3rd Biennial Conference of the International Association for the Study of Attachment (IASA) (University for Applied Sciences, Frankfurt am Main, Germany, 14-16 September 2012) TOWARD A DMM BASED DYNAMIC PSYCHOTHERAPY (DMM-DP) Franco Baldoni Attachment Assessment Lab Department of Psychology, University of Bologna, Italy 1
Attachment and psychotherapy Attachment theory has been slow to provide conceptual models and techniques to dynamic psychotherapy Until a few years ago, many analysts still viewed this perspective as "anti-psychoanalitical In "A secure base" (1988) Bowlby exposes its clinical thinking by providing the first fundamental guidelines for psychotherapy based on attachment theory Since then, attachment theory has become a useful paradigm for the development of psychotherapeutic techniques for the treatment of adult and children. Individual psychotherapy (Endres, Hauser, 2001; Holmes, 2001; Wallin, 2007; Jurist, Slade, Bergner, 2008; Slade, 2008; Milch, Sahhar, 2010) Group and Family therapy (Doane, Diamond, 1994; Byng-Hall, 1995, 1999 and Fearon et al., 2006; Johnson, 2008) Parenting care (video-feedback and parent training) (Cicchetti et al., 1999; Cassibba, van IJzendoorn, 2005; Juffer, Bakermans-Kranenburg, van IJzendoorn, 2007, Berlin, Zeanah, Lieberman, 2008; Slade, 2010) 2
Bowlby's tips for an attachment based psychotherapy 1. Give patients a secure base 2. Help patients to recognize their current mode of relating with others and to develop intimate relationships 3. Help patients to recognize the ways they connect with the therapist and how their perception is influenced by their internal working models 4. Help patients to recognize how their own childhood and adolescence experiences influence the way they perceive and react to the world - by promoting understanding and reconciliation towards attachment figures 5. Help patients to recognize how their representations of self and others - derived from the painful events of the past or distorted messages of parents - may or may not be appropriate for the present and future 3
Key concepts Motivations Models Confronting models in Dynamic Psychotherapy Contemporary Psychoanalysis Relationship, unconscious, transference, countertransference, conflicts, resistances, defenses (less importance of drives) Meeting the needs, limiting suffering Conflict, symbol, personality structure Attachment A-B-C+D Attachment relationships, secure base, IWM, mentalization Searching for Safety Secure and insecure attachment, IWM: A-B-C+D / Ds-F-E-U Defenses Neurotic or primitive Attachment behaviors, defensive exclusion, ambivalence Pathology Assessment Technique Psycho-neurosis, perversion, personality disorders, psychosis Clinical interview, projective tests, Manual: PDM, OPD Analysis: free associations, dreams, parapraxes, resistance and transference Processing of countertransference Focus on non-verbal and setting Empathic attitude Interpretation (less important in severe patients) Dysfunctional attachment, loss, trauma Clinical interview, SS, AAI, Self-report questionnaires Promote a secure base Encourage exploration Identify the IWM Analysis of transference and of attachment behaviors Interpretation Mentalization Attachment DMM Danger, adaptation, cognition, emotion, memory systems, patterns, self-protective strategies, dispositional representations Protection from danger Pattern: A-B-C, low and high index, mixed patterns, modifiers Strategies for self-protection from danger Dysfunctional adaptation, Modifiers (U/Tr, U/l, Dp, DO, ina) Clinical interview, CARE-Index, SS, PAA, SAA, TAAI, AAI Different theories (psychoanalysis, evolution theory, systemic, cognitivism, behaviorism, neuroscience) Different techniques (free associations, questions, interpretation, reformulations, CBT) Study of defensive strategies according to family context and specific conditions of danger Tailored therapy according to age, pattern and strategies for self-protection Therapist Less active More active More active
Toward a DMM based Dynamic Psychotherapy (DMM-DP) 1. Assessment of problems 2. Attachment styles of the patient and the clinician 3. Therapeutic aspects of the assessment a) Caring and Raising parents b) Clinical use of the Adult Attachment Interview 4. Therapeutic techniques 5. Integrated and customized treatments 6. Adopting a systemic biopsychosocial perspective 7. Clinical training 8. Assessing treatment efficacy 5
1- Assessment of problems The DMM analyzes the clinical problems in terms of strategies of attachment and relationship with the environment (What makes the patient feel safe?) and the possible presence of modifiers (Utr Ul, Dp, ina, DO) that alter their expression The symptomatic behaviors have played a protective role in the contexts in which they developed, and are activated under conditions of danger (study of the past to understand the present and predict the future) The patterns and behaviors are not "wrong or right, but appropriate or inappropriate given the specific context in which they are applied 6
2- Attachment patterns of the patient and the clinician The DMM pays attention to the patterns of attachment of the patient and the therapist and considers their matching By analyzing the configuration of attachment of the patient, the therapist may organize the most appropriate relational and therapeutic interventions (including interpretations) by considering the patient s specific ability to process cognitive and affective information 7
Clinical relationships examples Clinician Patient Results A (dismissing) C (preoccupied) A C B (secure or balanced) A C C A A, B, C Rigid technical-cognitive approach Unexplored and avoided areas Dismissing negative emotions False affects Emotional emphasis Excessive expectations Extended consultations Relationship conflicts Partial compensation Difficulty in understanding Therapy interruption Mentalization Affective and cognitive communication Tailored to the patient strategies (Baldoni 2012)
3 - Therapeutic aspects of the assessment The assessment techniques of the DMM (CARE-Index, SS, PAA, AAI) are relational experiences. They provide fundamental information on the patient s attachment pattern. They may be the patient s the first opportunity for treatment and for the development of a working alliance 9
3.a - Caring and Raising parents CARE-Index: video-feedback tecnique in therapies of families at high risk) DMM based Parent Training (DMM-PT): integrates psychodynamic interventions with other psychoeducational interventions (including the possible use of video-feedback tecniques like CARE- Index or Lausanne Trialogue Play) 10
3.b - Clinical implications of the Adult Attachment Interview (AAI) Intrinsic to the procedure Meta-cognitions, insight, acknowledgment of contradictions and discrepancies of thinking and behavior (meta-cognitive monitoring) Non-specific factors (to relate, tell, communicate emotions, empathic listening of the interviewer) Specific Returning to the codification Indications for treatment Example of clinical assessment 1. Clinical interview 2. AAI administration 3. Interview of restitution and eventual indications for treatment 11
4 -Therapeutic techniques The DMM proves a valuable guide in formulating verbal interventions (questions, comments, reformulations, interpretations, self-disclosure) Interpretations help the patient to recognize the significance of his adaptive and defensive behaviors, particularly those that are activated in situations of danger in the past and in present life. These interventions, accompanied by an empathic validation, are particularly important for patients who show a lack of processing of traumas or losses, or for those who have suffered deprivation, neglect and abuse in the past Treatment of severe patients: less emphasis is placed on interpretation, in favor of countertransference processing, analysis of relational dynamics, study of the discrepancies of thought, mentalization, constancy of the setting and non-verbal behaviors Integration of cognitive intervention, cognitive-behavioral and systemic tecniques 12
5- Integrate and customize treatments Tailored treatment based on the characteristics of the patient (age, past and present history, attachment pattern and defensive strategies, modifiers, what makes him feel insecure, current danger, adaptability, family and sociocultural relational context) Possibility of integration among different techniques psychoanalytic (free association, interpretation, work on the relationship, countertransference processing, empathy, non-verbal communication and constancy of the setting) cognitive (identification of problematic thoughts and attitudes, cognitive restructuring) cognitive-behavioral (prescriptions, desensitization techniques, psychoeducational interventions) systemic (circular, strategic or reflexive questions, family and group treatments). The therapist tends to be more active 13
6 - Adopting a systemic biopsychosocial perspective The DMM follows a biopsychosocial perspective and provides a key that places people within their own systems and subsystems, considering different levels of systems (genetic, developmental, neuropsychological, medical, psychological, individual, familiar, social, cultural, environmental) The DMM considers the therapeutic relationship as a primary source of information (here and now) Problems are always addressed by studying the functions of defensive behavior in different contexts of danger, especially taking into account family relationships, past and present 14
7 - Clinical training DMM education: courses on the tools for the assessment of attachment (a good knowledge of the model requires a basic knowledge in all DMM instruments) Therapist as a patient: individual psychotherapy that allows the therapist to be aware of his own psychological characteristics (in particular the attachment pattern and the personal experiences of trauma or loss) 15
8 -Assessing treatment efficacy Evidence-based perspective: follow-up studies, empirical studies and long term Randomized Controlled Trials (RCT) Research on: efficacy (to prove that a specific treatment acts on a specific disorder excluding the influence of other factors) effectiveness (to assess the outcome of psychotherapeutic methods as used in actual clinical practice) 16
For information Prof. Franco Baldoni Attachment Assessment Lab Department of Psychology University of Bologna Italy franco.baldoni@unibo.it 17