working with acutely psychotic inmates.

The problem of mental illness in incarcerated settings is a growing nationwide problem. identifying, treating and moving cases through the criminal justice system involves a complex system of highly trained professional workers. The demands upon law enforcement staff is significant, seeing that they do not possess basic and essential training on mental health issues, symptoms, or ways in which to work with mentally ill inmates.

whereas mentally ill inmates create a specific set of problems, the needs of acutely psychotic inmates constitutes a whole new arena of issues.

Many acutely psychotic inmates are severely decompesated. In many cases they lack basic cognitive ability to communicate, or to report on their symptoms. In cases where they do have cognitive ability, oftentimes paranoia, anger, or delusional systems impact the inmate to the extent that they are unable to engage with caregivers, or program with the structure of incarcerated settings.

Common problems with acutely psychotic inmates include poor hygiene, playing with their feces, not eating or drinking. yelling, screaming and pounding on walls or doors at all hours of the day and night. Behaviorally, many inmates will refuse to enter their cell, go back into their cell, or present themselves to be cuffed, chained or moved back and forth from court.

Where issues of competence come into play, the criminal justice progress grinds to a halt. If an inmate lacks the basic awareness of where they are, what their charges are, the role of the judge, lawyers and prosecutor, or to be able to meaningfully participate in their own defense, then legally, the process can not move forward.

Inmates, regardless of how psychotic they are, can not be forced to take medications. To force medications invovle a process of admittance to a psychiatric setting, consisten refusal of meds, a lack of competence combined with either grave disability, or a danger to self or others. Then the case must be presented before a judge and a client advocate (to argue on behalf of the inmates rights) and the issues of whether meds may be forced will be decided. such orders to force meds are called "Riese Hearings"

So far, what has been outlined can easily be understood as a significant challenge to mental health staff and law enforcement staff.

So the question for mental health staff in incarcerated settings becomes, "how to work with acutely psychotic individuals?"

In order to work with such individuals, requires an understanding or a model to understand what is going on in the minds of such individuals.

In a nutshell, the usual structures to be found in ones psyche, names the id, ego and super-ego, become scrambled from how they are usually understood. The ego is the seat of personality. the functions they provide are mainly perception, reality testing, regulation of emotions and affect, memory, cognition, personality, synthesis, decision making, orientation and the ability to pick up on cues and express onself in order to maintain and respond appropriately to relationships as well as activation of defenses (sublimation, rationalization, intellectualization, suppression, repression, projection, introjection, reaction formation, etc)

The Id is the seat of the rawest of impulses. Freud would say the id operates on a few basic principles. the pleasure principle, the death instinct, the desire for sex and relationship. The id is also the seat of the unconscious, that is, all the things that we are not aware of from painful memories, events that we are ashamed of, paranoia and all other things that make up the human being that we are not aware of. There are aspects of the pre-conscious that we do have access to. parts of these objects are accessible to the ego, such as memories, stored information, dreams, etc. If we have access to it, but we are not concious of it, then it is preconscious. if it is truly in the unconscious, then we do not have access to it. We can get indications of what lies in the unconscious through the process of free association, or interpretation of dreams, or what carl jung would call archetypes that are common themes that lie in the universal unconscious (jung).

the superego is the highest moral and ethical seat of the individual (in theory). The superego develops in the early life in the anal stage. raw desires of the id, make themselves aware to the ego, and they are moderated and transformed into appropriate and socially and culturally appropriate means of attainment through mediation by the superego. The superego is the mechanism that transforms the raw desire for sex, into an expression of ones passion and deisre through poetry, dinner and a conversation, or personal attainment such that the raw desire and impulse may be channeled into a higher function. Now, the large caveat on the superego, is that it is modeled after the moralistic and containing, boundary role that is played out by the primary caretakers. role models get to weigh in, but much like our early neurosis and self esteem is based upon our mirroring through the primary care-taker, our superego can only be (generally) as strong as the examples that are afforded to it. So, if your primary caretaker is on drugs, schizophrenic, prostitutes in front of you, deals drugs in front of you, beats you, abuses you, condemns god and others, is racist, discriminatory, unpredictable, inconsistent.... i think you get the picture...

In the severely psychotic individual, the ego is destroyed through a whole scale bleeding through of unconscious raw id impulses. what ego remains is under constant attack by the self, through the inability to modulate ones emotions, fears, and unresolved thematic threats extending back through early childhood, or unresolved traumas. The ego, left unprotected by the inabilty to perform it's interpretive and modulating/reality-interpreting fucntions, is left literally in a state where the inmates are running the asylum. The degree to which the psychotic individual displays neurotic (obsessional, constrictued, ritualistic) vs. psychosis (disorganized, emotional, labile) behaviors and symptoms will depend on the type of mental illness (bi-polar, depressive psychosis, schizophrenia, mania) and the level of insight and superego/ego disability.

The technique I employ is based upon a non-reliance on psychotropic medication. Psychotropic medications are a goal, but in the beginning, it is not relied upon. The main duty in the beginning phase of working with acutely psychotic individuals is engagement. Don't give up. don't simply gain enough observational and verbal information to simply make the diagnosis of psychosis and then set about trying to get the inmate medicated or sent to an inpatient center.

talk with the inmate, try to engage with the inmate. Literally, try to become a part of their world. Get them to acknowledge you, to repond to you, to talk to you, regardless of how little at first.

To get the inmate to acknowledge and respond to you, is to pull them out of their psychotic, self-absorbed state. The therapist must be able to tolerate silence and uncertainty. You must be able to tolerate that silence, which can take anywhere from 5 to 10 minutes of talking with no response, until you get a response.

once the inmate responds to you, continute to talk. be directive, ask simple questions, show empathy, concern, sympathy. try to become an allie. Be directive to the extent that you allow the inmate to speak, but when they run off track, you interject another question, or refocus the inmate to respond to diagnostic or direct questioning.

the goal of this engagement is several.
1. pull the inmate out of their regressed, self-absorbed state
2. align yourself with the inmate, join with them, such that you are able to lend the inmate your ego strength to guide them, provide boundaries, reality testing and orientation... functions that the inmate can not provide for himself/herself.
3. gain an alignment to build trust, lessen paranoia and build towards moving the clinet towards taking medications, which will further the inmates ability to think clearly, respond apropriately and make greater and greater use of the lending of ego, which serves as the model for the inmate to reawaken and essentially "re-boot" their own ego's.

So throgh the bridge of engagement and dialogue, you are able to link and lend ego. you are able to provide ego strength. you are able to cognitively restructure the inmates thoughts and the way that they perceive and respond to reality. helping the inmate to know how to respond to law enforcement staff, and to program, to take meds, to go to court, to verbalize their needs with deputy staff, to be able to speak and communicate with the psychiatrist on symptoms, effectiveness of medications, etc.

of course the goal, is to assist the inmate in being able to move through the court system, become pschiatrically stable, gain insight into the importance of psychiatric medications as a pathway to avoiding jail and incarceration, and to create a positive therapist transference, that can be picked up and extended upon by community mental health treatment staff once the inmate is discharged.

of course, this is an overly simplified model, but it does provide some basic insight into a model of psychosis, a model of engagement, interaction, treatment and rehabilitation.