psychotherapeutic applications damon eaves, lcsw psychotherapeutic interventions for incarcerated...
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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