Psychotherapeutic Applications Damon Eaves, LCSW

1. Psychotherapeutic ApplicationsDamon Eaves, LCSW Psychotherapeutic Interventions for Incarcerated Psychotic inmates

2. 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)

3. 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

4. The Pseudo-Psychotic/Antisocial (Sklar) • 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. • They Present as: Hard to figure out, difficult to please, their “needs” are concrete and dictated, are savvy or intelligent • Defenses: withdrawal, denial, paranoid, somatic, a “false” self, primitive fantasy (psychopaths), projection (paranoids), blaming,, projection • 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.

5. Schizophrenia 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.

6. Thesis 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

7. 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

8. Freud’s Topographical Model1900 “The Interpretation of Dreams” • Our consciousmakes up a very small part of who we are. • Our preconscious or subconsciouscan 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”

9. Freud’s Topographic Model 1900, “The Interpretation of Dreams” Conscious Level Momentary Awareness Thoughts Perceptions Preconscious Level Accessible Memories Stored Knowledge Fears Violent Motives Immoral Urges Shameful Irrational Wishes Selfish Needs Experiences Unacceptable Sexual Desires Underlying Emotions Beliefs Impulses Unconscious Level Inaccessible Not aware of , not integrated into our personalities The Iceberg

10. Freud’s Structural Model1923, “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…

11. Freud’s Structural Model 1923, “The Ego and the Id” Conscious Preconscious Unconscious All psychic energy Originates Eros Thanatos 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

12. 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

13. 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 • in that the emphasis is placed on the “object relationships” vs. the resolution of erogenous zone stage conflicts.

14. Self Psychology • The “selfobject” relationship: We experience ourselves in relationship to others, and we experience others, in relationship to ourselves • Treatment • Principles: Mirroring, Idealizing & Twinship • Empathic Understanding • Analysis of Defense • Working through Self-Object Transference • Empathic Intune-ness between self/self-object • Differs from Freud • The focus is on the individual’s experience of relatedness through relationships vs. the resolution of erogenous zone stage conflicts.

15. Self-Psychology vs. Object Relations • Object Relations: Focus on (the quality of) the relationship. • Self-Psychology: Focus on (the subjectively experienced state of the self through) the relationship.

16. Acute Psychosis Conscious Level Thoughts Perceptions Preconscious Level Memories Stored Knowledge Indistinct Boundaries Fears Punishing Harsh Narcissistic Engrossed Regressed Paranoid Fears Violent Motives Immoral Urges Irrational Wishes Selfish Needs Shameful Experiences Unacceptable Sexual Desires Underlying Emotions Beliefs Impulses Ego Superego Id Unconscious Level

17. The Importance of Assessment & Relationship 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

18. Intervention with Psychotic Inmates Conscious Level Clinician/Therapist “Intra-Psychic” Agent. performing Ego/Superego functions Memories Stored Knowledge Preconscious Level Ego Superego Boundary Firming Id Unconscious Level Psychiatrist PHS Medications The Iceberg

19. 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

20. Rehabilitation Therapist takes the role of an Intra-Psychic Agent Lending Ego Strength “Socratic” Counseling “Reality Principle” Consistency Rationality Reality Testing “Soteria” Social Model Rehabilitation Clinician/Therapist “Intra-Psychic” Agent. Conscious Level Preconscious Level Ego Psychiatrist PHS Medications Superego Unconscious Level Id Medication Stabilization Positive Transference Discharge Planning The Iceberg

21. Clinical Social Work & 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”

22. For the future… • Multicultural Issues • Issues of Gender Identity & Sexual Preference • Discrimination, Sexism, Racism & Stigma • Social Justice Perspective • The Effect of Trauma & Crisis Intervention • Spirituality • Developmental Theory