Psychological basis for social phobia and violence, without it being chronic?

Hi,

I'm wondering about the setting of your story. Is it modern-day, in a modern country? The reason I wonder is because you say your mc is 15 years old, and was recently released from a psychiatric hospital after spending three years there. I was a psychiatric social worker back in the 1990's, and had over 100 adolescent clients. None of them spent anywhere close to three years in a psychiatric hospital. Ten days to two weeks was more typical. That allowed them to be stabilized to the point that they could be "stepped down" to something else--perhaps a residential program (that's different from a hospital) or a day program or intensive out-patient counseling.

I live in the U.S., and I'm guessing you live in the U.K. (You spelled a couple words with "se" at the end, whereas we in the U.S. spell them with "ze.") I suppose the typical length of psychiatric hospitalization in the U.K. for an adolescent might be different than here, but three years is very, very different. I should add that I worked for a government agency, and funding was an issue--maybe the length would be greater with private insurance. Still, I'm not thinking that much longer.

Another thing that struck me: The boy was living in foster homes, then a psychiatric hospital for a very long time, then he was placed with his aunt. With the boy's background, I don't think the child would step down directly from hospitalization to living with the aunt, unless a lot of "wrap around" services were in place--support from various sources (e.g., a social worker, a doctor, etc.) to help ensure the child would be okay in the new setting.

Hope that's useful.

I'm having a hard time thinking of something that would require an adolescent to be hospitalized for three years. As Amy said, that may be a UK vs US thing. Other than that, I could easily see a child being traumatized and developing a fear of people or social phobia. Perhaps he's tortured by his sadistic parents (which lands him into foster care and would certainly traumatize him). The fear of people would come about because really, who can he trust if he couldn't trust his parents? Or perhaps the torture came about as a result of social encounters and hence he can't stand to be out in public. With therapy, lots of therapy, he could gradually become acclimated to the public again and his fear of people could be reduced so that he would at least be able to function.

Not sure how helpful that is. Again, the three year hospitalization is the problem.

ETA: For the therapy, I would think CBT (cognitive-behavioral therapy) could be applicable.

Could you change it so that his aunt wouldn't take him in until he was fourteen, and he was therefore bounced around between foster homes? Perhaps she had other children in the home and didn't trust her nephew because of his past, and no longer has children in the home?

Maxinquaye:

I'm recalling an episode of M*A*S*H where Hawkeye is scratching and itching all over, and it won't stop. At the end of the episode, he has a revelation about an incident he suppressed, and it was triggered by a musty smell that came from a patient's clothes.

So maybe, by the time he's out, he's largely conquered it, but certain triggers set off flashbacks?

Also, does he himself have to be the victim? Maybe it's an accident or crime he witnessed, and he saw the results, or the brutality, without being the recipient.

Hi, Maxinquaye

The psychopathology you're describing of a social phobia combined with violence doesn't seem likely unless, possibly, it could be keyed off Bipolar Disorder I. I am not a psychologist, so you might want to check out AW's very own Archetypewriting's website or see if she can answer your question. She's wonderful about helping out and her book is amazing.

hth

Ari

Are you trying to say that your character has PTSD? PTSD can definitely result in violent behavior. The dissociation and flashbacks can lead to the person reacting violently when it's inappropriate because they think there's a serious threat in a situation which is actually benign, or even think a friend is one of their abusers during a dissociative episode*. Extreme social anxiety and panic attacks are also often a part of PTSD. So maybe that's what you should be researching.

And yeah, as others have said 3 year hospitalizations are extremely rare and not very believable under the circumstances you've described.

*I hope no-one misinterprets what I've said as meaning most people with PTSD are dangerous. But crazy things can happen when severely traumatized people have flashbacks. I know this first-hand, because I was in a relationship with someone who had severe PTSD for the better part of a year. It can be a very scary and unpredictable illness.

A few thoughts

I agree the long term hospitalization is a problem. The longest psychiatric hospitalisation I've known was a kid we believed would attempt suicide within a very short time of discharge and the length of stay was about finding a placement that could deal with that and keep him safe.About 18 months in total with one discharge in the middle that lasted about a month (where he made a serious suicide attempt).....all in all about 16 months too long in hospital.

The only other lengthy type of hospital stays usually revolve around eating disorders when someone is still resisting food and needing nasogastric feeding but 3 years is still about 2 years too long for that.

Second problem is if we assume he did spend a long time in hospital, what on earth were they doing for 3 years that meant he was discharged with a very intense social phobia that meant a community team was starting from step one? His therapy should have been well under way if not completed and he should have had lots of time out in the community with support prior to discharge.

Third, not sure about the US, but no self respecting UK psychiatrist or social worker is going to give local law enforcement a thick file on a patient when they're discharged. I'd expect to be up in front of the general medical council for that sort of breach of confidentiality.

There are a couple of situations that might suit your time scales. If you want a lad out of social circulation for a few years, traumatised and suddenly back on the streets and at the beginning of treatment then perhaps he's been locked in a cellar for a few years and percieved as threatening for being an unknown quantity, or perhaps he was "rescued" after a violent attack on his captor that made the news.

Or maybe you reverse the move and he's moving from his aunt to foster care for the first time after a violent incident that his aunt couldn't cope with. Change of city,change of setting and suddenly he's coping less well in a new town than he was in the last one. You get your fresh start in a new community. In the grand scheme of things it's hard to imagine anyone going to foster care before a willing aunt without very good reason.

Cognitive behavioural therapy is a good starting point for your therapy, perhaps with added stuff geared to trauma such as EMDR (eye movement desensitization - something I should remember starting with R) but your lad is also going to need a more psychodynamic approach that provides space for him to talk, think and make sense of things.

Craig

EMDR

Eye movement desensitivesation reprogramming What about he was kidnapped and living with the kidnapper and had stockholm syndrome (where he now was more comfortable with the kidnapper and his isolation). When he was freed and sent to his aunt he was retraumatized by the freedom

Full disclosure: I am not a psychologist. I hold a BA in psychology, have worked in several residential treatment programs (NOT hospitals) with kids and teens, and am the phobias guide for About.com. So this is just my "has enough knowledge to be dangerous" take.

I would switch the hospitalization to directly after the crime--maybe have him physically injured and go through the regular medical floors, and then sent to the psych ward based on behavioral observation/statements he makes.

But I can't fathom a diagnosis that would keep him in the hospital for more than a couple of weeks. In the US, long-term hospitalization really doesn't happen much anymore. He would have to be *actively* suicidal or homicidal...at least in FL, the standard involuntary hold is 72 hours. It can be extended by judicial order or they can try to talk him into staying, but not for anywhere close to that long.

I'd make the kid a revolving door case. We had, sadly, way too many of them in residential care. He's medically hospitalized, goes to the psych ward for a week or two. Gets transferred to a semi-open campus (kids live and go to school at the facility, but are allowed to leave the grounds with staff members if their behavior is good). Suicide attempt or major violence--goes back in the hospital for a 72 hour hold. Residential takes him back, it happens again. After 2-3 rounds, residential decides they can't handle him.

He goes to what we used to call a warehouse--a lockdown residential where they hold kids in transition. Some are coming out of the hospital, some out of juvenile justice, some just removed from rotten homes. He goes to a different semi-open residential, acts out again, goes back to the hospital. Wash, rinse, repeat. Eventually he settles down somewhat and is declared stable enough for a small group home or therapeutic foster care. They can't handle him and he goes back through the warehouse to yet another residential.

Every time he goes through these steps there are new caseworkers, new therapists, new psychiatrists and new meds involved. When I worked at the warehouse, we used to get 9 year olds with medication sheets as long as my arm. Our facility would try to dry them out as much as possible (under our in-house psychiatrist's supervision), but they'd leave and come back with a dozen new meds.

This revolving-door process could easily eat up your three years. During that time he learns to game the system and tell everybody what they want to hear, and he's eventually ruled stable enough to go to the aunt, especially if she's willing to go through training for therapeutic foster care certification.

Honestly, the traumatic event would be the least of his problems. Spending years in the system, bouncing around and spending his time with other kids with major problems, could easily cause/intensify the social phobia. I'd think about PTSD mixed with another preexisting disorder (maybe oppositional defiant disorder or bipolar disorder). He is treated for those along the way and they end up pretty well managed by the time he comes out. But he picks up the phobia along the way and no one really catches it.

I know you don't want him to have a chronic condition, but both ODD and bipolar can be very well controlled, with sufferers living normal lives. And so often trauma is the touchstone that sets off another disorder, which makes treatment more complicated.

I know I sound like I'm badmouthing the entire child psychology system, and I don't mean to. Plenty of kids go through the system and come out great. But the revolving-door stories are very, very sad.

I keep wondering a couple of things. First, why were the foster families not able to cope with your character? Because he was waking up in the middle of the night screaming with PTSD? Because he was threatening to other children? Something else?

I'm also thinking that when one is afraid of other people (e.g. with social phobia), that makes it difficult for him to be consistently aggressive towards people, since that requires some confidence and a willingness to interact with people (probably a lot of them, given that there are consequences to violence).

A lot of people have given you a lot of good info and ideas...maybe you could tell us where you are right now with your thoughts on all of this? That might help us help some more.

I agree with a lot of this advice, especially blackrose's about making your character a revolving case, and the advice about PTSD. I'm the US, and I also can't imagine any juvenile being hospitalized that long. There can be residential care, intensive outpatient treatment, or partial hospitalization programs. I've known two people who were hospitalized for a lengthy amount of time as adults, and those were cases of personality disorders or schizophrenia.

That said, I think the revolving door and/or being hospitalized against one's will is traumatic enough to induce the symptoms you're talking about.

What about Social Anxiety Disorder? Still wouldn't fit the profile for a three year hospitalization in the US, but seems to have the "comes and goes" I think you're looking for. It's worth noting that hospitals in the US work hard not to keep anyone for very long anymore, even for mental health. Convalescence in all but the most severe and at risk of infection cases is expected to happen at home.

In my experience, psychiatrists don't offer any type of therapy. They are really there to prescribe medications and monitor patient progress, usually in tandem with a psychologist offering therapy. They wouldn't be trained in things like CBT or DBT, usually. But there are exceptions. I think I once knew a psychiatrist who had gone through the Gestalt Institute. So it could happen, but it's very rare.

CBT and DBT are both talk therapies that are usually offered by a psychologist or a psychological counselor (LCPC) not a psychiatrist. No medicine is involved. Psychologists and LCPC's cannot prescribe (if that's what you meant by administor) anything only psychiatrists can do that. From your new description Luke definately, no questions asked, has PTSD he may have some other things too. But start researching PTSD so you really understand it. It will help you get to know your MC.

It depends on what kind of CBT. The CBT I went through (Group therapy) had a psychiatrist, a psychologist and several therapists in the large group sessions and a therapist with either one in the smaller free session and only a therapist in the programmed sessions.

Cognitive behavioral therapy is a combination of two approaches: cognitive psychology (Albert Ellis and Aaron Beck are probably the men who have done the most for cognitive psychology in terms of therapy) and behaviorism (BF Skinner was a radical behaviorist).

Cognitive psychology assumes that any problems are based heavily in the way the person is thinking, and seeks to change those irrational (Ellis) or dysfunctional (Beck) thoughts. Ellis's approach is to use REBT (rational-emotive behavioral therapy), which I usually call "ABCDE therapy" to my students. You can learn more about REBT and see it in action at http://ow.ly/aRz3l (Part I, which explains the ABC part) and http://ow.ly/aRz2E (Part II, which explains the DE part). As for Beck, well, he described a series of "cognitive distortions" that people who are having problems over-use. You can see the ones he came up with (and a few others) at http://ow.ly/aRz4E.

Cognitive therapy works REALLY well with anxiety and mood disorders, assuming the client is willing to do the work of the REBT homework.

PTSD usually requires behavioral interventions (in addition to cognitive interventions using the models mentioned above), most notably exposure therapies, in which the individual must confront the feared memories in some way. (EMDR, which someone mentioned above, is a form of exposure therapy, and the exposure seems to be what makes it work, rather than the eye movements.)

Do note that if your character has PTSD, you are looking at a somewhat chronic condition. People can certainly recover from PTSD, but a serious trauma does change the person forever, if in no other way than that they see the world differently due to the experienced trauma. If you need to do research on PTSD, I strongly suggest Aphrodite Matsakis's I Can't Get Over It (http://ow.ly/aRzha). It's the popular/layperson's version of a handbook she wrote for clinicians on PTSD.

Maxinquaye said:

What I worry a bit about is that this psychiatrist will have a markedly different approach to therapy than does a psychologist. I will look into this cognative behaviour therapy. Is that something that a psychiatrist would be likely to adminsiter?

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The key to understanding what psychiatrists can do and what they usually do is understanding the cost / wage issue. A psychiatrist in the UK earns more than a psychologist so very few organisations want a psychiatrist in their employ to spend time doing things a psychologist or another profession, such as a nurse, could do. I imagine the same would be true of a private insurance company.

Technically, any profession can hone their skills in any type of therapy to become fully qualified in its use but a greater number of psychologists achieve this than other professions.

There's nothing unbelieveable about a psychiatrist using CBT byut your typical CBT therapist is more likely to have a psychology background.

As for prescribing medication. To continue to prescribe a doctor in the UK must remain registered with the General Medical Council and they charge an annual fee for this. It's not so large as to be a problem for someone who's comfortable financially, and a lot of doctors remain registered once they retire so they can do a bit of private practice or even the occassional locum job, but a truly retired doctor probably isn't going to carry on paying the fee. Not sure if the system is different in the US though, but I imagine medical malpractice insurance is a much more significant cost there so you may need an interesting reason for a retired psychiatrist to think it's a good idea to take on case responsibility for a difficult and "dangerous" case if they aren't still carrying insurance.

Craig

Part of the issue I would have here is with the foster homes and THEN the aunt. Usually, here at least, a child is placed with relatives before and over a foster family. If he's been in care for a while, then you'll need to have a really good reason for his aunt not being able to take him before.

Maxinquaye said:

Hmmm, the hospitalisation was just my idea of getting him away until he was fourteen. If he was hospitalised, then obviously he couldn't be sent to his aunt. The theme of the story is about being accepted into a community; and I needed someone that had a history of violence and destruction, without him being a hardened juvenile delinquent.

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You could have a sort of mid point - like a youth home - a place for kids with problems and/or difficult pasts and criminal convictions.

A hospitalised youth obviously scores higher on the reader-sympathy scale than a criminal.

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I don't know. I mean, if he's been in hospital for 3 years I, as a reader, am going to assume that he's really fucked up, and I might have difficulty relating to him, verus, for example, a kid who's been in borstal for the same period.

A few things:

I have a problem with the idea of a social phobia/anxiety disorder being a cause for violence. In my experience, those dealing with anxiety issues are not violent against others (more to themselves), and usually an anxiety attack is physically debilitating. Violence, from my experience, in those with anxiety attacks/disorders comes from much more pressure placed onto the individual than anything so far presented.

I also have a problem with the idea of the foster dad holding the MC down while trying to forcibly medicate - really not bad mojo.

(and, as a friend and activist regarding bipolar perceptions, I'm going to ignore the suggestion of using it as a basis for making someone violent)

Others have stated that giving the kid's medical records to the sheriff is unbelievable, I concur. It's not just unbelievable, but highly illegal, as in a Federal law kind of way. As in HIPPA violations kind of way. (And in this case, it's a good thing).

HOWEVER, as the 'revolving door' approach comes up, the Sheriff will have access to the kid's criminal records and that could be the 'inch thick' file on him (though, inch thick is really pushing it). However, the sheriff (or anyone in his organization) is going to need a viable, valid reason to access those records otherwise - yep, you guessed it - Federal violation. Now, if the sheriff (or deputy) had a reason to obtain that information, that means that he's committed some other crime and their suspicions aren't so out of place and would lead sympathy away from the MC.

Rabe...

After scrolling through all of the replies (which were very good and insightful) I thought of something. You could have the child bouncing around in homes then the hospital (for a brief time as everyone else I agree that there really isn't a disorder that could warrant a 3 year hospitalization) and going to the aunt who didn't know that the kid was in foster care in the first place. Maybe this aunt was estranged from the kid's parents and didn't know about the violence especially if the parents were the perpetrators of said violence.
Also, someone mentioned earlier the work of the psychiatrist. Here in the US, the psychiatrist prescribes meds - a psychologist, social worker or licensed counselor (I'm one) does the therapy. CBT would would well with someone dealing with a phobia.
As someone who worked in therapeutic foster care for years, the likelihood of a male foster parent pinning down a child to give medication is zilch. Holding down a child is not allowed. If a child refuses medication (which at 15 in the US he/she can do), then the foster parent's option can be to call 911 and the foster care agency to report that.
Your MC sounds as if he's experienced a great deal of rejection, not necessarily violence (though it is very possible) and has not expressed it verbally. Kids who act out have trouble sharing their feelings and even processing what they are feeling in the moment. That could be the result of experiencing trauma as well as a specific diagnosis. Some I've seen are - Mood Disorder, Oppositional Defiant Disorder, Anxiety Disorder with (Depressive symptoms). Possibly your mc could be hospitalized due to suicidal ideation and kept there due to figuring out effective medication treatment (which could also be the reason why the kid bounced from home to home).
Every foster parent has a behavioral limit. Some foster parents can handle certain behaviors and not others. In my experience that has to do with the foster parents' personal values/experiences. I've seen this first hand where one foster parent can handle a child who lies while another can't. Or when a child steals or lashes out physically or even calls in a false report against the foster parent (which happened several times in my tenure).
I hope this helps. Please let me know if you have any other questions. Please note that each state has differences in how foster care works. I'm only speaking of what it is like here in NYC.

I survived said:

Eye movement desensitivesation reprogramming What about he was kidnapped and living with the kidnapper and had stockholm syndrome (where he now was more comfortable with the kidnapper and his isolation). When he was freed and sent to his aunt he was retraumatized by the freedom

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Or what if, after the trauma, his older/younger brother/sister disappeared with him off into the countryside, hiding him away so his PTSD or whatever isn't a problem - and then the sibling dies or is convinced to relinquish him to the aunt.