Case Study of Conversion Disorder with Paralysis: Therapeutic Relationship and Assessment Strategies

This manuscript discusses a case study of conversion disorder with paralysis, focusing on the development of an effective therapeutic relationship and various assessment strategies. It also explores the legal and ethical issues relevant to the case. The client's history, family dynamics, and formal assessments are examined to formulate a comprehensive understanding of the case. The document provides insights into the principles of risk assessment, risk management, and positive risk-taking in the context of mental health care.

Introduction
This manuscript discusses a case study of cconversion disorder. The subject was Ms.
S.r (initials instead of real name) from my clinical practice suffering from functional
paralysis. Conversion disorder shows prominence of somatic symptoms associated with
significant distress and impairment. The psychologists jobs is to treat the somatic
symptoms plus the underlying cause of the problem in case of Conversion disorder.
Taking into account the case study of Conversion disorder with paralysis with persistent
stressor, the current document deals with development of an effective therapeutic
relationship placing people at centre of their own decision making. It also examines
various assessment tools and strategies along with risk assessment and management.
Legal and ethical issues relevant to the case have also been taken into consideration. In
addition, evidence base supporting the notion of care and support for people with
mental health issues has also been discussed (Trøstrup and et. al., 2019).
Summary of service user
The current report is about Ms. S.R. from my clinical practice. A 25 year's old lady
belonging from London. Her family was middle class with father as the dominating figure
in the family. Her relationship with her mother and siblings was very good. When she
was 15, her father married a widow. From then on, both wives kept a rivalry amongst
themselves, each competing to his attention. Relationship of S.R was never good with
her step mother and step siblings. About a year ago, her mother died. Since then, her
father had been more for her step mother. Her step mother had been strict towards her,
both verbally and physically abusing her. Her left arm is paralyzed about three months
after her mother’s death. There had been no medical evidence for the paralysis so she
was referred to psychologist by the physician. Her siblings were cooperative towards
her; father had shown interest in her treatment while a step mother labeled her as
malingerer. Her first cousin had been manic and her mother was an attention seeking
lady. The psychologist had to treat her functional paralysis in left arm and its root cause.

Therapeutic Relationship
The most important aspect in any relationship is the desire to be listen, understood and
unconditionally accepted . An empathetic therapeutic relationship based on trust helps
the client to be more open and receptive to the therapy .
In addition to physical, social and emotional support for their well-being, people also
need independence in their decision making, whether it is for their general life or
medical decision making . People are usually made dependent on others to decide for
them that may lead to their self-doubting behavior . In a therapeutic setting, patients are
at the centre of the system’s framework. This lays importance of a system inculcating
patient centred health care and guidance of patient in all decision making of their
healthcare. The most important part of this process is promoting a better communication
between the patient and his health care team . Health care systems is include shared
decision making, leading and guiding the people towards making their own decisions
wherever and whenever possible. Shared decision making can lead to recovery focused
personalized care with person specific goals that have been organized to harvest
maximum achievements and encourage social integration . The monograph of NCI has
elaborated the functions of people-centred communication as promoting the healing
relationships, interchanging information, acknowledging emotions, management of
insecurity and doubt, making decisions, and enabling people to self-manage These
functions dynamically interact and affect the patient-therapist relationship quality and
health outcomes. Self-management facilitate people in managing their health issues as
well as adopting to the changing roles in their lives. It has been generally accepted that
levels of safety and security have close links to a better therapeutic and recovery
focused experience for both the patients and staff .
Therapeutic intervention with Client
I followed psychotherapy and psycho-therapeutic relationship for the client. When first
brought to the clinic, S.r was defensive. She was briefed about psychotherapy and
hence report was built. Through verbal and subtle behavioral cues with non-judgmental

environment and she was asked open ended questions along with utilizing the
techniques of reflective listening and empathy. Emotional intelligence and sensitivity to
the client’s comfort zone along with a consideration of client’s needs and values was
also part of practice. Utilizing the expertise and unique insights, informal yet
professional communication led to cut through flood of information by S.r Goals, merits,
and risk of the applied treatment and therapeutic techniques relative to other available
options were discussed while considering each other’s values and preferences.
Emotional support in this process of shared decision making and person-centered care
for relieving fear or anxiety and also guidance on mental health issues was provided.
She was explicitly told that success of the therapy depended on her cooperation and
will. Her family was also interviewed and involved in the therapy.
Boundaries of the therapeutic relationship were set and maintained, as overly
involvement on behalf of clinician can hold the client’s opportunity to identify and
develop on their own resources .
Health Assessment strategies and tools
Differential diagnosis of a medical illness from a functional illness remains to be a
challenge . A systematic and detailed psychiatric history and examination is essential to
elucidate symptoms, stressors, and comorbidity . Mental health assessment and
screening tools are vital for getting information about the patient’s illness, the extent and
duration of illness, leading to correct diagnosis and the treatment (Swann and et. al.,
2018).
Assessment of client
The client was assessed both formally and informally. Information from both formal and
informal assessments was integrated to get an integrated picture of the case and later,
these assessment tools.
Interview and observation
A semi structured interview was conducted with the patient utilizing both open ended
question and cross questioning. The patient memory and orientation towards time,

place and person were intact. She had fair insight of her problem with motivation to get
better. She was carefully observed during the whole therapeutic treatment by both direct
and indirect observational methods. For observation outside the clinic, services of her
brother were taken who was provided with a rating scale for the observation of the
client’s behaviour after fixed interval of time.
Mental State Examination (MSE) and physical health
A client was presenting a dominant somatic symptom, left arm paralysis, she was first
examined for physically and neurological impairment. Her neurological tests were
normal, and she had no physical illness or abnormality. She was not suffering from any
type of thyroid problem, chronic heart disease and diabetes. She also had no history of
any substance or medication abuse. For mental status examination.
Family
Her family members were also interviewed. Specifically, her father, step-mother and
brother. These interviews revealed that her relations with her step mother and step
siblings had been very conflicting, yet she tried to maintain a good relationship with her
father and taking his attention. She had good rapport with her brother and sister from
her mother, and they had been very cooperative with her. After her functional paralysis,
she had very irritating and depressed behaviour. Since then she was receiving much
help in her work by her family member. Yet her step mother still considered her
manipulating the household through a fake paralysis (Goloshumova and et. al., 2019).
History- timeline, records
Analysis of her medical reports, educational record and personal and family history
taken from various sources revealed that she had a normal birth with no prenatal or
postnatal complications. She achieved her developmental milestone duration. She had
usual diseases of childhood that left no serious complications. She started school at the
age of five and was an average student. She took interest in extracurricular activities
and adorning herself. She had a vast social circle and was very friendly to everybody
whom she met accept her step mother and step siblings. For her, her father’s attention
was most important. She was a graduate. She hoped to marry her cousin but about a

year ago he got married to someone else. There was history of heart disease in her
family. Her first cousin had been diagnosed as a bipolar patient.
Formal assessment
Formal assessment includes application of both objective and projection tests to
help in identification of symptoms, diagnosis and getting at least an idea of the patient’s
personality, strengths and weaknesses. They help in development and evaluation of
treatment plan, progress and goals by both professional, and client during and at the
end of therapy process. Psychometric properties, costs and cultural restrictions of
assessment tools are considered first. They should be reliable, valid, sensitive and
specific .
For the current case, DSM-V self-rated level 1 cross-cutting symptom measure –
Adult and WHODAS 2.0 were used from DSM-V. these scales showed that client had
severe feelings that her problem was not being taken seriously (Association, 2013
#140).
Beck Depression Inventory scores indicated presence of moderate depression. She
had moderate depressive symptoms with mild sleep, appetite and self-care disturbance;
with no problem in getting along with people. These tests helped in enlisting clear cut
symptoms and quantifying client’s depression level.
Despite cost effectiveness, objective scoring, standardized norms, reliability and validity,
scores of self-rating tests have probability of presence of some degree of distortion
produced by test giver to create a particular impression. Therefore, Bender Gestalt Test
(BGT) was also applied. BGT is a screening test for organic or neurological problem. In
addition, it also has subjective soring to give some idea of client’s personality.
Bender Gestalt Test (BGT) scores did not indicate presence of any organic problem,
its subjective scoring suggested poor planning, mental confusion and tendencies
towards acting out in the client. Despite its strengths, BGT is still a screening test.
Information gained from it should be used along with information from other tests’
scores, medical reports and history. Its subjective scoring is not standardized as that of
objective tests . All the tests scores were found to be consistent with client’s history.

Case Formulation
Integrative analysis of the client’s formal testing, information taken directly from client
and his family, observations, medical reports and history suggested the presence of
Conversion disorder with paralysis, persistent with psychological stressor.
The present case can be best explained by Psychodynamic model, according to
which conversion disorder is actually a disruption in the consciousness due to which the
patient fails to have explicit awareness of his sensory and motor information. This
means that on an unconscious level, there might be a psychological factor at work, that
might be to seek attention of her father. Her depressive symptoms can also be
explained by this model . According to Freud, loss of a loved one leads to a person’s
depression. Client’s mother death and her cousin’s marriage to someone else might be
behind her depression .
According to learning theory, the client probably learned attention seeking behaviour
from her mother and her behaviour had been reinforced by the attention and assistance
(secondary gain) she received after her functional paralysis which is a learned
maladaptive response to stress.
According to Diathesis stress model, client’s first cousin was bipolar in addition to her
mother’s attention seeking behaviour that she might also have learned. These factors
when combined with her stressful life events might led to her functional paralysis.
Principles of risk assessment, risk management and positive risk taking
At this stage in dealing a case, we now deal with clinical risk assessment leading to its
management. Risk assessment is actually assessment of risk based on a professionals’
clinical experience and clinical judgement (Reddy and et. al., 2019).
This involves getting information from the patient. There are two approaches to risk
assessment.
Actuarial approach to risk assessment
Risk assessment which have pointed out several static and historical variables on
empirical population based on the various researches conducted and that has been
identified to predict risk of a particular outcome is Actuarial approach to risk

assessment. Risky outcome takes forms of violence and/or self-harm and it some
exceptional instances it can be leading to suicide or homicide.
Structured clinical risk assessment
This is the approach which considers the actuarial risk factors, following the
standardized format in clinical judgement about risk. This risk assessment is for national
guidance.
Generally, researches reveal Actuarial approach to risk assessment to be more
accurate and standardized. It helps in forecasting long term risk factors. A limitation to
this approach is that usually the clinical requirement is the assessment of acute risk
rather than long term. In addition, this approach deals more with population than
individual clients which may lead to inaccurate predictions. A better way of risk
assessment and management should include both structured and actuarial information.
Current trends concern more about clinical formulation of risk than about prediction of
risk. Prediction about an individual’s particular behavior occurrence is sometimes highly
inaccurate so care is needed in this especially for high risk patients and clients. Risk
assessment and management helps in formulation of the conditions under which a
psychological treatment can safely take place.
Assessment and management of risk should be done with mutual cooperation of client
and the clinician, this is because clients’ needs to be made independent in their own
decision making and should be responsible in their risk management. The safety plan
should be constructed mutually so that the client follows it as routine. Risk management
is dynamic i.e. it should be continuously reviewed. Different criteria are there for
assessment of risk to oneself or others. Historical and statistical, evidence based facts
on an individual’s risk should also be considered in addition to clinical judgment based
on clinician interaction with the client for therapeutic treatment. One way of doing it is
gathering information from client, and his/her referral, and third parties like colleagues if
required. this may include asking of direct and cross questioning. The risk management
pans need to be kept updated and reviewed on the basis of recent researches and
incidents. Experience, comprehensive awareness and knowledge to the risk

management and assessment aids the clinician in identifying vulnerable adults and
children.
Risk assessment and management of the client
The client was assessed for self-harm through indirect questioning and reports from
referrals and other family members. The client showed vulnerability to self-harm as she
had tendencies of attention seeking that could lead to self-harm. Suicide risk was
minimal. In addition, she was victim of domestic abuse by her step mother so this was
also taken into account. The patient was informed about the treatment options and
risks. She was involved in decision making of her therapy as a step towards positive risk
taking. Her attention seeking behaviour was monitored and therapeutic interventions
mainly focussed on controlling it to lessen the self-harm risk. In addition, her family
members were also encouraged to monitor and report her behaviour.
Evidence base required to care for and support people with acute mental health
conditions
Mental health care is often taken as isolated from the general medical health and social
care in not only institutional, professional and clinical terms as well as in cultural terms
too. This means that people would be getting an isolated care for physical, mental and
social issues that would be fragmented dealing with different aspects. This calls for the
implementation of integrated health care systems dealing with physical and mental
health, and social care. As physical issues lead to mental issues and issues in social
relationships (Naylor et al 2012), also patients with acute mental health issues along
with poor health and lack of accessibility to healthcare may die earlier than general
(Working Group for Improving the Physical Health of People with SMI 2016). Therefore,
it is important to provide care to people especially with acute mental health issues
encompassing all aspects of health and social care. This care should lead them to live
at least adequately in their lives, deciding for themselves and not totally dependent on
others for their care.
the quality of patient centred clinical decision is reflected through the extent to which it is
in line with the patient’s needs and preferences. The importance of patient-centred

decision-making concept came to prominence with the IOM report Crossing the Quality
Chasm: A New Health System for the 21st Century (IOM, 2001). With time, other
institutions and individuals have worked on its attributes (Bechtel and Ness, 2010;
Epstein et al., 2010; Picker Institute, 2013). Instead of depending on clinician or
therapist directed decision making, over the previous few years, people both individually
and jointly have pushed for a greater role in healthcare decision making (Clancy, 2008).
Research show that people experience better outcomes if they are involved in decisions
relating to their own healthcare and are relatively more satisfied with it (Alston et al.,
2012; CFAH, 2010; Hibbard and Greene, 2013; Maurer et al., 2012; Roseman et al.,
2013).
A special mention of people with mental health issues especially the acute ones is
necessary. They require not only the support and care to recover but their relapse
prevention is also needs significant attention. In several cases unfortunately, the original
episode is successfully treated but the restriction in accessing as essential component
as relapse prevention. This may lead the people unsupported when they go back to
their communities, so they might end up readmitting to the hospital once again. The role
of mental health care system is very important for people with mental illnesses
especially acute ones who have to survive in the community, and this caring and
supporting role needs to be continuous and ongoing (Jablensky et al 2000).
For treatment of acute mental disorders, a basic reorientation of treatment approach is
needed. This can be very helpful in prevention of relapse of the disorder, yet its
potential at this paradigm has been underestimated. Usually, the patients’ treatment
focuses on eliminating the current symptoms that leads to a relatively earlier discharge
from hospital and mostly follow up is avoided. Currently, mental disorder treatment
focuses more on admitting the patient and less is planned about the discharging of
patient. If there is some discharge planning, that too is usually delayed by months after
discharge of patient. It has also been noticed that there had been negative attitudes
towards the recovery of patients of acute mental health problems. Evaluation of the
Second Mental Health Plan and the Out of hospital, Out of mind report of the MHCA
revealed the findings mentioned as above (Groom et al 2003). Therefore, attitude
change of the workforce in acute mental health care settings is a deep requirement of
the time (Brouwers and et. al., 2020).
Care planning process of the client

For the functional paralysis, physiotherapy was incorporated to reduce the effects of
paralysis. The therapeutic intervention was planned in collaboration with the client with
SMART goals i.e. Specific, Measureable, Achievable, Realistic and Timely goals. The
goals were to treat her functional paralysis, her attention seeking behaviour, and her
dysfunctional and irrational beliefs and attitudes that led her problematic relationships.
The best therapy in this regard is Cognitive Behaviour Therapy (CBT). Primary (self-
relief) and secondary gain (social attention) were considered. Cognitive restriction for
treating primary gains while withdrawal from reinforcing attention were applied.
Auto hypnosis along with relaxation techniques was taught to patient to relive her from
the stress, that would also be helpful in treating her functional symptoms.
Client’s initial recovery was slow but pairing of the three above mentioned therapeutic
interventions progressively treated her conversion disorder. A follow up was maintained
for 3 months, she also improved in her social relations with family (Strauss and et. al.,
2020).
Relevant legal and ethical issues when delivering and evaluating care
Legal and ethical considerations in mental health are gaining importance day by day
due to increased number of cases and their complexity. A managed care needs
observation of relevant laws and ethics to protect both the professional and the client.
Below follows the introduction of laws and policies relevant to the case study.
The Mental Health Act 2007 is an important law for ensuring rights of both professional
and client/ patient. The Mental Health Act 1983 can also be referred to in this regard.
This Act has been amended by 2007 Act. Professionals and their qualifications have
been specified to treat a client, has broadened the scope of the mental health
professionals. The Act and its amendment specified the role of the clinician as mental
health professional. Rights of confidentiality, appointment of nearest relative, consent
and provision of best treatment require special attention (Singh, 2007 #144).
As there is increased bend towards shared decision making in mental health with the
client, Mental Capacity Act 2005 gains importance. This Act is designed to protect
rights of patients with limited decision-making ability. Such people are mostly with

medical disorders like Alzheimer’s or they may be without a physical disorder yet
lacking the decision-making ability. This act states that a person should be allowed to
decide for himself unless he is proved to lack the ability and if it is the case, the
decisions should be made in his best interest (Boyle, 2008 #145). Also they have a right
to appoint independent advocate for themselves who can support them in important
decisions (Foskett and et. al., 2018). Equality Act 2010 also protect the clients from
any type of discrimination like gender, ethnicity etc., harassment and victimization in
public or workplace settings (Lockwood, 2012 #146). The Deprivation of Liberty
Safeguards (DoLS) is an amendment to The Mental Capacity Act 2005 that deals with
protecting the rights of person who, due to any reason cannot decide for themselves.
This act tends to safeguard their rights and ensures that best decisions are made for
them and in any case of any violation, provides legal protection to the person.
Safeguarding vulnerable Adults policy protects vulnerable adults, adults who cannot
care for themselves fully due to any reason, from harm caused due to neglect or abuse
(Hewitt, 2012 #143).
For registered nurses, midwives and nursing associates, the NMC Code 2018 serves
the purpose of determining the appropriate standards of behaviour for them. Thus, it
helps in clarifying the service users what to expect from nursing staff and ensures safe
and effective practice. Professionalism, accountability and competence should be
observed for all the service users at its best. references
It is important to observe ethics in clinical practice. Mental health care professionals
have to attend service users form diverse cultures, therefore the need for the clearance
of ethics is the demand of situation. Observation of ethics is the application of moral
principles to practice, and it can be referred to I case of conflict or complexity. These
help in sound clinical practice and care planning. These relate to the rights of service
user’s confidentiality, informed consent and conflict of interest. The most important
ethics in this regard are beneficence, non-maleficence, justice, autonomy. Beneficence
is the responsibility of professional to provide best decision for the service user, non-
maleficence is to prevent the person from harm or at least doing better than harm,

autonomy is the right of the service user to decide for his/her treatment. Justice is the
provision of sources equally to all (Barber, 2016 #142).
Legal and ethical consideration in the case of client
Legal and ethical considerations were taken into account for the client. Informed
consent was taken from the client. Her confidentiality was protected. She was involved
in the decisions for her therapeutic treatment. Her autonomy was protected. Mental
Capacity Act and The Deprivation of Liberty Safeguards (DoLS) were referred to in this
regard. The clinician observed beneficence and non-maleficence for the client.
Throughout the treatment, professionalism and accountability was also observed
according to the NMC Code 2018. Discrimination on any basis was avoided according
to Equality Act 2010 (Vincer, 2017 #141).
Conclusion
The current case study discussed care, treatment and legal and ethical considerations
of conversion disorder with paralysis and persistent stressor. It is now universally
accepted fact that people with mental health problems need care and support both in
hospital an after treatment and discharge to prevent relapse. also they should be
provided with patient-centred care and shared decision making should also take place.
This leads to better health outcomes, helping patients in learning to take responsibility
for themselves, self-management and independence. Therapeutic relationship based on
trust and mutual consideration of each other’s needs and preferences is most important
for recovery. Careful assessment of risk and its management is also required in addition
to consideration of legal and ethical issues. Integration of all these factors helps people
to live more healthy, satisfied and productive lives (Bingham., 2018).

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