Zogenaamde therapieresistente patiënten: Een nieuw perspectief
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1 Zogenaamde therapieresistente patiënten: Een nieuw perspectief Patrick Luyten University of Leuven, Belgium University College London & The Anna Freud National Centre for Children and Families, London, UK
2 Overview Wat is therapieresistentie? Een nieuw perspectief Rollenspel Luyten, P., & Fonagy, P. (in press). Mentalizing and trauma. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (2nd ed.). Washington, DC: American Psychiatric Publishing. Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience. Borderline Personality Disorder and Emotion Dysregulation, 4, 11. doi: /s
3 I hope it s a tv!
4 Wat is therapieresistentie? Null and negative outcomes Traditionele benaderingen: het zijn patiëntfactoren: Negatief therapeutische reactie: masochisme, envy Herhaling objectrelaties, schema s
5 Typical longer-term response to potentially traumatic event (PTE) Normative response: minimal impact resilience! Importance to distinguish between different types of trauma
6 Bonanno, G. A., & Diminich, E. D. (2013). Annual Research Review: Positive adjustment to adversity trajectories of minimal-impact resilience and emergent resilience. Journal of Child Psychology and Psychiatry, 54(4), doi: /jcpp.12021
7 Nieuw perspectief: combi van patiënt en hulpverlenerperspectief Gehechtheid Mentaliseren/sociale cognitie Epistemisch vertrouwen en salutogenese: hard-to-reach karakter van vele patiënten Luyten, P., & Fonagy, P. (in press). Mentalizing and trauma. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (2nd ed.). Washington, DC: American Psychiatric Publishing. Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience. Borderline Personality Disorder and Emotion Dysregulation, 4, 11. doi: /s
8 Gehechtheid
9 How Attachment Works Emotionally DISTRESS/FEAR Down Exposure Regulation to Threat of Emotions Activation of attachment Proximity seeking The interpersonal regulation of stress and arousal
10 Risk of re-victimization and intergenerational transmission Associated with unhealthy behaviors (smoking, eating disorders, risky sexual behaviors) Associated with self-harm/suicide Associated with re-victimization and intergenerational transmission of trauma
11 Mentaliseren
12 Holding mind in mind
13 Holding mind in mind in emotional states
14 Psychological equivalence Certainty about what you/others feel or think 14
15 Teleology Quick Fix thinking 15
16 Pretend Mode: hypermentalizing Blah blah blah blah blah blah blah blah blah blah. Gnnnnarrrgh! Gnnaaaaargh! Naaarrrrrgh! Blah blah blah 16
17 Self-destructiveness and Self-destructive relationships Torturing alien self Self representation Torturing alien self Externalization Perceived other Self-harm state Unbearably painful emotional states: Self experienced as evil/hateful Container Addictive bond Self experienced as as hated evil and attacked hateful Victimized state Projective identification is used to reduce the experience of unbearably painful emotional state of attack from within externalisation becomes a matter of life and death and addictive bond and terror of loss of (abusing) object develops
18 Externalisation & Violence Following Trauma Torturing alien self Self representation Torturing alien self Externalization Perceived other Self-harm state Unbearably painful emotional states: Self experienced as evil/hateful Container Addictive bond Violent act Self experienced as as righteously as hated evil and vindicated attacked hateful Violent state Projective identification is used to reduce the experience of unbearably painful emotional state of attack from within externalisation becomes a matter of life and death, the violent act protects against experience of intrusion and addictive bond and terror of loss of abused object can develop
19 Number of deaths US troops in 2010
20 Epistemisch vertrouwen Luyten, P., & Fonagy, P. (in press). Mentalizing and trauma. In A. Bateman & P. Fonagy (Eds.), Handbook of mentalizing in mental health practice (2nd ed.). Washington, DC: American Psychiatric Publishing. Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience. Borderline Personality Disorder and Emotion Dysregulation, 4, 11. doi: /s
21 Building a social network begins early
22 When the capacity to form bonds of trust is shaky and tends to break down
23 we lose our safety net
24 Reconceptualising hard-to-reach not in terms of vulnerability factors
25 but as an absence of epistemic trust
26 which may once have been adaptive
27 Treatment frame Develop a trusting relationship & formulate aims collaboratively Psychoeducation Validation and normalizing of feelings Manage anxiety and dissociation Micro-slice (traumatic) experiences and their impact, focus on relationships
28 Thanks!
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