Psychotherapeutic Applications The Woozy'com

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Psychotherapeutic ApplicationsThe Woozy.com

• Psychological Applications for Incarcerated
  Psychotic inmates

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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(medication
  s), delirium, culture bound
• -Not by self report, (Axis II)

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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

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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/factitiou
  s 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.

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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 20s, 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.

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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

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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

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Freuds Topographical Model1900 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

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Freuds 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

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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

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Object Relations

• Karl Abraham in 1927 Selected Papers
• Madeleine Klein in 1932 The Psychoanalysis of
  Children
• The British School in the 40s
• 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.

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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 individuals experience of
  relatedness through relationships vs. the
  resolution of erogenous zone stage conflicts.

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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.

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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

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Therapeutic Dos

• Dont worry, dont 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

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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
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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

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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