RUNNING HEAD: The Soloist

The Soloist:
A clinical review of Schizophrenia
CNS 770
Mary Winston Dozier
1/30/2022
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The character of Nathaniel Ayers Jr. in the film, The Soloist meets criterion A for 295.90

Schizophrenia per the DSM-V. Ayers meets two or more of the “A” criteria for a significant

amount of time (American Psychiatric Association, 2013, p.99). Ayers’s symptoms include the

presence of delusions, hallucinations (auditory & visual), disorganized/rapid speech (frequently

and incoherently), disorganized behavior or catatonia, and negative symptoms. Ayers holds

many beliefs that would be classified as delusions, for example Ayers refers to Lopez as “his

God” several times throughout the film highlighting his view of their relationship. Another

example is Ayers’s refusal to stay at the homeless shelter, LAMP, because of the cigarettes

littered on the ground which he believes are just “to torment him”. The third example that

highlights Ayers’s delusions took place during childhood when he forces his sister to eat the

soup she prepared for him, due to the fear of it being poisoned. This delusional flashback

occurred during Ayers’s concert when he experiences intense auditory hallucinations of voices

during a solo performance. These voices are sending conflicting and confusing messages to

Ayers making him feel upset and overwhelmed with the belief that people were trying to attack

him, leading him to flee.

Ayers has experienced hallucinations since the onset of schizophrenia signs and symptoms

during early adolescence. One of the first notable hallucinations is when Ayers’s sees a burning

car going down the street. Based on the progression in the film, it appears that the auditory

hallucinations are paranoid, obsessive, in multiples, and repetitive. The hallucinations progressed

throughout Ayers’s younger years until finally he had to leave Julliard School of the Arts and

quickly slipped into homelessness.

Ayers his disorganized speech patterns which is shown throughout the film in his

conversations with Lopez. Early on after a confusing rant, Ayers asks Lopez (who is standing

right beside him) if he is flying the plane above them in the sky.

Ayers meets the Schizophrenia B-F criteria and specifiers according to the DSM-V

(American Psychiatric Association, 2013.) Ayers has experienced consent and persistent signs

and symptoms of schizophrenia since early adolescence. These symptoms have impacted his

level of functioning in areas like work, interpersonal relationships, self-care, and occupational

functioning (homeless) (American Psychiatric Association, 2013 p. 99).

The relationship between Ayers and Lopez is complex and fragile. It is a relationship

consisting of both helpful and harmful elements. The basis on which their relationship began is

more harmful than helpful, given that Lopez viewed Ayers as an interesting story to write about.

It is apparent at first that Lopez views Ayers as a subject to benefit his writing career and not as a

friend. The initial interaction is bothersome given that it is one sided and Ayers is not able to

consent to due the nature of his situation. Given the confusing boundaries or lack thereof drawn

in the beginning of the relationship, Ayers is confused about the meaning of their relationship,

and it seems Lopez is too.

There is a huge power dynamic that is at play. Lopez has the upper hand and initially was

insistent on doing things his way. For example, he pressures Ayers to stay in an apartment

adamite that he should have a home because that was the normal thing to do. While Lopez makes

logical sense with his ideas, he neglects the fact that his suggestions may not be the best thing for

Ayers. In theory an apartment would be a safer place for Ayers than sleeping on the streets and it

most likely is, however historical being in confined spaces has triggered an episode of intense

auditory hallucinations for Ayers. There are a couple instances like the apartment example
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throughout the film that show Lopez trying to help Ayers but through his logical only and not

from a place of understanding the unique circumstances regarding Ayers’s well-being, needs,

and wants. For examples, Lopez tries to lure Ayers to LAMP with the cello instead of letting

Ayers keep it on the streets.

However, there are some healthy aspects to their relationship which is notable throughout the

film as their bond fosters trust and grows into a friendship. Lopez helps Ayers rediscover his

musical passion by providing him a cello and lessons. Lopez is concerned about Ayers’s

wellbeing and safety which is apparent in his frequent check-ins on Ayers. Lopez provides

human interaction and companionship for Ayers. Social and familial support can have a positive

influence on individuals like Ayers and may lead to better outcomes (Seligman & Reichenberg,

2014). Lopez helps to mend the relationship between Ayers and his estranged sister. Ayers also

provides companionship for Lopez and perspective of the value of life and relationships. It is his

relationship with Ayers that encourages Lopez to work on his relationship with his ex-wife. It is

clear by the end of the movie that Lopez and Ayers have a special bond as the last scene shows

them sitting together at an orchestra concert.

Throughout the film, Lopez and David Ellis, the director of the homeless shelter, disagree

over their views and approaches to helping Ayers. Lopez wants to have Ayers met with a

psychiatrist to be evaluated, properly diagnosed, and put on medication. Ellis reiterates the

importance of autonomy for Ayers and that they can not force him to do anything. Ellis explains

to Lopez that their role is to be a support, educator and provide resources. Despite their

differences Ellis and Lopez believe they have Ayers best interest at heart and want him to be safe

and healthy. I see arguments for both sides regarding the treatment approaches for Ayers. I agree

with Lopez in that it would be beneficial to get Ayers proper treatment, although the way Lopez
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wanted to go about doing that was wrong because it involved involuntary commitment. On the

other hand, Ellis looks at Ayers’s case from a pragmatic perspective, understanding that there is

no solution for Ayers’s condition, but that it can be treated and managed. Ellis was not quick to

give Ayers a label or diagnosis which brings up the “diagnosis controversy” that happens within

counseling. It is imperative for clients to be educated on their diagnosis and be a part of the

treatment discussion, so they can better manage medication and course of treatment. However, I

do understand the stance Ellis takes in Ayers’s case that more harm than good may come from a

diagnosis. In the film, Ayers was given paperwork to sign regarding his welfare by Lopez. While

reading the forms he read the label “a schizophrenic mind” which sent him into an outburst of

rage and anger. I think a compromise between Lopez and Ellis regarding course of treatment is

required to best support Ayers. It would be beneficial to address a diagnosis with Ayers in a

tactful, calm way after he has been in treatment for a while.

In looking at treatment options for Ayers, I think a first step would be to have him

hospitalized for inpatient care so that medication could be monitored and psychotherapy could be

administered. “Treatment for schizophrenia usually entails a combination of medication and

psychosocial interventions that target both the acute psychotic phase of the disorder and the

debilitating residual symptoms” (Seligman & Reichenberg, 2014 p. 413). I think behavioral

therapy could help Ayers navigate his diagnosis and course of treatment by learning practical

skills and having a safe place to practice them. Cognitive-behavioral therapy (CBT) may be

beneficial for Ayers’s course of treatment to help him in learning distress tolerance skills,

reducing negative emotions, and reducing self-stigma around his diagnosis. Another component

to Ayers’s treatment is familial education and social support. Providing families with

psychoeducation on schizophrenia has proven to increase medication compliance and decrease

the chance of relapse by 25% (Seligman & Reichenberg 2014). There is no cure for

schizophrenia, but with a combination of medication, psychosocial interventions, and familial

support, individuals with schizophrenia can live and manage symptoms (Seligman &

Reichenberg 2014).

CLIENT MAP (Seligman & Reichenberg, 2014)

Diagnosis: Schizophrenia 295.90 DSM-V

Objectives of Treatment: Foster a compassionate, safe environment for patient while

providing comprehensive care. Reduce severity of symptoms: delusions, hallucinations

(auditory & visual), disorganized/rapid speech (frequently and incoherently), disorganized

behavior or catatonia, and negative symptoms. Strength patient’s ability to regulate emotions,

self-efficacy, and interpersonal communication skills. Strength patient’s familial/social

support system. Improve patient’s distress tolerance skills and coping strategies. Establish

prevention relapse plan with patient and family.

Assessments: Physical wellness examination, medical, neurological, and psychological.

Clinician Characteristics: Compassionate, considerate, positive, and supportive towards the

patient and their treatment progression. The clinician needs to work on establishing a strong

therapeutic alliance with the patient to strengthen the effectiveness of treatment and support a

healthy, trusting relationship. A multidisciplinary team will work collaboratively with

patient’s family during patient’s treatment to ensure that all the patient’s needs are met,

including the clinician, psychiatrist, and physician.

Location of Treatment: Initial hospitalization; inpatient care then transition to outpatient

treatment care.
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References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental

Disorders - DSM-5TM (5th edition). American Psychiatric Publishing, Arlington, VA.

Seligman, L., & Reichenberg, L.W. (2014). Selecting Effective Treatments – A Comprehensive,

Systematic Guide to Treating Mental Disorders (4th edition, revised). Hoboken, NJ: John

Wiley & Sons, Inc.