landini iasa frankfurt iasa...andrea landini, m.d. iasa 2012 “attachment, assessment and...

21/09/12

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Therapeutic Responses to Patients’ Representations

of Danger

Andrea Landini, M.D.

IASA 2012 “Attachment, Assessment and Treatment: The DMM Approach”

A DMM / Information Processing perspective

s  When in trouble, we seek others for protection and comfort

s  Dispositional Representations (DRs) of danger guide protective action: s  Patients’ DRs s  Therapists’ DRs

Carol’s family

s  The family of a 15-year old girl asks for help

s  Carol “studies too much” s  Appointment with the family: only

father and son come, bringing their computer

Carol

s  "I won't remember this. I'll fail the test. I'll never remember all this. I'm going to fail. I'm scared. I won't make it! I'm sure I won't make it. I'll try to repeat it, but I'm sure I'll forget it."

Carol s  “Charles Dickens was an English writer and

social critic who is generally regarded as the greatest novelist of the Victorian period and the creator of some of the world's most memorable fictional characters. During his lifetime Dickens's works enjoyed unprecedented popularity and fame, and by the twentieth century his literary genius was fully recognized by critics and scholars. His novels and short stories continue to enjoy an enduring popularity among the general reading public.”

What is going wrong? Therapists’ DRs

s  Diagnosis: what is this? s  Description of the problem:

s Only behavioral -> therapeutic action often not clear

s Process -> sometimes action clearer s  If the process is not contextualized, therapeutic

action can be inefficient

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Carol

s  Descriptive diagnosis: anxiety disorder, obsessive-compulsive

s  Therapeutic actions: CBT, medication s  CBT refines diagnosis: pathological

processes = perfectionism, rumination, avoidance

Carol’s family responds

s  The parents refuse medication (father ambivalent, mother adamant)

s  Carol’s perfectionism and avoidance are sometimes punished, sometimes rewarded (unpredictably)

s  Changes in Carol are not predictably received by parents

s  CBT is stalled, therapist finds parents “uncollaborative”


s  Self-protective Strategies: how does the person function? s Developmentally attuned assessment

of attachment strategy s Information processing required by

the strategy s Symptomatic behavior interpreted

strategically

Carol’s TAAI

s  Alternation of: s  Compulsive caregiving and compliance (A3-4)

s  Coercive feigned helplessness and obsession for rescue (C4-6)

s  Some attempts to reflect

Carol’s symptoms, strategically

s  Perfectionism: prevents’ parents interference and absence (A3-4)

s  Displayed high arousal (vulnerability, avoidance): focuses parents on Carol in preference to other issues (C4-6)

s  Carol’s focus: the relationship with the parents

s  Limitations to her development (peers)

Why are Carol’s parents such bad guys??

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s  Functional formulation: how does this family function? s Developmentally attuned assessments

of all family members s Parents Interview s Strategies’ interplay in the family s Different DRs for same sensory

stimulation: different protective actions

Carol’s family strategies

s  Mother’s AAI: s  Unresolved trauma for illness of sister

(depriving her of parents’ attention) s  Anticipated trauma about her children’s

similar illnesses s  Unresolved loss of idealized grandmother s  All these confused and over-associated s  Strategies: A1(3)/C3-4(5)


s  Father’s AAI: s  Compulsive self-reliance (A6) s  Unresolved, dismissed trauma about own

illness as a child (scoliosis) s  Cares for wife and daughter without even

hope for reciprocity s  His own omitted desire for comfort can

motivate protective action (for self or others?)


s  Brother’s TAAI: s  Coercively punitive (C5) s  Functions like the invulnerable child in the

family (inconsistently rewarded by mother) s  His vulnerability leaks through

s Articulation speech disorder s denied worry about his social competence

Carol’s family as a system

s  Parents primed by Utr to respond to children’s signals of: s  Pathologic anomaly (M) s  Uncomforted distress (F)

s  Mother signals risks affectively s  Father reassures cognitively s  Carol keeps them together


s  Mother’s protection: s  From invisible dangers s  Requires incompatible responses:

s  inhibition of exploration (to escape risks of danger)

s Performance and social exploration (to prove normality)

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s  Father’s comfort: s  Reluctant (no reciprocity possible for him) s  Impossible with wife (too involved in family

of origin and children) s  Eager (stroking Carol’s back and studying

with her gives him some comfort)


s  Brother’s invulnerability: s  Ties him to mother s  Distances him from father and Carol s  Pushes him outside the family s  Prevents him going to parents for

protection and comfort

How can such different and incompatible DRs function

protectively?

BUT:

Representing threat in many different ways is useful for adaptation

Multiple DRs about threat

s  Surviving in the “semiotic niche” (Hoffmeyer)

s  Multiple representations = multiple protective actions

s  The mind: “A team of rivals” (Eagleton) s  “Rivals” DRs compete for shared goal s  “Team”-work enhanced by reflective

integration

Representations of danger: type of information

s  Somatic s  Cognitive

s  Events connected to somatic threats by expected temporal sequences

s  Affective s  Events connected to somatic threats by

spatial context

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Carol

s  COGNITIVELY: s  Knows that mother punishes predictably

her refusal to be adequate/normal in terms of performance

s  AFFECTIVELY: s  Knows that mother rewards unpredictably

her avoiding exploration (=potential injury/illness)

s  Knows that father rewards unpredictably her distress displays

Carol

s  INTEGRATION: s Mature enough to be almost able to ask

herself why her family works this way s  Considers too dangerous to take time to

think about it

s  SOMATICALLY: s  hits and scratches herself to highlight

painful representations of danger

Representations of danger: “memory systems”

Memory systems: The pathways and extent of neural

processing of somatic, cognitive, affective information

Representations of danger: “memory systems”

s  Implicit memory systems

s  Somatic, Procedural, Imaged s  Explicit memory systems

s  “Body-talk”, Semantic, Connotative s  Integrative memory systems

s  Episodic, Reflective

Carol’s parents

s  Act protectively out of their traumatized strategies on implicit DRs

s  Use explicit semantically acceptable and connotatively persuasive DRs when talking

s  The discrepancy between their implicit and explicit DRs makes them appear incoherent

Carol’s parents

s  Asking them why they do what they do: s  Before examining basic DRs: “empty”

answers s  After examining basic DRs and in safe/

comfortable circumstances: understanding

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Memory systems in strategic action

s  B: s  no simplification or clarification of DRs by

omission/distortion

s  A: s  omission of affective information (with

distortion of cognitive information)

s  C: s  omission of cognitive information (with

distortion of affective information)

Carol

s  Has all kinds of information available, but each type has omissions, distortions, falsifications

s  Safety for one member of the family is danger for another, so there is never time to stop acting protectively and reflect

Carol

s  Her parents’ perspectives are complex, trauma-influenced and not articulated

s  Carol distorts her contribution to family events: she thinks ordering objects (=OCD) is safe

s  This doesn’t address any specific danger s  Carol’s representations of danger are

unchanged

Defining the problem, defining relationships

s  Therapist “enters” the family system during assessment

s  Therapist responds to requests for protection and comfort = attachment figure s  personal strategies s  professional strategies

s  Therapist cooperates with family in exploration of DRs = a symmetrical relationship among peers

The therapeutic relationship

s  A transitory attachment relationship s  Symmetry:

s  For sustainable family, asymmetrical s  For changeable family, symmetrical

s  Non-reciprocity: s  The therapist is responsible for regulating

the actions on the basis of the patients’ ZPD

Relationships with Carol’s family

s  One therapist for the family, focusing on talking with the parents (symmetrically, non-reciprocally)

s  One therapist for Carol, focusing on her own increasing independence and openness to other relationships

s  Teachers, psychiatrists, physicians, other figures: managed with the help of the two therapists

s  Nobody directly for brother: signals of continued attention from family therapist

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Searching for the elusive Zone of Proximal Development

(ZPD)

s  What can the patient/family do on their own?

s  What are they unable to do? s  What can they be assisted to do?

(emerging abilities)

Searching for the elusive ZPD

s  Treatment actions: s  Serve explicit purposes

s Assessment s Symptom relief s Defining aims and goals s Pursuing change

s  Create interaction, clarifying ZPD s  Therapist seeks synchrony and fails s  Therapist and patients repair breaches in

synchrony

Some breaches with Carol and her family

s  Assessment and symptom relief through medication makes M feel “abnormal”

s  Carol is tempted to side with her therapist against parents

s  Family therapist’s attempts to comfort threaten father

s  Parents’ attempts to seek yet more doctors offend therapists

Repaired breaches and definition of shared goals

s  Understanding M’s intentions and actions (Utr)

s  Family therapist mediating between Carol’s indivdual therapist and her parents

s  Assist the family in helping children in transition to adulthood

The details of therapeutic interaction:

Reflecting on DRs

Work/Play on DRs

s  In the context of safety/comfort: s  Consider DRs s  Add omitted DRs s  Focus on discrepant DRs s  Correct distortions s  Find meaning in discrepancy s  Retain previous strategies s  Add degrees of freedom

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Therapeutic tools

s  Tools for collecting information s  Basic somatic, cognitive, affective DRs

s  “Enquiry” techiques

s  Tools for reflecting on information s  Episodic recall, integrative reflection

s  “Re-formulation” techiques

Errors

s  Using errors in treatment as opportunities for learning s  Trust in repair being possible s  Detect new information shown by “error” s  Consolidate a procedure for recognizing the

learning potential of errors s  Model the process for patients

s  Every error provides information about the ZPD of the patients and their relationships

How do we know what works?

s  Therapists work procedurally s  Asked about what they did, they verbalize

their DRs about patients, leaving the action implicit

s  DMM predicts how sensory stimuli (=interactive events) are perceived by patients (through their strategies)

How do we know what works?

s  Observations beyond therapists’ and patients’ perspectives: videos of sessions

s  Importance of multiple sources s  Specification of processes for transmission of

knowledge

A DMM perspective on treatment

s Assessment makes meaning of: s problems

s relationships


s  Choosing and reaching goals is

a dialogue

that highlights the patients’ ZPD

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s Work/play

on information processing

in the ZPD

increases strategic flexibility


s  Learning recursively

from errors in all this

brings change

(patients and therapists)

THANK YOU

s  To Kasia Kozlowska and Patricia Crittenden for help on this presentation

s  To the fantastic group of colleagues and friends here in Frankfurt.

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