Case Study: DB
Please read over the following information and submit a reaction paper/essay in response to the prompts that follow the case discussion.
Patient Information and Reason for Treatment
DB is a 38-year-old male serving 14 years in state prison for arson, animal cruelty, and aggravated assault with a deadly weapon. At the time that treatment was initiated with me, the inmate patient had already served eight years of his sentence (at seven different prisons), and, with gain time and county jail credit time (the time served in county jail prior to being sentenced), was only two years away from prison release.
He had been in and out of treatment during his incarceration and had carried a variety of diagnoses. The presenting problem almost always had to do with violence toward other inmates and extreme anger. Most recently, and immediately prior to beginning this course of therapy, the patient had been seeing a mental health counselor in the prison with whom he did not get along. DB had made several complaints to me, the psychological services director (PSD), that he was not getting "good treatment" from his counselor (SM) and did not feel he was being listened to. SM had 15 years of experience in the prison and was generally regarded by all (inmates and staff alike) as a warm, empathetic, and effective therapist throughout his career. DB simply said, "I don't like him."
After several conversations between the PSD and SM, it seemed clear that what DB objected to most was being confronted about his refusal to take responsibility for his behavior. SM explained that he had tried to gently confront DB about his problems, but the patient was never able to accept this and continued to blame others for his problems. Finally, SM asked me to take over the case. SM confided, "I've tried hard to keep these feelings back, but I can't stand the inmate.
He's rude and obnoxious. Please take him off my hands." Although this is not something I usually do, I felt as though this was the best course of action.
Therapeutic Approach:
I am a psychodynamically oriented therapist. After reading through the psychological record and looking at this behavior in prison, it was clear that most of those who had worked with him had attempted to help him get his anger under control. It never really worked because he had continued to fight and act out in prison (see below under Background Information). I wanted to keep this target goal as I put together a treatment strategy (which clearly underwent modification as I got into therapy with him) that would focus on uncovering the origins of his anger problems.
I wanted to help him understand why he was so angry (not just provide him with techniques for mitigating his anger when he experienced it) and hoped this would lead to a more permanent reduction in his aggression and violent outbursts.
I wanted to explore his childhood and use dream analysis, projective assessment, and any other relevant opportunities to excavate his unconscious functioning, bring it to light, and show it to him.
Psychological Testing Data:
He had a great deal of psychological testing during his incarceration, though most was done at the time he was received, which was many years before our therapy began. This is a summary of the tests and their results.
BETA-II: this is a standardized IQ measure, with 100 being the average score. He scored 94, and then, two years later, 91. These IQ measures fall into the lower range of average intellectual functioning and show no significant cognitive deficits.
Beck Hopelessness Scale (BHS): this is 20 T/F questions that ask about a person's outlook on the future, as well as their optimism about their life being happy and fulfilling. Each response is scored according to whether the patient endorses the "depressed" view, and if this is so, they get one point. Scores range from 0 to 20, and the higher the score, the more depressed and hopeless the individual seems to be. The typical score we see at the prison is between 5 and 10.
Anything over 12 is considered a red flag for diagnostic depression, so the person should be evaluated further. We do not diagnose depression based on a BECK score, but it becomes a guidepost for follow-up interview and evaluation.
DB scored a 1 during reception. He was retested at two other prisons and got scores of 2 and 4.
These are all very low scores. Interpretation? This is not a depressed individual, and he is actually quite upbeat and confident in his ability to handle all that life throws his way.
MMPI-2: this is the gold standard of objective assessment. The MMPI yields diagnostic information and compares the patient's responses to those of other individuals who have been diagnosed and treated for various psychological disorders and conditions.
DB took the MMPI-2 twice: once when he came into prison, and again four years later. The results on both yielded a classic 4-9 profile, the constellation which shows contempt for authority, chronic anger and cynicism, aggression, poor impulse control, lack of inhibition, and tremendous risk for violence. In short, this is a profile that most often indicates antisocial personality disorder and problems with the regulation of anger.
Rorschach: this is the famous "ink blot" test and is the only one of the four instruments that I administered myself. I gave him a Rorschach prior to our first therapy session (as I usually do prior to starting therapy) because it is not a good idea for a therapist to give a patient this test once therapy has started. (The interpersonal dynamics may distort the results.)
Without getting too technical, I can say that his Rorschach was dominated by unmodulated color responses and morbid content. Taken together, these features suggest poor emotional controls (particularly the inability to regulate intense emotion), possible aggression, and possible self-concept and esteem deficits. It is as if he feels damaged in some way and allows his poor emotional controls to be his way of defending himself against a world that constantly reminds him of this.
- Diagnosis
- Intermittent Explosive Disorder
- Antisocial Personality Disorder
- Alcohol Dependence
The DSM diagnostic criteria for intermittent explosive disorder are as follows:
A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property
B. A degree of aggressiveness expressed during the episodes that is grossly out of proportion to any precipitating psychosocial stressors
C. Aggressive episodes that are not better accounted for by another mental disorder (e.g., antisocial personality disorder, borderline personality disorder, a psychotic disorder, a manic episode, conduct disorder, or attention-deficit/hyperactivity disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease)
DSM diagnostic criteria for antisocial personality disorder are as follows:
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since 15 years of age, as indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
B. The individual is at least 18 years of age.
The DSM diagnostic criteria for alcohol dependence consists of a maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1. Tolerance, as defined by either of the following:
- A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
- Markedly diminished effect with continued use of the same amount of alcohol
2. Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria sets for withdrawal from alcohol)
Alcohol (or a closely related drug, such as valium) is used to relieve or avoid withdrawal symptoms
3. Alcohol is often used in larger amounts or over a longer period than was intended
4. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
5. A great deal of time is spent on activities necessary to obtain alcohol, use alcohol, or recover from its effects
6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use
7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
Legal History and Crime:
His crime was as follows. He had been living with his girlfriend at her house for over two years, and their relationship had been characterized by sporadic episodes in which he had abused (punched) her. The police had been called several times, but he had managed to escape having charges filed against him. His girlfriend had a four-year-old daughter from a previous relationship.
She was a dog breeder and often had puppies in the home, something which DB did not like because he felt the dogs (and the child also) "took too much effort."
They had an argument in the kitchen. He was drunk. He pulled her hair, broke furniture in the house, and took a butcher knife from the drawer and held it to her throat as he threatened to kill her. He finally stepped away with the knife, and she screamed that she could not take it anymore and told him to "get out." In a rage, he went into the next room and violently grabbed three puppies from a litter that had just been born three weeks prior. He returned to the kitchen, screaming, and threw each puppy against the wall. This killed each.
His girlfriend's daughter was nearby, crying hysterically, and she grabbed her. The mother and daughter fled the house and ran down the street to a neighbor's house. DB calmly walked to the garage, got a can of gas, doused the kitchen, walked out of the house, and threw a lighted match into the doorway. The house went up in flames quickly.
He was sitting at the end of the driveway when the police arrived and arrested him without resistance.
DB was 28 when this incident occurred. He had been in prison once before for domestic strangulation. He served two years and was released to the community. Prior to the first incarceration, he had been arrested 12 times (first arrest age 14) for various crimes, such as breaking and entering, grand theft, burglary, robbery, and three incidents of aggravated assault.
These charges had resulted in four commitments to a juvenile facility prior to age 20.
Childhood:
The following is an overview of his childhood and those aspects of it that are relevant to the content and direction of therapy.
DB was raised in a midwestern state. He is the oldest of three boys. His parents "moved around a lot" when he was a child, and this seems to have been because his father had difficulty maintaining work. He was raised throughout his life by both his mother and his father, and they were still together at the time of this current course of therapy. His father has held various jobs over the years but has worked mostly as a trucker. His mother never worked.
DB describes his childhood as "rough and poor" but adds that "this made me stronger."
DB described himself as the "black sheep," saying that "both my brothers always seemed to have it together." One of his brothers died in a hunting accident when DB was 12, but neither brother had any legal problems or behavior problems in school.
DB described himself as a "so-so" student. He appears to have made average to below average grades, but the problem was not his academics, but rather his behavior. He reports constant fights dating back to elementary school, and this behavior culminated in several suspensions and an expulsion in middle school. He dropped out of high school in his junior year but eventually got his GED.
His relationship with his mother appears to have always been a source of comfort to him. "She's always been good to me," he said. DB describes his father as a "hard-drinking bad ass" who was "real hard on me a lot of the time." DB remembers being punished severely for making "bad grades" in elementary school, and he recalls being hit with a hose and frequently being slapped in the back of the head. His toys were taken from him many times (and disposed of), and he says that his father sometimes made him kneel (while in his underwear) on popcorn kernels that he (his father) had poured on the floor. His father made him put his hands on his head and stay motionless "for a real long time."
DB says he "liked" matches at a young age and often started fires in the woods near his house.
"But I always put them out," he added, but not because he was concerned with the damage they would do. Rather, he was scared of what his father would do to him if he found out.
After I asked him if he had any pets when he was a child, DB related an incident from his childhood that he said was "kind of messed up." He was watching the fire pit outside the house when he was around 12. His family routinely burned their trash. He saw a wild kitten in the woods nearby, went over and was able to catch it, and began to play with it. The kitten wanted to get away and began scratching and clawing at him, so he walked over (he could not recall what he was feeling at this point) to the fire and threw it in "just to see what it would do." He watched the kitten die in the fire.
Course of Treatment:
Therapy began with an exploration of why I was taking his case. He, of course, felt that I had done this because his counselor was "a real dud... in the wrong profession..." In other words, my agreement to take over the case had only made it easier for him to blame someone else for his problems. I knew this was likely to be the way he made sense of the situation. This was to be a theme which reverberated throughout our work. DB was always blaming someone else for his troubles; it was always somebody else's fault.
I finally got him to see that he may have had something to do with the problems. We began to talk about his childhood and the rather pronounced history of problems he had getting along with others. He loved girls and women but had never been in a relationship for more than a year.
He did not grasp that he had a problem with women and did not know how to treat them, or that he had a domestic violence problem. He said, "Every woman I've ever been with was a nut case.
That's why it never worked."
It was important for us to find common ground on the presenting issues and what he wanted to do in therapy. Luckily, we both agreed that he needed to feel more in control of his anger because it often led him to violence. Curiously, it was not the violence or the behavioral expression of the anger that troubled him. Very clearly, he told me early on that "I hate to be angry. I just don't like that feeling."
We began talking about his daily prison life and his contempt for just about everybody else, staff and inmates. He made no effort to hide his belief that he was smarter and more "together" than other inmates. He frequently referred to other inmates as "a whole bunch of idiots" and generally felt as though staff "don't know a damn thing about anything." He did not really like or admire anyone. He wrote very dismissive and sarcastic poetry and rap lyrics about the lack of integrity in prison and how he hated "the man." He tried to get me to do things for him (such as a job change or dorm change), which I refused to do. He would often tell me, "What you're saying is just a load of horseshit," and he would often say about even my most innocuous questions, "No, no, that ain't it. I ain't with all that."
During the course of our treatment (about a year in total), he continued to have some behavioral problems. He was locked up in confinement twice for fighting and both times said that he had "no choice" but to fight because the other inmates were "pushing me too far." Despite the fact that he downplayed his history of alcohol abuse, he was also locked up in confinement for possession of a "buck," which is homemade alcohol. He repeatedly assured me that he was into no illegal activities on the compound but was also locked up for possession of a (homemade) tattoo gun and for tattooing another inmate. In total, he had 36 disciplinary infractions on record during his incarceration, and this is a very high number of trips to lock down.
But from the very start, throughout our work, I played my favorite trump card regularly and often: his father. After getting a history, I zeroed in on his relationship with his father as perhaps the one thread which held all of his psychological and behavioral struggles together. His father was, for me, the glue which bound all the problems together; but I did not interpret this or dispense advice or suggestions. Instead, each week I asked about his father and whether he had spoken to him, what he remembered about him, and how they got along. I never really laid out my thinking on this, but he got it.
He asked me one day in a somewhat aggressive tone, "So you think my father abused me?" I said, "Do you think you were abused?" He snapped back, "No way; I deserved it when I got punished."
Later he commented that "you think all this stuff with my father is the reason I got anger issues, right?" I said, "Maybe." He said, "That's just a bunch of mumbo-jumbo."
He seemed to care very much about what I thought about him. He often became angry with me when I would not do things for him or when I would point out areas that he was denying. He became disrespectful only a few times, something which we do not tolerate in prison and resulted in me calling security to have him escorted from my office. He was verbally aggressive with me at times but never behaviorally aggressive.
One area that I often pushed him on was the need to understand why he cared more about feeling angry than being violent or aggressive and why he did not like to feel anger. After much discussion of this issue in indirect and metaphorical ways, I finally just told him what I thought. I told him that he cared more about feeling anger than being violent because he cared more about himself than others, and that he was, in many ways, highly narcissistic. I also told him that the fear he hated to feel was just a disguise for the deeper feeling from which he was hiding: fear. I told him that he was angry at that which he feared. It was easier for him to get mad than to feel vulnerable; he needed to put up an emotional shield (anger) to prevent himself from getting in touch with what probably had been his biggest source of fear since childhood. At this point, I hope we all know what that is.
One other incident in the course of our treatment is noteworthy. As mentioned, he frequently wrote poems or song lyrics and would bring them in and read them to me. They were full of negativity, cynicism, contempt, hatred, aggression, and unbridled bravado. One day, he read me a new poem he had written, and I said with gentle sincerity, "That's really good. You should publish that." He looked at me, paused, and then frowned and said, "You're making fun of me.
You don't think it's good at all." I was shocked and taken back by his comments; my tone had been complimentary and genuine. I explained that I liked his words and gave him some more feedback, but he persisted in his belief that I was mocking him and thought his poems were "just a bunch of shit."
Our work together was full of ups and downs and, as mentioned previously, often interrupted by him going to lockdown for a few weeks or a month. Therapy is very hard to continue there because there are few rooms available, which means that therapy is cursory, at best, or discontinued while the inmate is in lockdown. Much of what I was able to do with him was keep him balanced on a day-to-day basis and help him avoid aggression and violence as he went through the day.
I never got a chance to wind down with him. As if often the case with inmates, they are simply moved or transferred to other prisons for population adjustment or due to excessive disciplinary activity. DB was moved to another prison for disciplinary reasons, and I was not aware that this was happening. Our work was abruptly interrupted one day when he did not show up for his appointment, and I found out he had been moved the previous evening.
Case Study: Reaction Paper Assignment
We all would like to believe that therapy is an efficient, transparent process in which a patient comes in, tells the therapist in an honest way about all of his or her problems, and receives and follows the therapeutic guidance. Then, symptoms vanish and the therapist and patient have time to discuss termination and what therapy has meant.
I hope this case study shows that this is not always the case.
There are several aspects of this therapeutic relationship and DB's presentation that were difficult to manage and are important for students of psychology to think about and reflect upon.
Please provide a 1,000-word (about three pages), double-spaced, typed paper that is your reaction to the following five prompts:
1. In what ways does he show signs of resistance to therapy?
2. Did this resistance effect the direction of therapy?
3. How do you think you would work with someone who didn't like you, didn't want your help, and did not tell you the truth?
4. Why do you think he so grossly misinterpreted the compliments about his poetry? What does this tell you about what you need to do in therapy?
5. How would you feel and what would you do if very intense therapy with a patient ended suddenly and without warning? Does this possibility change how you would approach therapy?