Monday, 26 February 2018

Νηπιαγωγείο: Τι Αλλαγές Θα Φέρει Στην Ζωή Του Παιδιού Μας;


Η είσοδος στο σχολείο είναι ένα γεγονός γεμάτο δυσκολίες, γιατί αντιπροσωπεύει μία από τις σημαντικότερες αλλαγές στον τρόπο ζωής των παιδιών. Για τα περισσότερα παιδιά, η φοίτηση στο σχολείο αποτελεί την πρώτη τους εμπειρία παρατεταμένης απομάκρυνσης από το σπίτι. Για πολλές ώρες, κάθε εργάσιμης ημέρας, το παιδί απομακρύνεται από τις γνώριμές του και βολικές συνήθειες του σπιτιού, από έναν τρόπο ζωής όλο παιχνίδι και με μία στοργική μητέρα γύρω του, πάντα διαθέσιμη, για να βρεθεί σε ένα καθεστώς γεμάτο πειθαρχεία, όπου το παιδί δεν έχει καμία πρόσβαση και καμία δυνατότητα προσφυγής στην μητρική προστασία και συμπαράσταση.

Το παιδί από τον 7ο κιόλας μήνα της ζωής του, αναπτύσσει έναν ισχυρό συναισθηματικό δεσμό με την μητέρα του. Το φαινόμενο αυτό λέγεται προσκόλληση του παιδιού στο μητρικό πρόσωπο και αργότερα αναπτύσσει πρόσθετες προσκολλήσεις, κυρίως προς τα πρόσωπα που έχει στενή επαφή και αλληλεπίδραση μαζί τους. Απόρροια της προσκόλλησης αυτής είναι ότι το παιδί νιώθει το λεγόμενο Άγχος του Αποχωρισμού, φοβάται κι ανησυχεί δηλαδή μήπως η μητέρα του το εγκαταλείψει και φύγει. Το άγχος αυτό κορυφώνεται μεταξύ του 13ου και του 18ου μήνα. Η υπερνίκηση του άγχους του αποχωρισμού είναι ένα ορόσημο στην πορεία του ατόμου προς την συναισθηματική ωριμότητα.

Από το 3ο έτος και έπειτα, τα περισσότερα παιδιά ξεπερνούν το άγχος του αποχωρισμού και, χωρίς διαμαρτυρίες, μπορούν να βρεθούν μακριά από την μητέρα τους και με άγνωστα πρόσωπα. Δυστυχώς όμως, μερικά παιδιά συνεχίζουν να βιώνουν έντονο άγχος αποχωρισμού και πέραν του 3ου έτους, σε μεγαλύτερες ηλικίες, οπότε ενδεχομένως να συναντήσουμε άγχος σε παιδιά που τους ζητείται να πάνε στον Παιδικό Σταθμό ή αργότερα στο Νηπιαγωγείο. Γενικά πρέπει τα παιδιά να έχουν κλείσει τα 3 χρόνια για να μπορούν να νιώθουν ασφαλή σε άγνωστα μέρη, με άγνωστα πρόσωπα.

Το παιδί με την είσοδό του στο σχολείο, μεταφέρεται από ένα σχετικά «κλειστό» σύστημα, όπου οι κανόνες και οι απαιτήσεις του είναι λίγο έως πολύ προβλέψιμες και γνωστές, σε ένα σύστημα «ανοιχτό», όπου η ζωή, τις πρώτες τουλάχιστον εβδομάδες είναι γεμάτη από απροσδόκητα, απρόβλεπτα και ίσως μερικές φορές δυσάρεστα γεγονότα. Το παιδί πρέπει να δεχτεί τους κανόνες και να ανταποκριθεί στις απαιτήσεις ενός κόσμου με άγνωστα πρόσωπα και οργανωμένο πρόγραμμα.

Η σχολική ζωή προβάλλει στο παιδί απαιτήσεις – ιδιαίτερα όσον αφορά στην συγκέντρωση της προσοχής του, την ικανότητα να κάθεται στην θέση του ήσυχο και να εργάζεται ως την ολοκλήρωση του έργου που κάθε φορά αναλαμβάνει – οι οποίες του είναι ουσιαστικά πρωτόγνωρες.

Υπάρχουν ακόμη κάποια προσωπικά ζητήματα του παιδιού, όπως είναι η χρήση της τουαλέτας, τα οποία πρέπει να εκτελεστούν σε ένα επίπεδο λιγότερο ιδιωτικό από αυτόν που έχει συνηθίσει (το να σηκώσει το χέρι του για να ζητήσει την άδεια να πάει στην τουαλέτα μπορεί να προκαλέσει στο παιδί αγωνία κι αμηχανία, κυρίως όταν η εκπαίδευσή του σε αυτό το θέμα έχει γίνει πρόσφατα).

Πρέπει ακόμη να μάθει να συναναστρέφεται με άλλα παιδιά, που το καθένα έχει τις δικές του απόψεις, με παιδιά που δεν συμμερίζονται πάντα την δική του γνώμη και δεν λαμβάνουν υπόψη τα δικά του συναισθήματα. Ειδικά όταν πρόκειται για ένα παιδί που δεν έχει αδέλφια, ή δεν ήταν εφικτό να έχει κοινωνική επαφή με άλλα παιδιά της ηλικίας του, είναι αρκετά πιο δύσκολο να μάθει να μοιράζεται πράγματα ή να συμπεριφέρεται και να συνεργάζεται σωστά μέσα στην ομάδα.

Έτσι αρχίζοντας τον παιδικό σταθμό (κι αργότερα το σχολείο) το παιδί αποκτά την κοινωνική του ταυτότητα, φεύγοντας από την αποκλειστικότητα της οικογένειας, αφού ξαφνικά βρίσκεται σε ένα περιβάλλον που είναι ίσος μεταξύ ίσων. Οι παιδαγωγοί δεν εμπλέκονται συναισθηματικά με το κάθε παιδί (όπως οι γονείς με τα δικά τους), δεν έχουν προσωπικές προσδοκίες, οπότε το κάθε παιδί μαθαίνει να διεκδικεί την θέση του στην ομάδα και να προσαρμόζεται στις εκάστοτε συνθήκες. Επομένως αυτή η μετάβαση αρχικά δυσκολεύει το παιδί και κυρίως όταν αυτό έχει μάθει να κατακτά χωρίς κόπο και εύκολα από τους γονείς ότι επιζητά ή όταν υπάρχουν επιβαρυντικοί παράγοντες και αλλαγές στην ζωή του παιδιού όπως ένα νέο μωρό, αρρώστια στην οικογένεια, διαζύγιο, κτλ.

ΠΗΓΗ:


Forensic psychopathology - a summary of disorders, e.g. personal disorder, psychopathy

Numerous studies have indicated a higher prevalence's of psychiatric disorders in prisoners than in the general population. (Hollin, 1989; Singleton et al, 1998; Singleton et al, 1999; Fazel & Danesh, 2002)

However, it is a common misconception that mental illness and offending behaviour are closely related. (Gunn, 1977). Higgins (1995) cautions that the relationship between mental ill health and offending behaviour is complex, and can be oversimplified. "Even severe psychopathology, for which treatment in hospital may be advised, will rarely provide a complete explanation for the offending behaviour." (ibid: 53)

A study of 3,142 prisoners in England ands Wales by the ONS exploring the prevalence of 5 psychiatric disorders (psychosis, neurosis, personality disorder, hazardous drinking and drug dependence) found 'probable psychosis' in amongst 4% of sentenced male prisoners and 9% of male prisoners on remand. In females these rates increased to 10% and 21% respectively. The prevalence's of 'neurotic disorders' (which includes phobias, panic and anxiety disorders, depression, OCD and PTSD) were higher, in females 76% of those on remand and 63% of those sentenced, and for males 59% and 40% respectively. (Singleton et al, 1998)

In a meta-analytic study of 109 samples including 33, 588 prisoners in 24 countries Fazel & Seewald (2012) found a prevalence of psychosis of 3.6% in male prisoners and 3.9% in female prisoners, which increased to 5.5% in low-middle income countries. The prevalence of major depression was 10.2% in male prisoners and 14.1% in female prisoners.

Although it is typical to think in terms of diagnoses, Yakeley (2010) proposes that "psychological theories of mind linking personality with mental illness" (ibid, pp.28) could have more explanatory power than diagnostic classifications based on epidemiological research and empirical observation, in seeking the root causes of offending behaviour. The forensic patient can have psychopathology ranging from dementia to overt psychosis, including psychopathic personality. (Welldon, 1997)


What follows is structured in diagnostic categories.

Common disorders in forensic populations

Schizophrenia

"Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behaviour, and other symptoms that cause social or occupational dysfunction. For a diagnosis, symptoms must have been present for six months and include at least one month of active symptoms."

American Psychiatric Association, DSM V (2013)

Singleton, et al (1998) found that of a sample of prisoners in England and Wales, diagnosed through clinical interviews, 2% of males on remand, 1% of males sentenced, and 3% of female prisoners indicated schizophrenia. Taylor & Gunn (1984) found 6.1% of male prisoners had a diagnosis of schizophrenia.

Individuals diagnosed with schizophrenia are no more likely than the rest of the population to commit an offence (Lindqvist & Allebeck, 1990). However, they are more likely to be detected and arrested (Robertson, 1988), and they are more likely to have committed a violent offence. (Zitrin et al, 1976; Humphreys et al, 1992; Noble & Rodger, 1989; Taylor & Gunn, 1984; Taylor et al , 1994; Link & Stueve, 1994; Hodgins, 1992; Eronen et al, 1996; Wallace et al, 1998) Swanson et al (1996) identified command hallucinations, delusions of thoughts-insertion, or of the individual's mind being controlled by an external entity as linked to greater risk of aggression.

Individuals diagnosed with schizophrenia who offend fall into two broad categories. The first category includes acutely ill patients with positive symptoms, who are responding to a delusional idea, and the connection between the abnormal mental experience and the offending behaviour is usually clear. The second category of patients includes some less prominent positive features, alongside the negative symptoms which have emerged during the course of chronic illness. In these cases the offence is committed unintentionally, out of necessity to achieve survival, admission to hospital or prison, or prevent admission to hospital. (Higgins, 1995)


Depression

There is a broad range of depressive disorders.

"The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. What differs among them are issues of duration, timing, or presumed etiology."

American Psychiatric Association, DSM V (2013)

Depression does not present often in violent forensic populations. One in six individuals diagnosed as manic-depressive commit suicide, and violence towards others is much rarer, around 6 in 100,000 (Hafner & Boker, 1982). Violence towards others is usually constrained to close family members, and emanates from psychotic depression with delusional ideas. (Higgins, 1995)

Shoplifting is associated with depression. In a large sample of female shoplifters, 5% needed psychiatric treatment, 24% suffered a depressive disorder and 2% had manic-depression. However, the picture is likely to be more complicated; Gudjonsson (1990) found that psychologically disturbed shoplifters often present comorbidities.


Learning Disability

Whilst it is unusual for individuals with profound, severe or moderate learning disability to be within the forensic population, there are characteristics of having a mild learning disability which, when coupled with diminished or lacking protective factors, or with unexpected adverse life events, can result in offending behaviour. According to the UK Department of Education learning difficulties could include any of the following specific learning disabilities or dyslexia, dyspraxia, speech, language and communication problems, sensory impairments, attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD). In the UK the rate of intellectual impairment amongst offenders is higher when both intellectual disability and learning difficulties are present (at between 20-30%) (Talbot, 2008) than in the general population - 2% with intellectual disability (Loucks, 2007) and IQ lower than 85 (17%). However, it also true that unless the offending behaviour is especially serious, those with moderate to severe intellectual disability are rarely dealt with through the criminal; justice system. (RCPsych, 2014)


Substance misuse (alcohol, drugs)

There are marked relationships between drug and alcohol abuse, although these are not causal as a number of other factors also contribute, for example, personality characteristics, social and family background, etc. Alcohol and drug use and dependency does produce effects that make offending more likely, especially violent behaviour (Steadman et al, 1998). However, it is often the case that individuals have offended prior to drug or alcohol abuse. (Higgins, 1995)

Alcohol misuse is present in a significant number of the perpetrators of rape (34-72%), in child sexual offences (49%) and in instances of abuse and neglect within families (Wolfgang & Strohm, 1956; Rada, 1976; Coid, 1986).

Drug-dependence and habitual criminality are often in close association. (Gordon, 1990) As in the case of alcohol misuse, a history of offending usually predates drug-related offending.


Sexual offending

In England and Wales, the numbers of offenders in custody for sexual offences has increased from 9% in 2005 to 14% in 2013. In 2011, 42% of prisoners sentenced for sexual offences had committed 'other sexual offences', which includes sexual activity with minors (excluding rape and sexual assaults), exposure, voyeurism etc.

In a study exploring the psychopathology of sex offenders in Colorado in comparison to general inmates, Ahlmeyer, et al (2003) found that sex offenders displayed characteristics in keeping with schizoid, avoidant, depressive, dependent, self-defeating, and schizotypal personality disorders, alongside anxiety, dysthymia, PTSD, and major depression.


Disorders of Personality

Individuals with disorders of personality make up a high proportion of patients seen in forensic settings. Singleton, et al (1998) found that of a sample of prisoners in England and Wales, diagnosed through clinical interviews, 78% of males on remand, 64% of males sentenced, and 50% of female prisoners manifested a personality disorder. In all three groups, antisocial personality disorder was most common (63%, 49% and 31% respectively). Such rates have not been found in other studies. Taylor & Gunn (1984) found 13.8% of male prisoners had a personality disorder.


Antisocial personality disorder

"APD (Antisocial Personality Disorder) is a diagnosis assigned to individuals who habitually violate the rights of others without remorse."

American Psychiatric Association, DSM V (2013)

Personality traits such as "immaturity", "inadequacy", "hostility and aggression", and "abnormal sexuality" are commonly associated with anti social personality disorder. (Higgins, 1995)

Higgins (1995) makes clear that, in a clinical sense, antisocial personality disorder is the modern form of now anachronistic terms 'psychopathic' or 'psychopath', which implies in its perjorative sense, that a patient is untreatable, is used to reject patients from hospital, and applied casually to those with other psychiatric disorders, such as schizophrenia, or hypomania. (Coid, 1988) However, the term is likely to remain in use as it is enshrined in the Mental Health Act (1983) applying to "a persistent disorder or disability of mind […] which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned." (ibid, Section 1(2)). In a similar way, there is much to be desired in the clarity of the concepts of personality disorder. (Dolan & Coid, 1993; Coid, 1992)


Borderline Personality disorder

"A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts."

American Psychiatric Association, DSM V (2013)

This is a term that has evolved jointly through psychoanalysis and hospital psychiatry, and has been useful to describe a set of individuals with impaired sense of self-worth, who tend of develop damaged and volatile relationships. (Higgins, 1995) Such individuals tend to exhibit behaviours that are impulsive, destructive and self-destructive, and experience periods of despair, and anomie, and sometimes brief psychotic episodes. (Jackson & Tarnopolsky, 1990) Such people are capable of serious offences including sexual offences and arson, and when in prison or hospital of serious self-harm and arson. Treatment has a reputation for being challenging. The different approaches have been explored by Tantam & Whittaker (1992)


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Friday, 23 February 2018

Treatment approaches to forensic psychopathology - psychodynamic, CBT

Estela Welldon (1993) states simply that whilst society strongly supports the treatment of victims, the same does not apply to offenders.

In the Mikado, the librettist W. S. Gilbert coined the phrase "let the punishment fit the crime", which Dr Estela Welldon transposed to "let the treatment fit the crime". This latter approach is axiomatic of an evidence-based paradigm, which will guide the discussion of treatment approaches for this paper, though will not exclude those treatments where an evidence base is still being assembled.

In terms of the availability of treatment for offenders, a recent report by the Centre for Mental Health (Durcan, 2016) has found that only a few prisons are able to offer psychological therapies, and that primary mental health care is the weakest element for inmates needing mental health support.

In a systematic review of psychotherapeutic approaches for forensic and clinical cases, Ross et al (2013) identified cognitive behavioral treatments as the dominant paradigm for the rehabilitation of offenders, and a meta-analysis of cognitive behavioural approaches by Landenberger and Lipsey (2005) concluded that such an approach is most effective with higher risk individuals.

Eastman (1993: 28) noted that "in a specialty where there is an extraordinary level of psychopathology, as well as of childhood deprivation and abuse, it seems extraordinary that the (forensic) establishment has paid so little attention to the psychopathological understanding and psychotherapy". Fortunately, much work has been done since then to elucidate a broad array of aspects of clinical treatment of offenders from a psychodynamic perspective, and this will be explored further down. Welldon (1988, 2011), Cordess & Cox (1996), Welldon & Van Velsen (1997), van Marle (1997).

We will begin by exploring the treatment settings, and continue on to common treatments and interventions. When considering treatment approaches, the setting is crucial, (Taylor, 1997) as it will delimit the range of treatments available. In turn patients may have self-referred, as yet undetected and be seen in an outpatient unit, or they may be in the process of being charged, or they may already be in custody.


Treatment settings

Special hospitals are the most secure settings in the UK, and take the most serious offenders, considered to pose a serious threat to the public. Nursing staff are trained in control and restraint, as well as dealing with high-risk incidents such as hostage-taking. Such hospitals may focus on treating specific disorders. Broadmoor High-Security Hospital, for example, treats substance misuse, and young offenders with psychopathy.

Medium secure units are locked, and self-contained buildings, with some internal security, and no perimeter wall. They would take prisoners who are ready for rehabilitation, or conversely, patients from psychiatric wards or prisons displaying levels of violence in the context of their illness that additional security is indicated. As security is lower, and with sufficient determination, there is some risk of absconscion, as once well and trusted enough they may be allowed leave (either escorted or unescorted).

Such units can vary in size from between 15 to 60 beds. They usually offer treatment to psychotic patients, as patients with a personality disorder are considered more difficult to treat. The size of the units limits the range of treatment offered, which would preclude occupational therapies. Once discharged, a patient would be offered outpatient follow-up, social work supervision (though these may be mandatory if discharge is conditional and a restriction order is in place) and support from a community psychiatric nursing service.

Locked wards and specialized intensive care units within general hospital psychiatric units are suited to managing patients with challenging behaviour. These are not ideal for long admissions, as they often do not have outdoor or day areas. However, they are usually more accessible for visiting partners and family.

There are also a handful of specialist services, such as the Portman Clinic, which offers outpatient psychotherapy for patients with sexually related issues, and the Henderson Hospital, which is an inpatient unit for treatment of personality disordered men and women on a voluntary basis.


Treatments and interventions

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is "designed to help the patient test certain maladaptive cognitions and assumptions" (Beck 1979), and is the dominant form of treatment in the rehabilitation of offenders. (Polaschek, Wilson, Townsend, & Daly, 2005)

Landenberger and Lipsey (2005) carried out a meta-analysis of cognitive behavioral approaches which employed elements of problem solving, victim impact/ empathy, anger control, and behaviour modification, and found them to be most effective with higher risk cases.

Specifically, CBT has been used with men who are violent towards intimate female partners, accessed either through self-referral, or through a court order. CBT attempts to change how these men view their violence, and how they manage their behaviour. However a Cochrane Review of the RCTs conducted in this area found that the data available was inconclusive in demonstrating any significant effect of the treatment. (Smedslund, et al, 2007)

Ross et al (2013) conducted a systematic review of the efficacy of a range of psychotherapeutic interventions for forensic and clinical cases. The 8 of 10 studies utilising a CBT model demonstrated reductions in aggression following CBT, however, the data was often not robust and the reductions were not found to be obdurate on follow-up. The results are also not entirely comparable as whilst most of the studies used a CBT framework, they differed in terms of delivery, some favouring individual, others group, and some a blend of the two. The treatment programmes also varied, from standard CBT, to inclusion of components of interpersonal therapy and motivational interviewing, and drama therapy. However, it was noted that other factors associated with criminal behaviour, such as problematic drinking, social functioning, and beliefs about others, did appear to be reduced. The authors also hypothesise about whether the variety of settings in which forensic patients are treated might have lead to adaptations, which is yet another confounding factor in the review.


Treatments for Personality Disorder

Approximately 5% of the population has a personality disorder (Singleton, et al, 2001). Amongst offenders this rate increases dramatically with 66% in the prison population (Singleton, et al, 1998), and there are indications that the rate is 50% in probation caseloads. (Centre for Mental Health, 2012) The Bradley Report (2009) recognised the need for significant intervention in this area.

Common treatments for personality disorders include Mentalization Based Therapy (MBT), Structured Clinical Management, and Dialectical Behaviour Therapy (DBT).


Mentalization Based Therapy

MBT is a treatment commonly offered to violent offenders, particularly those with diagnoses of anti-social and borderline personality disorder. It focuses on improving control over behaviour and emotions, improving relationships, and working towards life goals by addressing attachment difficulties, and, through mentalization. Mentalization is an approach to developing our understanding of our own and others mental states, and the interpretation of our own and others actions. Mentalizaion can be seriously disrupted in individuals whose upbringings have been characterized by violent and abusive parenting, that itself lacks mentalization. (McGauley's Inaugural Lecture, 2016) The effectiveness of this treatment is being studied currently in a nationwide RCT led by Peter Fonagy, Antony Bateman, and Jessica Yakeley. There is already evidence that it improves outcomes and compares well with other interventions (Bateman & Fonagy, 2009), and that improvements are lasting. (Bateman & Fonagy, 2008)


Structured Clinical Management

SCM has also been developed by Bateman, Fonagy, and others, and includes regularly counselling, practical support, advocacy and case management. It ahs also been shown to be effective. (Bateman & Fonagy, 2009)


Dialectical Behaviour Therapy

DBT is an offshoot of CBT. (Dimeff & Linehan, 2001) The treatment is designed to reduce unwanted behaviours and improve emotional regulation. The development of mindfulness, founded on Buddhist meditation, is a core element, and there is a burgeoning evidence base for its effectiveness. (Feigenbaum, 2007; Verheul, R, et al, 2003))


Other approaches

Ross et al (2013) note that other forms of intervention are being trialed, for example, "Silence the Violence", a behavioural programme described by Minnaar (2010), being tested in South Africa and the UK which operates on vicarious modeling behaviour. Other documented treatment programmes include 'collective efficacy' (Sabol, Coulton, & Kolbin, 2004), Aggression Replacement Therapy (Hornsveld, Nijman, Hollin, & Kraaimaat, 2007), and Social Activity Therapy (Blacker, Watson, & Beech, 2008). These are predominantly founded on behavioral or cognitive behavioral principles, though differ in delivery and structure.


Psychodynamic approach

Forensic psychotherapy "is a bridge between traditional forensic psychiatry with a major focus on diagnosis and risk, and traditional psychotherapy with a focus on understanding why things happen." (Welldon, 2015)

"Forensic psychotherapists not only provide treatment but also apply psychodynamic thinking to the complexities and dynamics within staff teams and institutions treating this patient group." (McGauley, 2002: 118)

Forensic psychotherapy is typically a multi-disciplinary team approach, that requires collegiate working between the psychotherapist (s), psychiatry, psychology, nursing, social work or creative arts, as well as other helpers, such as managers and administrators. (Welldon, 2015) This is in recognition of the complex interconnected set of systems through which the forensic patient moves. Most patients are treated with a combination of medication, CBT and group or individual psychodynamic work.

Individual and group psychodynamic forensic psychotherapy is increasingly available across a range of settings, but usually with little capacity, meaning only a very few of the patients who would benefit from it, receive it. (McGauley, 2002: 118)

Many authors have described their psychotherapeutic work with both men and women within prison and maximum-security units. Aiyegbusi & Kelly (2012) explore the technical challenges of working within boundaries in the forensic space, with individuals whose psychopathologies often hinge on transgressions of societal laws, organizational rules, and other's people's bodies and lives, which are re-enactments of violations they themselves have suffered. Kelly (2012) explores the boundary challenges of psychotherapeutic work with men who have sexually offended. Moore and Ramsden (2012) elucidate the inherent challenges of working in psychotherapeutic groups with male offenders who have histories of boundary violations whilst in detention. Guanieri (2012) explores how dramatherapy enables creative therapeutic work with individuals using non-verbal and verbal articulations of internal boundary confusion. Dickinson and Benn (2012) look at boundary issues in delivering music therapy in high security settings, and Bownas (2012) investigates boundary characteristics of family therapy in secure inpatient units. The milieu therapy reviewed by Wolf (1977) that is a characteristic of inpatient settings, that brings together containment, structure, involvement with a focus on practical matters can be beneficial to those who've experienced chaotic lives.


The Assessment

Any forensic intervention should begin with a comprehensive assessment of the patient that is clearly demarcated from the legalistic encounters the patient may be familiar with. It should explore developmental and family history, alongside their and context and circumstances, and will likely reveal to the psychotherapist some of what may make an offender suitable for treatment, as well as clues to early traumatic experiences. (Welldon, 1993) Assessments should be approached with the utmost honesty and transparency, which extends to the 'structuring of time" (Cox, 1978).


Selection criteria for psychodynamic treatment

Not all offenders warrant treatment, not all want treatment, and not all can benefit from it. This may be due to careerist criminality. Obversely, the clumsily executed criminal act has become the equivalent of the neurotic symptom that emerges from the unconscious as a flag to a psychopathology needing treatment. (Welldon, 2015)

Exploring the particular psychopathologies can assist with determining whether individual or group psychotherapy will be most effective. For example, an individual with a serious personality disorder, who is unlikely to develop relationships, will not be a good candidate for group psychotherapy. (Welldon, 1993)


Individual psychodynamic treatment

The forensic psychotherapist seeks to help individuals understand their own minds better, and through this to develop a capacity to tolerate their own unpalatable thoughts and emotional states, rather than acting on them. (McGauley, 2002)

Typically treatment is over months, and sometimes years. However, this continuity that is key to a psychodynamic approach can be disrupted due to individuals being moved into different institutions depending on the status of the judiciary proceedings against them. (McGauley, 2002)

There are various characteristics that indicate an individual can make good use of individual psychotherapy. For instance, patients who've experienced a very close, merged relationship with one parent usually benefit from the warmer, less threatening atmosphere in a group. (Welldon, 1993)


Group therapy

Violent offenders tend to benefit more from group psychotherapy, due to the mechanism of identification with others, which, as Freud (1921) observed, tends to limit aggression towards them. Being surrounded by others who can sense hostility welling up before it is articulated gives a group the capacity to confront and defuse violent behaviour before it is enacted, and the multiplicity of the transference diversifies and softens the anger which would otherwise have focused intensely on a single target. (Welldon, 1993)

There are also those whose present circumstances preclude them from making good use of group therapy, for example, for those whose own or spouses criminal activities continue, where the rule of confidentiality would be impossible to uphold.

Group-analytic therapy is also indicated for those patients who've experienced abuse, both abusers and abused, since the group functions to re-create the family constellation, the violent and anti-social nature of which is at the root of many of their problems. The group setting is also a bulwark against the secrecy that has often perpetuated incestuous relations in the family, as well as the therapists being drawn into a transferential-counter-transferential dynamic that recapitulates the original traumatic experience. (Welldon, 1993)

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Wednesday, 21 February 2018

Aetiology of Forensic Psychopathology

Aetiology is "the study of the causes of disease." (Reber and Reber, 2001)

The concept originates in a medical model that looks predominantly at biological factors, for example the genetic basis of bipolar disorder. This is broadened within the psychiatric model to include aspects of the environment, which would include psychological or social factors. There is a risk when employing the medical model of attributing the cause of a mood disorder to biology, rather than recognizing biological factors as contributing to an individual's affective experience, alongside environmental factors. (Bartlett, 2010)

Spitzer and Wilson (1975) explored whether psychiatric disorders can justifiably be referred to as physiological dysfunction, and concluded that they cannot. Their reasons were: 1) that the aetiology of psychiatric disorders is never fully understood, and they are typically multi-factorial; 2) that features of psychiatric disorders are often part and parcel of normal experience, unlike, for example, 'coughs' or 'heart pain'; 3) that there would need to be a demonstrable physical change in the individual - in fact that there are instances where this is the case, as well as more recent research into genetic pre-disposing factors in personality disorder (Tobena, 2000), and; 4) that physiological dysfunction should proceed independently of environmental influences, which is not the case.

It is important to note that Caspi et al (2014), and Patalay et al (2015) have recently elucidated a general factor for psychopathology (p-factor) in psychiatric disorders onto which all aetiological factors load. Higher p scores have been associated with greater life impairment, greater familiarity, poorer developmental histories and more compromised early brain function. The authors propose that the p-factor explains the challenges of identifying common aetiological factors associated with any specific psychiatric disorders.

In terms of the relationship between psychopathology and offending behavior, the psychodynamic perspective presents with another useful way of thinking:

"At times, the criminal act is the expression of more severe psychopathology; it is secretive, completely encapsulated and split from the rest of the patient's personality, which acts as a defence against a psychotic illness (Hopper, 1991). On the other hand, it can be a calculated act associated with professional, careerist criminality. The forensic psychotherapist can help to clarify these difficult diagnostic issues. " (Welldon, 2011: 174)

Welldon (2011) reminds us further on that patients with severe psychopathology have experienced profound instability and inconsistency at crucial junctures in their early lives in which both their psychological and physiological survival were in jeopardy. These experiences have effectively disrupted processes of individuation and separation through undermining the basic trust towards primary caregivers that most people are able to depend on.

This paper will examine the work carried out so far to identify the aetiologies of common forensic psychopathology that manifest specific offending behaviours, considering physiological and environmental factors, and including psychodynamic perspectives.


Violent crimes

Despite the media's portrayal of mentally ill individuals as the common perpetrators of violent crimes, most individuals with mental illness are not violent, although there is a small but significant association. (Yakeley, 2010)

It is worth bearing in mind Estela Welldon's (2015) observations, that the common public response to violence is rarely scrutinised as it appears on the surface to be logical and pragmatic. Projection and splitting are usually at play, and as a result perpetrators are labelled 'bad', with those looking on defending their 'goodness' in contrast, which is an example of Melanie Klein's (1946) 'projective identification'. As this approach to understanding the dynamics of violence is often viewed as condoning the criminal act, psychodynamic approaches can be vilified, and as a result the forensic psychotherapist has the invidious task both of trying to help their patient, whilst working through some of the painful problems that wider society contends with.

If we turn to research studies, this is what we find.

Violence in individuals with mental disorder has been correlated with a range of maladjusted behavior during early childhood, which in turn are associated with aetiological factors. (Burke, 2010)

Such maladjusted behaviours include attention and concentration problems, recurrent failure in academic settings, and truancy and expulsion from school (Harris, et al 1993), anti-social behavior at an early age (such as chronic alcohol/substance abuse, and aggressiveness) (Farrington, 2001), impulsive, reckless behavior during adolescence, problems with peer group relationships, and hostility towards authority (Melton et al, 1997).

The aetiological factors associated with these maladaptive behaviors are sexual and physical abuse and neglect (Ferguson and Lynskey, 1997; Weiler and Widom, 1996; Widom, 1989), separation from parents at an early age (under 16 years), parental rejection, low parental involvement, cruel and inconsistent parenting (Muetzell, 1995), parental alcoholism (Moffitt, 1987; Rydelius, 1994; Virkkunen et al 1996) and violence within the family (Blomhoff et al, 1990; Fitch and Papantonio 1983; Johnston 1988; Ryan, 1989).

Burke (2010) stresses that whilst these factors may not directly cause violent behavior, they may "structure potential violence" (41) and they may shape triggers to future violence. Glasser (1996) noted that an individual diagnosed with schizophrenia does not commit a homicidal act as a result of psychological malfunctioning. As Doctor (2008: 2) avers "even the most apparently insane violence has a meaning in the mind of the person who commits it. There is a need to be aware of this meaning and to learn from it in an attempt to prevent further violence."

If we are thinking less about the root causes, and more about the moment to moment dynamics that precede violent crimes, it is helpful to remember James Gilligan's assertion that acts of violence, and this is especially true of those acts that appear irrational, are most often preceded by subjective feelings of humiliation. (Gilligan, 1996)

For more detail on the psychodynamics underpinning violent crimes, we have learnt from De Zulueta (2006) what some consider to be a nearly ineluctable process that takes place in between mental and physical pain and its development into physical violence. Where De Zulueta makes reference to individual situations, Meloy and Yakeley (2014) apply a similar approach to the context of group and social violence, including acts of genocide and terrorism.


Violence towards women

As with any other offending behavior explored here, there is a biological theory underpinning domestic violence against women, which points to men's average greater size and physical strength. Dobash and Dobash (1992), and Koss et al (1994), note that this implies such incidents have different meanings and physical consequences for the victims. There are also powerful discourses that make aggression, and therefore violence, as naturally masculine behavior, as well a biological sub-plot, which connects levels of testosterone and aggression. (Hearn, 1998)

From a psychological perspective, a commonly attributed cause is problematic personality types, or personality disorders (Dobash et al 2000; Hearn, 1998; Koss et al, 1994), though this has been criticized as withdrawing the agency from such men, which also makes the possibly of them engaging in transformative change of themselves difficult. (Dobash et al, 2000)


Sexual offending

The prevalence of mental ill health amongst sexual offenders is low (10% or less) (Sahota and Chesterman, 1998b), although in the region of 30%-50% for personality disorders. (Ahlmeyer at al, 2003; Madsen et al, 2006) However, there is no causal relationship between mental ill health and sexual offending. Any relationship is complex, and needs to take into account aetiological and risk factors.

It is important to bear in mind that whilst the following characteristics have been observed in men who've committed sexual offences, they will not be present in all individuals who offend. (Houston, 2010)

As discussed above, early attempts to understand sexual offending began with a focus on biology, such as Goodman's (1987) theory, which concentrated on hormonal and genetic factors. Elaborating on Marshall's (1989) observations of an interaction between deficits in the capacity to have intimate relationships, and sexual offending, Marshall and Barbaree (1990) proposed a multifactor 'integrated' theory. The theory included genetic factors alongside the influence of the criticial adolescent developmental task in males of distinguishing between aggressive and sexual impulses, as they emanate from the same brain structures. They recognized that hormonal factors will render this task more challenging, especially in the context of unfavorable early development.

Hudson and Ward (1997) hypothesized that men who have sexually offended against children tend to have anxious, pre-occupied and fearful styles of attachment. Attachment theory is the psychological model of the dynamics of human relationships, learnt in early childhood, and articulated especially in times of stress. (Bowlby, 1971) Smallbone (2006) later developed an 'attachment-theoretical revision' of the 'integrated' theory.

The significance of negative early childhood experiences and their contribution to the development of maladaptive patterns of attachment in later sexual offending has been increasingly examined in the last two decades. Craissati et al (2002) found that the family history of sexual offenders involved high levels of disruption, neglect and violence, and Prentky et al (1989) found a relationship between inconsistency in caregivers, and familial sexual deviation and abuse, with severity of sexual aggression within a cohort of sentenced rapists.

Higher levels of physical abuse have been identified in the family lives of rapists than other sexual offenders (Marshall et al, 1991) or non-sexual offenders (Leonard, 1993). High rates (40%) have been found amongst convicted child abusers (Craisatti and McClurg, 1996).

A history of sexual abuse has consistently been found to be more common in sexual offenders than in either non-sexual offenders or non-offenders. In men who have sexually offended against children, the rates of victimization have been found to be between 46% and 51% (Craissati et al, 2002; Craisatti and McClurg, 1996; Houston and Scoales 2008).

Studies have also examined underlying beliefs and cognitive schema of sexual offenders, for example, the work on cognitive distortions by Abel et al (1989), and implicit theories that underpin these cognitive distortions amongst men who offend against children (Ward and Keenan, 1999), and amongst convicted rapists. (Polaschek and Ward, 2002)

There are various theories that bring these things together, such as Finkelhor's (1984) model of sexual offending against children, Wolf's (1985) model of the influence of early childhood adversity leading to sexually deviant interests, and Ward & Siegert's (2002) aetiological theory of sexual offenders against children, and the heterogeneity amongst them. In addition, models of sexual aggression towards women have been constructed by Hall and Hirschmann (1991), which has been critically evaluated by Ward et al (2006), and Malamuth et al (1993).


SOURCE:

Forensic psychotherapy - history and theoretical schools of thought


Forensic psychotherapy "is a bridge between traditional forensic psychiatry with a major focus on diagnosis and risk, and traditional psychotherapy with a focus on understanding why things happen." (Welldon, 2015b) Williams (1991) examines the difficulties in bridging these disciplines. Eastman (1993: 28) noted that "in a specialty where there is an extraordinary level of psychopathology, as well as of childhood deprivation and abuse, it seems extraordinary that the (forensic) establishment has paid so little attention to the psychopathological understanding and psychotherapy".

Forensic Psychotherapy seeks to understand the unconscious motivations of the offender's antisocial behaviours, with the objective of preventing their repetition, which might lead to further crimes against society. The better the criminal mind can be understood, the more effectively positive action can be taken to prevent criminal acts, and the better counter-transferential responses can be understood and managed. The expectation is that in time, this should lead to more effective and economically viable treatments. (Welldon, 1994)

Typically, criminal behaviour is responded to with punishment, so a compassionate response that attempts to understand the offender and his delinquent actions in the context of self-destructive and compulsive behaviours is equated with condonement. (Welldon, 2015) As such the Forensic Psychotherapist has the invidious task of both trying to help his/her patient, whilst also trying to work through some of the painful problems that society contends with.

Unlike the dyadic relationship between therapist and patient in traditional psychotherapy, forensic psychotherapy involves a triadic relationship between therapist, patient, and society. (de Smit, 1992) Welldon (2015b) draws other triadic relationships into this work: between the social roles of 'bully', 'victim' and 'bystander' (Twemlow, Sacco and Williams, 1996), and; between the cultures of concern, learning and blaming. (Welldon, 2011)

The modifications of traditional psychoanalytic practice that have led to forensic psychotherapy as a model in its own right have received support from eminent psychoanalysts such as Kernberg (2014) and Twemlow (2013).

Over the years this approach has made progress, and behaviours traditionally treated as transgressions deserving punishment have been steadily recognised as being understandable, with a basis in the patients life experiences. This is evidenced by the inclusion of such behaviours in the Diagnostic Statistical Manuals, e.g. DSM - III-R ((American Psychiatric Association (APA), 1987).

Fishman and Ruscynski (2004) note that it is due to the work of the International Association of Forensic Psychotherapy and Dr Estela Welldon, that the title of forensic psychotherapist came into existence.


History

The UK has been at the vanguard of the development of forensic psychotherapy, since, in 1931, the Institute for the Scientific Treatment of Delinquency and Crime was established. This later became known as the Institute for the Study and Treatment of Delinquency (ISTD) (Cordess, 1992; Glover, 1960). The Institute identified its goal as to promote alternative and better ways of dealing with criminals than imprisoning them. It also sought to advance understanding of the causes and prevention of crime through scientific research, as well as consolidating the literature already extant, promoting cooperation between the relevant statutory and professional bodies involved in forensic work, and to advise and educate colleagues and the public. Its first chair was the eminent and influential psychoanalyst Dr Edward Glover.

The ISTD was strongly influenced by the work of the psychiatrist and psychotherapist, Dr Grace Pailthorpe, who worked in Birmingham and Holloway prisons following time as a doctor in the trenches in the First World War. Dr Pailthorpe eventually wrote Studies in the Psychology of Delinquency (1932) in which she explored her interest in the personalities of female prisoners, which attracted other like minded psychoanalysts, including Dr Glover, who had himself been expanding the literature around sexuality, criminality, and addictions.

Glover wrote in his own history of the ISTD that, as the work dealt with social phenomena, it required the involvement of a variety of disciplines, including social workers and social psychologists, but that the most vital approach to making sense of crime, was psychoanalytic. (Fishman & Ruszcynski, 2004) Welldon (2015) notes that forensic psychotherapy is typically a multi-disciplinary team approach, in recognition of the complex interconnected set of systems through which the forensic patient moves.

Due to the stigma attached to its work, the clinicians of the ISTD were prevented from working under one roof until May 1937. In 1948, with the establishment of the National Health Service, one part of the ISTD joined the NHS as the Portman Clinic, offering treatment primarily, and a part that remained the ISTD (now located at Kings College London) focused on research and training. (Welldon, 1992) In the United States during the early 20th century, Dr Karl Menninger was establishing the Menninger School of Psychiatry in Topeka, Kansas. He believed that punishment protected neither society not the criminal, and went considerably further with a psychodynamic perspective.

Dr Menninger famously critiqued the popular interpretation of Lee Harvey Oswald's case, as an example of the alienated, little man, gaining attention and notoriety through a transgressive act directed at society (1967).

In the UK, during the mid 1960s, Dr Maxwell Jones founded a "therapeutic community" (Jones, 1953) at the Henderson Hospital for the treatment of severe personality disorders, at the time known in a pejorative sense as psychopaths. This clinic was run in such a way as to achieve greater parity and equality between staff and patients, with patients having a much greater say in the running of the institution, and even the discharge of their peers. In this way Dr Jones further eroded the stigma engrained in the treatment of such individuals.

During the 1960s the Portman Clinic continued to play a central part in the development of the field, holding conferences (in 1961), and publishing volumes (the same year, and a second edition in 1979) on pathology and the treatment of sexual deviation, such as "Sexual Deviation" (Eds Ismond Rosen, 1964)

Fishman & Ruszcynski (2004) note that a number of seminal works emanated from clinicians working within the Portman Clinic. For example "From the analysis of a transvestite" (1979a), and "On violence: a preliminary communication" (1998) by Dr Mervin Glasser, "Clinical types of homosexuality" (1989c) and "A re-evaluation of acting out in relation to working through" (1966) by Adam Limentani and Estela Welldon's work on female perversion "Mother, Madonna, Whore" (1988). Another key publication is the twin volume edition "Forensic Psychotherapy" edited by Christopher Cordess and Murray Cox.

Having been embedded within the fabric of the NHS for some years, and established a theoretical basis, the place of forensic psychotherapy within statutory services in the UK was at risk during the mid 1980s, due to a serious review of the role of psychotherapeutic work offered through the NHS. However, the Seymour review (1985) ultimately concluded that psychotherapy did have a part to play in the NHS.


Founding of the IAFP

A pivotal moment in the recognition of forensic psychotherapy as a discipline in it's own right, was the initiation of the International Association of Forensic Psychotherapy (IAFP). As an idea, the IAFP emerged from a conference on Law & Psychotherapy in Leuven, Belgium, in 1991.

At this time, the gap between the psychodynamic and judicial understandings of criminal behaviour was being bridged through residential weekends for judges, co-led by staff from the Portman Clinic, to enable them to become familiar with a psychodynamic understanding of unconscious motivations of offenders. (Welldon, 2015b)

The IAFP emerged, driven by Dr Welldon, from the European symposia, originating in the 1980s with annual meetings at the Portman Clinic that brought together practitioners from Holland, Belgium, Austria and Germany, along with staff from the Portman Clinic, to explore work with patients involved with the criminal justice system due to their psychopathology.

The IAFP is a robust enterprise, which marked its 25th anniversary in 2016, with its 25th annual conference in Ghent, Belgium.


Training in Forensic Psychotherapy

The most important contribution to the field emerged from the Portman's array of workshops and conferences was the 2 year Diploma in Forensic Psychotherapeutic Studies, sponsored first by the British Post Graduate Medical Federation, and later by UCL. The course was pioneered by Dr Estela Welldon, who was appointed as clinical tutor at the Portman Clinic in 1988. Dr Welldon and Professor Michael Peckham structured the course, with a faculty of Portman Clinic staff, and other consultants delivering the teaching. The course was the first of its kind, and ran for 4 years and was the embodiment of the challenges of bridging the disciplines of forensic psychiatry, and of psychodynamic psychotherapy. In this respect, it played a crucial role in furthering understanding of the field, and creating a cohort of newly equipped clinicians, in this "evolving species". (Adshead, 1991).

Many of the alumni have become influential figures in the sector and held leading offices within the IAFP, and since the course was multidisciplinary, books from a broad range of different professions continue to emerge, illuminating and widening the scope of this field.

These books include Toxic Couples: The Psychology of Domestic Violence (2014) and The Psychology of Female Violence: Crimes Against the Body (2008) by Anna Motz, and Dangerous Patients: A Psychodynamic Approach to Risk Assessment and Management (2003) and Murder: A Psychotherapeutic Investigation (2008) by Ronald Doctor.

The first consultant psychiatry post in forensic psychotherapy was created in 1994 by Professor Eastman and Margaret Orr, then medical director at Broadmoor Prison, which was held by Dr Gill McGauley. (McGauley, 2016)

Forensic psychotherapy is being adapted for a variety of purposes, for example, working with offenders with learning difficulties (Corbett, 2014; Sinason, 2010; Curen & Sinason, 2010), music therapy and art therapy have been shown to be effective for patients in prisons and other secure settings (Compton Dickinson, Odell-Miller, & Adlam, 2012). Group analysis has also been utilised effectively with forensic patients. (Welldon, 1993)

Despite a growing body of evidence for both the effectiveness of these treatments, and the cost-effectiveness of such an approach in comparison to penitentiary and other traditional responses to crime, there are still those who question it's efficacy. (Altshul, 2013)

SOURCE:

Friday, 16 February 2018

Ο Γιώργος και η Ελένη, Αλκοολικοί Ανώνυμοι, μιλούν για τις εμπειρίες τους στην A.V.


«Βιώνουμε μια σκληρή δοκιμασία, σωματική, διανοητική, συναισθηματική»

Αισιοδοξία και ελπίδα είχα γεμίσει, φεύγοντας από τον 6ο όροφο της λεωφόρου Αλεξάνδρας 112, από την έδρα των Αλκοολικών Ανωνύμων! Ο Γιώργος, πρόεδρος του σωματείου για τις δραστηριότητες των ΑΑ, και η Ελένη, γενική γραμματέας Δημόσιας Πληροφόρησης Ελλάδας των ΑΑ, είναι δύο μαχητές της ζωής και η κουβέντα που κάναμε μαζί τους ήταν κάτι σαν λυτρωτική ψυχοθεραπεία για όλους μας, ενώ στα διπλανά δωμάτια ήταν σε πλήρη εξέλιξη δραστηριότητες ομάδων των ΑΑ. Η συζήτηση ήταν όμορφη και ιδιαιτέρως διαφωτιστική!

Ελένη, σε ποια ηλικία ενεπλάκης στη συστηματική κατάχρηση του αλκοόλ;

Σε συστηματική, καθημερινή πόση από την ηλικία των 19 ετών!

Και είχες δοκιμάσει αλκοόλ στις κοινωνικές συναναστροφές σου πολύ νωρίτερα, ασφαλώς…




Στα 14!

Πότε ένιωσες ότι έχεις πρόβλημα με το αλκοόλ; Συνέβη κάτι συνταρακτικό, το οποίο σε ταρακούνησε για τα καλά;

Θα σας πω τι συνέβη την πρώτη φορά που δοκίμασα αλκοόλ, τότε που δεν είχε συμβεί τίποτε συνταρακτικό. Γιατί αυτό είναι το αξιοσημείωτο. Ήμουν 14 ετών και απλά δοκίμασα, έτσι, για πρώτη φορά. Η επίδραση του αλκοόλ ήταν πολύ έντονη. Ένιωσα πρωτόγνωρα και έντονα συναισθήματα! Βίωσα μία αυτοπεποίθηση, την οποία δεν είχα, ασφαλώς, σαν παιδί. Έτσι, αργότερα, με την πρώτη δυσκολία χρειαζόμουν να πιω κάτι, να ανακαλέσω εκείνη την πρώτη εντύπωση, την πρώτη αίσθηση, και σε βάθος χρόνου έφτασα στην καθημερινή και ολοήμερη, εικοσιτετράωρη κατανάλωση αλκοόλ!



Ελένη, θυμάσαι κάτι το οποίο να σε συγκλόνισε, κατά τη διάρκεια των ετών που ήσουν στην εικοσιτετράωρη κατανάλωση αλκοόλ. Συνέβη ποτέ κάτι, το οποίο να σε έκανε να πεις «δεν πάει άλλο! Ως εδώ!»;

Θα σας μιλήσω για ένα πολύ έντονο περιστατικό, το οποίο συνέβη λίγο πριν έρθω στους Αλκοολικούς Ανώνυμους: Ξεκίνησα να πίνω από τις 6 το πρωί και κατά τις 12 το μεσημέρι με πήρε ο ύπνος και κόντεψα να καώ! Ήμουν δίπλα σε μία ηλεκτρική σόμπα και, ενώ καιγόμουν, δεν καταλάβαινα τίποτε, δεν ένιωθα το κάψιμο… Με ξύπνησε ο σύντροφός μου!

Εκεί αποφάσισες ότι κάτι πρέπει να κάνεις για τον εαυτό σου;

Από εκεί ξεκινώ πλέον να προβληματίζομαι. Βλέπω ότι δεν μπορώ να σταματήσω να πίνω. Απευθύνομαι σε ειδικούς, με τη βοήθεια συγγενικών προσώπων. Με παραπέμπουν σε ψυχίατρο ειδικό στις εξαρτήσεις, ο οποίος με παρέπεμψε, μετά από ένα χρόνο, στους ΑΑ, γιατί δεν μπορούσα να σταματήσω να πίνω… Περισσότερο από δύο – τρεις μέρες δεν μπορούσα, δεν γινόταν να μείνω χωρίς να πιω. Η ανάγκη μου να πιω ήταν τεράστια! Την ημέρα που έπινα κατανάλωνα ό,τι δεν είχα πιει τις προηγούμενες δύο – τρεις ημέρες…

Γιώργο, κάτι θέλεις να πεις…

Αυτό που λέγεται είναι ότι ένας ψυχικά ασθενής, μη αλκοολικός, είτε πάσχει από κατάθλιψη είτε από ψύχωση, θα λάβει μία φαρμακευτική αγωγή και θα ησυχάσει. Όμως, ο αλκοολικός έχει την ανάγκη να πιει! Δεν δουλεύει τίποτε!

Υπάρχουν περιπτώσεις αλκοολικών, οι οποίοι να μην τα κατάφεραν ούτε μέσα από τους ΑΑ;

Ναι, φυσικά!

Πως «μετράτε» την επιθυμία ενός αλκοολικού να πάψει να πίνει. Λέει «επιθυμώ να σταματήσω» και την επόμενη στιγμή θέλει να πιει και πίνει, Γιώργο…

Ωραία ερώτηση! Στους ΑΑ έχουμε ένα συγκεκριμένο πρόγραμμα ανάρρωσης. Εάν κάποιος θελήσει να δουλέψει το πρόγραμμα, έχει πολύ υψηλές πιθανότητες να βγει νηφάλιος στο τέλος. Εάν, όμως, μείνει μόνο με την επιθυμία του να διακόψει, δύσκολα παραμένει «καθαρός». Δεν φτάνει μόνο η απόφαση.

Τι κάνετε στο πρόγραμμα ανάρρωσης;

Ο αλκοολικός έρχεται στις συναντήσεις και λαμβάνει στις αρχές βασικές οδηγίες για να μπορεί να αντέξει κατά τις πρώτες ημέρες, βασικές οδηγίες τις οποίες ακολουθήσαμε όλοι. Δηλαδή του λέμε ό,τι είπαν σε εμάς οι παλαιότεροι: Να πίνεις πάρα πολλά υγρά, να λαμβάνεις πολύ ζάχαρη, διότι ο οργανισμός στερείται το αλκοόλ και παθαίνει ισχυρό κλονισμό. Ψάχνουμε τα υποκατάστατα. Άλλες σημαντικές προτάσεις είναι να αποφεύγουμε πρόσωπα, καταστάσεις και μέρη που μας αναστάτωναν… Ξέρεις, μιλάμε για μία θανατηφόρα ασθένεια. Είναι ζήτημα ζωής και θανάτου για μας. Έτσι, ακολουθώντας εκείνα τα οποία προτείνουν οι παλαιότεροι, έχει κανείς πολλές πιθανότητες να απομακρυνθεί από την επιθυμία. Θα υπάρχει η επιθυμία, αλλά δεν θα είναι τόσο έντονη όσο ακολουθείς τις προτάσεις του προγράμματος και των παλαιοτέρων ΑΑ.

Είναι τελικά μύθος αυτό το οποίο πιστεύουμε όλοι μας, δηλαδή ότι, εάν ο νηφάλιος αλκοολικός πιεί λίγο, τότε ξανακυλάει στην κατάχρηση του αλκοόλ;

Όχι, δεν είναι μύθος, είναι η αλήθεια. Εγώ προσωπικά ήμουν δύο χρόνια «καθαρός» και ήπια. Μετά από δύο χρόνια. Βρέθηκα ακριβώς σε εκείνο το παλιό σημείο. Βρέθηκα με τη μία στην αρχή…

Τελικά, Γιώργο, πόσο συχνές είναι οι υποτροπές; Ο καθένας κάνει υποτροπή;

Εδώ, στους ΑΑ, δεν είναι συνηθισμένες οι υποτροπές. Όταν ήρθα στους ΑΑ ένιωσα αυτό το οποίο χρειάστηκε η ψυχή μου και έτσι νιώθει όποιος έρχεται στους ΑΑ. Βρήκα αγάπη, βρήκα στοργή, βρήκα ομοίους μου και αυτό το είχα πολύ μεγάλη ανάγκη μέσα μου. Σε τέτοιο περιβάλλον δεν είναι πολύ συνηθισμένες οι υποτροπές. Βεβαίως, υπάρχουν άνθρωποι οι οποίοι φεύγουν κάποια στιγμή…

Γιατί φεύγουν, Γιώργο;

Δεν είναι έτοιμοι. Γι’ αυτό φεύγουν. Έρχονται για λίγο και φεύγουν. Φεύγουν σχεδόν από την αρχή. Δεν είναι τόσο θέμα απόφασης όσο είναι το θέμα να είναι κανείς έτοιμος να ακολουθήσει πρόγραμμα ανάρρωσης . Το θέμα είναι πόσο έτοιμος είναι κανείς να σταματήσει να πίνει. Για εντελώς προσωπικούς λόγους κάποιοι δεν είμαστε έτοιμοι. Κάποιοι είμαστε έτοιμοι, γιατί δεν πάει άλλο, δεν έχουμε άλλα περιθώρια.

Ελένη, ο αλκοολικός στιγματίζεται; Υπάρχει κοινωνικό στίγμα για αυτήν την ασθένεια; Μήπως δεν υπάρχει στίγμα, επειδή δεν είναι ορατός σε εμάς ο αλκοολικός; Πρέπει να έχει πιει όλη μέρα για να καταλάβουμε τον αλκοολικό…

Θα σας πω μόνο αυτό: Δεν έπινα έξω από το σπίτι, γιατί ήθελα να αποφύγω ακριβώς τον στιγματισμό μου. Κλεινόμουν στο σπίτι και έπινα! Ήθελα να αποφύγω το στίγμα! Με ένοιαζε πολύ η εικόνα μου.

Στο σπίτι, λοιπόν, από τα πιο κοντινά σου πρόσωπα τι μηνύματα ελάμβανες; Τι σου έλεγαν;

Δεν μπορούσαν με τίποτε να κατανοήσουν ότι ο αλκοολισμός είναι ασθένεια. Νόμιζαν ότι απλώς κάνω τα δικά μου, για διασκέδαση, για να περνάω καλά και να μη με νοιάζει τίποτε! Και μιλάμε ακόμη και για την αδελφή μου ή τον σύντροφό μου!

(Γιώργος): Το έχουν πει οι ΑΑ πριν από περίπου 100 χρόνια: Ο αλκοολισμός είναι ασθένεια. Είναι σωματική ασθένεια, είναι διανοητική ασθένεια και συναισθηματική ασθένεια. Καταλαβαίνετε, λοιπόν, ότι χρειάζεται καλή ανάρρωση, γιατί ελλοχεύει πάντα η υποτροπή! Δεν είναι εύκολο να μείνει «καθαρός» από αλκοόλ, όταν το βρίσκεις ακόμη και στα περίπτερα! Η επιθυμία πάντα θα υπάρχει, ο αλκοολισμός είναι μία χρόνια ασθένεια, αλλά όσο αναρρώνεις απομακρύνεσαι από την επιθυμία.

Ελένη, είπες ότι ακόμη και οι πιο κοντινοί σου άνθρωποι δεν καταλάβαιναν ότι ο αλκοολισμός είναι ασθένεια και όχι διασκέδαση. Πως έλαβες, τότε, την απόφαση να έρθεις στους ΑΑ; Τι σε ώθησε;

Με απείλησαν ότι θα με κλείσουν σε ίδρυμα… Δηλαδή, δεν ήμουν πια σε θέση να διαχειρίζομαι τη ζωή μου. Είχα παραιτηθεί από τη δουλειά μου, έπινα από το πρωί μέχρι το βράδυ και, έτσι, οι γονείς μου με απείλησαν ότι θα με κλείσουν σε ίδρυμα. Έπρεπε να κάνω εγώ κάτι. Ήρθα εδώ, στους ΑΑ. Αυτό έκανα. Χρόνια γνώριζα ότι υπάρχουν οι ΑΑ. Απλώς δεν ήξερα τι ακριβώς κάνουν οι ΑΑ. Αλλά φοβήθηκα τόσο τον εγκλεισμό μου…

ΠΗΓΗ:

Τι κάνουμε όταν ακούσουμε τι φράση: «Μαμά θέλω να μου πάρεις κινητό τηλέφωνο»;





Είναι δεδομένο ότι το να αγοράσετε στο παιδί σας smartphone δεν είναι μία εύκολη απόφαση. Όμως, σήμερα, τα περισσότερα παιδιά έχουν μία νέα μορφή επικοινωνίας μεταξύ τους, μέσω κινητού τηλεφώνου. Η επικοινωνία δεν σταματά ποτέ, αλλά ξετυλίγεται μέσα από αλληλουχίες μηνυμάτων, με τους δικούς τους κώδικες και τη δική τους γλώσσα.

Τα παιδιά, μέσω αυτού, έχουν την αίσθηση ότι διαχειρίζονται, χωρίς παρεμβάσεις το καθημερινό τους πρόγραμμα, κανονίζουν ραντεβού με τους φίλους τους, μιλούν με όποιον και όσο θέλουν, χωρίς τον έλεγχο ή την επίβλεψη του γονιού απαραίτητα. Ωστόσο, οι γονείς θα πρέπει να είναι πολύ προσεκτικοί και να λαμβάνουν υπόψη τους πολλές παραμέτρους για το συγκεκριμένο θέμα:
Kατ’αρχάς, θα πρέπει να εκτιμούν την αναπτυξιακή ωριμότητα του παιδιού πριν προχωρήσουν στη συγκεκριμένη παροχή, δεδομένου ότι δεν συνιστάται η χρήση κινητού από παιδιά ηλικίας μικρότερης των 8 ετών.
Θα πρέπει να είναι πάντα σε θέση να επιβλέπουν και να γνωρίζουν το πώς επικοινωνεί το παιδί, ώστε να το συμβουλεύουν ανάλογα.
Θα πρέπει να ενημερώνουν το παιδί ότι πρέπει να αποφεύγει τη φύλαξη του κινητού σε τσέπες ή στη ζώνη και να προτιμά τη φύλαξη σε τσάντα. Επίσης, πρέπει να αποτρέπεται η χρήση του κινητού στο αυτοκίνητο.
Θα πρέπει να συζητούν με τo παιδί για τις επαφές και τις δραστηριότητες που έχει μέσω τηλεφώνου.
Θα πρέπει να προσέχουν αν το παιδί επικοινωνεί υπερβολικά μέσω του τηλεφώνου, περιορίζοντας τις πρόσωπο με πρόσωπο στιγμές που έχει με τους φίλους του. Αν συμβαίνει αυτό, θα πρέπει να περνούν περισσότερο χρόνο ουσιαστικής επαφής και επικοινωνίας μαζί του και να το ενθαρρύνουν να έχει και ζωντανές, πρόσωπο με πρόσωπο στιγμές με τους φίλους του, όχι μόνο μέσω του κινητού και του Internet.
Επίσης, θα πρέπει να του εξηγήσουν ότι έχουν την ευθύνη κατοχής του κινητού και ότι δεν πρέπει ποτέ να το δίνουν σε αγνώστους. Ο κωδικός κλειδώματος της SIM κάρτας είναι αυστηρά προσωπικός και το παιδί δεν πρέπει να απαντά σε κλήσεις από άγνωστους αριθμούς ή από γραμμές με απόκρυψη, καθώς και να μην ανταλλάσσει γραπτά μηνύματα ή οποιουδήποτε άλλου είδους περιεχόμενο με αγνώστους.
Τέλος, θα πρέπει να συζητήσουν με το παιδί για την ύπαρξη αριθμών αυξημένης χρέωσης.

ΠΗΓΗ:


Monday, 12 February 2018

Σχολικός Εκφοβισμός


Το παιδί που βιώνει εκφοβισμό - Προφίλ


Το παιδί που εκφοβίζει επιλέγει το παιδί που θα εκφοβίσει πολύ συγκεκριμένα και καθόλου τυχαία. Συνήθως θα επιλέξει παιδί που:

● Διαφέρει με κάποιον τρόπο από τα υπόλοιπα (είναι από άλλη χώρα, έχει άλλη θρησκεία, φοράει σιδεράκια γενικά παιδί που διαφέρει από τη μέση εικόνα ενός μαθητή)
● Δύσκολα θα βοηθήσει κάποιος (παιδιά μοναχικά που δεν κάνουν εύκολα φίλους)
● Που είναι «λιγότερα» δυνατά

Ωστόσο και το παιδί που βιώνει εκφοβισμό γεννά πολλές φορές αντικρουόμενα συναισθήματα. Πολλές φορές γεννά συναισθήματα θυμού προς γονείς, εκπαιδευτικούς και συμμαθητές καθώς είτε δεν του αναγνωρίζουν την αδυναμία του να αντιδράσει είτε θεωρούν ότι αυτό ευθύνεται για τον εκφοβισμό που βιώνει.

Σε γενικές γραμμές πολλά από τα στοιχεία της προσωπικότητας του παιδιού που βιώνει τον εκφοβισμό ευνοούν την στοχοποίηση τους. Στο σημείο αυτό θα αναφερθεί ότι τα παιδιά που βιώνουν εκφοβισμό παρουσιάζουν:

● χαμηλή αυτοεκτίμηση,
● αδυναμία επίλυσης προβλημάτων,
● καταθλιπτικά στοιχεία,
● συναισθηματικές δυσκολίες,
● αίσθημα μοναξιάς,
● χαμηλές σχολικές επιδόσεις και απουσίες
● Διαταραχές συμπεριφοράς
● Ψυχολογικά / ψυχοσωματικά προβλήματα (πονοκέφαλοι, κοιλιακά άλγη, ενούρηση, διαταραχές ύπνου)
● Άγχος
● Φοβίες
● Δεν μπορούν να μείνουν μόνα
● Αποφεύγουν τη βλεματική επαφή

Θα πρέπει να λαμβάνεται υπόψη ο συναισθηματικός κόσμος των παιδιών, ο οποίος στην περίπτωση του σχολικού εκφοβισμού δεν διαφέρει από οποιαδήποτε άλλη μορφή βίας. Τα παιδιά βιώνουν:

» Θυμό
Για αυτό που τους συμβαίνει, που δεν μπορούν να αντιδράσουν. Ο θυμός συνήθως εκφράζεται σε οικεία αγαπημένα πρόσωπα όπως ο πατέρας, η μητέρα ή ο αδελφός

» Ντροπή
Ντρέπονται για αυτό που τους συμβαίνει και θεωρούν ότι όλοι οι συμμαθητές τους, τους θεωρούν δειλούς/ δειλές. Έτσι δυσκολεύονται να κάνουν φίλους καθώς θεωρούν εκ προοιμίου ότι κανείς δεν θα τους θέλει για φίλους. Επίσης ντρέπονται να το αποκαλύψουν στους γονείς τους καθώς θα τους «απογοητεύσουν»

» Ενοχή
Θεωρούν ότι εκείνοι φταίνε για αυτό που γίνεται, (πχ. «με λένε γυαλάκια -} φοράω γυαλιά -} άρα έχουν δίκιο -} είμαι γυαλάκιας).

» Φόβος
Ζουν συνεχώς με το συναίσθημα ότι θα τους κοροϊδέψουν, ότι θα γελάσουν μαζί τους

Ο συνδυασμός του θυμού - φόβου- ντροπής και ενοχής οδηγούν τα παιδιά να μην λένε σε κανένα αυτό που τους συμβαίνει και συνεπώς να μην ζητάνε βοήθεια. Αυτή η συναισθηματική απομόνωση οδηγεί στην γενικότερη απομόνωση των παιδιών. Εάν δεν λάβουν την κατάλληλη στήριξη στο μέλλον είναι δυνατό να επιδείξουν αδυναμία:

● να αναλάβουν ευθύνες,
● να επιδείξουν συνέπεια στον κοινωνικό τους ρόλο,
● να συνάψουν διαπροσωπικές σχέσεις
● να έχουν ομαλή σεξουαλική ζωή



Το παιδί που εκφοβίζει - Προφίλ


Στην εκδήλωση του φαινόμενου ιδιαίτερο ενδιαφέρον συγκεντρώνει το παιδί (ή ομάδα παιδιών) που εκφοβίζουν το οποίο συχνά γεννά αντιφατικά συναισθήματα. Σε πολλούς ανθρώπους γεννά θυμό και αγανάκτηση ενώ πολλοί αναγνωρίζουν την ανάγκη για στήριξη που έχει αυτό το παιδί.

Πάντα θα πρέπει να θυμόμαστε ότι πίσω από ένα παιδί που εκφοβίζει θα βρεθούν

● Ανάγκη για κυριαρχία πάνω σε άλλους
● Αδυναμία ελέγχου παρορμήσεων
● Μειωμένη ικανότητα αυτοελέγχου
● Αδυναμία τήρησης κανόνων και ορίων
● Ασυνήθιστα χαμηλό άγχος
● Διογκωμένη αυτοεικόνα
● Έλλειψη αίσθησης του μέτρου
● Η δημοτικότητα τους βρίσκεται στο μέσο όρο ή κάτω από αυτόν και χαμηλώνει καθώς προσχωρούν στις εκπαιδευτικές βαθμίδες
● Είναι εχθρικό απέναντι στο περιβάλλον του (ιδιαίτερα σε γονείς και εκπαιδευτικούς)
● Απόλυτη έλλειψη ενσυναίσθησης
● Είναι δυνατό να περιβάλλονται από άλλους συμμαθητές τους οι οποίοι δεν εκφοβίζουν άμεσα αλλά ενισχύουν το παιδί που εκφοβίζει

Εάν δεν ληφθεί άμεσα η κατάλληλη φροντίδα υπάρχουν αυξημένα ποσοστά μελλοντικής
● παραβατικής συμπεριφοράς,
● χρήσης ουσιών και
● εμπλοκής με το νόμο



Ο ρόλος των παιδιών θεατών


Σημείο - κλειδί στην εμφάνιση του φαινόμενου αποτελούν τα παιδιά - θεατές. Με την συμπεριφορά τους διευκολύνουν ή λειτουργούν ανασταλτικά στην εμφάνιση του φαινόμενου.

Οι αναμενόμενες αντιδράσεις των υπόλοιπων παιδιών είναι:

● Να γελάσουν
● Να χαμογελάσουν
● Να αδιαφορήσουν
● Να μιλήσουν στο διπλανό τους και να σχολιάσουν αυτό που γίνεται είτε θετικά είτε αρνητικά
● Να κοιτούν και να μην κάνουν απολύτως τίποτε

Οι συγκεκριμένες αντιδράσεις ενισχύουν την συμπεριφορά του παιδιού που ασκεί βια καθώς με το να γελάσουν / χαμογελάσουν οι υπόλοιποι ή να σχολιάσουν το γεγονός έχει επιτύχει να κερδίσει την προσοχή τους.

Στις υπόλοιπες αντιδράσεις αδιαφορία / απραξία είτε δεν δίνει σημασία είτε εντείνει την επιθετική συμπεριφορά προς το παιδί προκειμένου να «κερδίσει» και αυτούς.

Από την άλλη πλευρά οι συγκεκριμένες αντιδράσεις επηρεάζουν σημαντικά το παιδί που δέχεται εκφοβισμό. Το γέλιο, το χαμόγελο, η αδιαφορία και η απραξία ενισχύουν τη μοναξιά του παιδιού και σε ένα δεύτερο επίπεδο την επιβεβαίωση της πράξης του παιδιού που εκφοβίζει και άρα ενισχύει την ενοχή του παιδιού.

Επίσης ο σχολιασμός του γεγονότος ενισχύει με τη σειρά του και την ντροπή που βιώνει το παιδί και τη μοναξιά του.



Ο ρόλος των εκπαιδευτικών


Στην εκδήλωση ενός φαινόμενου μέσα στο σχολικό πλαίσιο πρώτο λόγο οφείλουν να έχουν και οι εκπαιδευτικοί.

Σε γενικές γραμμές ο εκπαιδευτικός θα πρέπει να:
● ενημερωθεί για το φαινόμενο και ως συνέπεια να γίνει ικανότερος να το αναγνωρίζει να το σταματά άμεσα και να μπορεί να αναπτύξει στη συνέχεια προγράμματα ή τεχνικές παρέμβασης για εκτόνωση του
● Μην αγνοήσει ή υποτιμήσει κάτι που του αναφέρει το παιδί
● Κάνει άμεση και αυστηρή παρατήρηση αμέσως μετά το περιστατικό
● Να αξιοποιήσει τη «δύναμη» του παιδιού που ασκεί βία σε θετικές συμπεριφορές
● Να αναπτύξει δραστηριότητες σχετικά με το φαινόμενο (συζήτηση, παιχνίδι ρόλων, ανάγνωση λογοτεχνικών κειμένων)
● Να Δημιουργήσει θετικό κλίμα στο σχολείο
● Να προστατεύσει το παιδί που δέχεται τη βία, να μη του ζητάτε να εξηγήσει μπροστά σε άλλους τι έχει γίνει, αλλά σε κατ’ ιδίαν συνάντηση να γίνεται προσπάθεια αποενοχοποίησης και συναισθηματικής ενίσχυσης

Επίσης:
● Συστήνεται να αποφεύγεται η ποινικοποίηση της πράξης και η τιμωρία του παιδιού με αποβολές από τη σχολική μονάδα καθώς δεν είναι αποτελεσματικές.
● Θα πρέπει να δημιουργείται τέτοιο κλίμα στο σχολείο ουτώς ώστε να μην καλύτονται τέτοια μυστικά.
● Είναι ιδιαίτερα σημαντικό να μην ζητηθεί η «συμφιλίωση» μεταξύ παιδιού που δέχεται βία και παιδιού που ασκεί βία καθώς υπάρχει ο κίνδυνος να επαναθυματοποιηθεί το ένα παιδί και το άλλο να επιβεβαιώσει την «δύναμη» και κυριαρχία» του.

ΠΗΓΗ:


Πως θα καταλάβω αν η σχέση μας ...«χάνεται»;





-«Και η σχέση σας πως είναι;»


-«Καλή, τσακωνόμαστε αλλά όπως όλα τα ζευγάρια... απλά δεν έχουμε σεξουαλική ζωή, γιατί;»


Μήπως αναγνωρίζετε τον εαυτό σας στον παραπάνω διάλογο; Πρόκειται για έναν από τους «κλασσικούς διαλόγους» που γίνονται στις συνεδρίες με ζευγάρια που αντιμετωπίζουν πρόβλημα στη σεξουαλική τους ζωή. Μάλιστα, έρχονται γιατί «τα άφησε» το σεξ και όχι γιατί αναγνωρίζουν την προβληματική κατάσταση ανάμεσά τους, άλλωστε, «τσακώνονται όπως και όλα τα άλλα ζευγάρια!»

Σύμφωνοι, όλες οι σχέσεις έχουν τα πάνω και τα κάτω τους, όλα τα ζευγάρια καυγαδίζουν. Τι γίνεται όμως με συμπεριφορές που ενοχλούν και πληγώνουν; Τις αναγνωρίζουμε ή τις κρύβουμε …κάτω από το χαλί, μαζί με την σκόνη των προβλημάτων που εμφανίζονται ανάμεσά μας;




Μήπως αναγνωρίζετε και δικές σας «συνήθειες» στα παρακάτω;

Κρίνω τον σύντροφό μου αυστηρά
Μιλάω απότομα αρκετές φορές
Μιλάω νευριασμένα πολλές φορές
Εκνευρίζομαι κάποιες φορές μόνο που τον βλέπω
Δεν μπορώ να του συγχωρήσω πια ότι…
Δεν μοιράζομαι μαζί του παρά μόνο τις καθημερινές υποχρεώσεις ή για τα παιδιά…
Δεν βγαίνουμε μόνοι μας, μόνο με παρέα ή με τα παιδιά
Δεν βγαίνουμε γενικότερα, μένουμε μέσα
Δεν μιλάμε για εμάς
Δεν κάνουμε όνειρα…
Δεν σχεδιάζουμε το μέλλον μας ως ζευγάρι, παρά μόνο των παιδιών
Ντύνομαι όμορφα μόνο όταν είναι να συναντηθώ με άλλους ανθρώπους
Έχω παραμελήσει την εμφάνισή μου
Έχω πάρει ή χάσει αρκετά κιλά
Δεν κάνουμε πράγματα μαζί
Χαζεύουμε στην τηλεόραση, στο κινητό ή στο τάμπλετ, αντί να μιλάμε μεταξύ μας
Δεν έχω πια ερωτική επιθυμία
Βαριέμαι πια στο σεξ, μου φαίνεται αγγαρεία
Φαντασιώνω άλλους άνδρες σεξουαλικά
Περνάω πιο καλά μόνη μου κάνοντας πράγματα ή με φίλες…

ΠΗΓΗ:

This Common Activity Identifies A Narcissist



How to spot a narcissist from their online behaviour.



People who are addicted to Facebook are more likely to be narcissists, new research finds.

The study followed the Facebook use of 179 German students over a year.

All were asked about their personalities and other aspects of their psychological life, like levels of depression and anxiety.

The results showed that people with narcissistic personalities were more likely to get addicted to Facebook.

The study’s authors write:


“Facebook use holds a particular meaning for narcissistic people.

On Facebook, they can quickly initiate many superficial relationships with new Facebook-friends and get a large audience for their well-planned self-presentation.

The more Facebook-friends they have, the higher is the possibility that they attain the popularity and admiration they are seeking; whereas in the offline world they might not be as popular since their interaction partners can quickly perceive their low agreeableness and exaggerated sense of self-importance.”

The researchers also found that Facebook addiction was linked to higher levels of depression and anxiety.

Whether people can really be ‘addicted’ to Facebook is still a controversial issue.



However, people addicted to Facebook typically show the six characteristics of addiction, the authors argue:


“FAD [Facebook Addiction Disorder] is defined by six typical characteristics of addiction disorders: salience (e.g., permanent thinking of Facebook use), tolerance (e.g., requiring increasing time on Facebook to achieve previous positive using effect), mood modification (e.g., mood improvement by Facebook use), relapse (reverting to earlier use pattern after ineffective attempts to reduce Facebook use), withdrawal symptoms (e.g., becoming nervous without possibility to use Facebook), and conflict (e.g., interpersonal problems caused by intensive Facebook use).”

SOURCE:

Wednesday, 7 February 2018

Are religious people really less smart, on average, than atheists?




Of course, there are examples of extremely intelligent individuals with strong religious convictions. But various studies have found that, on average, belief in God is associated with lower scores on IQ tests. “It is well established that religiosity correlates inversely with intelligence,” note Richard Daws and Adam Hampshire at Imperial College London, in a new paper published in Frontiers in Psychology, which seeks to explore why.

It’s a question with some urgency – the proportion of people with a religious belief is growing: by 2050, if current trends continue, people who say they are not religious will make up only 13 per cent of the global population. Based on the low-IQ-religiosity link, it could be argued that humanity is on course to become collectively less smart.



One suggestion is that perhaps religious people tend to rely more on intuition. So, rather than having impaired general intelligence, they might be comparatively poor only on tasks in which intuition and logic come into conflict – and this might explain the lower overall IQ test results.

To investigate, Daws and Hampshire surveyed more than 63,000 people online, and had them complete a 30-minute set of 12 cognitive tasks that measured planning, reasoning, attention and working memory. The participants also indicated whether they were religious, agnostic or atheist.

As predicted, the atheists performed better overall than the religious participants, even after controlling for demographic factors like age and education. Agnostics tended to place between atheists and believers on all tasks. In fact, strength of religious conviction correlated with poorer cognitive performance. However, while the religious respondents performed worse overall on tasks that required reasoning, there were only very small differences in working memory.

Also, some of the reasoning tasks, such as an extra-hard version of the Stroop Task known as “colour-word remapping”, had been designed to create maximum conflict between an intuitive response and a logical one, and the biggest group differences emerged on these tasks, consistent with the idea that religious people rely more on their intuition. In contrast, for a complex reasoning task – “deductive reasoning” – for which there were no obviously intuitive answers, there was much less of a group difference.

Daws and Hampshire concluded: “These findings provide evidence in support of the hypothesis that the religiosity effect relates to conflict [between reasoning and intuition] as opposed to reasoning ability or intelligence more generally.”

If, as this work suggests, religious belief predisposes people to rely more heavily on intuition in decision-making – and the stronger their belief, the more pronounced the impact – how much of a difference does this make to actual achievement in the real world? At the moment, there’s no data on this. But in theory, perhaps cognitive training could allow religious people to maintain their beliefs without over-relying on intuition when it conflicts with logic in day to day decision-making.

SOURCE:

Friday, 2 February 2018

RECOGNITION and DESTRUCTION: An Outline of Intersubjectivity



We are all of us born in moral stupidity, taking the world as an udder to feed our supreme selves: Dorothea had early begun to emerge from that stupidity, but yet it had been easier for her to imagine how she would...become wise and strong in his strength and wisdom, than to conceive with that distinctness which is no longer reflection but feeling...that he had an equivalent center of self, whence the lights and shadows must always fall with a certain difference. George Eliot, Middlemarch


In recent years analysts from diverse psychoanalytic schools have converged in the effort to formulate relational theories of the self (Eagle 1984, S. Mitchell 1988). What these approaches share is the belief that the human mind is interactive rather than monadic, that the psychoanalytic process should be understood as occurring between subjects rather than within the individual (Atwood and Stolorow 1984, S. Mitchell 1988). Mental life is seen from an intersubjective perspective. Although this perspective has transformed both our theory and our practice in important ways, such transformations create new problems. A theory in which the individual subject no longer reigns absolute must confront the difficulty each subject has in recognizing the other as an equivalent center of experience (Benjamin 1988). 

The problem of recognizing the other emerges the moment we consider that troublesome legacy of intrapsychic theory, the term object. In the original usage, still common in self psychology and object relations theories, the concept of object relations refers to the psychic internalization and representation of interactions between self and objects. While such theories ascribe a considerable role to the early environment and parental objects--in short, "real" others--they have taken us only to the point of recognizing that "where ego is, objects must be." So, for example, neither Fairbairn's insistence on the need for the whole object nor Kohut's declaration that selfobjects remain important throughout life addresses directly the difference between object and other. Perhaps the elision between "real"others and their internal representation is so widely tolerated because the epistemological question of what is reality and what is representation appears to us--in our justifiable humility--too ecumenical and lofty for our parochial craft. Or perhaps, as psychoanalysts, we are not really troubled by the question of reality. But the unfortunate tendency to collapse other subjects into the rubric objects cannot be ascribed simply to this irresoluteness regarding reality. Nor can it be dismissed as a terminological embarrassment that greater linguistic precision might dissolve (see Kohut, 1984). Rather, it is a symptom of the very problems in psychoanalysis that a relational theory should aim to cure. The inquiry into the intersubjective dimension of the analytic encounter would aim to change our theory and practice so that "where object were, subjects must be." What does such a change mean? 

A beginning has been made with the introduction of the term Jessica Benjamin: Recognition and Destruction http://www.psychematters.com/papers/benjamin.htm 2 of 10 4/20/2006 11:49 PM intersubjectivity--the field of intersection between two subjectivities, the interplay between two different subjective worlds to define the analytic situation (Atwood and Stolorow, 1984; Stolorow, Brandschaft, and Atwood 1987). 

But how is the meeting of two subjects different from the meeting of a subject and an object? Once we have acknowledged that the object makes an important contribution to the life of the subject, what is added by deciding to call this object another subject? And what are the impediments to the meeting of the two minds? To begin this inquiry, we must ask: what difference does the other make, the other who is truly perceived as outside, distinct from our mental field of operations? Isn't there a dramatic difference between the experience with the other perceived as outside the self and that with the subjectively conceived object? Winnicott formulated the basic outlines of this distinction in what may well be considered his most daring and radical statement, "The Use of an Object and Relating Through Identifications" (1969b). Since then, with a few recent exceptions (Eigen 1981, Modell 1984, Ghent 1989, Bollas, 1989), there has been little effort to elaborate Winnicott's juxtaposition of the two possible relationships to the object. Yet, as I will show, the difference between the other as subject and the other as object is crucial for a relational psychoanalysis. The distinction between the two types of relationships to the other can emerge clearly only if we acknowledge that both are endemic to psychic experience and hence are valid areas of psychoanalytic knowledge. If there is a contradiction between the two modes of experience, then we ought to probe it as a condition of knowledge rather than assume it to be a fork in the road. 


Other theoretical grids that have split psychoanalytic thought--drive theory versus object relations theory, ego versus id psychology, intrapsychic versus interpersonal theory--insisted on a choice between opposing perspectives. I am proposing, instead, that the two dimensions of experience with the object/other are complementary, though they sometimes stand in oppositional relationship. By embracing both dimensions, we can fulfill the intention of relational theories; to account both for the pervasive effects of human relationships on psychic development and for the equally ubiquitous effects of internal psychic mechanisms and fantasies in shaping psychological life and interaction. I refer to the two categories of experience as the intrapsychic and the intersubjective dimension (Benjamin 1988). The idea of intersubjectivity, which has been brought into psychoanalysis from philosophy (Habermas 1970, 1971, 992), is useful because it specifically addresses the problem of defining the other as object. Intersubjectivity was formulated in deliberate contrast to the logic of subject and object, which predominates in Western philosophy and science. It refers to that zone of experience or theory in which the other is not merely the object of the ego's need/drive or cognition/perception but has a separate and equivalent center of self. Intersubjective theory postulates that the other must be recognized as another subject in order for the self to fully experience his or her subjectivity in the other's presence. 

This means that we have a need for recognition and that we have a capacity to recognize others in return, thus making mutual recognition possible. But recognition is a capacity of individual development that is only unevenly realized--in a sense, the point of a relational psychoanalysis is to explain this fact. In Freudian metapsychology the process of recognizing the other "with that distinctness which is no longer reflection but feeling" would appear, at best, as a background effect of the relationship between ego and external reality. Feminist critics of psychoanalysis have suggested that the conceptualization of the first other, the mother, as an object underlies this theoretical lacuna. The cultural antithesis between male subject and female object contributed much to the failure to take into account the subjectivity of the other. Denial of the mother's subjectivity, in theory and in practice, profoundly impedes our ability to see the world as inhabited by equal subjects. My purpose is to show that, in fact, the capacity to recognize the mother as a subject is an important part of early development, and to bring the process of recognition into the foreground of our thinking. I will suggest some preliminary outlines of the development of the capacity for recognition. In particular, I will focus on separation-individuation theory, showing how much more it can reveal when it is viewed through the intersubjective lens, especially in light of the contributions of both Daniel Stern and Winnicott. Because separation-individuation theory is formulated in terms of ego and object, it does not fully realize its own potential contribution. In the ego-object Jessica Benjamin: Recognition and Destruction http://www.psychematters.com/papers/benjamin.htm 3 of 10 4/20/2006 11:49 PM perspective the child is the individual, is seen as moving in a progression toward autonomy and separateness. 

The telos of this process is the creation of psychic structure through internalization of the object in the service of greater independence. Separation-individuation theory thus focuses on the structural residue of the child's interaction with the mother as object; it leaves in the unexamined background the aspect of engagement, connection, and active assertion that occur with the mother as other. This perspective is infantocentric, unconcerned with the source of the mother's responses, which reflect not only her pathology or health ("narcissistic" versus "good enough") but also her necessarily independent subjectivity. It also misses the pleasure of the evolving relationship with a partner from whom one knows how to elicit a response but whose responses are not entirely predictable and assimilable to internal fantasy. The idea of pleasure was lost when ego psychology put the id on the back burner, but it might be restored by recognizing the subjectivity of the other. An intersubjective perspective helps us transcend the infantocentric viewpoint of intrapsychic theory by asking how a person becomes capable of enjoying recognition with an other. Logically, recognizing the parent as subject cannot be the result simply of internalizing her as mental object. This is a developmental process that has barely begun to be explicated. How does a child develop into a person who, as a parent, is able to recognize her or his own child? What are the internal processes, the psychic landmarks, of such development? Where is the theory that tracks the development of the child's responsiveness, empathy, and concern, and not just the parent's sufficiency or failure? It is in regard to these questions that most theories of the self have fallen short. Even self psychology, which has placed such emphasis on attunement and empathy and has focused on the intersubjectivity of the analytic encounter, has been tacitly one-sided in its understanding of the parent-child relationship and the development of intersubjective relatedness. 

Perhaps in reaction against the oedipal reality principle, Kohut (1977, 1984) defined the necessary confrontation with the other's needs or with limits in a self-referential way--optimal failures in empathy (parallel to analysts' errors)--as if there were nothing for children to learn about the other's rights or feelings. Although Kohut's goal was to enable individuals to open "new channels of empathy" and "in-tuneness between self and selfobject:" (1984, p. 66), the self was always the recipient, not the giver, of empathy. The responsiveness of the selfobject by definition serves the function of "shoring up our self" throughout life; but at what point are we concerned with the responsiveness of the outside other whom we love? The occasionally mentioned (perhaps more frequently assumed) "love object" who would presumably hold the place of outside other, has no articulated place in the theory. Thus, once again, the pleasure in mutuality between two subjects is reduced to its function of stabilizing the self, not of enlarging our awareness of the outside or of (recognizing others as animated by independent, though similar, feelings.(1) In this essay I would like to outline some crucial points in the development of recognition. It is certainly true that recognition begins with the other's confirming response, which tells us that we have created meaning, had an impact, revealed an intention. But very early on we find that recognition between persons--understanding and being understood, being in attunement--is becoming an end to itself. Recognition between persons is essentially mutual. By our very enjoyment of the other's confirming response, we recognize her in return. 

What the research on mother-infant interaction has uncovered about early reciprocity and mutual influence is best conceptualized as the development of the capacity for mutual recognition. The frame-by-frame studies of face-to-face play at three or four months of age have given us a kind of early history of recognition. The pathbreaking work of Stern (1974, 1977, 1985) and the more recent contributions of Beebe (Beebe and Stern 1977, Beebe 1985, Beebe and Lachmann 1988) have illuminated how crucial the relationship of mutual influence is for early self-development. They have also shown that self-regulation is achieved at this point through regulating the other: I can change my own mental state by causing the other to be more or less stimulating. Mother's recognition is the basis for the baby's sense of agency. Equally important, although less emphasized, is the other side of this play interaction: the mother is dependent to some degree on the baby's recognition. A baby who is less responsive is a less "recognizing" baby, and the mother who reacts to her apathetic or fussy baby by overstimulating or withdrawing is a mother feeling despair that the baby does recognize her.

 In Stern's view, however, early play does not yet constitute intersubjective relatedness (1985). Rather, he designates the next phase, when affective attunement develops at eight or nine months of age, as intersubjectivity proper. This is the moment when we discover that "there are other minds out there!" and that separate minds can share a similar state. I would agree that this phase constitutes an advance in recognition of the other, but the earlier interaction can be considered an antecedent in the form of concrete affective sharing. 

Certainly, from the standpoint of the mother whose infant returns her smile this is already the beginning of reciprocal recognition. Therefore, rather than designate the later phase as intersubjective relatedness, I would conceptualize a development of intersubjectivity in which there are key moments of transformation. In this phase, as Stern (1985) emphasizes, the new thing is the sharing of the inner world. The infant begins to checkout how the parent feels when the infant is discovering a new toy, and the parent demonstrates attunement by responding in another medium. By translating the same affective level into another modality--for example, from kinetic to vocal--the adult conveys the crucial fact that it is the inner experience that is congruent. The difference in form makes the element of similarity or sharing clear. I would add, the parent is not literally sharing the same state, for the parent is (usually) excited by the infant's reaction, not by the toy itself. The parent is in fact taking pleasure in contacting the child's mind. This is a good point at which to consider the contrast between intersubjective theory and ego psychology, a contrast that Stern stresses. The phase of discovering other minds coincides roughly with Mahler's differentiation and practicing, but there is an important difference in emphasis. In the intersubjective view, the infant's greater separation, which Mahler underscores in this period, actually proceeds in tandem with and enhances the felt connection with the other. The joy of intersubjective attunement is: This Other can share my feeling. 

According to Mahler (Mahler, Pine, and Bergmann 1975), though, the infant of ten months is primarily involved in exploring, in the "love affair with the world." The checking back to look at mother is not about sharing the experience but about safety/anxiety issues, "refueling." This is a phase in which Mahler see the mother not as contacting the child's mind but as giving him or her a push from the nest. While Stern emphasizes his differences with Mahler, I think the two models are complementary, not mutually exclusive. It seems to me that intersubjective theory amplifies separation-individuation theory at this point by focusing on the affective exchange between parent and child and by stressing the simultaneity of connection and separation. Instead of opposite endpoints of a longitudinal trajectory, connection and separation form a tension that requires the equal magnetism of both sides. It is this tension between connection and separation that I want to track beyond the period of affective attunement. if we follow it into the second year of life, we can see a tension developing between assertion of self and recognition of the other. 

Translating Mahler's rapprochement crisis into the terms of intersubjectivity, we can say that in this crisis the tension between asserting self and recognizing the other breaks down and is manifested as a conflict between self and other. My analysis of this crisis derives, in part, from philosophy, from Hegel's formulation of the problem of recognition in The Phenomenology of Spirit. In his discussion of the conflict between "the independence and dependence of self-consciousness" Hegel showed how the self's wish for absolute independence conflicts with the self's need for recognition. In trying to establish itself as an independent entity, the self must yet recognize the other as a subject like itself in order to be recognized by the other. 

This immediately compromises the self's absoluteness and poses the problem that the other could be equally absolute and independent. Each self wants to be recognized and yet to maintain its absolute identity: the self says, I want to affect you, but I want nothing you do or say to affect me, I am who I am. In its encounter with the other, the self wishes to affirm its absolute independence, even though its need for the other and the other's similar wish undercut that affirmation. 

This description of the self's absoluteness covers approximately the same territory as narcissism in Freudian theory, particularly its manifestation as omnipotence: the insistence on being one (everyone is identical to me) and all alone (there is nothing outside of me that I do not control). Freud's conception of the earliest ego (1911, 1915a), with its hostility to the outside or its incorporation of everything good into itself, is not unlike Hegel's absolute self. Hegel's notion of the conflict between independence and dependence meshes with the classic psychoanalytic view in which the self does not wish to give up omnipotence.. But even if we reject the Freudian view of the ego, the confrontation with the other's subjectivity and with the limits of self-assertion is difficult to negotiate. The need for recognition entails this fundamental paradox: at the very moment of realizing our own independent will, we are dependent upon another to recognize it. At the very moment we come to understand the meaning of I, myself, we are forced to see the limitations of that self. At the moment when we understand that separate minds can share similar feelings, we begin to learn that these minds can also disagree. 

Let us return to Mahler's description of rapprochement and see how it illustrates the paradox of recognition and how the infant is supposed to negotiate that paradox. Before rapprochement, in the self assertion of the practicing phase, the infant still takes herself for granted, and her mother as well. She does not make a sharp discrimination between doing things with mother's help and doing without it. She is too excited by what she doing to reflect on who is doing it. Beginning when the child is about fourteen months of age, a conflict emerges between her grandiose aspirations and the perceived reality of her limitations and dependency. 

Although she is now able to do more, the toddler is aware of what she can't do and what she can't make mother do--for example, stay with her instead of going out. Many of the power struggles that begin here (wanting the whole pear, not a slice) can be summed up as a demand: "Recognize my intent!" She will insist that mother share everything, participate in all her deeds, acquiesce to all her demands. The toddler is also up against the increased awareness of separateness, and, consequently, of vulnerability: she can move away from mother--but mother can also move away from her. 

If we reframe this description from the intersubjective perspective, the infant now knows that different minds can feel differently, that she ids dependent as well as independent. In this sense, rapprochement is the crisis of recognizing the other--specifically, of confronting mother's independence. It is no accident that mother's leaving becomes a focal point here, for it confronts the child not only with separation but with the other's independent aims. For similar reasons, the mother may experience conflict at this point: the child's demands are now threatening, no longer simply needs but expressions of the child's independent (tyrannical) will. The child is different from the mother's own mental fantasy, no longer her object. The child may switch places with the mother, from passive to active. The omnipotence once attributed to the "good" all-giving mother now resides instead in the child. 

How the mother responds to her child's and her own aggression depends on her ability to mitigate such fantasies with a sense of real agency and separate selfhood, on her confidence in her child's ability to survive conflict, loss, imperfection. The mother has to be able both to set clear boundaries for her child and to recognize the child's will, both to insist on her own independence and to respect that of the child--in short, to balance assertion and recognition. If she cannot do this, omnipotence continues, attributed either to the mother or the self; in neither case can we say that the development of mutual recognition has been furthered. From the standpoint of intersubjective theory, the ideal "resolution" of the paradox of recognition is that it continue as a constant tension between recognizing the other and asserting the self. In Mahler's theory, however, the rapprochement conflict appears to be resolved through internalization, the achievement of object constancy--when the child can separate from mother or be angry at her and still be able to contact her presence or goodness. 

In a sense, this resolution sets the goal of development too low: it is difficult and therefore sufficient for the child to accomplish the realistic integration of good and bad object representations (Kernberg 1980). The sparse formulation of the end of the rapprochement conflict is anticlimactic, leaving us to wonder, is this all? In this picture, the child has only to accept that mother can disappoint her; she does not begin to shift her center of gravity to recognize that mother does this because she has her own center. 

The breakdown and re-creation of the tension between asserting one's own reality and accepting the other's is a neglected but equally important aspect of the crisis. This aspect emerges when we superimpose Winnicott's idea of destroying the object (1969b)) on Mahler's rapprochement crisis. It is destruction--negation in Hegel's sense--that enables the subject to go beyond relating to the object through identification, projection, and other intrapsychic processes pertaining to the subjectively conceived object. Destruction makes possible the transition from relating (intrapsychic) to using the object, to carrying on a relationship with an other who is objectively perceived as existing outside the self, an entity in her own right. That is, in the mental act of negating or obliterating the object, which may be expressed in the real effort to attack the other, we find out whether the real other survives. If she survives without retaliating or withdrawing under the attack, then we know her to exist outside ourselves, not just as our mental product. Winnicott's scheme can be expanded to postulate not a sequential relationship but rather a basic tension between denial and affirmation of the other, between omnipotence and recognition of reality. 


Another way to understand the conflicts that occur in rapprochement is through the concepts of destruction and survival: the wish to assert the self absolutely and deny everything outside one's own mental omnipotence must sometimes crash against the implacable reality of the other. In the collision Winnicott has in mind, however, aggression does not occur "reactive to the encounter with the reality principle" but rather "creates the quality of externality." 

When the destructiveness damages neither the parent nor the self, external reality comes into view as a sharp, distinct contrast to the inner fantasy world. The outcome of this process is not simply reparation or restoration of the good object (Eigen 1981; Ghent, 1990) but love, the sense of discovering the other. ("I destroyed you!" "I love you!") The flip side of Winnicott's analysis could be stated as follows: when destruction is not countered with survival, when the other's reality does not come into view, a defensive process of internalization takes place. 

Aggression becomes a problem--how to dispose of the bad feeling. ("What about waste-disposal?") What cannot be worked through and dissolved with the outside other is transposed into a drama of internal objects, shifting from the domain of the intersubjective into the domain of the intrapsychic. In real life, even when the other's response dissipates aggression, there is no perfect process of destruction and survival; there is always also internalization. All experience is elaborated intrapsychically; we might venture to say, but when the other does not survive and aggression is not dissipated, experience becomes almost exclusively intrapsychic. It therefore seem fallacious to regard internalization processes only as breakdown products or as defenses; rather, we could see them as a kind of underlying substratum of mental activity--a constant symbolic digestion process that constitutes an important part of the cycle of exchange between the individual and the outside. It is the loss of balance between the intrapsychic and the intersubjective, between fantasy and reality, that is the problem. Indeed, the problem in psychoanalytic theory has been that internalization--either the defensive or the structure-building aspects, depending on which object relations theory you favor--has obscured the component of destruction that Winnicott emphasizes discovering "that fantasy and fact, both important, are nevertheless different from each other" (1964, p. 62). 

The complementarity of the intrapsychic and intersubjective modalities is important here: as Winnicott makes clear, it is in contrast to the fantasy of destruction that the reality of survival is so satisfying and authentic. Winnicott thus offers the notion of a reality that can be loved, something beyond the integration of good and bad. While the intrapsychic ego discovers reality. This reality principle does not represent a detour to wish fulfillment or a modification of the pleasure principle. Nor is it the acceptance of a false life of adaptation. Rather, it is a continuation under more complex conditions of the infant's original fascination with and love of what is outside, her appreciation of difference and novelty. The appreciation is the element to differentiation that gives separation its positive, rather than simply hostile, coloring: love of the world, not merely leaving or distancing from mother. To the extent that mother herself is placed outside, she can be loved; then separation is truly the other side of connection to the other. 

 It is this appreciation of the other's reality that completes the picture of separation and explains what there is beyond internalization: the establishment of shared reality. Elsa First (1988) has provided some relevant observations of how the toddler begins to apprehend mutuality as a concomitant of separateness--specifically, in relation to the mother's leaving. The vehicle of this resolution is, expanding Winnicott's notion, cross-identification: the capacity to put oneself in the place of the other based on empathic understanding of similarities of inner experience. The two-year-old's initial role-playing imitation of the departing mother is characterized by the spirit of pure retaliation and reversal--"I'll do to you what you do to me." But gradually the child begins to identify with the mother's subjective experience and realizes, "I could miss you as you miss me," and, therefore, "I know that you could wish to have your own life as I wish to have mine." First, shows how, by recognizing such shared experience, the child actually moves from a retaliatory world of control to a world of mutual understanding and shared feeling. This analysis amplifies the idea of object constancy, in which the good object survives the bad experience, by adding the idea of recognizing that the leaving mother is not bad but independent, a person like me.


 In recognizing this, the child gains not only her own independence (as traditionally emphasized) but also the pleasure of shared understanding. Looking backward, we can trace the outlines of a developmental trajectory of intersubjective relatedness up to this point. Its core feature is recognizing the similarity of inner experience in tandem with difference. Recognition begins with "We are feeling this feeling: and move to I know that you, who are another mind, share this same feeling." In rapprochement, however, a crisis occurs as the child begins to confront difference--"You and I don't want or feel the same thing." The initial response to this discovery is a breakdown of recognition between self and other: "I insist on my way, I refuse to recognize you, I begin to try to coerce you; and therefore I experience your refusal as a reversal: you are coercing me." 

As in earlier phases, the capacity for mutual recognition must stretch to accommodate the tension of difference, the knowledge of conflicting feelings. In the third year of life this issue can emerge in symbolic play. The early play at retaliatory reversal may be a kind of empowerment, where the child feels, "I can do to you what you do to me." But then the play expands to include the emotional identification with the other's position and becomes reflexive, so that, as First puts it, "I know you know what I feel." In this sense, the medium of shared feeling remains as important to intersubjectivity in later phases as in early ones, but it is now extended to symbolic understanding of feeling so that "You know what I feel, even when I want or feel the opposite of what you want or feel." This advance in differentiation means that "We can share feelings without my fearing that my feelings are simply your feelings." The child who can imaginatively entertain both roles--leaving and being left--begins to transcend the complementary form of the mother-child relationship. The complementary structure organizes the relationship of giver and taker, doer and done to, powerful and powerless. It allows us to reverse roles, but not to alter them. In the reversible relationship, each person can play only one role at a time: one person is recognized, the other negated, one is subject, the other object. 

This complementarity does not dissolve omnipotence but shifts it from one partner to the other. The movement out of the world of complementary power relations into the world of mutual understanding constitutes an important step in the dismantling of omnipotence: power is dissolved rather than transferred back and forth between child and mother in an endless cycle. Again, this movement refers not to a one-time sequence or final accomplishment but to an ongoing tension between complementarity and mutuality. When mutual recognition is not restored, when shared reality does not survive destruction, then complementary structures and "relating" to the inner object predominate. Because this occurs commonly enough, the intrapsychic, subject-object concept of the mind actually conforms to the dominant mode of internal experience. This is why--notwithstanding our intersubjective potential--the reversible complementarity of subject and object that is conceptualized by intrapsychic theory illuminates so much of the internal world. The principles of mind Freud first analyzed--for example, reversal of opposites like active and passive, the exchangeability or displacement of objects--thus remain indispensable guides to the inner world of objects. J

But even when the capacity for recognition is well developed, when the subject can use shared reality and receive the nourishment of "other-than-me substance," the intrapsychic capacities remain. The mind's ability to manipulate, to displace, to reverse, to turn one thing into another, is not a mere negative of reality but the source of mental creativity. Furthermore, when things go well, complementarity is a step on the road to mutuality. The toddler's insistent reciprocity--his efforts to reverse the relationship with the mother, to play at feeding, grooming, and leaving her--is one step in the process of identification that ultimately leads to understanding. Only when this process is disrupted, when the complementary form of the relationship is not balanced by mutual activity, does reversal become entrenched and the relationship become a struggle for power. The creation of a symbolic space within the infant-mother relationship fosters the dimension of intersubjectivity, a concomitant of mutual understanding. This space, as Winnicott emphasized; is a function not only of the child's play alone in the presence of the mother but also of play between mother and child, beginning with the earliest play of mutual gaze. As we see in 

First's analysis of play using identification with the leaving mother, the transitional space also evolves within the interaction between mother and child. Within this play, the mother is "related to" in fantasy but at the same time "used" to establish mutual understanding, a pattern that parallels transference play in the analytic situation. In the elaboration of this play the mother can appear as the child's fantasy object and another subject without threatening the child's subjectivity. The existence of this space is ultimately what makes the intrapsychic capacities creative rather than destructive; perhaps it is another way of referring to the tension between using and relating. Using--that is, recognizing--implies the capacity to transcend complementary structures, but not the absence of them. It does not mean the disappearance of fantasy r negation but that "destruction becomes the unconscious backcloth for love of a real object: (Winnicott 1969b, p. 111). 

It means a balance of destruction with recognition. In the broadest sense, internal fantasy is always eating up or negating external reality--"While I am loving you I am all the time destroying you in (unconscious) fantasy" (p. 106). The loved one is continually being destroyed, but its survival means that we can eat our reality and have it too. From the intersubjective standpoint, all fantasy is the negation of the real other, whether its content is negative or idealized--just as, from the intrapsychic view, external reality is simply that which is internalized as fantasy. The ongoing interplay of destruction and recognition is a dialectic between fantasy and external reality. The original challenge for interpersonal and object relations theories was to eliminate the notion of a biological drive underpinning destructiveness and yet find a place for the destructive and reality-negating forces in mental life. My exposition of the crisis of the self is meant, in part, to answer this challenge. If we want to claim that relations with others are essential to the self, then we cannot help but acknowledge aggression as a necessary moment of psychic life. Many relational thinkers have argued that aggression is not a primary but a secondary response to deprivation or frustration. But this is true only from the point of view of one-person psychology, of intrapsychic experience, which defines that which frustrates us--the will of the other--as inessential, external, not intrinsic to the self. From an intersubjective standpoint, the clash of two wills is inherent in subject-subject relations, an ineluctable moment that every self has to confront. (Any parent who has daily experience with two toddlers grabbing the same toy and screeching "Mine!" is bound to wonder whether it was naive to abandon drive theory; only the most utopian anarchist could deny that this crisis is one that everyone who has equals must confront.) Of course, we may theoretically distinguish between reaction to "unnecessary" frustration and loss and this sort of aggression, even if in practice the lines between them sometimes smudge. The intersubjective analysis of the crisis of recognition may help to counter the idealism that otherwise afflicts relational theories--the tendency to throw out with the drives the fundamental psychic place of aggression. I suspect that we need this fundamental acceptance to tolerate and work with aggression in the clinical situation, that otherwise we may be tempted to see it as defensive, "bad," or inauthentic. 


In any event, respect for the inner world--including the "bad"--leads me to prefer a theoretical perspective in which intersubjectivity rivals but does not defeat the intrapsychic. Such a theoretical approach can then explicitly try to account for the imbalance between intrapsychic and intersubjective structures without succumbing to the temptation to make the inner world a mere reflection of or reaction to the outer. In the analytic process, the effort to share the productions of fantasy changes the status of fantasy itself, moving it from inner reality to intersubjective communication. The fantasy object who is being related to or destroyed and the usable other who is "there to receive the communication" and be loved complement each other. 

What we find in the good hour is a momentary balance between intrapsychic and intersubjective dimensions, a sustained tension or rapid movement between the patient's experience of us as inner material and as the recognizing other. Suspension of the conflict between the two experiences reflects the establishment of a transitional space in which the otherness of the analyst can be ignored as well as recognized. (2) The experience of a space that allows both creative exploration within omnipotence and acknowledgement of an understanding other is, in part, what is therapeutic about the relationship. The restoration of balance between the intrapsychic and the intersubjective in the psychoanalytic process should not be construed as an adaptation that reduces fantasy to reality; rather, it is practice in the sustaining of contradiction. When the tension of sustaining contradiction breaks down, as it frequently does, the intersubjective structures--mutuality, simultaneity, and paradox--are subordinated to complementary structures. The breakdown of tension between self and other in favor of relating as subject and object is a common fact of mental life. For that matter, breakdown of tension between self and other in favor of relating as subject and object is a common fact of mental life. For that matter, breakdown is a common feature within intersubjective relatedness--what counts is the ability to restore or repair the relationship. 

As Beebe and Lachmann have proposed, one of the main principles of the early dyad is that relatedness is characterized not by continuous harmony but by continuous disruption and repair (Beebe and Lachmann 1988, 1994; Tronick 1989). Thus an intersubjective theory can explore the development of mutual recognition without equating breakdown with pathology. It does not require a normative ideal of balance that equates breakdown with failure and the accompanying phenomena--internalization, fantasy, aggression--with pathology. If the clash of two wills is an inherent part of intersubjective relations, then no perfect environment can take the sting from the encounter with otherness. 

The question becomes how inevitable elements of negation are processed. It is "good enough" that the inward movement of negating reality and creating fantasy should eventually be counterbalanced by an outward movement of recognizing the outside. To claim anything more for intersubjectivity would invite a triumph of the external, a terrifying psychic vacuity, an end to creativity altogether. A relation psychoanalysis should leave room for that messy, intrapsychic side of creativity and aggression; it is the contribution of the intersubjective view that may give these elements a more hopeful cast, showing destruction to be the Other of recognition.

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