ED Patient: Innocent or complicitous victim?
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Transcript of ED Patient: Innocent or complicitous victim?
ED Patient: Innocent or complicitous victim?
An exploration of
self-protective strategies in ED
PM Crittenden & SR Wilkinson
4th April 2005 Crittenden & Wilkinson 2 www.ssbu.no
Four Parts of Presentation
1. Overview of attachment (DMM)
2. Discussion of appearance & reality in ED
3. Three ED examples
4. Closing discussion
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Three Aspects of Attachment
• Inter-personal: Strategies for eliciting protection and comfort
• Intra-personal: Information processing
• Familial: Array of interacting strategies
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Central concepts in the Dynamic Maturational Model of Attachment (DMM)
1. Attachment refers to self-protective processes used in the face of threat or danger.
– Attachment is about HOW to protect oneself, not how strong the bond is.
– Its form depends on the information available to the child’s mind.
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2. Attachment behaviour organizes into strategies for elicting protection and comfort (9-11 mo.)
3. The array of possible strategies increases as the brain matures – making new information and new actions possible (1 year-old age).
Central Concepts in the DMM, con’t
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Attachment Models
• Ainsworth: A B C
• Main & Solomon: A B C D (disorganized)
• In practice: Secure (B) versus Insecure
• Dynamic-Maturational Model (DMM, Crittenden)
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Ainsworth Patterns of Infant Attachment
Predictability Negative Affect
Integration
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Ainsworth Patterns of Infant AttachmentPlus Main & Solomon’s Disorganized
↑← Disorganized → ↓
Predictability Negative Affect
Integration
Secure
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DMM: Transforming Information
• Serves a self-protective function
• Becomes more sophisticated with maturation of brain
• Appearance ≠ reality
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DMM in Infancy
Integrated True InformationTrue Cognition True Negative Affect
pre-compulsive
Avoidant
ComfortableB3
ReservedB1-2 B4-5
Reactive
A1-2
A+
C1-2Resistant/
Passive
A/Cpre-
coerciveC+
Balanced
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Psychological Advances
• Implicit (non-verbal) causality
• Implicit affective states
• Being together:
- in temporal contingency and
- affective attunement
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DMM in the Preschool Years
False Positive Affect
Integrated True InformationTrue Cognition True Negative Affect
Compulsively Caregiving/Compliant
Socially Facile/Inhibited
A1-2
A3-4
ComfortableB3
ReservedB1-2 B4-5
Reactive
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
A/CDistorted CognitionOmitted Neg. Affect
Distorted Neg. AffectOmitted Cognition
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Psychological Advances
• Verbal statements of what causes what
• Words for feeling states
• Construction of interpersonal episodes
• Or the absence of these
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DMM in the School Years
False Positive Affect
Integrated True Information
True Cognition True Negative Affect
False Cognition
Compulsively Caregiving/Compliant
Socially Facile/Inhibited
A1-2
A3-4
ComfortableB3
ReservedB1-2 B4-5
Reactive
C5-6
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
Punitive/Seductive
A/CDistorted CognitionOmitted Neg. Affect
Distorted Neg. AffectOmitted Cognition
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Psychological Advances
• Why did you do that – when you knew you weren’t supposed to?!!
• Understanding the causes of one’s own behavior – Which DR regulated action?
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DMM in Adolescence
False Positive Affect
Integrated True InformationTrue Cognition True Negative Affect
False Cognition
Compulsively Promiscuous/Self-Reliant
ComfortableB3
ReservedB1-2 B4-5
Reactive
A5-6 C5-6
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
Punitive/Seductive
Compulsively Caregiving/Compliant
Socially Facile/Inhibited
A1-2
A3-4
A/CDistorted CognitionOmitted Neg. Affect
Distorted Neg. AffectOmitted Cognition
Sexual desire
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Psychological Advances
• Wordless communication:
– Type A: Borrowed words & ideas
– Type C: Sullen wordlessness, behavioral communication
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DMM in Adulthood
Compulsively Caregiving/Compliant
Delusional Idealization/Externally
Assembled Self
Compulsively Promiscuous/Self-Reliant
Socially Facile/Inhibited
ComfortableB3
ReservedB1-2 B4-5
Reactive
A1-2
A3-4
A7-8
A5-6
C7-8
C5-6
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
Punitive/Seductive
Menacing/ParanoidAC
Psychopathy
A/C
Cognition Negative Affect
False Positive Affect False Cognition
Integration of True Information
Integration of False Information
Distorted CognitionOmitted Neg. Affect
Distorted Neg. AffectOmitted Cognition
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Strategies for Dangerous Caregivers
Type A:
• Do the right thing from the perspective of others.
• Inhibit displays of negative affect.
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Strategies for Non-contingent Parents
Type C:
• Stick to your own feelings – bribe & threaten.
• Demand what you feel you need – now!
(The future is unpredictable.)
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DMM in Adulthood
Compulsively Caregiving/Compliant
Delusional Idealization/Externally
Assembled Self
Compulsively Promiscuous/Self-Reliant
Socially Facile/Inhibited
ComfortableB3
ReservedB1-2 B4-5
Reactive
A1-2
A3-4
A7-8
A5-6
C7-8
C5-6
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
Punitive/Seductive
Menacing/ParanoidAC
Psychopathy
A/C
Very severe pathology Very severe pathology
No psychopathology
Extreme pathology
Apparently not clinical, sometimes somatic
Inexplicable & troublingpsychopathology
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Strategies & Representations
• The construct of “internal working models” has been used to describe the mental component of the strategies employed to protect the self.
• “Dispositional representations” (DRs) are a more accurate way of describing the interface between psychological functioning and behavior.
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Dispositional Representations (DRs)
• Network of firing neurons representing the state of- self now- context now- associations with self and context in past (Perception is 90% memory - Gregory)
• DRs function to dispose self to act.
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• No model is stored.
• DRs are always generated anew in the present.
• The presence, and probability of firing, of synapses reflects past experience.
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• Parallel processing yields:
– Many different DRs;
– Each processed differently by the brain;
– Multiple solutions to each problem.
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Types of information guiding self-protective strategies
1. Predictable consequences (Type A)– Understanding of causation;– Low & slow arousal → little somatic
awareness;– Inhibition of negative affect & display of
false positive affect (fear smile);– Therefore: temporal order of events guides
DRs.
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2. Unpredictable consequences (Type C)– Lack of understanding of causation;– High & fast arousal;– Use of displays of affect to elicit protection &
comfort;– Therefore: feelings guide DRs.
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Integration
• Integration corrects error, selects the best DR, constructs new and more comprehensive DRs.
• Integration is slow.
• Integration consumes brain resources, i.e., it reduces scanning for danger.
• Integration is dangerous if danger is near.
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Safety in the face of danger requires a fast response at the
cost accuracy of response.
Hence, exposure to danger reduces integration.
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Peter Cook and Dudley MoorePeter Cook and Dudley Moore
Dud: So would you say you’ve learned from your mistakes?
Pete: Oh yes, I’m sure I could repeat them exactly.
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Defining Crazy
Doing again what failed every time before -
and expecting a different outcome this time.
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Three hypotheses:
• ED girls are trying to protect themselves.
• Parents of ED girls are trying to protect the girls.
• Appearance does not equal reality.
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Three Examples of Appearance/Reality Discrepancy
• Ringer & Crittenden findings with DMM
• Case study from in-patient treatment
• Case study of family process & politics:
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Adult Attachment Interview
• DMM classifications & method
• Assess strategy & information processing
• Multiple DRs assessed
• Strategy, trauma, modifiers
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Failure of Strategies
• Localized, topic-specific failure of strategic functioning: Unresolved trauma
• Generalized, pervasive failure of strategic functioning: Depression & Disorientation
• Punctuated, generalized & pervasive failure of strategy with imaginary intrusions: Disorganization
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Questions
• Are ED patients strategic?
• What strategies do they use?
• What transformations of information are needed – and why?
• Do different symptoms presentations differ by strategy & transformation?
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Ringer Sample
• 19 Anorectics (restricting)
• 26 Bulimics
• 17 Anorectics (binging)
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Ringer & Crittenden Results
• Limited engagement with interviewer, few episodes
• Several strategies used by EDs
• No difference by type of ED
• Strategies not unique to ED
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Common DMM strategies for ED
• C5-6
• C3-4 (bulimic)
• A1/C5-6
• [A] C5-6 (false A1)
• A3-4
(Ringer & Crittenden)
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Ringer & Crittenden Results, Con’t
• Few Utr; most imagined (erroneous causation)
• Almost no modifiers – very strategic (not Dp)
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Transformations
• Exaggerated affect
• Non-verbal communication
• Strategy employed without regard to outcomes
• Strategy can be used self-destructively without regard to results
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Psychological & Strategic Effects: Deception
• Adol and family both focus on what can be said or talked about (displacement of problems).
• This misleads everyone. It isn’t “lying”, but it deceives the self and others.
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Why use deception?
Parents’ perspective:
1. To protect the child from bad stuff;
2. To protect the parent from bad stuff;
3. Because they don’t know how to fix the bad stuff.
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Why use deception?
Adolescents’ perspective:
1. To avoid losing contact with a protective parent;
2. To communicate with the skills that one has.
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Deception Scale
• Lie
• Intentional deception
• Self-deception
• Involving self-deception
• Reciprocal & involving self-deception
• Reciprocal, involving, & intentional self- and other-deception
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Familial Processes
Two cases of ED adolescents & parents:
- Exploration of AAIs
- In-patient clinical experience.
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Truth in ED Families
• Parents have past dangers with current traumatic effects.
• Parents have current problems (e.g., marital discord).
• Parents try to protect their children from these – by hiding them.
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A Developmental Perspective on “Truth”
• Truth about the past is not predictive truth.
• The brain is evolved to use information to predict the future.
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The only information that we have is information about the past
whereas
The only information that we need is information about the future.
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Consequently, information from the past must be transformed to maximally
predict danger in the future.
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Five Transformations of Information• Truly predictive (things are as they appear).
• Erroneous (things have no meaning, but they appear to, trust them)
• Omitted (important things appear irrelevant, forget them)
• Distorted (things appear, but must be minimized or exaggerated to fit the future)
• Falsely predictive (things mean the opposite of what they appear to mean).
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Discovery of “truth” by pre-ED baby
Infancy: • M is caring & baby wants her.
• M is sometimes unavailable or upset & B gets anxiously upset.
• M gets more upset when B gets upset.
• Outcomes: B wants M, can’t predict M’s behavior, inhibits angry feelings but is aroused.
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Psychological & Strategic Effects
• Causal information is omitted.
• Affect is exaggerated.
• Child is Type C2-4 and maybe also idealizing of M (A1/C2-4)
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Discovery of “truth” by pre-ED child
Preschool: • M is caring & child wants her.
• M is sometimes unavailable or upset & child tries to talk about it, but M won’t tell this story.
• M is most comforting when child needs help.
• Outcomes: Child wants M, doesn’t understand causation, doesn’t learn language of feeling, can’t tell episodes of difficulties, learns to appear helpless.
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Psychological & Strategic Effects
• Language does not replace affect for communication – so information is not explicit.
• Angry feelings are hidden from view – so anger is not experienced or expressed explicitly.
• Child becomes excessively dependent on M for comfort and well-being.
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Discovery of “truth” by pre-ED child
School-age: • M is caring & child wants her- so child hides her
anger.
• Child feels bad & acts different from peers, has few friends, but can’t explain why.
• Child finds erroneous causal explanations.
• Outcomes: Child wants M, is angry but acts meek, creates erroneous explanations, can’t use language to solve problems. M tries harder to help, worries, but can’t talk about bad stuff.
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Psychological & Strategic Effects
• Lacking words, episodes, and a dialogue, child does not learn to reflect integratively on self, feelings, and behavior;
• False explanations and distorted feelings are generated by child and accepted with relief by parents.
• Everyone thinks life is hunky-dory. It is not.
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Discovery of “truth” by ED adolescent
Secondary school:• M is worried; Adolescent uses passive aggression;
• Adolescent feels hopeless, becomes sullen (if words don’t function, why use them?);
• Adolescent can’t become independent, doesn’t want to leave, but can’t stay;
• M doesn’t understand, tries to help, makes it worse;
• Outcomes: Adolescent becomes symptomatic, hides symptoms, & misunderstands causal relations.
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Psychological & Strategic Effects:Ignorance and Incompetence
• Adolescent is in an internal struggle & lacks the mental skills to resolve it.
• Adolescent is in an interpersonal struggle and lacks the social & communicative skills to resolve it.
• Adolescent does not know and cannot tell about the true issues – nor can the family.
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Psychological & Strategic Effects: Deception
• Adolescent and family both focus on what can be said or talked about (displacement of problems).
• This misleads everyone. It isn’t “lying”, but it deceives the self and others.
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Macro-system processes:Terri Schiavo case
• Adolescent bulimia, quick marriage;
• Black hole of desperation (family follows her to FL)
• Triangulated struggle between Terri, husband, her family (as if she had a lover!)
• Recurrence of bulimia, heart attack, & brain damage
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Terri Sciavo, con’t
• Imagined processes (right to life);
• Obscured issues (family struggle & Terri’s adulthood);
• Unexpected outcomes at all levels (government becomes part of family mental illness and displaced struggle);
• Unexpected effects of media attention to ED: increase prevalence of this symptom display in troubled youth?
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Psychological & Strategic Effects:The Breaking Point
• By adolescence, everything is at stake: - self-identity;- understanding causality & feelings;- personal independence;- future family & reproduction.
• The struggle to survive the struggles becomes itself a death struggle with phantom problems.
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In the eating disorders, the struggle to survive the obscured family struggles
becomes itself a death struggle around phantom problems.
Appearance no longer resembles reality.
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Treatment
• Therapist (T) needs a mental model of ED.
• T needs to discover the specifics of the ED patient & her parents.
• T needs to know own strategy (usually Utr, often A3, sometimes C3-6, some earned B).
• As and Cs usually need different intervention strategies
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Treatment, con’t
• Establish safety: patient, parents, & staff.
• Be open & explicit, not entrapped.
• In parallel, (1) increase skills of ED patient and family (2) open family secrets to view – safely.
• Avoid moral judgment; this is about safety & comfort.
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Three central ideas
• Patients and parents use protective strategies.– That have unexpected outcomes.– That lack and verbal integrating processes.
• A & C require different approaches.
• Trauma is not central.
• Developmental pathways and dispositional representations are.
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