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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”
What is going wrong? Therapists’ DRs
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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What is going wrong? Therapists’ DRs
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)
Carol’s family strategies
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?)
Carol’s family strategies
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
Carol’s family as a system
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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Carol’s family as a system
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)
Carol’s family as a system
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
A DMM perspective on treatment
s Choosing and reaching goals is
a dialogue
that highlights the patients’ ZPD
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A DMM perspective on treatment
s Work/play
on information processing
in the ZPD
increases strategic flexibility
A DMM perspective on treatment
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.