describes his mother as“always worn out, always sad.”
At the time of his father’s death, there were three
younger children, ages 5 years, 3 years, and 6 months.
Mr. Ramirez early took on the role of family supporter,
working after school and on weekends to add to the
family income, and helping to discipline his younger
siblings. He remembers his development years as“not
much fun, a lot of struggling to survive.”
At school he was an isolate because of his work
schedule and also because he was determined to com-
plete his education, and thus had no time for“fooling
with the guys.”He learned to fight in self-defense
when necessary, to pursue his own course, and to per-
sist at whatever he tried. His sexual development was
unremarkable. Since his mother seemed already to be
burdened and since he had no close friends, he learned
to keep problems and feelings to himself. After 2 years
of college he entered the police academy, attracted by
the discipline and structure of the organization and
the opportunity to defend the public. On the police
force he acquired a reputation for being fair, even-
tempered, tough, and completely dependable, but not
an easy person to get close to—indeed, almost fright-
ening in his self-sufficiency.
In the last 3 months, he has experienced a number
of disturbing events. His partner was wounded during
a raid; Mr. Ramirez himself was shot at, though not
injured, while making a routine traffic check; his wife
was attacked, though not raped or physically harmed,
on the way home from work one evening; and he was
the first on the scene to discover two children under
the age of 5 beaten to death in a“crack”house.
This accumulation of violence appears to have
affected Mr. Ramirez in several ways. He has had sev-
eral uncharacteristic outbursts of temper at minor
frustrations; on one occasion, to the distress of his fel-
low officers, he fired his police weapon with insuffi-
cient provocation. Somatic symptoms include a 15-
pound weight loss over the past 2 months, and
(according to his wife) restless sleep and nightmares
several times a week. In addition, he has become irra-
tionally overprotective of his family, refusing to let the
children visit friends’houses, and angrily demanding
that his wife stop work. At work he appears jumpy and
distractible, to an extent that has become a concern to
his fellow officers. When doing work requiring close
attention, he has, on several occasions, developed a
headache. Several of his written reports, usually
meticulously completed, have contained careless errors
and omissions. He has refused to discuss any of theseincidents or their impact with his partner, his immedi-
ate supervisor, or the police-appointed physician.
When asked about these unusual behaviors, Mr.
Ramirez denied that he had changed and claimed that
people were exaggerating. On probing, he admitted
that sometimes, when he is involved in unrelated daily
activities, he gets flashbacks (especially to the scene
with the dead children), but claimed that they neither
upset him nor made him lose concentration. He attrib-
uted his weight loss and restless sleep to the hot sum-
mer weather, and insisted throughout the assessment
process that he is“fine,”that the events of the past
months are just part of his job and of life, and that he
is capable of continuing to work as before.Reliability and Validity of Conclusions
At various points in the evaluation, Mr. Ramirez
became agitated and appeared irritated; he jokingly
accused the examiner of trying to make him remember
“things best forgotten.”In unstructured situations (the
Rorschach), he produced fewer responses as the test
proceeded. It is likely that his high level of arousal
affected the validity of his responses to unstructured
materials. He had fewer complaints regarding struc-
tured materials (the MMPI-2), but indices of validity
indicate an effort to present himself in a favorable
light and to deny pathology. During intellectually
challenging tasks (the WAIS-R), he appeared to try
hard and was minimally distracted.
All external evidence indicates that Mr. Ramirez’s
behavior over the past few weeks represents a consid-
erable departure from premorbid levels of functioning,
despite his denials. The results of procedures should
therefore be interpreted in the light of objective
information from external sources.Summary of Impressions and Findings
On both days of assessment, Mr. Ramirez arrived
punctually, in full uniform and meticulously groomed.
Whether standing or sitting, he held himself rigidly
and made little movement, as if at attention. He made
eye contact infrequently and briefly, and spoke in a
clear, quite loud, monotone voice, often pausing
before speaking, and rarely expanding upon his
answers without prompting. Even when he spoke of
his inner experiences, he gave the impression of a per-
son making a formal report to a superior. Only while
he was responding to unstructured material was there
a sense that his responses were spontaneous.A Case Illustration of a Clinical Report (Continued)304 CHAPTER 10