16. Flower or Fury- Psychotic - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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16. Flower or Fury- Psychotic

Therapist Resources > Therapy Books > How Dangerous

 How Dangerous is this Person? Assessing Danger & Violence Potential Before Tragedy Strikes

PSYCHOTIC: Characteristics, Criteria, or Elements for Aggression & Violence Potential
-- Code: NO=not applicable; YES=applicable; DEPENDS= Depends on other issues or occurs sometimes

PSYCHOTIC: YES, Specific Triggering Event
PSYCHOTIC: DEPENDS, Opportunistic Behavior
PSYCHOTIC: DEPENDS, Sense of Entitlement
PSYCHOTIC: DEPENDS, Self-Righteous Attitude
PSYCHOTIC: DEPENDS, Ego-syntonic Perception
PSYCHOTIC: DEPENDS, Self-Esteem Gain or Loss
PSYCHOTIC: YES, Intense Emotional Arousal
PSYCHOTIC: NO, Functional Reinforcement (positive or negative)
PSYCHOTIC: DEPENDS, Characterlogical Behavior/Perceptions
PSYCHOTIC: DEPENDS, Transitory Behavior/Perceptions
PSYCHOTIC: NO, Isolation/Avoidance Behavior
PSYCHOTIC: DEPENDS, Presence of Remorse

Intervention or treatment for the psychotic individual usually focuses on stabilization to non-psychotic functioning.  Rapid decomposition when the individual becomes dangerous to self or others becomes a crisis situation where safety is paramount.  Therapy, professional, or other intervention per se must be focused on ensuring the safety of the individual and those around him or her, and secondarily on stabilizing the psychotic individual.  If individual is stable, then maintenance of stability becomes the goal of treatment.  Modern treatment of psychosis focuses on biochemical issues and primarily psychopharmacological intervention.  Intense emotional or psychological stress from overwhelming experiences, trauma, loss, depression, and anxiety can trigger otherwise non-disordered individuals into psychosis.  Individuals with personality disorders can also become psychotic when characterological issues combine overwhelmingly with psychosocial stressors.  Treatment or therapy for “normal neurotics” and personality-disordered individuals follows the protocol of safety first.  After safety is established, stabilization to avoid future decomposition and reoccurrence of psychosis becomes critical.  This may involve possibly dealing with stressors, underlying emotional and psychological issues that created vulnerability to breaking down, and/or the various consequences to the psychotic episode.  These strategies for treatment overtly seek to prevent relapse into another psychotic episode.  Individual, couples, or family therapy or any treatment with someone who is actively psychotic would first follow initial safe and stabilization protocols.  Only then should an individual be assessed as to whether the mode of treatment is appropriate for continued treatment.  It may necessary to refer to other treatment modality or other therapists or professionals for either misfit in both or either scope of practice and scope of competence.

How the individual acts during psychosis or a psychotic episode including violence potential depends on the nature of the psychosis.  While the individual may have wild hallucinations completely disconnected from objective reality, the psychosis does not necessarily compel socially odd or disruptive behavior.  Or, if the behavior is odd or nonsensical to others, it may not necessarily be disruptive or dangerous to others.  Someone who believes him or herself a flower growing in the garden may act and look quite strange to others, but does not harm anyone.  However, hallucinations of worms burrowing beneath skin, compelling the psychotic to rip the skin in order to expel them becomes self-injurious.  When psychosis causes fury and delusions of imminent danger and persecutory projections onto others, then the potential for violence can be great.  In that sense, the psychotic individual may have perspectives and behaviors similar to but further intensified as the individual with paranoid personality disorder.  Paranoid-type schizophrenia as opposed to non-paranoid types of schizophrenia: disorganized-type, catatonic-type, or undifferentiated-type (which may include paranoid aspects less prevalent or severe as paranoid-type) has psychosis that could result in similar moods, cognitions, and behaviors. "Paranoid-type schizophrenia is characterized by delusions and auditory hallucinations (hearing voices that don't exist) but relatively normal intellectual functioning and expression of affect. The delusions can often be about being persecuted unfairly or being some other person who is famous. People with paranoid-type schizophrenia can exhibit anger, aloofness, anxiety, and argumentativeness" (WebMD, 2013).  The assessment of how dangerous is a psychotic individual is more aptly presented as how dangerous is this psychotic person?  What is the nature of the psychosis?  The following addresses a potentially violent psychotic individual rather than psychotic individuals in general or someone having a psychotic break generally- although many issues are relevant for most individuals with psychosis.  More than the other profiles, the relevance of most of the seventeen criteria is legitimately stated as “it depends.”

The potentially violent psychotic individual is triggered to violence, but rational real-world people cannot identify the trigger since it comes from the psychosis.  Even if a trigger can be identified from previous experience, it is from some largely psychotic symbolism rather than a logical symbolism that people in general can understand.  Depending on the nature of the psychosis, for example as being on a mission to eradicate Sharpies, the psychotic would seize every opportunity to annihilate the pens whenever one is visible.  The trio of entitlement, self-righteousness, and being ego-syntonic also depend on the nature of the psychosis.  Psychosis that makes one the omnipotent god-emperor, who cannot do wrong may create an individual who functions as a sociopath or an individual with antisocial personality disorder.  This creates a very different set of characteristics and behaviors than a psychosis that compels the individual to act against his or her desires or best interests.  The hallucination may be a god-like voice that commands the father to slay his own son.  The behavior may boost or hurt self-esteem and give pleasure or misery.  The emotional arousal is probably quite high in either case, but resentment would again depend on the nature of the psychosis- a paranoid psychosis increasing resentment and justification for violence.  A psychosis with an omnipotent command that cannot be resisted may create or exacerbate dependent personality traits.  Emotions, thoughts, and behavior that mimics borderline hurt, rage, and lashing out may be from psychosis.  Remorse would depend on the nature of the psychosis.  The individual however can be empathic to the degree he or she sees the abused person as a person.  However the psychosis may render another person experienced rather as an object or demonized character.  For someone who is actively psychotic and has not been, cannot be, or refuses to be stabilized to non-psychotic functioning, any violent urges thus are functionally characterological.  However, if the individual has been stabilized and remains otherwise non-psychotic, the violence may be considered transitory.  This would be in the circumstance where someone had a psychotic episode and returned to normal functioning without a history of relapse.

The psychotic individual does not receive positive functional reinforcement for odd much less violent behaviors.  He or she gets awful negative functional reinforcement and punishment... in the real world.  The loss of relationships, status, freedom, physical health, and security in the real world is extremely severe and may motivate the psychotic individual when more stable to seek treatment and change.  The psychotic individual is as likely as other people to wish to avoid isolation and to instead be socially involved and active.  Losing relationships may be a significant distress and hence, motivation to change.  That however can only happen if the individual is somewhat, occasionally, or periodically connected to the objective world.  And, have real world relationships with stable people.  As the psychotic slips in and out of psychosis, he or she realizes and suffers the destruction of his or her life.   As he or she is lucid, the individual may be willing to seek and make changes to stabilize and reconnect to the objective world.  Stabilization and maintenance become the primary goals of treatment.  Unfortunately, in his or her psychotic reality- hallucinatory or delusionary state, the individual often feels amply rewarded for odd or violent behavior.   In couple's therapy or in a couple or family, being with and staying with the partner and children may be the most significant motivation for the individual to stop psychotic behaviors (including aggression) and seek stabilization.  Safety for the individual, the partner, and children always are paramount for the therapist, professional, or other concerned person.  As the therapist or professional can maintain safety for all, then therapy or treatment should prompt the individual for his or her ability to remain lucid and determine and provoke him or her motivation to retain the relationship.  Simultaneously, the therapist or professional helps the partner or family member observe and determine the possibility and potential change and benefit in continuing the relationship.  Similar to non-psychotic but psychologically or culturally entrenched individuals, the threat or reality of separation may be sufficient or necessary to motivate investment in change.  Or not.

In any situation or with any individual who is potentially dangerous to self or others, the layperson is strongly cautioned not to assume adequate competency for assessment, much less intervention or treatment.  The non-professional concerned person should use the information in this book to help him or her seek additional professional assessment and intervention.  If there is any doubt, the layperson should definitely seek the consultation of professional trained resources.  This caution to seek safety determination from professional is even more critical in the case of potential psychosis.  Assessment or intervention definitely should not be undertaken by laypersons without the assistance of professionals suitably trained to recognize and treat psychosis.  Many professionals, who are otherwise well trained and competent in other areas, often fail to have sufficient education, training, experience, and expertise to identify or recognize, assess appropriately, or manage and treat active psychosis in individuals.  With the compelling possibility of physical danger to self or others, understanding an individual's unique psychotic process requires knowledge of extensive personal history of mood, cognition, and behaviors.  Irrespective of the individual's diagnosis, an assessment of little or no danger potential at any given time, the therapist or professional cannot be certain of his or her violence potential over a longer period or under differing conditions.  A fuller more comprehensive examination is needed- probably, never more than when the individual has psychotic episodes or frequent psychosis.   The therapist or professional, as well as the layperson who is not educated, trained, or experienced to be considered an expert regarding psychosis should seek specialized expert professional consultation.

3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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