Running head: THE SOLOIST
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The Soloist:
A Study on Schizophrenia
Kate Theall
Wake Forest University
9/8/14
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The Soloist: A Study on Schizophrenia
The Soloist follows the story of a phenomenon that is all-too-familiar in American society
today; a man experiencing mental illness and homelessness. Nathaniel Ayers is living out of a
shopping cart when a staff writer named Steve Lopez happens to run into him on the street.
Starved for a story, Lopez starts to catalog the interactions he has with Ayers, particularly as it
relates to Ayer’s incredible musical ability. What started as a human-interest story turned into
Lopez’s struggle between making the front page and navigating a friendship with a man affected
by schizophrenia.
Several diagnostic criteria must be present in order to assess and determine whether or
not a client has schizophrenia. Some of these qualifiers are obvious and demonstrated by Ayers
in his first meeting with Lopez. Others are hidden and take careful listening to discern. In the
DSM-5, “A” criteria consists of the presence of delusions, hallucinations, disorganized speech,
disorganized behavior or catatonia, and negative symptoms (American Psychiatric Association
2013.) Ayers has several beliefs that would classify as delusions. One of the earliest delusions
shown in the film is a young Ayers refusing soup a family member prepared for him due to his
belief that she was trying to feed him “acid.” Ayers asserts several times throughout his
relationship with Lopez that Lopez is “his God.” Ayer’s resists staying at the homeless shelter
because residents there litter cigarette butts “just to annoy him.”
It is clear that Ayers is plagued by hallucinations, even during childhood. Ayers
experiences an intense visual hallucination as an older child when he looks out his window late
one night and sees a flaming car roll by. During performance situations, Ayers hears
overwhelming auditory hallucinations of voices telling him various and often conflicting
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messages. In his conversations with Lopez, he asserts he can literally see the musical notes
floating in the underpass tunnel.
Within seconds of first meeting Ayers, Lopez experiences his disorganized speech
patterns. Ayers speaks quickly and jumps from topic to unrelated topic within seconds. Often
times his responses have nothing to do with the prompt or question at hand. After one
particularly long and confusing diatribe, Ayers quizzically asks Lopez if he is currently piloting
the airplane flying thousands of feet overhead. Along with disorganized speech, Ayer’s
behaviors could also be classified as disorganized.
Ayer’s behavior is erratic and sometimes volatile. When Ayers fled after becoming
distressed at the recital, Lopez had no clue as to where Ayers would end up. Ayer’s agitation
rose quickly when Lopez mentioned “schizophrenia,” and resulted in violence. Ayer also has
some negative symptoms such as limited facial expressions and avolitic, repetitive behavior. A
good example of this is when Lopez attempts to approach Ayers and Ayers is absorbed playing
the same violin chord repeatedly.
Ayers also meets the B-F criteria in the DSM-5 (American Psychiatric Association 2013.)
He is unable to care for himself and maintain a job due to his mental health status. Prior to the
disturbance, Ayers was a gifted musician training at a prestigious school. Ayers was unable to
complete his schooling and dropped out. Eventually he became estranged from his family and
lived on the street. It is clear that Ayers is not safe living without a home when he mentions to
Lopez how many times he has been mugged. Ayers had been experiencing symptoms for many
years, since late childhood. During the film, Ayers did not display any depressive or hypomanic
episodes that could account for his symptoms, nor did he use substances. There was no mention
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of Ayers being diagnosed with any childhood onset communication or autism spectrum disorders
(American Psychiatric Association 2013.)
The relationship between Lopez and Ayers could be described as both helpful and
harmful. The tone for the relationship is set by their first meeting, when Lopez sees Ayers as a
“human interest story” to benefit his writing career. In the beginning, Lopez is only considering
how he could benefit from the relationship, which I believe is unfair to Ayers due to his inability
to consent. Lopez and Ayers’ relationship is fairly unstructured, and the boundaries are blurred.
In an already chaotic world, I can understand how Ayers would be confused. How is it okay for
Lopez to sleep on the street next to Ayers and not okay for Ayers to show up at Lopez’s
workplace? The power differentials and blurry boundaries abound. Lopez added extra pressure
to Ayer’s life by having him perform a recital, which result in Ayers becoming so agitated that
he flees. Though Ayers’ and Lopez’s relationship had a rocky start, there are also some healthy
aspects of their relationship.
Lopez provided much needed human interaction and friendship for Ayers. Social and
familial support can lead to better outcomes for patients like Ayers (Seligman & Reichenberg
2014.) I think that Lopez’s frequent check-ins with Ayers convey a concern for Ayers’ safety.
Letting Ayers know that someone in the world cares about him can only be beneficial. Towards
the end of the film, Lopez reunites Ayers with his estranged sister and gets her involved in
Ayers’ life. Through Lopez, Ayers’ story is noticed by the public and policy-makers alike;
bringing money and aid to the homeless population in the area.
Lopez is confronted by Ellis and his differing views of how to best help Ayers. It is
obvious that both men care very much about helping Ayers. When Lopez brings up getting
Ayers evaluated and diagnosed, Ellis prefers that Ayers have autonomy over his care. I agree
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with Ellis’ point that the last thing Ayers needs is someone telling him something is “wrong”
with him; a statement he has probably heard from many different sources. I also agree with
Lopez’s approach to diagnosis getting Ayers access to proper care and a long term treatment
plan. Ellis counters by saying Ayers has not consented to treatment nor has he harmed anyone
else. I believe it is wrong of Lopez to try and look for evidence of Ayers being harmful so Ayers
will be involuntarily committed to treatment or hospitalization. Ellis seems to have a more
realistic outlook on Ayers’ condition and recovery. It is impossible to “fix” Ayers and rid him of
his condition, but it can be managed. Until the end of the film, Lopez is under the impression
that he can “fix” Ayers, and is almost in denial about his illness. Ellis’ and Lopez’s conversation
represent two sides of the diagnosis controversy. Ellis supports that diagnosis or labeling will do
more harm than good. Lopez asserts that proper diagnosis is needed to get appropriate help. I
think both men are right, but a compromise of both sides is what would aid Ayers the most.
Several kinds of interventions have been shown to help clients like Ayers. Stabilization
through medication and introduction of psychosocial interventions has been found to be most
effective. Behavioral, social skills training, cognitive behavioral therapy, familial education, and
medication management cover the many aspects of successfully treating a schizophrenic client
(Seligman & Reichenberg 2014.) Behavioral therapy could help Ayers take better care of
himself through learning practical and occupational life skills. Skills training in a group setting
could provide a safe place for Ayers to try out these new skills. Cognitive-behavioral therapy
(CBT) might be the most useful for Ayers in reducing stress associated with troublesome
psychotic symptoms. Research has shown that social support is as effective as CBT in reduction
of distressing symptoms, something Ayers seemed to respond well to in developing a friendship
with Lopez. It is obvious that Ayers experiences self-stigmatization when Lopez suggests that
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he has schizophrenia. CBT has been shown to reduce self-stigma surrounding mental illness.
CBT performed at the same time as antipsychotic medication can reduce positive symptoms of
schizophrenia. Ayers responded well to familial support at the end of the film. Educating the
family about schizophrenia has been shown to increase medication compliance and reduce
relapse by 25%. If Ayers remains on continuous medication and has his symptoms monitored,
is it possible he could increase functioning. Preventing relapse is essential to Ayers having a
positive prognosis (Seligman & Reichenberg 2014.)
The Soloist sparks an interesting debate regarding how our society views a mental illness
like schizophrenia. Like Lopez, I think many of us are tempted to label and “fix” someone like
Ayers through diagnosis and medication. While medication can help someone with
schizophrenia, I think it is important to consider the client’s autonomy in having a voice in their
care. Medication alone will not “cure” schizophrenia; but combined with psychosocial
interventions and social/familial support, clients with schizophrenia can live with less distress
associated with their illness (Seligman & Reichenberg 2014.) As mental health professionals we
have an important job to not only dispelling self-stigmatization in clients, but also to destigmatize mental illness in the eyes of the public.
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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.