THE SECURE & INSECURE CONTINUUM Conscious

Transcription

1 A Psychobiological Approach to Couple Therapy 1 A Psychobiological Approach to Couple Therapy 2 WORKING WITH DISORGANIZATION IN COUPLE THERAPY: A PACT PERSPECTIVE Stan Tatkin, Psy.D. Assistant Clinical Professor Department of Family Medicine University of California at Los Angeles David Geffen School of Medicine AGENDA Introduction What is PACT? Attachment Organized versus Disorganized Disorganized states versus traits Signs and symptoms Pre-cautions Treatment Stan Tatkin, Psy.D A Psychobiological Approach to Couple Therapy 3 A Psychobiological Approach to Couple Therapy 4 A Secure-Functioning Model of Therapy Conflict Model Social skills Content conflicts and power struggles Narrative Top-down processing Capacity Model Social-emotional capacity Psychoneurobiological, developmental, social-emotional skills and deficits Narrative coherence Bottom-up processing A Psychobiological Approach to Couple Therapy 5 A Psychobiological Approach to Couple Therapy 6 Ambassadors High Cortical Primitives Subcortical Relational Expensive Slow Survival Cheap Fast THE SECURE & INSECURE CONTINUUM Conscious Automatic If it s not one thing, it s your mother! Copyright Stan Tatkin, Psy.D. all rights reserved 1

2 A Psychobiological Approach to Couple Therapy 7 A Psychobiological Approach to Couple Therapy 8 ATTACHMENT and the Response System Signal SECURE-INSECURE CONTINUUM Organized Attachment Secure Insecure Two-person System One-person System Signal Response Consequence Fair Unfair Mutual Unjust Sensitive Insensitive A Psychobiological Approach to Couple Therapy 9 A Psychobiological Approach to Couple Therapy 10 ATTACHMENT TYPES THE THREE MAIN ATTACHMENT TYPES Secure = Anchor Avoidant = Island Angry resistant = Wave A Psychobiological Approach to Couple Therapy 11 Interactive A Psychobiological Approach to Couple Therapy 12 Interactive Island Distancing Auto Anchor Clinging External Wave Island Distancing Auto Anchor Clinging External Wave Self- Self- Regulated parents selfesteem. Had to perform. Signals rarely responded to with interactive regulation. Not often held or hugged. Neglected, dismissed. Help not available. Signals shut down. Disengages, distances. Auto-regulates. Parents not need regulation. Child loved for self. Signals usually responded to with interactive regulation. Often held and hugged. Much interactive play. Help usually available so Normal signals work. Is collaborative. Self-regulates. Regulated parents emotional well-being. Interactive regulation random, inconsistent. Sometimes held. Other times dropped. Signals louder, with angry protest. Hard to soothe. Clings. Gets preoccupied. Externally regulates. Aggrandized sense of independence and freedom (based on neglect). Addicted to alone time. Plays alone too much. Too much interaction can be stressful, draining, intrusive. Difficulty shifting from alone to interaction. ( What! ) Realistic sense of autonomy and relationship. Balanced aloneness and interaction. Doesn t fear engulfment or abandonment. Plays well with others. Does well alone too. Easy transitions between alone and interaction. Preoccupied with relationship (based on unpredictability). Allergic to hope. Expects to be dropped. Too much alone stressful (depression or anger). Difficulty shifting from interaction to alone. Copyright Stan Tatkin, Psy.D. all rights reserved 2

3 A Psychobiological Approach to Couple Therapy 13 Interactive A Psychobiological Approach to Couple Therapy 14 Interactive Island Distancing Auto Anchor Clinging External Wave Island Distancing Auto Anchor Clinging External Wave Self- Self- Low expressiveness (signals shut down). Normal expressiveness (simple signals work). Over-expressiveness (signals turned up). Passive-aggressive (cold anger). Effective verbal and nonverbal social skills. Negativistic, punishing, critical attacks (hot anger). Deductive, logical, reasonable (left brain bias). Process info cross-modally (right and left brains well coordinated). Inductive, emotional, meaning-based (right brain bias). Fears blame, failure, inadequacy, loss of self. Shame-based. May be guilt-based (standards of mutuality, sensitivity, fairness). Fears being too needy, a burden, too much, unlovable, abandoned. Low verbal regarding self. Filtered, guarded, secretive. High verbal regarding self. Open, insightful, fresh. Excessive verbal re: self. Unfiltered, tangential. My complaint is that my partner complains. We want to work this out together. My complaint is that I m overwhelmed. Low facial, vocal, and gestural cueing. Good facial, vocal, and gestural cueing. High facial, vocal, and gestural cueing. Wants to just move forward. Dismissive: The past is the past, get over it. Collaborative. Engages in mutual repair. Stays wellconnected, in real-time. Can t move on. Preoccupied: I m not done with this yet A Psychobiological Approach to Couple Therapy 15 A Psychobiological Approach to Couple Therapy 16 Attachment Atypicals Type D (Ainsworth, Sroufe) Disorganized/disoriented (Ainsworth, Sroufe, Main) Preoccupied with trauma (Main) Helpless/hostile (Lyons-Ruth) Cannot classify (Main, Hesse) Extreme Av + AR = Disorganized Psychopathy Genetic brain damage AROUSAL REGULATION A Psychobiological Approach to Couple Therapy 17 A Psychobiological Approach to Couple Therapy 18 Window of Tolerance Copyright Stan Tatkin, Psy.D. all rights reserved 3

4 A Psychobiological Approach to Couple Therapy 19 Porges View of the ANS The metaphor of safety Environment: outside and inside the body A Psychobiological Approach to Couple Therapy 20 A Secure-Functioning Model of Therapy Conflict Model Capacity Model Optimal arousal level Rest and digest Parasympathetic ventral vagal system Social Engagement System Eye contact, facial expression, vocalization Nervous System Safety Danger Life threat Hyperarousal Increased Heart Rate Sympathetic System Mobilization fight-flight Dissociated rage, panic Hypoarousal Decreased Heart Rate Parasympathetic dorsal vagal system Immobilization freeze Dissociated collapse Wheatley-Crosbie, adapted from Porges, 2006 What content issues disrupt the relationship Content conflicts and power struggles Verbal communication skills Top-down processing How insecure functioning disrupts the relationship Psychoneurobiological, developmental, social-emotional skills and deficits Non-verbal acumen Bottom-up processing A Psychobiological Approach to Couple Therapy 21 A Psychobiological Approach to Couple Therapy 22 Signs and Symptoms Signs and Symptoms Continuous flirting with therapy, but not committing to a date or time; frequent cancellations or time changes prior to first appointment Strange behavior in the waiting room Seductiveness Seating positions Facial expressions Postures Strange behavior on phone, , in waiting room Partners avoid eye contact with the therapist Partners are not forthcoming Partners seem paranoid Partners are clearly holding secrets The therapist is confused after 20 minutes Biphasic arousal dysregulation Multiple timelines offered Recurring decompensation during sessions Long silences, incoherence, self-report of depersonalization or disorientation A Psychobiological Approach to Couple Therapy 23 A Psychobiological Approach to Couple Therapy 24 Signs and Symptoms Signs and Symptoms Strange gait while walking toward the therapy room Immediate sense of secrecy in the room; not forthcoming Couple asking you to leave the room so they can talk without you there Partners over-focusing on each other with eye contact, as a way to avoid therapist s eyes Intense use of primitive, lower-level defenses Projective identification (strong) Splitting Transference acting out Projection Withdrawal Dorsal motor vagal Avoidance Dissociation Inconsistent time lines Paranoia Narrative issues Long pauses between sentences in a partner s narrative Partner narrative includes people who are at once dead and not dead Partner speaks about an important person as if eulogizing him or her (flat tone) Confusion between now and then Confusion between I and thou Depersonalization Psychotic Copyright Stan Tatkin, Psy.D. all rights reserved 4

5 A Psychobiological Approach to Couple Therapy 25 A Psychobiological Approach to Couple Therapy 26 Signs and Symptoms Arousal issues Biphasic reactivity when speaking about an attachment figure, an unresolved event, a loss, or the partner; rapid cycling in arousal, not necessarily affect Dorsal motor vagal reactivity Simultaneous high sympathetic arousal and dmv activity (accelerator and brake) Countertransference Feel disorganization in your gut Fear (projective identification) Want to refer them out Cannot do bottom-up interventions early because they are already experiencing everything bottom up ETIOLOGY Copyright Stan Tatkin, PsyD - all rights reserved 27 A Psychobiological Approach to Couple Therapy 28 Type D infant (Emde) Type D infant A Psychobiological Approach to Couple Therapy 30 A Psychobiological Approach to Couple Therapy 31 Treatment Treatment Start low, go slow, but get there Safety first Understand and perhaps make explicit that the addition of a third person in the room (dyads to triads) can increase a sense of danger Do couple therapy; don t see partners alone Be prepared to step onto landmines that neither you nor the partners know exist Repair and work with these ruptures immediately; requires a reasonable amount of individual therapy within the couple session Work to move back to the couple as soon as reasonable Work early toward secure functioning inside and outside the therapy room Secure releases of information from all healthcare providers Get video release, and video record sessions Conditions that must be met before working through trauma: Full therapeutic alliance with both partners; no acting out Enough safety and security (and enough play ) in the couple system to hold whatever arises; sufficient ego function Equal unresolved material in both partners (level the playing field) Full acceptance that trauma and/or loss has occurred and a willingness to work on it in couple therapy Both partners highly resourced, both internally and externally Partners secure functioning in and out of the room After conditions are met, can do any PACT exercise (e.g., lovers pose) Copyright Stan Tatkin, Psy.D. all rights reserved 5

6 A Psychobiological Approach to Couple Therapy 32 A Psychobiological Approach to Couple Therapy 33 Considerations Therapeutic frame Partners may act out in dangerous ways inside and outside the session Cutting Head banging Suicide Murder Drugs and alcohol abuse Sexual acting out Legal troubles Antisocial activities Partners may scare everyone around them (e.g., family members, other healthcare providers) Fees Collection Time Starting and ending on time Therapist-patient role Outside communication Professional consultation with colleagues A Psychobiological Approach to Couple Therapy 34 A Psychobiological Approach to Couple Therapy 35 Considerations Invoke the PACT Serenity Prayer Stick to the therapeutic frame Expect the couple to be able to do secure functioning until they prove otherwise (quit therapy) Be cautious when making referrals, unless you are referring them to a different couple therapist Get supervision PACT serenity prayer A Psychobiological Approach to Couple Therapy 36 A Psychobiological Approach to Couple Therapy 37 THERAPIST SELF-REGULATION Therapist Self- Purpose Manage your own affect and arousal Influence couple s affect and arousal Serve as a model to teach self-regulation Track your face, voice, body Keep alert but relaxed state of mind/body Remain within window of tolerance Maintain a fearless attitude Know your threat-reflex: fight, flight, freeze, or fold? If you get dysregulated, everyone s in trouble Copyright Stan Tatkin, Psy.D. all rights reserved 6

7 A Psychobiological Approach to Couple Therapy 38 A Psychobiological Approach to Couple Therapy 39 Therapist Self- Be yourself, without pretense Practice mindfulness Maintain presence through outward focus (Morita) Learn ways to shift your state (e.g., by task diversion, movement, gaze change) Form a group for self-study Take care of yourself STATE DISORGANIZATION A Psychobiological Approach to Couple Therapy 40 A Psychobiological Approach to Couple Therapy 41 Patient Acting Out Disorganized pocket 01:39 Acting out behaviors include Cancelling appointments Showing up late Problems with fees, scheduling, phone calls, s, etc. Resisting therapeutic interventions, exercises, etc. Showing up intoxicated Blaming the other partner Blaming the therapist Attacking the therapy Transference acting out Mismanaging thirds in therapy Gross violations of Grice s maxims Poor or no self-activation Impulsivity, explosiveness, projection, projective identification, withdrawal, avoidance, and splitting. A Psychobiological Approach to Couple Therapy 42 A Psychobiological Approach to Couple Therapy 43 Therapist Acting Out Patient Acting Out Acting out behaviors include Cancelling appointments Showing up late Problems with fees, scheduling, phone calls, s, etc. Resisting therapeutic interventions, exercises, etc. Showing up intoxicated Blaming the patient Making multiple referrals Mismanaging thirds in therapy Gross violations of Grice s maxims Countertransference acting out Reasons partners act out To test the therapist s ability To feel better at the cost of getting better To avoid negative feelings To avoid remembering original attachment experiences/figures To get the therapist to adapt to their reality (i.e., pain avoidance) Copyright Stan Tatkin, Psy.D. all rights reserved 7

8 A Psychobiological Approach to Couple Therapy 44 A Psychobiological Approach to Couple Therapy 45 AROUSAL REGULATION ASSESSING EMOTIONAL REGULATION Observe visual / auditory cues of arousal: Skin / muscle tone and color Facial expression Eyes Breathing Posture Gesture Vocal tone A Psychobiological Approach to Couple Therapy 46 A Psychobiological Approach to Couple Therapy 47 Skin and Muscle Cues Facial Cues Tensed muscles Clenched fists Flushed skin Hunched over Listlessness Pale skin Increased muscle movement and contraction Tightening around mouth, cheeks Jutting out jaw Decreased muscle movement and tone Mouth and cheek pads remain still Droopy expression Clenched jaw A Psychobiological Approach to Couple Therapy 48 A Psychobiological Approach to Couple Therapy 49 Eye Cues Breathing Cues Dilated pupils Glaring of eyes Constricted pupils Dimming of eyes Rapid breath rate Breathing from chest Slow breath rate Breathing from diaphragm Copyright Stan Tatkin, Psy.D. all rights reserved 8

9 A Psychobiological Approach to Couple Therapy 50 A Psychobiological Approach to Couple Therapy 51 Posture Cues Gestural Cues Straightening of posture Slumping of posture Increased gestures Fewer gestures Lengthening of neck Head down Faster movements Slower movements Raising of chin Elbows resting on knees Sharp movements Holding stomach (nausea) Increased limb movement Curling of toes Hands going into fists Body tilting to left or right Bird-like jerky head movements Holding stomach (dyspepsia) Holding head (headache; ringing ears) A Psychobiological Approach to Couple Therapy 52 A Psychobiological Approach to Couple Therapy 53 Vocal Cues Loud Shrill, booming Fast Monotone Muffled Inaudible Disorganized pocket Staccato Slow High pitch Pleading sound Low pitch Resignation sound 01:39 A Psychobiological Approach to Couple Therapy 54 A Psychobiological Approach to Couple Therapy 55 Brain Plasticity TRAIT DISORGANIZATION Psychotic core Epigenetics Adaptation to environment The endangered brain is different Consequences to frontolimbic circuits Amygdala hypertrophy or atrophy Hippocampal atrophy Problems in medial prefrontal bundle Problems in anterior insula, anterior cingulate, temporal-parietal junction Dysregulated vagal function (both dorsal and ventral systems) Copyright Stan Tatkin, Psy.D. all rights reserved 9

10 A Psychobiological Approach to Couple Therapy 56 A Psychobiological Approach to Couple Therapy 57 Medications Generally not effective for Axis II Polypharmacy can sometimes be effective or can cause big problems Check other substances such as herbs and tinctures Use your drug reference (Epocrates) Primary Defense Distancing Avoidant style Engulfment, intrusion Injury may have been earlier in development Leaves treatment Fewer options for intervention Poorer prognosis Clinging Merging style Abandonment Injury may have been later in development Stays in treatment More options for intervention Better prognosis A Psychobiological Approach to Couple Therapy 58 A Psychobiological Approach to Couple Therapy 59 Disorganized Partners/Couples Disorganized Partners/Couples Self Activation Any self-initiating action that moves the person toward obtaining healthy self-entitlements. Rewarding, reciprocal primary relationship Rewarding, challenging work Physical and mental health Learning Hobbies and creative outlets Therapeutic Alliance Requires object constancy Continuous awareness of separate self and other in time and space Holding of other (or task) in mind during absence and through frustration Self and other contain both good and bad at the same time Requires collaboration Grice s maxims Quality Quantity Manner Relevance A Psychobiological Approach to Couple Therapy 60 Copyright Stan Tatkin, PsyD - all rights reserved 61 Therapist Self- Therapist is the master regulator in the room Get them face-to-face so that you can get them co-regulating Scan your body for tension, release, focus attention outward Withdraw if necessary Move if necessary Stay within window of tolerance (social engagement) Disorganized core Copyright Stan Tatkin, Psy.D. all rights reserved 10

11 Copyright Stan Tatkin, PsyD - all rights reserved 62 A Psychobiological Approach to Couple Therapy 63 Conclusion Conclusion Disorganization can be divided into low, mid, and high level functionality Disorganization can be state or trait Work requires more discipline, strong frame, and a good understanding of the testing phase of treatment Individuals with disorganization often get worse before getting better Start low, go slow, but get there (secure functioning) Remember the PACT Serenity Prayer PACT focuses on bottom-up interventions that bypass higher cortical areas PACT is the show me psychotherapy we look for proof The PACT therapist takes a stand for secure functioning relationship Secure functioning is available to all couples, despite each partner s internal working model Secure functioning will only occur if the couple therapist expects it A Psychobiological Approach to Couple Therapy 64 Q & A Copyright Stan Tatkin, Psy.D. all rights reserved 11