Ego Psychology and Communication, Research Paper Example

The Unique People Services (UPS)is a primarily minority-served, not-for -profit 501(c) 3 agency formed in 1991 by a group of concerned and experienced social service specialists with the intent to serve those individuals that “fall through the cracks of our society”. The agency’s goals are: to provide housing and comprehensive support services focused on meeting the physical, social, and emotional needs of each person served; to help those whose needs have been neglected or whose circumstances have prevented use of existing services; and to promote greater public understanding of the unmet needs of individuals with disabilities. These goals are accomplished by addressing the complete needs of its client population, with emphasis on individuality of services, the creation of “homelinks” (caring environments) and by allowing each individual to maximize his or her strengths and capabilities.One specific program of UPS is the Haven Apartments complex, which provides extended-stay housing to people who are or have been recently homeless and are suffering from a serious and persistent mental illness. The objective of the complex is to provide a safe, warm, supportive environment which will assist people in becoming more independent and successful in their transition to independent living within the community.

UPS serves a range of clients, and provides a comprehensive set of services that are tailored to meet the needs of each individual served.  This essay will present a detailed case review of one of the clients that was encountered during an internship at UPS, providing a psychosocial description of the client, his specific service needs, and the ways in which he was helped through the multi-faceted treatment plan developed for him by the interdisciplinary staff at UPS.

Client Presenting Problem: Nikko, a 45 year-old Afghan man, presents with a 35-year history of chemical dependency problems and is homeless. Presently, he is a voluntary participant inThe Bower Resident’s Committee, and appears motivated to seek treatment in a dual-diagnosis capacity, that is, interventions that will address both his mental health and substance abuse difficulties.

History of Presenting Problem: Nikko is originally from Afghanistan, and has been homeless for approximately nine months.  He is single and has no children.  Although he has three brothers currently living in Virginia and a younger sister living in California, both of his parents and older sister died in Afghanistan during the war; he witnessed their murders as a nine year old child.  Nikko’s subsequent history includes aggression directed outwardly as well as suicidal tendencies, and this behavior has resulted in several arrests.  In addition, he has a long history of poly-substance abuse from childhood onward.

Medical History: Nikko has been diagnosed with hypertension, glaucoma, arthritis and asthma, insomnia, depression, and anxiety.  In addition, he suffers from post traumatic stress syndrome.  He also experiences neurological problems in his legs below his knees which is a result of frequent running away from the Soviet military as a young boy.  He has blackouts, seizures, hallucinations, delirium tremens, and a history of suicide attempts.  He is being treated with anti-depressant medications, Prozac and Paxil.  Although he reports hearing voices, mostly when drinking, he does not appear to be psychotic.

Impressions: Nikko presents as a tall, stocky male with an untrimmed, graying beard and moustache appearing to be his stated age, with an unkempt, disheveled appearance.  He speaks English with an extremely heavy accent that is difficult to understand, but he communicates freely and openly, and presents in a pleasant manner.  On exam, he smells from alcohol, and acknowledges that although alcohol is his drug of choice, he also occasionally smokes marijuana.  He reports having had several unsuccessful detoxification experiences at various in-patient settings.  He has been unable to maintain sobriety since after being discharged from treatment,he experiences tremors in the morningand he invariably returns to the streets and resumes his former chemically dependent behaviors. Moreover, Nikko is able to make the connection between his use of chemicals and the need to repress painful memories from his childhood and young adulthood.  When he has used chemicals, he feels that he can be worry-free.

Nikko presents a significant strength that will be an asset to treatment, namely his strong motivation to seek help and get sober. In addition, he has extended family in the form of siblings who may be accessible via telephone contacts or possibly in person. Conversely, he has several limitations that will provide challenges to a successful treatment outcome: his language barrier, his homelessness, the physical distance between himself and family members, his lack of financial resources as well as a job, and perhaps most significantly, his lack of a coherent sense of self that has included even minimal successes in areas such as social, economic, or occupational outcomes.

Regarding ego functioning,Nikko is utilizing the defenses of repression and projection.  In her landmark book, The Ego and the Mechanisms of Defense, Anna Freud discusses the survival tools, or defense mechanisms, that are related to painful, upsetting experiences, and identifies the major psychological defense mechanism in this situation as repression (Freud 1936).  Nikko  is able to acknowledge that he has a lifelong history of sedating himself with chemical substances in order to repress his traumatic and painful memories of childhood.  Because his immature ego was unequipped to tolerate the bloody, devastating loss of his family members, he appears to have split off some of the memories and then medicated himself with alcohol and other drugs.  On the one hand, his substance abuse can be viewed as a primitive attempt to adapt to those memories; however, on the other, these attempts have not been successful as he is still well able to recall the dramatic events.In addition, Nikko has utilized projection when he has become involved in aggressive acts directed against others.

Suppressing retrieval can shut out intrusive memories, restoring control over the direction of thought and our emotional well-being (Levy, 2009.) As a young child, Nikko began to use suppression as a defense and it became his characteristic manner of coping with past trauma.  The cycle of substance abuse in which he has engaged is a further primitive attempt to utilize suppression to protect his ego from the intolerable pain of his past.

Nikko’s history of violence and attempted suicides further exemplifies his characteristic defense mechanisms. He uses aggression and repression to deal with his anguish,and his suicide attempts demonstrate repression through his aggression inward while his repeated arrests due to violence are simply his turning his aggression outward towards others (A.Apter 1989).

In Nikko’s life, the balance that is being struck between his ego, his id, and his superego is out of kilter, and his attempts to achieve homeostasis—through his substance abuse—has not only failed, but has produced other challenges that have been self-defeating.  For example, if he was not drinking to the extent that he has been, he might have been able to get a job and have a place to live.

The ways in which a person handles traumatic situations have been described using the terms “strong or weak ego” (Polansky1979.) Each individual has his own threshold of tolerance and pain; one of the drawbacks of ego psychology is the inability to measure a person’s functioning and perseverance which allows them to attend to their feelings and emotions.

Diagnostically, Nikko falls within several categories on the Axis I scale.  Posttraumatic stress disorder is the most obvious Axis I diagnosis, as well as Poly-substance Abuse Disorder; in addition, he appears to be suffering from Substance-Induced Mood Disorder.  His aggressive impulses may be explained by ruling out one of a few disorders: Intermittent Explosive Disorder, Impulse Control Disorder NOS, as well as Major Depression with or without Psychotic Features.  The fact that Nikko hears voices in his head when he drinks may be an indicator of one of several diagnoses:Substance-Abuse Psychotic Disorder, Major Depression with Psychotic Features, among others including the fact that he is also withdrawing from alcohol during the mornings before he has begun drinking.  In order to further assess the extent of Nikko’s depression, questions would need to be asked regarding his appetite, any recent weight gains or losses, his sleep patterns, i.e., how long does he sleep during the night, whether he suffers from early morning awakening or an inability to fall asleep at night, whether or not he is able to concentrate, etc.  In addition, he would need to be thoroughly evaluated regarding suicidal ideation, whether or not he has a serious intent to kill himself and if so, what method he would use and whether or not he has access to it.

Regarding an Axis II diagnosis, it is clear that Nikko exhibits characteristics contained by several Personality Disorders.  For example, his acts of hostility and aggression directed towards others leading to arrest on more than one occasion suggest that he suffers from Antisocial Personality Disorder.  He also demonstrates characteristics of Borderline Personality Disorder through his acts of suicidality, his impulsivity in ways that are self-damaging, and instability of mood.  In all likelihood, he could also be given a diagnosis of Mixed Personality Disorder NOS since he contains features of many of the other personality disorders without meeting all the criteria for any one of the other formal diagnoses.

As stated, Nikko has several health problems that would fall under the category of Axis III, including hypertension, glaucoma, arthritis and asthma, insomnia, depression, and anxiety.  Axis IV, which consists of  Psychosocial and Environmental Problems, contains virtually every issue that is a problem for Nikko: problems with the primary support group, or lack of one; problems related to the social environment; occupational problems; housing problems; financial problems; problems with access to the healthcare system; problems related to the legal system or crime; and other  social or environmental problems such as a lack of social contacts, alienation from family, and not having a structured existence.

Finally, regarding Axis V, The Global Assessment Scale, Nikko’s score is about as close to the bottom as one can get.  He would fall between the numbers of 11 and 20, in that he presents some danger of hurting himself or others, is frequently violent, and occasionally fails to maintain an acceptable degree of hygiene.

It is crucial to understand that in working with Nikko, respecting his defenses rather than breaking them down would be one of the objectives; he needs those tools in order to protect himself when he is feeling vulnerable.  His need to utilize those defenses might decrease or change in the future, depending on how successful his treatment outcome is.  In addition, when providing intervention to Nikko, it would be important to establish a level of respect for him by asking him what he prefers to be called, by his surname or his first name before establishing a first-name basis between us.  In addition, before meeting with Nikko, it would be extremely useful to do research on Afghani culture so that certain things which might be signs of respect for Nikko, or disrespect, could be utilized or avoided.

An extremely important value to establish for our contacts would be Nikko’s right to self- determination, his ability to be an active participant in his own treatment decisions.  One method of doing this would be to encourage him to give me feedback ongoing about whether or not our sessions were helpful to him and if not, how we could change them so that they would be more useful.  Another important value would be the concept of confidentiality, my guarantee to Nikko that whatever he talks about in our sessions would remain within the walls of the agency and would only be discussed with my supervisor or other staff in order to plan for his treatment.

Finally, I would discuss with Nikko the treatment plan which I would devise in consultation with my supervisor and possibly at a staffing.  My first act would be to establish a contract with Nikko including his willingness to participate in treatment and his commitment to remain in treatment and not withdraw without discussing it with me in an effort to try to resolve any problem issues that arose.  My next step would be to refer Nikko for a psychiatric evaluation so that a physician could evaluate his medications and determine whether Paxil and Prozac were indicated during this process.

A variety of behavioral techniques would need to be implemented in order to help Nikko change from his former maladaptive behaviors and to learn new, healthier ways of coping.  For instance, Nikko could be helped to identify the triggers to his drinking, that is, what happens to him physically and psychologically prior to having the urge to drink and then giving into it.  He could find new behaviors to utilize when he felt those urges, and learn to avoid those triggers whenever possible.

A drug and alcohol assessment would need to be provided next in order to make decisions about what form of treatment would maximize Nikko’s chance for success in achieving sobriety: a medically supervised detoxification program in-patient, which would be most likely followed by a commitment to participate in a 12-step program for at least 30 days following discharge.  This would allow Nikko to choose a sponsor, someone with whom he could attend meetings and could call any time of the day or night when he felt the urge to use substances or experienced any other problems.  Finally, Nikko would need a complete social service assessment that would provide him with a case manager who would be a person to coordinate all of his social service needs: housing, counseling, finances, health care and any other gaps in service that came up.

Nikko’s need to be connected with other people, either family members or other social contacts , would be crucial in his recovery and his ability to stay on a straight path.  He would most likely make contacts in his Alcoholics Anonymous home group, but a counselor would also likely want to make an effort to contact his family members.

Hopefully, another major component in the success of Nikko’s treatment would be the transferential relationship with me, in which trust could be established through my providing a consistent, safe settingin which Nikko could express his entire range of feelings and reactions without being pressured to do so.The goal would be for me to be a role model that he could utilize in a variety of ways: to help him find concrete services for himself, for me to provide an accepting and supportive environment without judging him, and for me to not disappear the way his family did, so that finally, he would have the experience of being able to count on someone to be there for him without him fearing abandonment.

References:

A.Apter, R. &. (1989). Defense mechanisms in risk of suicide and risk of violence. Retrieved December 1, 2009, from American Journal of Psychiatry:http://ajp.psychiatryonline.org/cgi/content/abstract/146/8/1027

Anderson, M.C.”&Levy, M. “Suppressing Unwanted Memories,”Psychological Science,.2009, Retrieved December 1, 2009, from: www.psychologicalscience.org/journals/cd/18_4…/andersonfinal.pdf

Freud, A. (1936). The Ego and The Mechanisms of Defense. New York: International Universities Press, Inc.

Polansky, N. (1979). Ego Psychology and Communication: Theory For The Interview. Retrieved December 18, 2009, from http://books.google.com/books?id=HWNW9kT11cEC&pg=PA48&lpg=PA48&dq=ego+psychology+strengths+and+weaknesses&source=bl&ots=mA8shi8eB_&sig=bpZitpoFt6JG-bsyWvMEFhXYgP4&hl=en&ei=PRMtS9XuOILZlAeSjKGqBw&sa=X&oi=book_result&ct=result&resnum=9&ved=0CDAQ6AEwCA#v=one