Psychotherapeutic Psychotherapeutic ApplicationsApplications

Damon Eaves, LCSWDamon Eaves, LCSW

Psychotherapeutic Psychotherapeutic Interventions for Interventions for

Incarcerated Psychotic Incarcerated Psychotic inmatesinmates

Psychosis/Schizophrenia Psychosis/Schizophrenia DefinedDefined

Orientation to and interpretation of reality.Orientation to and interpretation of reality.Effects all areas of perception.Effects all areas of perception.Psychosis can be found in: mood and personality disorders, Psychosis can be found in: mood and personality disorders,

schizophrenia, delusional disorder, and substance abuse.schizophrenia, delusional disorder, and substance abuse. Insight impaired, believe delusions/hallucinations are realInsight impaired, believe delusions/hallucinations are real

-Delusions -Delusions -Hallucinations -Hallucinations -disorganized, incoherent, Speech-disorganized, incoherent, Speech

-disorganized or catatonic behavior-disorganized or catatonic behavior

-Negative symptoms flat, impoverished, volition, hygiene-Negative symptoms flat, impoverished, volition, hygiene

-*No DD, medical condition, substances(medications), -*No DD, medical condition, substances(medications), delirium, culture bounddelirium, culture bound

-*Not by self report, (Axis II)-*Not by self report, (Axis II)

Problems Specific to Incarcerated Settings

-Engrossed/Regressed in urine/feces-Engrossed/Regressed in urine/feces

-Hygiene-Hygiene

-Inability to program/comply-Inability to program/comply

-Incompetent, resolution of charges-Incompetent, resolution of charges

-Non-compliance with medication-Non-compliance with medication

-5150-5150

-Discharge planning issues-Discharge planning issues

-Failure to thrive-Failure to thrive

-Extravert Psychotic (behavioral, hyper-verbal, Axis II-Extravert Psychotic (behavioral, hyper-verbal, Axis II

Suicidal, Threat to OthersSuicidal, Threat to Others

-Introvert Psychotic (regressed, isolated, failure to thrive, -Introvert Psychotic (regressed, isolated, failure to thrive, disengaged)disengaged)

Gravely DisabledGravely Disabled

The The Pseudo-Psychotic/AntisocPseudo-Psychotic/Antisoc

ial ial (Sklar)(Sklar) Symptoms are self- presented in clinical termsSymptoms are self- presented in clinical terms, , yet with little observed yet with little observed collaboration: i.e., auditory hallucinations, depressed, thoughts of self/harm, collaboration: i.e., auditory hallucinations, depressed, thoughts of self/harm, drug use history, malingering/factitious disorder. drug use history, malingering/factitious disorder.

They Present as:They Present as: Hard to figure out, difficult to please, their “needs” Hard to figure out, difficult to please, their “needs” are concrete and dictated, are savvy or are concrete and dictated, are savvy or intelligentintelligent

Defenses:Defenses: withdrawal, denial, paranoid, somatic, a “false” self, withdrawal, denial, paranoid, somatic, a “false” self, primitive fantasy (psychopaths), projection (paranoids), blaming,, primitive fantasy (psychopaths), projection (paranoids), blaming,, projectionprojection

Problematic behaviors:Problematic behaviors: poor hygiene, repetitive banging, threats of poor hygiene, repetitive banging, threats of suicide, frequent IOL, some safety cell, drug seeking, grievances, non-suicide, frequent IOL, some safety cell, drug seeking, grievances, non-compliant, refuses to be seen. compliant, refuses to be seen.

Rarely is the diagnostic picture, but with history, warrant medication ( Rarely is the diagnostic picture, but with history, warrant medication ( psychosis nos)psychosis nos)

Rarely do they exhibit classic thought and speech disturbance or Rarely do they exhibit classic thought and speech disturbance or classic positive or any negative symptoms. classic positive or any negative symptoms.

The goal is usually management with minimal investment and to not The goal is usually management with minimal investment and to not be outsmarted/manipulated.be outsmarted/manipulated.

Schizophrenia FactsSchizophrenia Facts• 1% of population regardless of culture, geography or

ethnicity.• Men and women =• Concordance in identical twins is only 50%.• It involves developmental & degenerative features.• Symptoms start in late teens, early 20’s, but can start

at any time. • Symptoms are highly variable, wax and wane and even

remit (lifelong process).• Rarity of rheumatoid arthritis.• Up to 80% of individuals with schizophrenia will abuse

substances.• 40% to 60% attempt suicide, 10% will die from suicide.

Thesis StatementThesis Statement

Regardless of psychosis diagnosis…• 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 TheoriesDevelopmental Theories

Sigmund Freud (1917): Sigmund Freud (1917): Oral, Anal, Phallic, Latency GenitalOral, Anal, Phallic, Latency Genital

Jean Piaget (1954):Jean Piaget (1954): Cognitive Development Cognitive Development

Erik Erikson (1950):Erik Erikson (1950): 8 Stages, Developmental Challenges 8 Stages, Developmental Challenges

Margaret Mahler(1974):Margaret Mahler(1974): 3 phases, 3 sub-phases of 3 phases, 3 sub-phases of individuationindividuation

Melanie KleinMelanie Klein: 2 positions, Infantile Psychic Development,: 2 positions, Infantile Psychic Development,

Lawrence Kohlberg (1970):Lawrence Kohlberg (1970): 6 Stages of Moral Development 6 Stages of Moral Development

John Bowlby:John Bowlby: Social, Attachment theory Social, Attachment theory

*Impacted by environment & caretaking/parenting*Impacted by environment & caretaking/parenting

*Development is linear. Each stage builds on each other*Development is linear. Each stage builds on each other

*The type of issue can be identified/predicted by the stage*The type of issue can be identified/predicted by the stage

*Criticism is Social, Cultural, Economic, Environment*Criticism is Social, Cultural, Economic, Environment

Freud’s Topographical Freud’s Topographical ModelModel

1900 “The Interpretation of Dreams”1900 “The Interpretation of Dreams”

• Our conscious makes up a very small part of who we are.

• Our preconscious or subconscious can be accessed by us if prompted. (If it can be accessed, then it is not in the unconscious)

• Most of what drives us lies in the unconscious unknowable, can not be accessed.

• “The Iceberg Theory”

Thoughts

Perceptions

Memories

Stored Knowledge

Fears Violent Motives

Immoral Urges Shameful

Irrational Wishes

Selfish Needs

Experiences

Unacceptable Sexual Desires

Underlying Emotions Beliefs

Impulses

Freud’s Topographic Model 1900, “The Interpretation of Dreams”

Conscious LevelMomentary Awareness

Preconscious LevelAccessible

Unconscious LevelInaccessible

Not aware of , not integrated into our personalities

The Iceberg

Freud’s Structural ModelFreud’s Structural Model1923, “The Ego and the Id”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 Model1923, “The Ego and the Id”

Superego (5)

Social

Conscience

& Ego Ideal

Morals/Ethics

Moral Anxiety

Emerges at the conclusion of the Phallic

Stage

Ego (0-3)

Psychological

“Reality Principle”

Secondary Process

Functions/Defenses

Reality Anxiety

Id (0)

Biological

“Pleasure Principle”

Primary Process

Desires/Drives

Eros & Thanatos

Neurotic Anxiety

The Iceberg

Conscious

Preconscious

Unconscious

All psychic energyOriginatesEros Thanatos

Ego Functions & Ego Functions & DefensesDefenses

Ego functions and defenses are mostly unconsciousEgo functions and defenses are mostly unconsciousseamless, 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 unhealthyDefenses are not necessarily unhealthy

Health Health involves good ego functions and selective/appropriate use of higher level defenses

Object RelationsObject RelationsKarl Abraham in 1927:Karl Abraham in 1927: “Selected Papers” “Selected Papers” Madeleine Klein in 1932:Madeleine Klein in 1932: “The Psychoanalysis of Children” “The Psychoanalysis of Children” The British School in the 40’s:The British School in the 40’s:

W. R. D. Fairbairn, D. W. Winnicott and Henry GuntripW. R. D. Fairbairn, D. W. Winnicott and Henry Guntrip

Object Relations Therapy is altering the selfobject Object Relations Therapy is altering the selfobject in relationships:in relationships:

1. Identifying Maladaptive Relational Patterns 2. Empathic Confrontation3. Working Through4. Transference5. Consolidation 6. Generalization7. Termination

Differs from FreudDiffers from Freud • in that the emphasis is placed on the “object relationships” vs. in that the emphasis is placed on the “object relationships” vs.

the resolution of erogenous zone stage conflicts.the resolution of erogenous zone stage conflicts.

Self PsychologySelf Psychology

• The “selfobject” relationship: We experience The “selfobject” relationship: We experience ourselves in relationship to others, and we ourselves in relationship to others, and we experience others, in relationship to ourselvesexperience others, in relationship to ourselves

• TreatmentTreatment• Principles: Mirroring, Idealizing & TwinshipPrinciples: Mirroring, Idealizing & Twinship

• Empathic UnderstandingEmpathic Understanding• Analysis of DefenseAnalysis of Defense• Working through Self-Object TransferenceWorking through Self-Object Transference• Empathic Intune-ness between self/self-objectEmpathic Intune-ness between self/self-object

Differs from FreudDiffers from Freud • The focus is on the individual’s experience of relatedness The focus is on the individual’s experience of relatedness

through relationships through relationships vs. the resolution of erogenous zone stage vs. the resolution of erogenous zone stage conflicts.conflicts.

Self-Psychology vs. Object Self-Psychology vs. Object RelationsRelations

Object Relations: Focus on (the Object Relations: Focus on (the quality of) the relationship.quality of) the relationship.

Self-Psychology: Focus on (the Self-Psychology: Focus on (the subjectively experienced state of the subjectively experienced state of the self through) the relationship. self through) the relationship.

Thoughts

Perceptions

Memories

Stored Knowledge

Fears Violent Motives

Immoral Urges Irrational Wishes

Selfish Needs Shameful

Experiences

Unacceptable Sexual Desires

Underlying Emotions Beliefs

Impulses

Acute Psychosis

Indistinct

Boundaries

Fears Punishing Harsh

Narcissistic Engrossed Regressed Paranoid

Ego

IdSuperego

Conscious Level

Preconscious Level

Unconscious Level

The Importance of Assessment & The Importance of Assessment & Relationship in TreatmentRelationship in Treatment

• Assessment & Relationship allows: • 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

Memories

Stored Knowledge

Intervention with Psychotic Inmates

Conscious Level

Preconscious Level

Unconscious Level

The Iceberg

Boundary

Firming

Clinician/Therapist

“Intra-Psychic” Agent.

performing Ego/Superego

functions

Psychiatrist

PHS

Medications

Ego

Superego

Id

Therapeutic “Do’s”Therapeutic “Do’s”Don’t worry, don’t be afraidRemember your purpose / rehab. behav.Focus on your Goals & ObjectivesBe Consistent and PredictableIntensityAssessment / Fact Gathering

OrientationRe-DirectionShort ResponseCut off RamblingEmpathyChallenge/ignore distortionsCall and response

RehabilitationTherapist takes the role of an Intra-

Psychic Agent

Lending Ego Strength

“Socratic” Counseling

“Reality Principle”

Consistency

Rationality

Reality Testing

“Soteria” Social Model Rehabilitation

Conscious Level

Preconscious Level

Unconscious Level

The Iceberg

Clinician/Therapist

“Intra-Psychic”

Agent.

Psychiatrist

PHS

Medications

Medication

Stabilization

Positive Transference

Discharge Planning

Ego

Id

Superego

Clinical Social Work Clinical Social Work & Forensic Psychosis & Forensic Psychosis

A person-in-situation perspective: psychology, development, environment, substance use, culture, education, disability, minority status, economics, medical, etc.

• Ego Rehabilitation: Lending of Ego, Ego Support, Superego Moderation, Id Taming

• Tasks: synthesis, integration, regulation, organization, decision making, delay, drive taming, rehearsal, judgment, memory, reality testing, speech

Important Points • Based on psycho-dynamic/therapeutic principles• Encourages worker to be eclectic/versatile in intervention

methods

(Freudian, Object Relations, Self-Psychology, Developmental Theorist)

• Therapist Factors: self-aware, self-critical, professionally disciplined, and “responsible”.

• Differs from “Therapy” in that it requires a “directive approach”

For the future…For the future…

Multicultural IssuesMulticultural Issues Issues of Gender Identity & Sexual PreferenceIssues of Gender Identity & Sexual Preference Discrimination, Sexism, Racism & StigmaDiscrimination, Sexism, Racism & Stigma Social Justice PerspectiveSocial Justice Perspective The Effect of Trauma & Crisis InterventionThe Effect of Trauma & Crisis Intervention SpiritualitySpirituality Developmental TheoryDevelopmental Theory