Dexter Morgan

FYI – This is an assignment from a class in which we are required to create a treatment plan for a television or movie character.  I’m not sure how on point this is, but thought it was a fun exercise and worth posting…

“Dexter Morgan is a forensic analyst specializing in blood spatter [analysis] who [also] happens to be a…serial killer devoted strictly to the murder of other killers…Born in 1971, as a child Dexter witnessed the violent murder of his mother Laura Moser and…remained in the shipping container for days, surrounded by the carnage…[as a result a] ‘Dark Passenger,’or psychopathic need to kill [existed inside]…This desire was…channeled by his…adoptive father, Harry Morgan…Dexter eventually incorporated ‘Harry’s Code’ into his life.” (Heueristic, n.d.).

In light of this complex biography, utilizing Dexter Morgan as the focus for this paper presents a unique challenge. As stated earlier, the purpose of this assignment is to apply key concepts discussed in this weeks readings on assessment, diagnosis, and treatment planning. Important ethical ramifications exist surrounding the notion of providing therapy to a prolific serial killer.   It will be the assumption throughout this hypothetical exercise that mental health services will be provided to Dexter Morgan, as an inmate in a correctional facility.   Accepting responsibility for his actions is not only ethically necessary, but essential for well-being and improved mental health. It would be impossible to consider this situation otherwise.

Assessment & Diagnosis

Assessment in the context of counseling practice can be thought of as involving data gathering with the underlying goal of better understanding treatment needs. (Prout & Wadkins, 2014)  Prout & Wadkins (2014) discuss testing, behavioral assessment, mental status exams, and collateral data as useful for case conceptualization in this respect. Whereas these assessments are useful in better understanding client symptoms, a DSM-5 diagnosis is essential for purposes of diagnostic classification (Prout & Wadkins, 2014, p187).   With this key differentiation in mind, assessment and diagnosis are discussed separately below.

Mental Health Assessment

            In bringing up Dexter Morgan in a conversation with any mental health worker this week, the concept of psychopathy often arose. Discussed in greater depth later, what follows is a discussion of insights from Dexter Morgan from within a mental health assessment framework.

Mental Status Exam. “A mental status exam is an interview screening evaluation of the most important areas of a patient’s emotional and cognitive functioning.” (Thomas & Hersen, 2007, p49). (((While by no means thorough what follows are just a few quick insights of this character from within the parameters of a mental status exam))))
  1. General Appearance & Behavior – The client is well-groomed preferring business casual clothing and is cooperative and focused throughout the exam. Displaying direct eye contact throughout the interview, he is very articulate with speech normal in rate and volume.
  2. Orientation & Concentration – Fully-oriented to time, place, and person, this client is able to successfully complete tests of concentration and memory.   It must also be noted that he provides a very insightful personal history, indicative of years of professional training.   It is felt this has also aided him in the concealment of his troubling symptomatology.
  3. Mood & Affect – The client’s affect at first meeting can be best described as a contrived attempt at friendly engagement. With his affect progressing to a bland demeanor later in the session he makes a point to mention his inability to understand or experience emotion.   Most notable throughout the interview, is a heightened excitement observed when discussing observations from his crime scene investigations: “No blood, no sticky, hot messy, awful blood; no blood at all. Why hadn’t I thought of that? No blood what a beautiful idea.” (Dexter, 2006) It is felt this high degree of incongruence may be indicative (in part) of unresolved trauma concealed by dissociative defense mechanisms.
  4. Thought Process & Content – Thought processes are linear and logically goal-oriented. Until the client’s recent incarceration, thought content was focused strictly around a few key endeavors that consumed the majority of his time including: the investigation crime, the concealment of crime, as well as planning future crimes. The client reports the majority of his time is currently spent reflecting upon such experiences and finding activities to occupy his time. Continuing to experience homicidal ideations he admits to an inability to control these impulses if he weren’t for the fact he was in prison.
  5. Cognition: Judgment & Insight – “This individual, like his [heroes is] a product of a subculture of violence in which socially shared constructions led to a climate permissive of…violent acts….” (Winter, 2007, p295). Living by an ethical standard described as the “Code of Harry” (Dexter, 2006), this individual’s judgment and insight are limited by a moral superiority and grandiose delusions (Martin, 2001, p1; Winter, et al, 2007).   This “Code of Harry” (Dexter, 2006), acts to limit his judgment to the exacting of revenge in the name of a defined code of justice.

Functional Behavioral Assessment.

Prout & Wadkins, (2014) state that a functional behavioral assessment is useful in understanding the nature of a behavior. This method would be useful to better understand the precipitating factors and motivational consequences of his crimes. (Prout & Wadkins, 2014, p181).  While obviously not very helpful in preventing these crimes it would prove beneficial, not only for the client, but research purposes as well.   Having said this, insights from what is known can be useful in guiding this process.

One such insight includes a history of suppressed trauma that contributed to his current state of mental health as an experiential precipitating factor. While this factor would take some time to explore due to its largely suppressed nature of Harry’s code might be a great place to start.   Described, as a “coping mechanism” for urges to kill, this ethical code existed as a standard around which this patient constructed his life.

DSM-5 Diagnosis.

The first that comes to mind when describing Dexter Morgan is the term psychopath.    “Psychopathy is commonly viewed as a personality disorder defined by a cluster of interpersonal, affective, lifestyle and antisocial traits and behaviors, grandiosity, egocentricity, shallow emotions, lack of empathy or remorse, irresponsibility, impulsivity and a tendency to violate social norms.” (Hare, & Neumann, 2009, p791). While not included in the DSM-5 Manual, an official diagnosis for this fictional character would include antisocial personality disorder with psychotic factors and possibly post-traumatic stress disorder with dissociative features.

Antisocial Personality Disorder with Psychotic Features.

“The essential feature of antisocial personality disorder is a pervasive pattern of disregard for and violation of, the rights of others that begins in childhood…also…referred to as psychopathy or sociopathy.” (American Psychiatric Association, 2013, p661). Alongside this underlying personality disorder, is belief in his own moral superiority, described in the DSM-5 Manual as a grandiose delusion (American Psychiatric Association, 2013, p91).

Post-Traumatic Stress Disorder.

In a scene, after which Dexter realizes that witnessing his mother’s death is correlated somehow with the dark passenger, he states following: “…and its like the mask is slipping…and things…people…who never mattered before are suddenly starting to matter. It scares the hell out of me.” (An Inconvenient Lie, 2007). This revelation helps to contextualizes observations from the client’s life in “present time” showing an absence of emotion. Dexter is observed throughout the series displaying many diagnostic criteria relevant for this diagnosis (i.e. exposure to a traumatic event and the presence of intrusive memories).  With this in mind, a diagnosis of post-traumatic stress disorder with dissociative features should also be considered.

Treatment Goals

What follows is just a brief suggestion of potential problems to address, based on the previous discussion.   A discussion then follows of potential treatment goals for possible consideration, pending review with the client. It is by no means comprehensive.

Creating a Problem List.

  1. Problem 1: Unresolved Trauma.
    1. As evidenced by: Flashbacks of childhood trauma.
    2. As evidenced by: The revelation of a previously unknown life history and new understanding of his personal hero, Harry Morgan.
    3. As evidenced by: A personal realization that the “dark passenger” he describes within him as a need to kill, exists in conjunction with this traumatic history.
  2. Problem 2: Persistent Alexithymia & Loss of Meaning
    1. As evidenced by: Frequent reports of an inability to both understand and experience emotion.
    2. As evidenced by: Frequent reports of needing to “act normal” as a person who has and understands feeling.
    3. As evidenced by: Recent incarceration and loss of employment.
  3. Problem 3: Poor Judgment & Insight
    1. As evidenced by: “The Code of Harry” (Dexter, 2006), as the sole measure of his judgment when engaging in criminal activity.
    2. As evidenced by Ability to eliminate from thought processes, anything that doesn’t coincide with “Code of Harry” (Dexter, 2006).
    3. As evidenced by: Displays of perceived moral superiority, and failure to consider his actions as the same sort of criminal behavior he punishes others for.

Developing Treatment Goals.

Problem 1: Unresolved Trauma.  The initial treatment goal to begin processing unresolved trauma is simply to share insights from flashbacks and missing memories as they are recovered.
  1. Objective One: Client will develop and maintain open dialogue with therapist.
    1. Intervention One: Client agrees to share any and all thoughts and feelings surrounding insights from uncovered memories as they arise.
    2. Intervention Two: Client will meet with therapist as per agreed upon schedule, and give advance notice if unable to attend.
  2. Objective Two: Process unresolved hurt and anxieties underlying trauma.
    1. Intervention One: Understanding and awareness of strategies to distance self from emotional trauma.
    2. Intervention Two: Discuss possibility of emotional exposure therapy & EMDR Therapies.
Problem 2: Persistent Alexithymia & Loss of Meaning. Due to recent incarceration, it will be important to find new activities and endeavors to discover a new meaning in life.
  1. Objective One: Consider participating in research to further understand psychopathology of serial killers.
    1. Intervention: Arrange time for researchers to review case file and meet with Dexter.
    2. Intervention: Utilize forensic background to share and contextualize details of personal history.
  2. Objective Two: Develop an awareness of dissociative defense mechanisms in relation to inability to experience emotion.
    1. Intervention: Client will work with therapist to complete functional behavioral assessment to better understand motivations and predisposing factors underlying criminal behavior.
    2. Client will report and discuss experiences of dissociation with therapist when they occur.
Problem 3: Poor Judgment & Insight  Repairing this client’s poor judgment and insight is a goal that may not be fully realized. Nonetheless, a reasonable first step exists in working through facts and underlying thought processes underlying faulty conclusions associated with grandiose delusions of moral superiority.
  1. Objective: Discuss originating factors underlying perception of moral superiority.
    • Intervention: Client will discuss the origins of the “Code of Harry”.
    • Intervention: Client will examine these origins and acknowledge any shortcomings as well as personal failings regarding lack of insight.
  2. Objective: Examine thought processes underlying grandiose delusions.
    1. Intervention: Client will discuss personal perceptions of criminal activity as an act of retribution.
    2. Intervention: Client will work with therapist to acknowledge faulty self-perception as a morally superior person.

Wellness-Based Considerations.

Prout & Wadkins (2014) discuss a Wheel of Wellness as yet another consideration in the development of a treatment plan. Based on Adler’s holistic perspective, the indivisible self is a central concept in the wheel of wellness, (Prout & Wadkins, 2014).   This multidimensional concept includes five components: a social self, an essential self, a physical self, a creative self, and a coping self (Prout & Wadkins, 2014). In light of this client’s incarceration several difficulties exist in utilizing this model.   In addition to the limitations in interventions available due to client incarceration, there exists an attitude predominant of individuals such as Dexter. In fact, “ psychologists in the criminal justice system [are often thought of] as ‘little more than high priced janitors hired to sweep the problems of the system under the rug.’” (Hilkey, 1988, p676) With this limitation in mind, a useful alternative is proposed in literature for such inmates utilizing Mazlow’s Hierarchy of needs (Hilkey, 1988). What follows is a listing of considerations based on this model:

Physiological & Safety Needs: A key consideration for incarcerated individuals includes basic physical needs and a sense of safety. While difficult to intervene in this hypothetical scenario, the therapist would need to monitor this. These basic aspects in Maslow’s need hierarchy seem to coincide with the physical and essential components of the self as discussed in the wheel of wellness (Prout & Wadkins, 2014; Hilkey, 1988).

Belonging & Self-Esteem Needs

These elements of Maslow’s need hierarchy coincide with the social self and the coping self from the wellness wheel discussed, (Hilkey, 1988; Prout & Wadkins, 2014). Providing a sense of belonging is naturally limited in this case, although creating a small community such as a self-help group could help. To improve self-esteem, ongoing participation in research with the client as subject could be helpful in providing a sense of purpose.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental  Disorders (5th ed.). Washington, DC: Author.
“An Inconvenient Lie” Dexter Morgan Showtime, California. October 14, 2007.
“Dexter” Dexter Morgan Showtime, California. October 1, 2006.
Hare, R.D., & Neumann, C.S., (2009) Psychopathy: Assessment and forensic implications. Canadian Journal of Psychiatry. 54(12) 191-802
Heueristic. (n.d.) IMBD Biography for Dexter Morgan. Retrieved from http://www.imdb.com/character/ch0026519/bio
Hilkey, J. H., PhD. (1988). A theoretical model for assessment of delivery of mental health services in the correctional facility. Psychiatric Annals, 18(12), 676-679. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/894251682?accountid=28125
Martens, W. H. J. (2014). The hidden suffering of the psychopath. Psychiatric Times, 31(10), 1.
Prout, T.A., & Wadkins, M.J. (2014). Essential Interviewing and Counseling Skills. New York: Springer Publishing Company.
Thomas, J.C. & Hersen, H. (2007) Handbook of Clinical Interviewing of Adults. Thousand Oaks, CA: Sage Publications.
Winter, D.A. (2007) Construing the Construction Processes of Serial Killers And Other Violent
Offenders: 2. The Limits of Credulity. Journal of Constructivist Psychology, 20(3), 247-275.
Winter d., Felxas, G., Dalton, R., (Jarque-Llamazares, L., Laso, El, Mallindine, C., & Patient, S.
(2007) Construing the Construction Process of Serial Killers and Other Violent Offenders: 1. The Analysis of Narratives. Journal of Constructivist Psychology, 20(1), 1-22

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DBT Skills – Emotional Regulation

This post is part of a series where I discuss Dialectical Behavioral Therapy Life Skills. 

What are emotions?

Emotions are mental states, experienced as physical sensations in response to our perceptions.  These perceptions are byproducts of the brain’s ongoing mental efforts to interpret sensory information. It is through this ongoing effort that a mind-body connection is created.   It then makes sense that “emotions are signals within our body that tell [us] what’s happening (McKay, et al, 2007, p. 130).”  In this respect emotions can be considered as byproducts of an individual’s interaction with the environment.  Appraisal theories, common in the social sciences, focus on how people understand and interpret their environment when examining the nature of feelings (Ellsworth, 1994).  In contrast, universal theories reflect a biological perspective, which focuses on emotions as hardwired byproducts of primitive brain function (Ellsworth, 1994).

How are emotions generated?

imageSince emotions are byproducts of our interactions with the environment, it is important to understand how these factors interact to generate our emotional experiences.   Since emotions are byproducts of our interactions with the world around us, several solutions are available to help us regulate our emotions. Emotional regulation is a vital coping skill that allows us to influence what we feel at a particular moment & how we express this feelings.  According to Dialectical Behavioral Therapy (DBT) four key factors play a role in the generation of emotions.

The Situation

imageAs the saying goes “life happens when you’re doing other things.”  This statement reminds us of life’s inherent unpredictability.  All well-laid plans must therefore do amenable to change since life inevitably throws us the occasional monkey wrench or two.  Dealing with these curveballs is disconcerting to say the least.   The generation of emotional reactions starts when we encounter a situation that doesn’t go as we may have predicted.  How can you describe the movie reel experience you’re reacting to right now?  What happened?  Who was there?  List the specific sequence of events.

Our Attention

imageWhile life can be unpredictable & uncertain, we aren’t helpless victims.  The manner in which we choose to take in life experiences profoundly influence the impact of life events.   There’s definitely more than a grain of truth to the idea that “its all in how you choose to take it”.   Oftentimes we’re so focused on the event itself, that we fail to consider how we’re choosing to take it in.  For example, my endless fretful worry about finding a new internship, has been highly anxiety-producing.   The problem often isn’t the situation itself, but how I’ve chosen to take it.

Our Appraisal

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As new and unexpected life situations present themselves, we immediately set about determining how we should respond to it.  Before we are able to react effectively to a situation, we must interpret it. What sort of emotional reaction is appropriate given what we know about the situation?   I discuss this subject in more detail in a post titled “Stolen Watermelons Taste Better,” where I discuss the subject of affective forecasting.

Our Reaction

When we act upon our appraisal to a situation, our reactions are guided by our perceptions and beliefs.  In this  respect, that our beliefs are able to influence our life experiences, and act as self-fulfilling prophecies. It is in this respect that we often “grow into” what we believe we are, and acquire what we believe is possible.

What is Emotional Regulation?

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It is by understanding how emotions are generated that we can begin regulating them.  In my old DBT Skills group, emotional regulation was defined as “the process by which we influence the emotions we have: when we have them, how we experience them, and our manner of expressing them.”  We can regulate emotions by selecting and modifying the situations we find ourselves in.  We can modify our emotional states by re-examine how we attend to and appraise these situations.  Finally, we can modify our emotional by modifying our reactions to situations….

Situational Selection

Sometimes we find ourselves in situations that are not of our own choosing.  However, it is possible to be mindful of what situations we gravitate toward and what situations we avoid.  Examining this requires us to look closely at the expectations guiding our situational selection process.  What belief systems are these expectations based on?  What personal insecurities & past experiences guide our decisions to avoid certain situations and avoid others?

Situational Modification

Modifying the situations we find ourselves is also a useful emotional regulation tool.  What options are available to us to change the situation?  Stepping back to examine our options and carefully considering them is also useful.  Do you need to step back from a difficult situation?  Or does addressing this difficult situation require you to make your options known?

Attentional Deployment

I have a bad habit of ruminating endlessly over aspects of a situation that have elicit strong emotions within me. When I do this, my desire is to control those aspects of a situation that elicit strong emotions.  I become hell bent to “fix the situation” or produce a remedy for the stress/anxiety/etc.  Oftentimes, this hurts more than it helps.   Immersing myself into what needs to be done in the moment helps, distract my mind from those aspects of a situation that cause stress.

Cognitive Change

Examining your appraisal of a situation is useful as a means of altering its impact on you.  What is the significance of the situation?  Stepping back and examining how you construe life events, can often help us realize it isn’t what we see but “how we see it” that causes problems.

Response Modulation

Expressive suppression is useful in decreasing our chances of reacting harshly to situations in a manner that we might regret latter.  Managing our overall physiological responses to situations is also useful through mindfulness and relaxation techniques.  Finally, discussing the situation with someone you trust in order to attain another perspective of matters , does help.

Click here for a worksheet to understand & describe your emotions

3 Emotional Regulation Exercises

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In my own DBT Skills Group – many years ago – I was taught three emotional regulation exercises.  The first skill involves simply describing and observing emotions.  The second involves improving our overall level of self-care in order to reduce our vulnerability to emotions.  Finally, increasing positive emotional experiences can also help improve our overall mental health.  I review these three below.

Describing & Observing Emotions

imageThere’s a big difference between thinking with your emotions and thinking through them.  When you thinking with your emotions, they exist as an all-powerful dictator within your brain.  Everything you encounter in life, becomes a definitive subject to your emotional state.  As you feel it, so it shall become for you in your lived experience.  What follows is an example that applies key steps in observing our emotions:

Name the Emotion – I am very anxious.
 Describe the Event – The Internship Interview.
What are your Thoughts & Assumptions – I’ve had four interviews so far and none have gone very well.  I’m told “we’re considering other options”, etc.  I worry if anyone will ever see what I have to offer.  Will I be able to find an internship opportunity?  How long will this take?
What are your Bodily Sensations –  Sweat drips down my armpits & my hands shake uncontrollably as my hard starts pounding outside my chest.
What is your body language & facial expression – With a stupid blank smile plastered across my face and cross my arms, in an attempt to hide my shaking hands.
What do you feel like doing & saying?  Part of me wants to run from the room screaming.  Within me is a deep well of frustration & anxiety.  I want to just stand up to this person and say “give me the dang job damnit”…
What do you actually do?  I tell myself to calm down.  I focus on the present moment & set aside these irrational concerns.  Instead I immerse myself in the conversation.  I listen about the internship opportunity available & his career experience.
Aftereffects of the Event?  I get the job.  It goes well.  I’m beyond elated.

Reduce Vulnerability

The second emotional regulation exercise is actually better characterized as an overall lifestyle change. Improving our level of self care is critical in reducing our vulnerability to emotions.  In class, we learned the acronym “PLEASE MASTER” to remember the following key tips for improving our overall well-being

*P*L*E*A*S*E* *M*A*S*T*E*R*
treat PhysicaL illness
balanced Eating
Avoid mood-altering drugs
plenty of Sleep
get Exercise
build MASTERY by doing one thing at a time to feel in control.

Increasing Positive Experiences

What activities can you include in your daily routine that improve your overall emotional state? I love blogging, hanging out with my family, and anything that allows me to utilize my creativity.  Additionally, I don’t live to work, I work to live.  As a working mother who is completing a graduate degree, scheduling regular “playtime” for mommy is essential.  All work and no play is a shitty way to live.

Click here for a worksheet to help you observe & describe you emotions.
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References

Ellsworth P.C. (1994). Sense, culture and sensibility. In S.E. Kitayama, & H.R.E. Markus, (1994). Emotion and culture: Empirical studies of mutual influence. (p.p. 23-50). American Psychological Association.
Mckay, M., Wood, J., & Brantley, J. (2007). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation & distress tolerance. New Harbinger: Oakland, CA.

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