Pyschody Edited1

COURTSHIP and MARRIAGE Family, basic social group united through bonds of kinship or marriage, present in all societies. Mr. Victoriano Poria Jr. is a fisherman in Baon San Isidro, Davao Oriental and Mrs. Cepriana Lanida is a teacher. They first met in a fish market when Ma’am Cepriana bought fishes from Sir Victoriano. They began to converse with each other and then later became friends. Friendship wasn’t enough for this two and so Sir Victoriano courted Ma’am. The parents of Sir Victoriano approved of Ma’am Cepriana because they find her very educated. Ma’am Cepriana’s parents approved with Sir Victoriano because they find him very hardworking and know how to fish and farm. After four months of courting they became a couple. Since, Sir Victoriano and Ma’am Ceprianna’s parents approved of each other it can be concluded that the family of the couple has supported their relationship that can yield a good outcome for the couple and their future children. Acceptance is a great deal for couple starting a family since this can affect their life as a couple and family. Family conflict can affect a child or an uninvolved party in many aspects. Ma’am Cepriana and Sir Victoriano Sr. got married two years after. They were married in a Catholic Church (San Isidro Parish) on June 25, 1953 . Ma’am Cepriana was 21 years old and Sir Victoriano Sr. was 23 years old at that time. During the wedding ceremony their families were present to support this joyous event. Ideally, the family provides its members with protection, companionship, security, and socialization. Contemporary society generally views family as a haven from the world, supplying absolute fulfillment. The family is considered to encourage "intimacy, love and trust where individuals may escape the competition of dehumanizing forces in modern society from the rough and tumble industrialized world, and as a place where warmth, tenderness and understanding can be expected from a loving mother, and protection from the world can be expected from the father.

PRENATAL Prenatal care, essential for ensuring the overall health of newborns and their mothers, is a major strategy to help reduce the number of low birth weight infants. According Ma’am Nelda their mother does not have regular pre- natal check ups when he was pregnant with Jaime. Pre natal care is important because lack of it is associated with the birth of pre term infants and various complications for women. Since, this is her sixth pregnancy and considering the clinic is far form their barrio she did not consider going for pre natal check up as that important. Ma’am Cepriana never experienced any sickness during pregnancy such as rubeola, rubella and varicella but did experience cough and colds but attended to this with the use of proper food, adequate rest and drinking calamansi juice. She has good nutrition during her pregnancy. The food that she takes in consists mostly of fruits and vegetables. Both the nutritional state that a woman brings into pregnancy and her nutrition during pregnancy has a direct bearing on her health and on fetal growth and development.

BIRTH Although labor usually proceeds without any deviations for the normal, many potential complications can occur. Jaime was delivered just in their home via “NSVD”, a week earlier than expected which lasted for 8 hours. A “hilot” attended the procedure. According to Ma’am Nelda the delivery was a success and did not encounter any problems during the delivery process. In addition, in their place the hospital is very far and the use of “hilot” in delivering a child is very prevalent in their barrio. Any complications during labor can have an effect to the fetus even though, as verbalized by Ma’am Nelda that during Jaime’s delivery there were no complications the fact that he was home delivered can have many unpredictable complications since, sufficient materials needed for a safe child delivery is not available and a health center is not accessible. All of Mrs. Poria’s children are fully immunized.

INFANCY (0- 1 yr) Trust vs. Mistrust Oral Stage The first stage of Erikson’s theory of psychosocial development occurs between birth and one year of age and is the most fundamental stage in life. Because an infant is utterly dependent, the development of trust is based on the dependability and quality of the child’s caregivers. According to Ma’am Nelda their mother serves as their primary caregiver. She verbalized that “ang mama jud namo ang nagalaga sa amoa, mama jud siya sa amoa, hands on jud siya magalaga sa amoa”. Mrs. Poria attended to the basic needs of Jaime and all of her children. Even if Ma’am Cepriana is the primary caregiver of the Jaime it should be noted that Jaime is the sixth child of the family, the age gap of each child is two years old and Ma’am Cepriana doesn’t have anyone to help her in doing household chores having said this, a child, may be deprived of enough attention that is necessary in the child’s growth and development. In addition, Ma’am Cepriana does all the household chores and feed all her six children including Jaime, an infant at this stage. Infants need the necessary attention and care since, Ma’am Cepriana is very busy attending to household chores, her other children and her husband then she might have not given full care and attention the Sir Jaime needs. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. The balance of trust with mistrust depends largely on the quality of maternal relationship. Oral Stage this occurs from birth to about 1 year, and the libido is focused on the mouth. According to this theory, infant suck, for enjoyment, relief of tension and for nourishment. As a child, Jaime likes to put things in his mouth as verbalized by Ma’am Nelda she stated that “magsige siya butang ug masking unsa sa iyang baba labi na ang iyang kamot kanang makitan nimo sa mga bata mahilig magthumb suck”. There mother would attend to this strictly because their mother find it very messy and has a fear that Jaime might develop and overbite. She started weaning Jaime when he was a year to a year and a half years old. Sucking is a surprisingly strong need. Being

fixated at this stage may mean an excessive use of oral stimulation, such as cigarettes, drinking or eating. At first, Jaime was breast then he had been bottle-fed with the milk Bona and changed to Nestrogen after 2 months, sometimes positioned on bed and there are only time that he is cuddled by her mother because his mother is very tired from doing all the household chores. Cuddling is very important because this makes the child feel secured and loved by his/ her care givers. Jaime, in his 2nd to 3rd month had been suspected to have baby meningitis and had “tipdas” on his 8-9th month, which then was cured after 2 weeks. Having to have thought to have meningitis may have an effect on both child and family because their roles are altered and much attention should be given to Jaime. At this time his older brother and older sister (Victoriano and Nelda) may have taken the role of their mother temporarily.

TODDLERHOOD (1- 3 yrs) Autonomy vs. Shame and Doubt Anal Stage Erikson defines the development of task of the toddler age as learning autonomy versus shame and doubt. The second stage of Erikson's theory of psychosocial development takes place during early childhood and is focused on children developing a greater sense of personal control. Like Freud, Erikson believed that toilet training was a vital part of this process. However, Erikson's reasoning was quite different then that of Freud's. Erikson believe that learning to control one’s body functions leads to a feeling of control and a sense of independence. Our client was toilet trained by his mother personally as explained by Ma’am Nelda. Sir Jaime was toilet trained before he started to walked. His mother’s method was placing him in urinal or place Jaime on her lap as she coaches Jaime to defecate by saying “uu..uu”. Ma’am Nelda said that their mother is not that strict in toilet training, she verbalized “dili man siya strickta…dili man pud siya mamalo…mangasaba lang siya sa ako mga manghod kay hugawan man siya”. Jaime developed bowel control before he reached the age of two. A few months after, bladder control followed. Children who successfully complete this stage feel secure and confident, while those who do not are left with a sense of inadequacy and self-doubt.

Preschooler (3-6 yrs) Initiative vs. Guilt Phallic Stage Erikson defines the developmental task of the preschool period as learning initiative versus guilt. Learning initiative is learning how to do things. Children can initiate motor activities of various sorts on their own and no longer respond to or imitate the actions of other children or of their parents. During the preschool years, children begin to assert their power and control over the world through directing play and other social interaction. Children who are successful at this stage feel capable and able to lead others. Those who fail to acquire these skills are left with a sense of guilt, self-doubt and lack of initiative. Whether children leave this stage with a sense of initiative outweighing sense of guilt depends largely on how parents respond to self-initiated activities. The role of parental figure is very important for the child to be guided in his self-initiated activities. The combination of comfort and discipline from parental care plays an integral role in achieving initiative during this stage. Parent’s discipline towards the child’s initiated acts will help him realize what is right from wrong and parental comfort and reinforcement helps the client acquire learning from his environment. After the death of our client’s mother, a revolutionary change had occurred. As he began to initiate things to do as a child, mother figure was not present during that time to guide him as he grows. Moreover, not only did Sir Jaime lost his mother but he also lost the care and attention from his father because Sir Victoriano Sr. after the death of his wife became busy in managing their farm. As an effect, the child’s behaviors and actions were not guided. He was not presented to the reality of right from wrong. As he began to assert his self to do things by his own, no one would praise and reinforce the good deeds that he has done, he felt alone because he lacks attention and that had created the shadows of guilt in the heart of our client when he was in this

stage making him feel guilty and regret the day he was born. Our client generally felt guilty whether his actions are right or wrong because no one would reinforce or discipline his actions. Erikson believes the preschooler is entering a wider range of social interaction and is developing a more purposeful behavior in order to deal with challenging responsibilities. This is a time where children may begin to develop feelings of guilt and begin to feel anxious. Furthermore, it is common that mothers are the primary and the best teachers to their children, because of her early death, no one would fully guide our client’s growth and development and assist him in socializing with others except her and that made our client feel guilty as he would try to mingle with other children of his same age who has both mother and father. A major effect of this is very apparent as the child joined to group of friends who are of bad influence because no one would guide and watch over him. At the very moment, it can really be observed that the client is feeling guilt deep inside him. The root of this guilt is expressed in his restlessness and anxiousness. He is guilty of being hospitalized and being placed away from his family because of abusing substances, he verbalized “ gago man gud ko ba mao na naa ko diri, unta wala na lang na ko ni gibuhat. Hahahaha (client laughs)”. During the preschool period, children’s pleasure zone appears to shift from the anal to the genital area. Freud called this period the phallic stage. Masturbation is common during this phase. At the age of 5 or 6, near the end of the phallic stage, boys experience the Oedipus complex whilst girls experience the Electra conflict, which is a process through which they learn to identify with the same gender parent by acting as much like that parent as possible. In Oedipus complex a male child begins to be attracted to her mother and in order to win her attention, the child identifies with his father. Because of the lost mother figure, Sir Jaime did not feel the balance of care that should be given by both father and mother. Because of the early death of the client’s mother, he basically did not undergo the Oedipal complex and the effect of this could be seen in the client’s relationship with the opposite sex as he reached his adulthood stage. With the absence of mother figure, our client’s perception of a woman is different because he was not able to receive the full caress of her mother and that is why he was not able to have a lasting relationship with the opposite sex. At the present, it is quite evident that the client show no interest in having relationship with his opposite sex and when we asked him why he answered “wala koy panahon anang mga babae, mao lang man gihapon wala mana silay gamit”. Base from this statement, it clearly depicts the effect of the early loss of the client’s mother to his perception on women.

School Age (6-12 yrs) Industry vs. Inferiority Latency Stage This stage covers the early school years from approximately age 5 to 11.Through social interactions, children begin to develop a sense of pride in their accomplishments and abilities. Erikson viewed the developmental task of school – age period as developing industry versus inferiority, or accomplishment rather than inferiority. During the preschool period, children learned initiative – how to do something. During school age, children learn how to do things well. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills. Those who receive little or no encouragement from parents, teachers, or peers will doubt their ability to be successful. The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence. In this stage the child’s libido is directed in his activities in school and activities that require social interaction and development of one’s skills. In the case of our client, the encouragement and appreciation from the parents were not felt because of the death oh her mother and the less attention given by his father. Because of his mother’s death, our client’s father became busy with his farm trying to forget the loss of his wife and as an effect, the performance of our client in the school was not attended. The client’s thirst for attention and appreciation from his Father in his school activities was not quenched and this had led to the child’s declining grades and performance and made the child to become inferior and feel useless. In addition, our client usually feels being inferior being compared to his brothers and sisters who had done well in school. He shared to us that he doesn’t like the feeling of being compared which his father usually does to him when he was in elementary. Because of being inferior he resorted to join group of people who indulges in illicit drugs at a

very young age as a means of an ineffective coping in order to suffice his hunger for love and appreciation. It is in that group that he felt being “high”, being superior as they bully other pupils in school which he did not feel in his family. For us, the child’s failing grades were not caused by the influence of his barkadas but it is his lack of attention and appreciation from his father that drive him to seek the approval of peers and friends of bad influence. The attention that he cannot get from his family is filled by the attention of being a “siga” and “astig” in their group. The love and care that he cannot get from his family was compensated by the feeling of being one in a nonsense brotherhood of addicts. At present, if you would try to observe Sir Jaime, you can really notice that deep inside him is a feeling of inferiority. With a short hours of interaction, you may say that he is not a type of person who has feelings of inferiority because he is very participative, active and full of enthusiasm but all of these were just only his façade and they are just superficial. His actions and behaviors do hide his inferiority by using the ego defense mechanism of compensation. He raises his voice and shouts, join the activities actively, and act as if he knows everything just to conceal his inferiority. According to Freud, children who lack the reinforcements and appreciation from their parents would tend to express their inferiority through insecurity. Our client would only like to be just a follower than leading the group and it is quite evident that he is envious with other residents in the hospital; this was observed when he insisted to sing more 5 songs because he did not want a fellow resident to sing more than what he sang.

ADOLESCENCE (12- 18 yrs) Identity vs. Role Confusion Genital Stage Erikson believes that the new interpersonal dimension that emerges during adolescence is a sense of identity versus role confusion. During adolescence, children are exploring their independence and developing a sense of self. Those who receive proper encouragement and reinforcement through personal exploration will emerge from this stage with a strong sense of self and a feeling of independence and control. Those who remain unsure of their beliefs and desires will insecure and confused about themselves and the future. GENITAL Stage Begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the

opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that. At this stage without a mother to guide him properly as said by Ma’am Nelda, Jaime was a boy who was influenced by his friends. He would always go out and would drink, smoke, gamble and even take marijuana. Ma’am Nelda also said that he gets into a lot of trouble such as fighting with other people. Ma’am Nelda verbalized “pag naay away o samok siya jud nagpasimuno ana”. His interpersonal relationship with other people was not good. These were the effect of the lack of attention and care that the client experienced from his family. Because of lack of guidance and attention, our client doesn’t know what the right role to embody as he relates with his family and the people around him. He thinks that he can get the attention that he needs every time he is scolded and reprimanded by his father and his brother and sister. According to Erikson, a strong influence from the parents will guide the child to the roles that he should perform. Because our client is a male, he is expected to help his father in the farm but according to Ma’am Nelda, our client’s father was frustrated because he turned out to be an addict who always stays with his barkada’s place. Our client was expected with a lot of roles, but he was not able to accomplish in identifying to where he really belongs because of the lack of love and attention from his father, the only parent left that should be assisting his son in the endeavors that he may take. Our client’s father was not able to assist his son in the right path because he had made himself too much busy in order to cope up with his wife’s death and because of this; our client became astray and was not able to fulfill his role as a son, as a brother, as a student, and as a responsible citizen. Because of his frustrations in fulfilling his roles, he resorted to engage in taking drugs and in joining friends of bad influence in order to fill the feelings of emptiness because it is where in his friends that he could feel his role of being a brother in their brotherhood that is only present when there are drugs to bond them and it is where in his barkadas that he feels the sense of belongingness; no expectations just a happy-go-lucky life - very perfect to make him forget the painful things that he had experienced in his life. At present, it is very evident that the client hungers for belongingness and acceptance. It is really evident that the client until now seeks the feeling of acceptance through identifying himself and conforming his roles with fellow residents in order to win their acceptance. You can really observe that the client really tries to mingle and join the group of residents in the hospital. He joins

participative in order to project that he wants to identify with his fellows. He acts as if he knows everything and that he is good in doing things to impress and gain other’s approval. These behaviors are really manifestations that the client wants approval, love, belongingness and acceptance through identifying himself with his fellows.

EARLY ADULTHOOD (18- 30 years) Intimacy vs. Isolation This stage covers the period of early adulthood when people are exploring personal relationships. Intimacy is the ability to relate well with people not only with members of the opposite sex but also with one’s own sex to form a long- lasting friendship. Erikson believed it was vital that people develop close, committed relationships with other people. A balance between intimacy and isolation makes love possible as we must know how to be alone in order to learn to truly love. Having a balanced stage 6 will help tremendously later in the coming stages when unwelcome or unexpected isolation surfaces, for example, the death of a spouse or a loved one. Those who are successful at this step will develop relationships that are committed and secure. Remember that each step builds on skills learned in previous steps. Erikson believed that a strong sense of personal identity was important to developing intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. Our ego should also be prepared for rejection, the challenge of breakups, and isolation, being alone. Erikson believes we are sometimes isolated due to the above. We are afraid of rejection; being turned down, our partners breaking up with us. We are familiar with pain and to some of us rejection is painful, our egos cannot bear the pain. A loss of mother can affect a person’s perception of what a woman is their function in society and the role they play in a child’s life. Although, sir Jaime can relate to both opposite and same sex as his he, still has not established a family

of his own or even find a woman that he would want to marry. According to Ma’am Nelda, Sir Jaime, had his girlfriend namely “inday” but their relationship did not last long. In addition, Ma’am Nelda also stated that his brother Jaime, did not share anything about his relationship with women including that of Inday’s. If intimacy is not achieved at this time the individual will feel isolated, just like Mr. Jaime’s case. Fear of sharing oneself with another and fear of not achieving intimacy are common fears in this stage. According to Dr. Stanley Greenspan, a clinical professor of Psychiatry at George Washington University Medical School, an individual may battle with intimacy issues their entire lives. According to Victoriano, when he gets upset or have problems most of the time he goes to him and pour out all her grief and sorrow. Then, he just listens and tries to give pieces of advice. Sometimes, he just keeps it to himself though, like what happened in Japan. His family is trying to help him in times of Jaime’s crises; they started from encouraging him to voice out or express his feelings and problems. As they said, Jaime is not used to share problems to her family. There are instances that he preferred sharing feelings with Victoriano, since he thinks that he would just receive sermons from his father if he has problems. In addition Mr. Jaime Poria may not be ready for commitments yet. He may have fears in handling relationships with the opposite sex. Jaime’s brothers and sisters all love him, Victoriano claimed, only that Jaime distances when they sincerely reach out, especially when it comes to expressing his feelings.

MIDDLE ADULTHOOD (mid 20’s – late 50’s) Generativity vs. Stagnation The developmental task of middle age is to establish a sense of generativity versus stagnation. People extend their concern from just themselves and their families to the community and the world. During adulthood, we continue to build our lives, focusing on our career and family. Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world. People with a sense of generativity are self-confident and better able to juggle their various lives. People without this sense become stagnated or self absorbed. Those who have devoted themselves to only one role are more likely to find themselves at the end of middle age with a narrow perspective and lack of ability to cope with change.

When Sir Jaime was still 34 years old he went to Japan and worked as a butcher. He also verbalized “malungkot man didto”. After three years he came back to the Philippines the reason was that their stay was illegal. When he came back to his hometown he worked in their land. According to Ma’am Nelda, when Sir Jaime returned from Japan there are lot of changes occurred. He became more inclined in helping his neighbors and other people than helping his own family and relatives. This had hurt the feelings of his relatives. The reason for his change of heart was unknown to his family and relatives. Even though, his family felt this way they, still love and took care of him. His older brother Victoriano and older sister Nelda are the ones who spend for his hospitalization and medications. Despite that Sir Jaime changed his way of dealing with his relatives he still maintain good contact and relationship with them. Ma’am Nelda also found out “nagshabu man daw to siya didto ingon sa iyang mga kauban sa amoa”. As Mr. Jaime Poria explore potential careers here and in Japan, and develop his talents, he also became intimate or close to his life's work. He felt connected to the world through his work and by giving of this aspect; he felt the rewards of feeling an important part of the world. He was so desolated upon the non reimbursement of his earnings in Japan that is why he was not able to invest in his own car, house, etc. He hid not felt a strong connection with those things he have worked hard to achieve since in the first place, there was no proper compensation for the efforts and sacrifices he put into the job. Tin stead of seeing independence from financial burden, he was so depressed to found out that because of what happened, he must work hard to open the door to opportunities and even harder to succeed. This can lead to a real sense of isolation as others move on in life, leaving some in menial jobs paying little more than minimum wage. One significant task in this stage also is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness. As one can trace, Mr. Jaime Poria has no kids to tend yet, so basically this aspect of transmission of culture and values is not yet applicable.

Precipitating Factors • Depression • Inability to cope up with external stimuli • Peer influence • Environmental factors • Death of Mother • Japan Experiences

Predisposing Factors • Age • Genetic • Race • Sex

FIRST ADMISION He was first admitted at Dr. Mabungga Rehabilitation center on March 2004 and stayed for a year. He was admitted due to behavioural changes.

SECOND ADMISSION Readmitted at Dr. Mabungga rehabilitation center last February 2005. He stayed for a month.

THIRD ADMISSION Admitted at Davao Mental Hospital on July 4, 2008 and stayed there for two weeks.

FOURTH FOURTH ADMISSION ADMISSION Readmitted at Dela Cerna Hopsital Readmitted at Dela Cerna Hopsital last last October October 4, 4, 2008. 2008. He He was was admitted admitted due due to to reoccurrence reoccurrence of of symptoms symptoms such such as as MNA, MNA, restlessness, restlessness, always always pacing pacing back back and and forth, forth, difficulty difficulty in in falling falling asleep, asleep, bathing bathing more more that that the the usual without any reason and increase in libido. usual without any reason and increase in libido. In In addition, addition, the the client client also also told told his his older older sister sister Nelda Nelda to to readmit readmit him him because because he he doesn’t doesn’t know know what what he he is is feeling feeling and if he will not be admitted he will be better and if he will not be admitted he will be better of of to to kill kill himself. himself.

• •

MEDICATIONS GIVEN Lithium Carbonate Laractyl

Experienced SIDE EFFECTS: restlessness, headache

dry

mouth,

When our client comply with his medications he can be productive and is able to relate well with is family and relatives. But, when he doesn’t take his medications for more than three consecutive days he begins to manifest behavioural changes and begin to have MNA, restlessness, always pacing back and forth, difficulty in falling asleep, bathing more that the usual without any reason and increase in libido. The family will readmit him again

If treated: Medical Management Adjunctive Management: • Art therapy • Occupational Therapy • Music Therapy • Remotivation therapy • Milieu therapy

GOOD PROGNOSIS

If not treated: Relapse of illness recurrence of the signs and symptoms of the disorder

POOR PROGNOSIS