Transcript 7. Forensic Mental Health: Psychotherpeutic

Psychotherapeutic
Applications
Damon Eaves, LCSW
Psychotherapeutic
Interventions for Incarcerated
Psychotic inmates
Psychosis/Schizophrenia
Defined
Orientation to and interpretation of reality.
Effects all areas of perception.
Psychosis can be found in: mood and personality disorders,
schizophrenia, delusional disorder, and substance abuse.
Insight impaired, believe delusions/hallucinations are real
-Delusions
-Hallucinations
-disorganized, incoherent, Speech
-disorganized or catatonic behavior
-Negative symptoms flat, impoverished, volition, hygiene
-*No DD, medical condition, substances(medications), delirium,
culture bound
-*Not by self report, (Axis II)
Problems Specific to
Incarcerated Settings
-Engrossed/Regressed in urine/feces
-Hygiene
-Inability to program/comply
-Incompetent, resolution of charges
-Non-compliance with medication
-5150
-Discharge planning issues
-Failure to thrive
-Extravert Psychotic (behavioral, hyper-verbal, Axis II
Suicidal, Threat to Others
-Introvert Psychotic (regressed, isolated, failure to thrive, disengaged)
Gravely Disabled
The PseudoPsychotic/Antisocial (Sklar)
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Symptoms are self- presented in clinical terms, yet with little observed
collaboration: i.e., auditory hallucinations, depressed, thoughts of self/harm, drug use
history, malingering/factitious disorder.
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They Present as: Hard to figure out, difficult to please, their “needs” are
concrete and dictated, are savvy or intelligent
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Defenses: withdrawal, denial, paranoid, somatic, a “false” self, primitive
fantasy (psychopaths), projection (paranoids), blaming,, projection
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Problematic behaviors: poor hygiene, repetitive banging, threats of suicide,
frequent IOL, some safety cell, drug seeking, grievances, non-compliant,
refuses to be seen.
Rarely is the diagnostic picture, but with history, warrant medication (
psychosis nos)
Rarely do they exhibit classic thought and speech disturbance or classic
positive or any negative symptoms.
The goal is usually management with minimal investment and to not be
outsmarted/manipulated.
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Schizophrenia Facts
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1% of population regardless of culture, geography or ethnicity.
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Men and women =
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Concordance in identical twins is only 50%.
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It involves developmental & degenerative features.
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Symptoms start in late teens, early 20’s, but can start at any
time.
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Symptoms are highly variable, wax and wane and even remit
(lifelong process).
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Rarity of rheumatoid arthritis.
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Up to 80% of individuals with schizophrenia will abuse
substances.
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40% to 60% attempt suicide, 10% will die from suicide.
Thesis Statement
Regardless of psychosis diagnosis…
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Understanding the patients developmental history
The use of models of development
The use of models of Personality/Psychic Development
We can enhance rehabilitation
We can target our psychodynamic & psychopharmacological
interventions
• Thereby increasing our chances of treatment success in and out
of custody
Goal…
By using Freud, Object-relations, Self-Psychology, we will look
at psychotic structure and arrive at an understanding which
will serve as the basis for our intervention
Developmental Theories
Sigmund Freud (1917): Oral, Anal, Phallic, Latency Genital
Jean Piaget (1954): Cognitive Development
Erik Erikson (1950): 8 Stages, Developmental Challenges
Margaret Mahler(1974): 3 phases, 3 sub-phases of individuation
Melanie Klein: 2 positions, Infantile Psychic Development,
Lawrence Kohlberg (1970): 6 Stages of Moral Development
John Bowlby: Social, Attachment theory
*Impacted by environment & caretaking/parenting
*Development is linear. Each stage builds on each other
*The type of issue can be identified/predicted by the stage
*Criticism is Social, Cultural, Economic, Environment
Freud’s Topographical Model
1900 “The Interpretation of Dreams”
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Our conscious makes up a very small part of who we are.
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Our preconscious or subconscious can be
accessed by us if prompted. (If it can be accessed, then it is
not in the unconscious)
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Most of what drives us lies in the unconscious
unknowable, can not be accessed.
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“The Iceberg Theory”
Freud’s Topographic Model
1900, “The Interpretation of Dreams”
Conscious Level
Thoughts
Momentary Awareness
Perceptions
Memories
Preconscious Level
Stored Knowledge
Accessible
Fears
Violent Motives
Immoral Urges
Shameful
Irrational Wishes
Selfish Needs
Unconscious Level
Experiences
Inaccessible
Not aware of , not integrated into
our personalities
Unacceptable Sexual Desires
Underlying Emotions
Impulses
Beliefs
The Iceberg
Freud’s Structural Model
1923, “The Ego and the Id”
Superego- end of the Phallic Stage, by the age of 5
“Conscience”
Ego- with interaction with the world, the ego develops.
“Reality Principle”
Id- we are born with the id. Our most basic needs
“Pleasure Principle”
In healthy individuals
the ego is able to transform and
satisfy the drives of the id, act in accordance with the superego and
while finding appropriate reality outlets to achieve the organisms
ends.
In unhealthy individuals…
Freud’s Structural Model
1923, “The Ego and the Id”
Conscious
Superego (5)
Ego (0-3)
Psychological
Preconscious
“Reality Principle”
Secondary Process
Social
Functions/Defenses
Reality Anxiety
Conscience
& Ego Ideal
Id (0)
Unconscious
Biological
Morals/Ethics
All psychic energy
Originates
Moral Anxiety
Eros Thanatos
Emerges at the
conclusion of the
Phallic Stage
“Pleasure Principle”
Primary Process
Desires/Drives
Eros & Thanatos
Neurotic Anxiety
The Iceberg
Ego Functions & Defenses
Ego functions and defenses are mostly unconscious
seamless, varied, integrated, “real”
Ego Functions: interpretation, synthesis, regulation,
judgment, volition,
Ego Defenses: defense mechanisms to decrease
anxiety, to mediate relationships and respond to
ego threats
Defenses are not necessarily unhealthy
Health involves good ego functions and
selective/appropriate use of higher level defenses
Object Relations
Karl Abraham in 1927: “Selected Papers”
Madeleine Klein in 1932: “The Psychoanalysis of Children”
The British School in the 40’s:
W. R. D. Fairbairn, D. W. Winnicott and Henry Guntrip
Object Relations Therapy is altering the selfobject in
relationships:
1. Identifying Maladaptive Relational Patterns
2. Empathic Confrontation
3. Working Through
4. Transference
5. Consolidation
6. Generalization
7. Termination
Differs from Freud
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in that the emphasis is placed on the “object relationships” vs. the
resolution of erogenous zone stage conflicts.
Self Psychology
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The “selfobject” relationship: We experience
ourselves in relationship to others, and we
experience others, in relationship to ourselves
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Treatment
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Principles: Mirroring, Idealizing & Twinship
• Empathic Understanding
• Analysis of Defense
• Working through Self-Object Transference
• Empathic Intune-ness between self/self-object
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Differs from Freud
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The focus is on the individual’s experience of relatedness
through relationships vs. the resolution of erogenous zone stage
conflicts.
Self-Psychology vs. Object Relations
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Object Relations: Focus on (the quality of)
the relationship.
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Self-Psychology: Focus on (the
subjectively experienced state of the self
through) the relationship.
Acute Psychosis
Conscious Level
Thoughts
Perceptions
Memories
Preconscious Level
Stored
Knowledge
Indistinct
Fears
Boundaries
Violent Motives
Immoral Urges Fears
Irrational
Punishing
WishesHarsh
Narcissistic
Selfish Needs
Unconscious Level
Shameful
Engrossed
Experiences
Regressed
Unacceptable
Sexual Desires
Paranoid
Underlying Emotions
Impulses
Beliefs
The Importance of Assessment &
Relationship in Treatment
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Assessment & Relationship allows:
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Insight into the quality of early life Development,
Insight into the current issues
diagnostic information of the psychic apparatus/issue
in need of intervention
Forms the basis of the Intervention/Objectives/Tx.
Plan
Clinically Supported Prediction:
Behavior during psychosis and content
Intervention with Psychotic Inmates
Conscious Level
Clinician/Therapist
“Intra-Psychic”
Preconscious Level
Memories
Stored Knowledge
Agent.
performing
Ego/Superego
functions
Boundary
Firming
Unconscious Level
Psychiatrist
PHS
Medication
s
The Iceberg
Therapeutic “Do’s”
Don’t worry, don’t be afraid
Remember your purpose / rehab. behav.
Focus on your Goals & Objectives
Be Consistent and Predictable
Intensity
Assessment / Fact Gathering
Orientation
Re-Direction
Short Response
Cut off Rambling
Empathy
Challenge/ignore distortions
Call and response
Rehabilitation
Therapist takes the role of an IntraPsychic Agent
Lending Ego Strength
Clinician/Therapist
“Socratic” Counseling
“Reality Principle”
Conscious Level
“Intra-Psychic”
Consistency
Agent.
Rationality
Reality Testing
Preconscious Level
“Soteria” Social Model
Rehabilitation
Superego
Ego
Psychiatrist
PHS
Medications
Unconscious Level
Id
Medication
Stabilization
Positive
Transference
Discharge
Planning
The Iceberg
Clinical Social Work
& Forensic Psychosis
A person-in-situation perspective: psychology, development, environment,
substance use, culture, education, disability, minority status, economics, medical, etc.
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Ego Rehabilitation: Lending of Ego, Ego Support, Superego
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Moderation, Id Taming
Tasks: synthesis, integration, regulation, organization, decision making,
delay, drive taming, rehearsal, judgment, memory, reality testing, speech
Important Points
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Based on psycho-dynamic/therapeutic principles
Encourages worker to be eclectic/versatile in intervention methods
(Freudian, Object Relations, Self-Psychology, Developmental Theorist)
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Therapist Factors: self-aware, self-critical, professionally disciplined,
and “responsible”.
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Differs from “Therapy” in that it requires a “directive approach”
For the future…
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Multicultural Issues
Issues of Gender Identity & Sexual Preference
Discrimination, Sexism, Racism & Stigma
Social Justice Perspective
The Effect of Trauma & Crisis Intervention
Spirituality
Developmental Theory