be dropped, she became extremely agitated, angry, and abusive to the officers. Shortly thereafter, she complained of a headache and said she had no recollection of her abusive behavior. Later that evening she accosted an officer angrily. When the officer responded and addressed the patient by name, “Naomi,” the patient said that her name was “Oprah” and that she would not allow herself to be called “Naomi,” whom she described as a “wimp and a loser.”
“Oprahâ€™s” voice and movement were somewhat different from those of “Naomi.” She claimed that she had done the shoplifting and stepped back so that “Naomi” could be caught and humiliated, and that if she had wanted to, she could have evaded detection easily. She was returned to the ER and subsequently admitted to the inpatient psychiatric unit for observation. For the next two days, the patient had many apparent switches of personality, accompanied by conspicuous changes in dress, makeup, and demeanor. On several occasions “Oprah” was disruptive, and twice “Naomi” reported to nurses that she had found things belonging to other patients in her possession.
There were no consistent differences in blood-sugar levels in the different personalities or changes at the time of the shifts. A neurological workup with extensive electroencephalographic studies proved unremarkable. The patient began to complain that her behavior was out of her control and that she could not be held accountable for it. Each day’s progress notes revealed further details of the differences between “Oprah” and “Naomi.”
A counselor was asked to see the patient. He observed the presence of both “Oprah” and “Naomi” and documented their polarized and clear-cut differences. The personalities were detailed and elaborate as they discussed issues relating to the patient’s current legal difficulties. He learned that the patient had an extensive history of discrepant behaviors that she had “forgotten,” to which many witnesses would attest, and that her family often remarked that she was “like two different people.” He found that these episodes had usually occurred when the patient had engaged in behavior that brought adverse personal consequences upon her. He noted that the patient was on a unit that, by coincidence, had three other patients with similar symptomology and that, beginning the day the patient learned that the charges against her would not be dropped, she had begun to associate more frequently with those patients.
An extensive history, taken over several days, and ancillary sources failed to reveal any history of childhood abuse and there was no indication that the patient had experienced any other overwhelming traumatic events. Furthermore, the history indicated that the patient, despite the apparently classic nature of her two personalities, had never shown or complained of any other significant psychological symptomology. Her history includes having been raised as an only child in a middle-class urban environment by her mother and grandmother. She reports that she has a good relationship with all members of her family although she has a more distant relationship with her father, who works long hours as an engineer. His mother and grandmother work as teachers in nearby private schools. Both her parents are of Haitian descent though the patient was born and has lived her entire life in the United States.
The patientâ€™s developmental history includes having met all physical and cognitive developmental milestones on time, with mild difficulties in reading and peer relationships. In early elementary school she was reported to have had some â€˜acting outâ€™ problems including hitting another child, and talking back to adults, however, these behaviors were not severe or long-term enough to warrant suspension or ongoing concern. In high school, no behavior problems were noted, and she was described as socially somewhat reclusive, having only one or two close friends.
Prior hospital records were found for â€œNaomiâ€ indicating a long history of alcohol, heroin, and cocaine use, but upon confrontation about this history she claimed to have been clean for three weeks prior to her arrest. Her initial blood work was positive for both opiods and cannabis.
The counselor also noted that the “Naomi” he was interviewing was somewhat different from the “Naomi” with whom her family and friends were familiar. The usual “Naomi” was pleasant and mild-mannered unless “crossed,” at which times she became angry and belligerent. He also found that the patient was not very hypnotizable. He undertook a prolonged interview in which he covered a wide range of topics over several hours. As the interview proceeded, “Oprah,” who was completely consistent in her presentation during her discussion of matters related to the shoplifting and disruptive events on the ward, began to become inconsistent in her voice and manner. She complained that the consultant disbelieved her and was trying to “trick” her. As “Oprah” seemed unable to maintain her presentation, “Namoi” vehemently reproached the consultant for doubting the account offered by “Oprah,” for whose past behaviors and current interactions with the consultant she had consistently maintained she had amnesia. At these angry moments, her behavior was indistinguishable from “Oprah’s.” After another hour’s interviewing, during which the patient made several efforts to convince the consultant that she had amnesia during the shop lifting episode, she ceased to display the amnesiac behaviors.
When she was introduced to her public defender who told her she would be arraigned the following day, she flew into a rage and threatened that she would slash her wrists with the first sharp object she could find. She also claimed that she was hearing voices in her head telling her to kill herself.
Psychological Theory and Practice
- What assessment would you conduct to enhance your understanding of the client(s) problems and how would your assessment direct your diagnostic formation? In addition, what formal assessment procedures (either conducted by you or by someone you would refer to) would enhance your understanding of the problems and direct your treatment planning? Why?
- Provide a possible multi-axial diagnosis (based on all five (5) axes of the DSM-IV-TR) for this individual. In narrative form, describe the differential diagnostic thought process that you used to reach your hypotheses. What additional information would you need for each of the possible diagnoses in order to confirm your diagnoses and/or rule out the others?
Legal Theory and Application
- Using information from the provided vignette, describe the background, current presentation, and behavior of the client from a perspective which takes into consideration (either via inclusion or elimination) theories of offender and/or victim psychology to support your position.
- Describe the psycho-legal standards and/or definitions for each of the following: competence to stand trial, risk of dangerousness, and insanity. Identify and describe one or more landmark case(s) for each standard (at least three cases total). Describe the elements or issues that a mental health professional usually focuses on when assessing a personâ€™s adjudicative competence, risk and insanity, and any additional items that might be especially important to focus on in the provided vignette.
Research and Evaluation
- Describe what tests or assessment procedures that you would employ in the vignette to address these forensic issues (competence to stand trial, risk of dangerousness, and insanity) (you may refer to these from the Psychological Theory and Assessment Section A. if you already covered them there) and what your anticipated conclusions would be based upon that information provided in the vignette.
- Develop one empirically supported therapeutic treatment plan for the client in the vignette. Please make sure you identify the name of the theory your treatment plan is based on and summarize the empirical evidence with appropriate citations to support your treatment choice in working with this client. Be sure to discuss the effectiveness and limitations in working with this particular client (including effectiveness/limitations in working with this particular clientâ€™s background using the above theories and treatment plans)
- What factors or cultural considerations would you take into account in rendering diagnoses, case conceptualization, and treatment planning? What other cultural factors may be salient for this client?
- Your writing, use of citations, and proper APA Style will be evaluated as a measure of your interpersonal effectiveness. No response is required for this section.
Leadership, Consultation, and Ethics
- Describe how you would work within a professional team to consult, triage and/or treat this case. Include a description of the various members of the professional team with which you would be likely to interact.
- What are the ethical and legal dilemmas this vignette introduced? What would be your immediate steps and why? Please be specific and m ake sure that you describe your process of ethical decision making and the solutions/consequences this process might lead to.