Erik Erikson's Stages of Development: Part 2

Welcome back!  We’re still discussing Erik Erikson’s stages of psychosocial development.  In my last entry we covered ages 0 - 12.  This one will cover adolescence through adulthood.  

Ego Identity vs Role Confusion (12 - 18 years):  During adolescence a person is starting to look forward, and becoming more independent.  They will start to explore different roles they will assume in adulthood, both personally and professionally.  The person is also changing physically as they enter puberty.  Too much pressure from outside sources leads to rebellion.  Yet at the same time, guidance is still needed, as the person is not yet capable of making long-term, adult decisions.  Role confusion occurs when the person is not able to make decisions about themselves or their role in society by the end of this stage.  The person may go through different phases of trying on different roles.  It is important not to minimize these roles.  They are of the utmost significance for the person to come to a personal identity.  Rather, parents, teachers, and other significant adults can act as guides and mentors.  Encourage teens to explore within safe limits.  Talk to them about what they’re learning as they move through this period of time.  the trust, autonomy, initiative, and industry the person has developed in the 12 years prior will be necessary in order to resolve this stage.  See how that works?  Stages can’t be skipped, and have to happen in their proper order.  The virtue developed during Ego Identity versus Role Confusion is fidelity.  In this context, fidelity refers to the ability to commit oneself to others, even when there may be significant differences, such as beliefs.  Pressuring someone into an identity or role during this time can not only result in rebellion, but also in confusion about oneself, and place in society.

Intimacy vs Isolation (18 - 40 years):  This is when we start focusing on romantic and sexual relationships.  We explore these relationships, and begin to establish commitments to long term partners.  Since we know that stages build on the ones before it, we can see how the stage preceding this one is so important: a person needs to have an established identity in order to function as part of a couple.  The virtue of fidelity, the ability to commit, is key in establishing long term relationships.  

Close friendships are also important.  Erikson defined an intimate relationship as one characterized by closeness, intimacy, and love. Successful completing of this stage leads to commitment, safety, and care.  Isolation, loneliness, and depression can result if this stage is not resolved.  The virtue learned during this stage is love.

Generativity vs Stagnation (40 - 65 years):  Okay, so we trust people and are able to individuate and be independent.  We can take initiative, and feel competent.  We even have a committed relationship.  Not too shabby!  So now we take all of these accomplishments, and focus on career and family.  We begin to focus on the bigger picture: What do I contribute to society?  These contributions come in the form of raising our children, and being productive in the workplace.  Additionally it may come from commitments made to others, developing familial relationships, and mentoring and contributing to the next generation or generations.  Generativity comes from feeling that we are, indeed, of value, and have a place in the bigger picture.  Stagnation is the feeling that we have not contributed.  A person experiencing stagnation may feel insignificant, disconnected, or apathetic about their community and society. 

It is also important to note that this age is also when people may experience “midlife crisis.”  They may regret past choices, and feel that they no longer have time to correct mistakes.  Some may still make changes that lead to increased feelings of productivity.  Those who are able to make changes which end up enhancing their quality of life report greater satisfaction long-term.  Those with health problems, troubled relationships, and feel they have no control over their life’s trajectory are more likely to experience stagnation.  The virtue developed in this stage is care.

Integrity vs Despair (65+):  It is worth noting that Erikson is one of the few developmental theorists to address aging.  It’s also interesting (and I think pretty cool!) that Erikson acknowledged that development continues throughout a person’s life, and does not end when a person reaches adulthood (take that, Siggy!). The final stage is that of Integrity versus despair.  A person in this stage is coming to terms with whether they feel thy have lived a meaningful life?  During this time, a person will likely experience significant losses of a spouse, siblings, extended family, and/or friends.  The onset of this stage is often precipitated by a significant loss.  A person who achieves integrity during this stage will look back at their life with feelings of content, wisdom, and peace.  Wisdom is, in fact, the virtue attained during this stage. 

Erikson’s theory has limitations, as any theory does.  It does not define definite tasks that symbolize when one stage ends, and another begins.  Later stages also don’t carry the same diagnostic influences on personality as earlier stages.  It’s also very ethnocentric to western culture.  What I like about this theory is it feels like something almost everybody in western culture can relate to, and understand.  When I talk about this theory with clients and friends, it makes sense.  As a clinician, I see elements of all of the developmental theories and models which are relevant.  Yes, I said all.  I present this information here to you to help you to be better informed.  I strongly discourage self-diagnosis.  But if this gives you context and language to better understand yourself or someone else, then I have achieved my goal for this blog.  Pop quiz…what stage would this be?

Be well.

Cherry, K. (2016). Erik Erikson's Stages of Psychosocial Development. Retrieved from https://www.verywell.com/erik-eriksons-stages-of-psychosocial-development-2795740

McLeod, S. A. (2013). Erik Erikson. Retrieved from www.simplypsychology.org/Erik-Erikson.html

Erik Erikson's Stages of Development: Part 1

I am going to start a series on personality disorders soon.  Call me crazy (groan), but I’m looking forward to it.  Before we get to personality disorders, however, I’ve got another developmental theory I need to share with you first.  I really like this one.  It makes so much sense to me.  The theorist is a German-born American psychoanalyst named Erik Erikson…the theorist so nice, they named him twice!  Sorry, I’m just really happy to not be writing about Freud.  Erikson was actually heavily influenced by Freud.  But I like his theory so much, I don’t hold it against him, it’s THAT good!

Erikson’s 8 stages of psychosocial development cover the entire lifespan.  Each stage consists of a crisis that must be resolved in order to move on to the next stage.  Like we’ve talked about before, a person has to resolve a stage before they can go on to the next one.  If they don’t, they won’t have the skills they will need to resolve future stages.  The super scientific clinical term for this is the epigenic principle.  And away we go…

Trust vs Mistrust (0 - 18 months):  I always think about this stage when someone says somebody was too young to remember something, or have an event affect them.  There’s no such thing as too young.  Our task as newborns is to eat, sleep, and eliminate.  It’s pretty basic.  However, we are also completely dependent on our caregivers.  At this stage, especially early in the stage, our only means of communication is to cry.  One of two things happens when we cry as newborns: either our caregiver comes and meets our need (feeding, changing, rocking), or they don’t.  If they come take care of us, we learn that the world is basically a safe place, and we can trust other people when we have needs.  If they don’t, we learn that people are not to be trusted.  Our need doesn’t change, but our ability to create trusting bonds never develops.  Also remember that a person has to resolve this stage in order to move on to the next.  Our ability to trust is being developed as soon as we are born.  This is a core need in relationships.  Successfully resolving this stage teaches the virtue of hope.

Autonomy vs Shame and Doubt (18 months - 3 years):  At this age, we are starting to explore, independent of our caregiver.  We begin to develop and express preferences.  Examples of choices we may make for ourselves, whether invited to or not, include food, clothes, and toys.  Terrible two’s, anyone?  While this may be an incredibly frustrating time for the caregiver, the child is doing exactly what they are supposed to do…learning to assert their autonomy!  The child is no longer an extension of the caregiver.  This stage requires a delicate balance.  On one hand, the child needs to assert autonomy, and start learning tasks.  On the other, failure to achieve tasks results in shame and doubt.  The caregiver can help the child resolve this stage by providing positive encouragement.  If the child fails at a task, the caregiver can still praise them for trying, and help them modify the task and try again.  Successful resolution of this stage results in confidence and security in abilities.  Children who are criticized or overly controlled during this stage will doubt their own abilities, which may lead to dependence, and lack of self esteem.  The value learned at this stage is will.

Initiative vs Guilt (3 - 5 years):  During this stage, a child is starting to interact with other children, and is learning to play with others.  Play involves making up games, planning activities, and initiating activities with others.  The child is learning decision making, and the beginnings of leadership.  If these tasks are thwarted too much by criticism or control, the child will develop guilt about these activities, and will end up lacking initiative.  This is also the “why?” stage.  As frustrating as it may be, it is extremely important that the child not be treated as a nuisance, nor shamed.  This inhibits creativity and relationship building. 

Morality is also taking shape at this stage.  Positive reinforcement can help the child learn right from wrong without introducing an undue amount of guilt.  Resolution of this stage results in the virtue of purpose.

Industry vs Inferiority (5 - 12 years):  Think of “industry” as competence.  This is the elementary school age, when the child is learning basic academic skills like reading, writing and math.  The child’s peers become more significant, and the focus becomes earning acceptance.  Self esteem comes from having competence reinforced and encouraged.  Otherwise the child will doubt their abilities.  A sense of inferiority comes from not being able to attain desired skills.  While a degree of modesty is also important, it must be balanced with competence.  Competence is the value learned during this stage. 

I’m going to break this up into two entries.  This one has covered childhood, and the skills a person needs going into adolescence.  From here, we start moving into sexual and romantic relationships.  See you there!

Be well.

Cherry, K. (2016). Erik Erikson's Stages of Psychosocial Development. Retrieved from https://www.verywell.com/erik-eriksons-stages-of-psychosocial-development-2795740

McLeod, S. A. (2013). Erik Erikson. Retrieved from www.simplypsychology.org/Erik-Erikson.html

Yo' Momma! Freud's Stages of Development

This entry will use sexual terminology.  Some people with trauma history may find it triggering.  As with anything on IOI, please be safe.

All right friends, I am so sorry to do this to you.  I really like you guys, gals, and however else you may identify.  I agonized over this decision, and just couldn’t find any way around it.  I am so sorry.  Let’s just rip the bandage off and get this done…Today’s entry is about Dr. Sigmund Freud’s theory of development.  I went back and forth on whether to write about Freud.  There are other theories I will be writing about that expand and improve on Freud’s theory.  Freud also made some contributions to psychiatry and psychology with which I strongly agree, and I look forward to writing about those.  I think it’s important to know Freud’s stages though.  They are such a part of our everyday life, we talk about them without really being aware of it.  So, let’s jump right in and get this done.  Here we go…

Freud’s stages of psychosexual development:

Freud’s theory consists of five stages.  During each stage, a person faces a unique conflict, which must be resolved in order to move on to the next stage, and develop a healthy personality.  Problems arise when a conflict is not resolved, and libido gets stuck.  Libido is an unconscious, basic, internal energy bade up of basic needs: hunger, thirst, and sexual. 

The Oral Stage (0 - 1.5 years): During the Oral Stage, the pleasure center is the mouth.  The focus is on feeding, weaning, and then tooth eruption.  Not resolving the Oral Stage results in dependency, sarcasm, rejection, smoking, addiction, gullibility, and starving oneself, over eating, or any eating disorder.  If you hear someone being referred to as “orally fixated,” this is to what that phrase is referring!

The Anal Stage (1.5 - 2.5 years): The pleasure source is the anus.  The task to be mastered is toilet training.  Problems arising from not resolving this stage include rigidity, over-generosity, stinginess, Obsessive-Compulsive Disorder, irresponsibility, and rebelliousness.  When someone is referred to as “anal retentive,”  this is it right here!  An unresolved Anal Stage.

The Phallic Stage (2.5 - 5 or 6 years): As you’d expect from the name, the pleasure source is the genitals.   During this time, the task is to identify with the same-sex parent.  Not resolving this stage is what we are talking about when someone is said to have an “Oedipal Complex.”  During this stage, a person desires the opposite-sex parent, and sees the same-sex parent as competition.  An unresolved phallic stage is the cause of anxiety, extreme guilt, phobias, depression, improper sexual identity, and fear of authority.

The Latency Stage (Age 6 - pre-adolescence): During this time, earlier stages and libido are suppressed.  The focus is on play, and relationships with same-gender peers.

The Genital Stage (Adolescence through Adulthood): The task for this stage is finding a spouse.  During this stage, there are no new conflicts to resolve.  However, older, unresolved conflicts will arise.  Adult behavior, according to this theory, is influenced by all of the previous stages.  

We did it, friends!  That’s Freud’s theory of psychosexual development.  I believe it has merit, but that human development and behavior is more complicated than this.  Fortunately, so did other behaviorists.  As we discuss future theories on development, Freud’s influence will be apparent.  Freud’s theory of development will also be seen in some of his other theories, like the Model of the Mind.  But now that we’ve got this one out of the way, we can get onto some more fun stuff.  Leave it to Siggy to take the fun out of talking about sex!  I’m going to go orally fixate on some lunch now.

Be Well.

A Quick Admin Note

Hi friends!

I have changed a couple of settings: First, I've made it so that you can comment anonymously and without a Google account.  But in order to do this and keep spam and trolls off the blog, I have changed settings so that I have to approve comments before they are published.  This will (I hope) keep our little IOI community a safe place for people to comment, discuss, and ask questions.

Be well.

A Crash Course on Schizophrenia

From my experience working in mental health and describing to people what I do for a living, I have come to the conclusion that Schizophrenia is one of the least understood psychiatric diagnoses.  I will describe some of the symptoms, and how a person comes to be diagnosed.  Then I will try to speak to some of the prevalent misconceptions.

As you, intelligent friend, will remember from an earlier article about finding a therapist, the first thing to be done is rule out physical reasons for the person’s symptoms.  Additionally, a mental health professional will need to rule out substance use that could be causing the symptoms.  Perhaps the person is experiencing hallucinations due to a psychedelic drug?  Once these factors have been ruled out, the clinician can screen for the symptoms of Schizophrenia.

The person must have experienced at least two of these for most of the time over a one-month period, with some level of disturbance occurring for at least six months:

• Delusions: A delusion is a false belief.  Common delusions experienced by a person with Schizophrenia include persecutory delusions.  This means the person believes they are being targeted by someone.  Often they will say they are being followed, hurt, poisoned, or tormented by someone.  Referential delusions mean that a person believes that the words or gestures of someone are directed at them.  They may tell you that a song on the radio is about them, or a television show.  Delusions of grandeur mean that the person believes that they are someone of great importance.  In my time working inpatient mental health, I have met two directors of the CIA, one head of the FBI, and about half a dozen Jesus’s.  Thankfully, I only had one Jesus on my unit at a time.  That could have gotten messy!  Speaking of Jesus, the next type is religious delusions.  Types of delusions may overlap.  A person could have a religious delusion and a delusion of grandeur that he is Jesus.  Someone else could believe that they are the lead singer of a famous rock band, and that the band’s new song contains messages to him or her.  Somatic delusions are delusions about one’s body.  The patient may say that he has a radio transmitter implanted in his teeth.  Delusions of control occur when someone believes they are being controlled by an outside source.  I have had patients believe we were able to steal their thoughts from their minds, and put new ones in.  Delusions of any type can be very scary for the person who has them.  People experience these beliefs as being as real and logical as anything you or I know to be true.  Delusions are not often treatable.  At best, we are able to get the person to understand that other people don’t experience what they are experiencing.  But their delusions are often accompanied by our next topic, hallucinations.
• Hallucinations are sensory experiences in the absence of stimulus:  hearing, seeing, smelling, touching, or tasting something that’s not there.  The most common is auditory, meaning the patient hears things no one else does.  Usually, these are voices no one else hears.  They are often quite frightening for the person.  The voices tell them bad things about themselves.  They may also command the person to do things.  This is a tormenting experience.  A person with Schizophrenia may commit a crime that the voices tell them to, believing it will make the voices go away.  Sometimes the voices talk to each other, or warn the patient they are in (false) danger.  Any sense can be affected by hallucinations, but auditory hallucinations are the most common.
• Disorganized Speech - A person with Schizophrenia may have trouble organizing their thoughts into words.  The words they say may be out of order, or unrelated to one another.  This is called word salad.  Loose associations are another type of disorganized speech.  The person may jump quickly from one topic to another, to another.  The topic will be related, but the sentences will not go together to make a coherent thought.
• Extremely Disorganized Behavior - A person with Schizophrenia may do things that don’t make sense to anyone else.  I had a patient who wore a heavy sweater no matter what the weather.  This was in a place where summer temperatures were at least in the 90’s every day. 
• Negative Symptoms - Negative symptoms refer to the absence of something.  This includes something called “flat affect.”  Someone with flat affect will have less facial expressions, emotions, and/or vocal tone than what is otherwise socially accepted.  They may have reduced enjoyment of activities, or difficulty initiating tasks.  This may make a person appear lazy or unwilling, but it’s different.  It is a symptom of the Schizophrenia, not a defect of character. 

I hope that this entry has given you a better understanding of what a person with Schizophrenia experiences.  One of the hardest things about working in mental health is helping people who don’t have a particular mental illness to understand those that do.  It can be extremely frustrating when a loved one is experiencing a delusion, for example.  You know that what they are telling you isn’t real.  It may be interfering with your relationship with them.  But no matter how many times you present them with evidence to the contrary, they won’t budge.  It’s not personal.  They’re not doing it to make you mad.  They truly cannot help it.  They believe their experience just as strongly as you believe yours.  

Many symptoms of Schizophrenia can be greatly reduced with antipsychotic medications.  Medications currently available have fewer and less severe side effects than the first generation of these meds.  It is important to note that these medications take time to work.  It can take weeks, or even a couple of months to get enough of the medication in a person’s body to make a difference.  This is called a therapeutic level (look how smart you’re going to be now!).

Individual therapy, social skills training, family therapy, and supported employment may also be useful to help the person be as productive as possible.  These may help the person learn to better manage their symptoms, which will help them to feel and be that much more productive.  See how that can set someone up to succeed?  Just like anything, when we feel better, we do better, and when we do better, we feel better.  

I hope that this entry can clear up some misunderstandings about Schizophrenia.  People with Schizophrenia are not inherently dangerous.  Treatment is available which can help a person be productive and successful.  Like anything worth having, it’s work.  But that’s what makes it worth having in the first place.

Be well.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Fighting Fair: Are You Tearing Down, or Building Up Your Relationship?

It happens to the best of us, in the best relationships.  It’s inevitable, really.  There’s no way around it, so let’s just put it out there: Fighting. No two people are going to agree about everything all the time.  Most of us would certainly prefer that we sit down and have a nice, rational conversation where everybody is heard, and we come to a mutual understanding.  The timing would always be perfect, there’d be no distractions, and at the end, we’d hug it out and go on with our mutually improved lives.  Sounds great, and would eat into a significant amount of therapists’ profits!  But since we’re still in business, that doesn’t seem to be happening.  

First, let’s talk about the things that should, ideally, happen beforehand.  I know that fighting often seems spontaneous.  But after the fact, it’s often easy to see that the conflict had been brewing, or that preventable circumstances were a contributing factor.

• Know what you want, and what you will accept.  Make sure the two are different.
• Make sure you’re not having a misunderstanding.  Do you have all the facts about your point of view?  Does your partner?
• NEVER fight after consuming mind altering substances.  They will cloud your judgement and may lower your inhibitions.  Even a glass of wine to calm down is unacceptable.  If your partner has had a beer or two, or six, it’s not the right time.
• Take a cooling off break before you discuss the issue.  Get your head around the issue, what you want to say, and how you want to say it.  
• You both must consent to the discussion.  When your wife has a migraine or your son just worked a 10-hour day after taking a final exam the night before is not fair to anyone.
• Violence is never an acceptable solution.  Do not fight near weapons.
• Do not involve other people, unless it’s in a professional capacity.
• If it is with an intimate partner, don’t fight in the bedroom.  That should be a place you both can go for safety, calm, and intimacy.

During the fight:

• ABSOLUTELY NO ABUSE OF ANY FORM.  If you feel you are losing control, get out of the situation immediately.
• Use “I” statements.  These start with phrases like, “I feel,” “I need,” “I want,” “I saw.”  Avoid “you” statements.  If you need to start with a “you” statement, immediately follow it with an “I” statement: “You drowned my goldfish. I was really upset by that.”
• Avoid absolutes like “always” and “never.” I know it’s easy to fall into these statements.  I am human, and do it too.  If you really feel you need to use one of these, own it: “I feel like I always have to be the one to walk fluffy the goldfish.  I know you have done it in the past, but I have to do it so often, it feels unfair.”
• No distractions.  Turn the TV off.  Don’t answer the phone.
• Do not hit below the belt.  It can feel really good in the moment to take your partner’s vulnerability and use it against them.  It feels awful after the fact.  Stick to the issue at hand.
• Be honest.  If you knew your partner wasn’t telling the truth during a fight, how would that be for you?  Honesty is a risk, and it makes us vulnerable.  This is especially true when we’re taking responsibility for doing something wrong.  But lying doesn’t help the situation, and will actually make it worse.  The truth will come out, and then you’ll have to deal with the original issue, plus the fact that you lied.
• Take responsibility for your part.  This is a tough one, but it’s so important.  Fights are almost never completely one-sided.  Even if it’s something you had no idea was a problem, let your partner know that they matter to you.  It’s okay to do the best you can with what you have.  But once you have new information, you move forward, raising the bar as to what is your best.
• Do not be the relationship’s historian.  If you’re fighting about something that just happened, you don’t get to bring up the fact that it happened 3 years ago too.  That’s a separate issue.  Also, you can’t go back and fix anything.  Stay focused on how you want to move forward.
• No ultimatums. No threats. No tantrums. No storming out.
• Again, no storming out.  Taking a breather is fine, but has to be agreed upon. THIS IS DIFFERENT THAN ESCAPING IF THE FIGHT ESCALATES, AND YOU ARE UNSAFE.
• Respect tears, and respect laughter, even if they seem inappropriate.  These are ways that our bodies process the influx of hormones that are driving our feelings and reactions.
• Use professional help as necessary.  If you’re at such an impasse that you can’t solve the issue together, couples’ counseling may be in order.  

After the fight:

• You will both be tired.  Your body will be processing all of the hormones it released during the conflict.  Remember our discussion about fight or flight?  Here it is in action!  You may be emotionally tired too.  You and your partner may have different needs.  That’s okay.  Figure out together what needs to happen next.
• Forgiveness has to be unconditional.  Once the fight is over, it’s done.  You don’t get to make snide comments the next day.  You don’t get to bring up the issue in your next fight.  
• Stick to your word.  If you agree to something, you’re responsible for following through.  If something needs to be changed, make sure your partner is as involved as possible.
• If there are children in the home, they will be affected by the conflict.  Do not minimize or underestimate this.  You are responsible to them and for them.  They will process their feelings differently than adults.  They’re supposed to.  They’re children.  They need to know that they are safe and loved.  Remember that children are little narcissists.  It’s not a bad thing, it’s childhood!  But because of this, they will be quick to blame themselves. PLEASE remember this, and care for them.

No one is going to do these perfectly.  We’re human, and it’s who we are.  What I hope you will take from this is to always keep yourself safe, and then do what you can to keep those around you safe.  Safety is not only physical.  It is physical, mental, emotional, spiritual, and sexual.  While almost no one wants conflict, it will happen.  What’s important is what you do with it.  If you can take the fight and resolve it to the point that you actually end up closer, wonderful.  It can take stress out of the relationship and bring about resolutions.  Anyone who says they never fight with their partner worries me.  I always wonder what they are sacrificing? What are they not saying? What need is not being met?  Relationships are paramount to our human experience.  Do what is necessary to cultivate yours.

Be well.

Things That Fly: Balloons, Angels, Minds

It's Friday, and I feel like we are due for a lighter entry.  Forensics can be pretty dry, and I sincerely appreciate those of you who read!  So here’s one of my favorite stories from my time working at the State Hospital:

The hospital is located in a very scenic place.  So much so, hot air balloons often fly over.  One day a patient returned early from a walk on grounds.  This was completely unlike him.  He would always stay out until the last possible moment.  He was flushed and somewhat frantic.

“There are balloons falling out of the sky!” he shouted as he gave the nurse his grounds pass.  We looked at each other, and offered him medication.

“No!  You don’t understand!  There are balloons falling out of the sky!  Go see!”  We did our best to get him settled.  He wasn’t dangerous, just extremely preoccupied with the balloons falling out of the sky.  The nursing staff was about to change shifts, which included a meeting with both the outgoing and incoming shifts to discuss the events of the day.  About the time we settled in for our meeting, a staff member coming in for his shift bounced gleefully into the staff room.

“You guys are not going to believe this.  A hot air balloon pilot got confused, and just landed on the lawn outside our building!”  We certainly owed our patient an apology!  

It’s one of my favorite things that happened with a patient, and that’s saying a lot.  I loved my job.  But that incident taught me something important about listening to my patients.  No matter what someone’s illness is, they need to be heard.  We all dismissed it as a hallucination or delusion, but he was right.  When I am having a depressive episode, my thought process completely changes.  The things I know to be true, in many cases, are not.  Nonetheless, they are real to me.  Advice that was given to me when I first started working mental health was this: When your patient comes in from the yard and tells you he was out there talking to angels, maybe he was.

Be well.

Forensic Mental Health - Part 2: If You Weren't Crazy When You got Here...

Welcome to day 2 of Forensic Mental Health!  Let's jump right in with...

Not Guilty by reason of Insanity:  First, the defendant has to already have been diagnosed with a mental illness.  So, the NGI defense is an admission that the defendant did the crime of which they are being accused.  However, due to the symptoms of the mental illness, the person was unable to understand the nature of the criminal act, or that what they were doing was wrong.  Also, the severity of the symptoms must also have been the cause of the criminal act.  This part I think a lot of people have trouble grasping when they hear that someone was found NGI.  It’s almost impossible to understand the mindset of someone experiencing the symptoms of mental illness.  I worked with people with Major Depression for years before experiencing my first episode.  I am good at the work I’ve done.  I enjoy the therapeutic process.  I have seen profound changes in my clients.  All of this is to say that even working every day in this field and hearing the same experience come from different clients time and time again, I couldn’t possibly have understood how a person’s thought process completely changes when mental illness takes hold.  This is why we have the NGI defense.  A person is truly unable to understand the true nature and outcome of their actions.  In a criminal trial, the burden of proof is on the prosecution to make the case the the defendant is guilty.  For an NGI, the burden of proof is on the defense to make the case for insanity.

Once a person has been found Not Guilty by reason of Insanity, they will be committed to the State Hospital.  This is the part that people don’t seem to understand.  The person is not just set free.  Once they are committed to the State Hospital on an NGI, it is extremely difficult to be released.  People will often be committed to a State Hospital far longer than they would have served in prison.  What is often reported, which is technically true, is that the minimum a person can be hospitalized for NGI is 6 months.  This is the part public defenders tell their clients: “You could be out in 6 months!” IT NEVER HAPPENS.  EVER.  I can think of one person, in the whole time I worked there, who was out in less than a year.  It was an extraordinary case.  

When a person is released after an NGI, they are released to their county’s Mental Health department.  For the time that they are hospitalized, a member of the treatment team, usually the patient’s psychiatrist, will write a letter to the court detailing the person’s progress in treatment.  In order to even be considered for release, the patient will have to demonstrate a significant period of time without the symptoms of their mental illness interfering with their ability to function.  They will also have to write an accurate and detailed account of the crime, including how their mental health symptoms led to the event.  They must take responsibility for their part. They must be able to state, from memory, what medications they take, how much, how often, and for what symptom.  If the medications changed the day before the interview, they are still responsible for this knowledge.  They must have a detailed Wellness and Recovery Plan.  They have to know their triggers, warning signs, decomposition signs, and what to do every step of the way.  They will also be required to complete anger management, symptom management, and substance recovery groups.  All factors which lead to the committing offense must be resolved to the satisfaction of every party who has a say in the decision to release the person.  This is in addition to managing day to day life on a psychiatric ward.  Once a person has achieved all of these things to the satisfaction of the treatment team, the county is notified.  They will then come to see the patient.  They will review every word in that patient’s chart.  They may decide that even though the patient has done well for the last year, they were not able to discuss their specific triggers for substance abuse during the interview, and are therefore not ready for release.  Now let’s say that during the next 6 month period, the patient has a bad day, and yells at their roommate, who has been singing all night for the past 3 nights.  The yelling goes in the chart.  When they are reevaluated at the end of the 6 months, it is decided that they need to attend anger management because of the incident.  A person without a mental illness would be discouraged and feel stress.  Mental illness, however, is opportunistic.  So guess who’s starting to have symptoms again?  I have had clients who would have served 3 years in prison for their offense who had been hospitalized for 10, 15, or 20 years with no end in sight.

I am not attempting to garner sympathy for these patients.  Many of them are right where they should be.  Ideally, they would be getting all of their treatment needs met, and on their way in a reasonable amount of time.  Budgets and staff ratios make this nearly impossible.  I believe we can have compassion for people without making excuses for them.  But the next time you hear that someone has been found Not Guilty by reason of Insanity I hope you will have a better understanding of what that’s going to mean for them.  Try to imagine knowing that, in an altered state of consciousness, you had committed a felony.  Maybe you even harmed the person you love the most. Now you’re not only going away for it, but indefinitely.  Possibly for life.  Now tell me it’s a Get Out of Jail Free card.  All right, this one was heavy, but important.  I’ll try to post something lighter next.

Be well.

Forensic Mental Health - Part 1: It's Not What You Think

I want to use this entry to clear up a couple things about forensic mental health.  I believe there is a lot of misinformation and misunderstanding about a couple of concepts: being found Incompetent to Stand Trial (IST), and being found Not Guilty by reason of Insanity (NGI).  I became well acquainted with, and well versed in, both topics during my time working at a state hospital.  I will speak to the application of these laws in my state.  

I like to read the comment sections of news articles.  Maybe I’m a masochist, but that’s a topic for another entry…not to mention my therapist!  At any rate, I find the lack of knowledge on this topic alarming.  As a member of a society, I want to know what a law means and how it is applied.  Remember our stages of moral development?  We can’t live by rules and laws we don’t understand.  So for these two topics in particular, here goes…

Incompetence to Stand Trial:  A person is arrested and accused of a crime.  They are, according to the 6th amendment of the US Constitution, afforded the right to a fair trial.  This means two things under IST law: If the person is 1) unable to understand the nature of the criminal proceedings, or 2) unable to assist his or her attorney in a rational manner, they can be found incompetent to stand trial.  Either or both of these conditions MUST be due to mental illness.  In either case, the person’s symptoms prevent them for understanding what is going on in court.  They have to be able to work with their attorney.  The 6th Amendment of the US constitution affords the right of the accused to know the nature of the charges, and the evidence against the defendant.  A person can’t do this if their mental illness is keeping them from understanding this information.   It is usually the judge or the public defender who will raise the issue of the defendant’s trial competence.  At that point, the defendant is transferred to the State Hospital.  By law, they have 3 years in which to become competent to stand trial.  Should they become competent, they will be transferred back to county jail to await trial.  During the time they are hospitalized, they will receive treatment for the mental illness, and education about their diagnosis, treatment, and the court process.  If the 3 years go by and the person has not regained competency, usually one of two things will happen: If the crime is not serious and the time they would have been incarcerated had they been found guilty is less than the time they have spent in the State Hospital, the prosecuting attorney may decide to drop the charges.  If this is not the case and the charges are for a violent crime, the patient will often be put on a conservatorship.  This means they will be assigned to a county mental health worker.  Often, especially if the charges are for a violent offense, the person will be confined to the State Hospital indefinitely, until such a time they regain competency to stand trial.  Read that again: They will be confined to the State Hospital indefinitely.  Being found IST is NOT a Get Out Of Jail Free card. 

Tomorrow's post will be about what happens when a person is found Not Guilty by reason of Insanity.  Stay tuned to find out just how hard it is to be released from a State Hospital!

No Laughing Matter: A Rare Entry About Politics

Friends, 

Today’s blog entry is going to be directly anti-Donald Trump.  Insight Outside In is intended to be educational, informational, and a medium to share my own experiences in mental health.  For the most part, I try to keep politics off the blog.  My goal is not to alienate anyone, but I’ve had something circling in my brain that’s been bothering me about recent political events.  A number of things I have found problematic, I have been able to identify and address either in my own processing, or discuss within my own circle of friends and family.  I haven’t been able to put my finger on it until earlier today.  I was browsing a social media site, and came across a series of tweets by a gentleman named Jason P. Steed, an attorney from Dallas, Tx.  I am, with permission, sharing them here with you.  I am sharing them all together in sentence form instead of the series of 140 character posts of the cited content.  Content is unchanged, except for where changes in punctuation serve to convert the text from a series of tweets to paragraph form.

“I wrote my PhD dissertation on the social function of humor (in literature & film) and here's the thing about ‘just joking.’  You're never ‘just joking.’ Nobody is ever ‘just joking.’ Humor is a social act that performs a social function (always).  To say humor is social act is to say it is always in social context; we don't joke alone. Humor is a way we relate/interact with others.  Which is to say, humor is a way we construct identity - who we are in relation to others. We use humor to form groups and to find our individual place in or out of those groups. In short, joking/humor is one tool by which we assimilate or alienate.  IOW (In other words), we use humor to bring people into - or keep them out of - our social groups. This is what humor *does.* What it's for.

Consequently, how we use humor is tied up with ethics - who do we embrace, who do we shun, and how/why?  And the assimilating/alienating function of humor works not only only people but also on *ideas.* This is important.  This is why, e.g., racist "jokes" are bad. Not just because they serve to alienate certain people, but also because they serve to assimilate the idea of racism (the idea of alienating people based on their race). And so we come to Trump.  A racist joke sends a message to the in-group that racism is acceptable. (If you don't find it acceptable, you're in the out-group.)  The racist joke teller might say ‘just joking’ - but this is a *defense* to the out-group. He doesn't have to say this to the in-group.  This is why we're never ‘just joking.’ To the in-group, no defense of the joke is needed; the idea conveyed is accepted/acceptable.  So, when Trump jokes about assassination or armed revolt, he's asking the in-group to assimilate/accept that idea. That's what jokes do.  And when he says ‘just joking,’ that's a defense offered to the out-group who was never meant to assimilate the idea in the first place.

Indeed, circling back to the start, the joke *itself* is a way to define in-group and out-group, through assimilation & alienation.  If you're willing to accept "just joking" as defense, you're willing to enter in-group where idea conveyed by the joke is acceptable.  IOW, if ‘just joking’ excuses racist jokes, then in-group has accepted idea of racism as part of being in-group.  Same goes for ‘jokes' about armed revolt or assassinating Hillary Clinton. They cannot be accepted as ‘just joking.’  

Now, a big caveat: humor (like all language) is complicated and always a matter of interpretation. For example, we might have racist humor that is, in fact, designed to alienate (rather than assimilate) the idea of racism. (Think satire or parody.)

But I think it's pretty clear Trump was not engaging in some complex satirical form of humor. He was "just joking." In the worst sense.  Bottom line: don't accept ‘just joking’ as excuse for what Trump said today. The in-group for that joke should be tiny. Like his hands.”

Mr. Steed very eloquently stated what I have been feeling: the jokes are designed to make us who disagree feel like outsiders.  This is always unsettling.  Human beings are pack animals.  We need to belong.  Regardless of what a person’s specific opinion is, they are likely to feel strongly about it and confident in their belief.  

We look to leaders to guide us.  They are in a position to be role models.  Whether it’s a teacher, religious leader, a coach, a celebrity or a politician, people are listening.  I am all about personal responsibility.  If a role model advocates my causing harm to someone else, it is still up to me to know right from wrong, and not hurt another person.  But not everybody is going to think or feel the same way I do.  We trust our leaders not to steer us in the wrong direction.  This is responsibility that we give to them.  I feel this responsibility as someone who blogs about mental health.  I do my best to give accurate information, and state wherever appropriate ways for someone to be safe.

Getting back to Mr. Trump: stating that he was joking when he called for harm to come to another presidential candidate, or their hypothetical Supreme Court nominee, is reckless.  He has assumed a leadership role by accepting his party’s nomination, and is soliciting your vote and mine.  I believe he has betrayed us.  Saying he was just joking is how he goes about denying any responsibility for what may come of his words.  Whichever way a person may, in his opinion, misinterpret his joking has the potential to cause harm.  If a person takes him seriously, another human being’s life is endangered.  For the rest of us who don’t see the humor, we are the outsiders.  This is not a position I am second-guessing whatsoever.  I am perfectly happy not to be supporting him.  But at a deeper level, calling it a joke is designed to discount our feelings and experience, and therefore, our basic humanity.  I don’t want IOI to turn into a political blog, nor will I allow it.  But especially after reading the words of Mr. Steed, I felt compelled to share them with you, and say something.  

As I wrote in an earlier entry about media saturation, I encourage you to take care of yourself, and monitor your own exposure.  I get to where it’s too much, and I have to change the radio, or turn off the TV.  No matter your political affiliation,

Be well.

Trauma, Part Two: Therapy and Helping the Trauma Survivor

Yesterday I wrote about Post-Traumatic Stress Disorder.  I described the symptoms, and how some of them may appear.  Today I am writing about some of the different treatment modalities for PTSD.  This list is not meant to be exhaustive.  I always encourage you to work with your mental health professional to decide what will best help you in your situation.  This entry may also be useful to someone with a loved one who has experienced trauma.    

In an earlier entry about finding a mental health professional, I mentioned that it is not uncommon for a therapist to want a new patient to see a medical doctor, if they have not seen one recently.  The therapist may also want to refer a client to a psychiatrist for a medication evaluation.  If you go to see a therapist to deal with trauma specifically, this may still be the case.  Certain antidepressants may help with symptoms of anxiety.  This can help reduce symptoms to a more manageable level while they are getting therapy.  It all works together.  Therapy for trauma may be more effective while the patient is on antidepressants, and the antidepressants will help the patient get more out of the therapy for the trauma.  There are several different methods of therapy that are effective for helping a person deal with trauma.  Here are descriptions of some of these methods.  Your mental health professional will work with you to find the best treatment for your specific situation.  This list and the accompanying descriptions are not meant to be exhaustive:

Exposure Therapy - Exposure Therapy involves recalling the traumatic experience and, things associated with it, repeatedly.  While this may sound frightening, the goal is to help the patient be able to remember the event without experiencing PTSD symptoms.  This is often done by having the patient describe the event to the therapist multiple times, over a period of time.  This helps the survivor to lessen the avoidance of reminders of the trauma by making them feel less sensitive to them.  Think of it this way: the first time you watch a scary movie, you jump out of your skin when the killer jumps out at the unsuspecting victim.  Then next time you watch it, the scene may still be suspenseful, even scary, but it loses some of the shock value.  Every time you watch that scene, it gets a little less frightening.  It’s the same concept with exposure therapy.  Talking about the experience multiple desensitizes you to it, until you get to the point you can go make more popcorn during that scene.

Cognitive Therapy - During Cognitive Therapy, the therapist will work with the client to help change the thoughts about the traumatic event to make them less distressing.  The client learns to identify the thoughts which are upsetting, and begins to change their perspective.  An example may be that a person may experience guilt for not fighting off an attacker during a mugging.  However, during cognitive therapy, the focus will be placed on the fact that attempting to fight the attacker, the client may have been stabbed, since the attacker had a knife.  The therapist will work with the client to focus on the fact that they were not harmed physically during the mugging, instead of focusing on the guilt of not fighting back.

Group Therapy - Some trauma survivors benefit from group therapy.  Group therapy is designed to bring people together who have had a similar experience.  Trauma survivors may feel alone in their victimization.  This may foster feelings of shame, which make healing more difficult.  Group therapy allows survivors to talk about their experiences with a therapist as a facilitator.  Sharing with one another helps to reduce isolation.  It can also facilitate hope as survivors see others recovering after a similar experience.  Group therapy may also be used with a group of people who have all experienced the same traumatic event.

Brief Therapy - Brief therapy uses a set number of sessions, usually between 4 and 8.  A specific goal is established, and the sessions are used to move the client toward that goal.  Brief Therapy will often use some of the same principles of Cognitive Therapy.  The focus will be on the stated goal, and how to get the client to that goal.  

EMDR and Hypnosis - EMDR, or Eye Movement Desensitization and Reprocessing, and hypnosis are sometimes used in trauma recovery.  According to the EMDR Institute Inc (www.emdr.com), the purpose of the treatment is to help the brain to process information about the trauma, and move toward healing. Hypnotherapy is sometimes used to help the client have controlled access to the memory of the event.  Through this process, they are able to recall the event, but the memory will be less distressing.  EMDR and Hypnotherapy should only be attempted with a professional who is certified in the particular method.  

If someone you love has experienced trauma, it can make you feel powerless.  It’s hard to see someone go through an event, and then continue to experience symptoms.  Remember that you are only one person, and there is only so much you can do.  You may be able to help them meet day to day needs.  They may ask you to just listen, or to keep them company.  If you see the person experiencing distress, you can encourage them to seek professional help.  Knowing the symptoms of PTSD will help you to know what to look for.  Just remember that you can only provide assistance when it is not causing you harm or distress as well.  Take care of yourself in the process of taking care of another so that you both achieve wellness.  That’s my goal for this blog, to always help you to…

Be well.

I'VE GOT MAIL!

Friends, 

I realize posting a comment on a blog, even anonymously, may not be right for everyone.  Now you can contact IOI directly: Email me at InsightOutsideIn@gmail.com

Be well!

Trauma, Part One: Definitions and Diagnosis

Any time I write about diagnostic criteria, it is for information purposes only.  I cannot diagnose nor treat anyone over a blog.  If you experience symptoms I discuss on Insight Outside In and are not seeing a mental health professional, I encourage you to access services available to you.  I am happy to answer questions within my scope of knowledge and ability, given the limited nature of this medium.

All right, this one’s a biggie, get comfortable: I am writing about trauma today.

If you personally have an active diagnosis of Post-Traumatic Stress Disorder (PTSD) or have experienced trauma that still causes you distress, you may want to skip this one.  Always do what you can to keep yourself safe.

I’m going to break this up into two entries.  This one will talk about what PTSD is from a diagnostic standpoint, according to the DSM-5.  In my next entry I’ll write more about treatment, coping strategies, and helping a loved one with PTSD.

There are five different criteria for a person to be diagnosed with PTSD.  First, the person has to have had a traumatic experience.  According to American Psychiatric Publishing, the DSM-5 defines a traumatic experience as “exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:

• directly experiences the traumatic event;

• witnesses the traumatic event in person;

• learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or

• experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).”

Next, the person will reexperience the the trauma in one or more ways:

• Thoughts or perceptions
• Images
• Dreams
• Illusions or hallucinations
• Flashbacks
• Distress related to cues that symbolize some aspect of the traumatic event

The third criteria is that the person will avoid stimuli associated with the trauma such as:

• Avoiding thoughts, feelings, or conversations about the traumatic event
• Avoiding people, places, things, or situations which remind them of the event.

Fourth, the person will have negative changes in thinking and mood, including two or more of the following:

• Irritability, angry outbursts
• Reckless or self-destructive behavior
• Hypervigilance - the person may be jumpy, or seem more alert to the possibility of threats.  Their senses may seem heightened since their brain is staying in fight-or-flight mode.
• Being easily startled
• Trouble concentrating
• Problems with sleeping

These symptoms must have persisted for at least a month in order for the diagnosis to be PTSD.  They must cause the person distress or interfere with functioning.  Also, the symptoms cannot be better accounted for by a medical condition or substance use.

So, to sum up: 

A person experiences something traumatic.  They start reexperiencing the event by way of things like flashbacks, hallucinations, or nightmares.  They start avoiding things or situations that would remind them of the trauma.  It starts affecting their mood, making them nervous, distracted, irritable.  

These are not things that a person just gets over.  I think that telling someone that they need to “get over it,” or “stop feeling this way” cause more harm, and can exacerbate symptoms.  Tomorrow I’ll write about what can help someone who has experienced trauma, both professionally and personally.

Be well.

Sorry to Tell You, This One's About Apologies

I can’t run a blog about mental health without spending a good bit of time talking about relationships.  Our relationships with others start shaping our personalities from the time we are born.  As we go through life, our personalities affect how we will relate to other people.  A couple weeks ago I wrote about mistakes, and how working through mistakes can strengthen relationships.  Today I’m writing about apologies.

I think a common experience of childhood is being told to apologize to someone.  If you recall the entry about moral development, perhaps you’ll recall that children make moral decisions for one of two reasons: to avoid punishment, and then to earn reward.  It isn’t really until adolescence that a person will start to see themselves as a member of a society.  The person will not fully grasp the consequences of their actions on an altruistic level, they will at least understand the need to maintain relationships in order to function in life.

It’s not possible to have relationships without conflict.  If you know of a relationship in which the parties say that they never disagree, there’s a problem.  It’s a loss of individuality, but that’s a topic for another blog entry.  In my entry about mistakes, I talked about how mistakes can be learning experiences that can help relationships to grow.  Now I’m going to take it a step further, and talk about how.  

A true apology must involve taking responsibility.  This can’t be the non-apology of “I’m sorry you got your feelings hurt.”  Even if I had absolutely no intention of causing harm, the damage is done.  The person doing the apologizing can phrase it as, “If I’d known…I never would have…” For example: “If I had known your goldfish had drowned, I never would have made a joke about fish drowning.”  It’s part of our experience as human beings to want to be heard and understood.  

It’s tricky when we don’t feel we have done anything wrong.  When this is the case, it’s easy to fall into the traps of the power struggle, and the non-apology.  Neither of these, however, maintain, build, nor support healthy relationships.  

Next comes acknowledging the harm that’s been done.  Whether we intended to do harm or not, it needs to be acknowledged.  This is the heart of the apology.  It’s how we communicate that we are hearing and understanding the other person’s experience.  If you’re not sure what the other person is feeling, ask!  Let them know that you are trying to understand how they are feeling so that the two of you don’t end up in the same conflict again.  Try not to parrot back to them what they’ve said.  Let’s avoid, “I was hurt when you said fish can’t drown.”

“You were hurt when I said fish can’t drown.”  Take it one step further: “I was hurt when you said fish can’t drown.”

“So when I made that joke about fish drowning, that upset you because Fluffy the Goldfish did drown.  I’m sorry for upsetting you.”  

So now we have taken responsibility, and acknowledged the harm we have done.  But if anything is going to change long term, we must learn from the experience.  We have to be willing to let our guard down, and accept this place of vulnerability.  It never feels good to know that we have harmed someone we care for, but when it comes to relationships, it’s inevitable.  Once it happens, we can’t take it back.  But the best way we can show that we truly regret the consequences of what we have done is to learn from it.  We learn about the other person.  We learn about their point of view.  We learn about their needs, how they communicate, what they expect, and their priorities. 

We continue to put weight and meaning behind our apology as we move forward by doing better.  We allow ourselves to learn from the experience.  Ideally, this happens not just on a small scale with the person with whom we originally had conflict, but across other relationships as well.  In the entry about mistakes, I wrote about someone in my life who needed better communication from me.  This has taught me to be more aware of my level of communication in other relationships as well.  It has also taught me to listen more carefully to what the person in that particular conflict is saying.  That whole situation could have been resolved so much sooner if I’d been listening, instead of just being defensive.  So part of my apology involves doing what I can not to hurt that person the same way again.

Conflict and mistakes are part of relationships.  They also have the potential to be learning experiences.  An apology is not always going to be a cure for what has gone wrong.  There are times when a relationship may not be salvageable.  In these cases, the best we can do is learn from the experience as we move forward.  So if anyone’s goldfish has in fact drowned and you were upset by my use of that as an example, I am sorry. 

Be well.

I'm home

Hey there, IOI!  I've missed you.

It's been a great week.  I got to spend time with family and friends, as well as get to know a new city which I really enjoyed.  This week gave me ideas for some new topics, and I am really excited to get back to writing.  

For right now, I am catching up on sleep and laundry.  My goal is to get a new entry posted this weekend.  What's new with you?

Be well.