interpersonal dependence and pathological bonding … · 2014. 12. 14. · patterns (id - pbp)...

INTERPERSONAL DEPENDENCE

AND PATHOLOGICAL BONDING

PATTERNS (ID - PBP)

Workshop

Nederland, 2014

Arun S Mansukhani. PsyD. EMDR Consultant . IASP. Málaga, Spain

ID (and PBP) is a major social and clinical problem:

– Underlying feature or comorbid in most emotional and mental disorders. Related to all five major symptomps clusters in psycho-emotional disorders (S-Seglert, 2006).

– Great subjective suffering in people messed up in disruptive relations and others that have given up on having a (healthy) relationship.

– Directly related to major social problems as gender and domestic violence, including suicides and homicides.

www.arunmansukhani.com

High number of direct

and indirect cases

Major soc. & clinical

problem

ID+PBP is overlooked and remains unattended

in most cases

Lack of integrative models to assess and treat PBP

ID + PBP

UNTREATED UNDERDIAGNOSED


Some typically

overlooked cases: • People who exhibit ID-PBP problems in any

type of interpersonal relationships (not only significant) but have made this symptoms ego-sintonic and don’t detect nor refer them.

• People who only show ID-PBP problems in significant inter-personal relationships and are stable when not in a couple.

• People who only show ID-PBP problems only in a particular type of significant relationships, frequently have chosen partners that have compatible ID-PBP features. (V: LS-1)

• The avoidante types.


Major types of patients

• Type 1: Symptomatic patiens (mainly Axis

I features).

• Type 2: Chaotic patients (mainly Axis II

features; frequently PDNOS or BPD).

• Type 3: Stable (seemingly) unsymptomatic

patients (frequently undiagnosticated or

OCPD traits or avoidant PD). www.arunmansukhani.com


Type 1: Symptomatic patiens : Axis I Symptomps

Dual attention easily

Type 2: Chaotic patients : BPD -PDNOS

Difficulties staying present:

Frequent abreactions (hyperactive dissociation)

Type 3: Stable unsymptomatic patients: no D-OCPD-APD

Difficulties conecting with past/sensations:

Frequent numbness or sleep or “getting off” (hypoactive dissociation)


(V: DS-1)

1. ID and PBP?


Independence

Healthy dependence

(Healthy bonding patterns)

in adults


Healthy dependence


in adults


Self-depend (auto-regulate + safe)

+

Inter-depend (co-regulate + trust)

=

Horizontal Relationship

(Reciprocal regulation; Cooperation and Reciprocity)

“People think that to love is

easy and that the difficult

task is to find and

apropriate obejct to love…

Nevertheless, all intents of

loving will be condemed

until the person doesn’t

develop a complete and

mature personality… A

culture in which these

qualities are rare, the

capacity to love will be rare

too”.

Erich

Fromm

2. Diagnosis


When do ID and BP become

pathological?

A persistent pattern or tendency:

-To have a number of conflictive interpersonal

relationships adopting submissive, dominant or

avoidant (manifest or emotional) patterns in

their various forms.

-Forsake having a partner or interpersonal

relationships through manifest or emotional

avoidance.

-To feel that our emotional needs are not being

fulfilled in the relationship with significant others

feeling frequently frustration, responsibility,

deception or betrayal. www.arunmansukhani.com

PBP - Characteristics.

-Emotional de-regulation:

-Frequent hyper o hypo arousal.

-External regulation: excessive need of co-

(fusion) or auto- (separation)

-Deregulation of self:

-Externally cued sense of identity.

-Fragile and changing self esteem.

-Difficulty maintaining sense of self


-Interpersonal-Behavioral deregulation:

-Difficulty managing self needs and others

needs. Difficulty establishing limits.

-Pathological bonding patterns: clinging or

avoidant.

-Need to control partners behavior: direct or

indirect means, due to fear.

-Need to harm (emotionally or physically).

PBP - Characteristics


PBP-Types & Subtypes

SUBMISSIVE

(Anxiety/Frustration)

DOMINANT

(Fear/Anger)

AVOIDANT

(Sadness/Distrust)

Pleasing

Helpless

*Oscilatting

Agresive

Pasive-Agresive

*Carer-Codependent (Inverse Dep.)

Manifest

Emotional

*Suspicious/Seductive

www.arunmansukhani.com V-DL DS

PBP – Who links with who?

Submissive pleasing

Submissive helpless

Oscillating

Domintant Aggressive

Passive-Aggresive

Carer

Avoidant manifest

Avoidant emotional

Avoidant Seductive

Submissive pleasing

Submissive helpless

Oscillating

Domintant Aggressive

Passive-Aggresive

Carer

Avoidant manifest

Avoidant emotional

Avoidant Seductive

Healthy dependence


in adults


Self-depend (auto-regulate + safe)

+

Inter-depend (co-regulate + trust)

=

Horizontal Relationship

(Reciprocal regulation; Cooperation and Reciprocity)

Variables that underly BP

SECURITY

Security (trust)

Vs.

Fear (distrust)

SELF REGULATION

Auto-Regulation

Vs.

Co-Regulation

Myers 1940, Van der Hart 2006, 2010,

Panksepp 1998. Porges 1995, 1998

,

Tronic (1989), Sroufe 1995, Schore

2000, 2013.

Gerzon 1998, Sanz 2007


Variables that underly PBP

AUTO

REGULT. CO

REGULT.

SECURITY

(TRUST)

FEAR

(DISTRUST)


SECURE

FEARFUL

Bonding patterns

AUTO

REGULT.

CO

REGULT.


Bonding patterns

SECURE

FEARFUL

AUTO

REGULT.

CO

REGULT.



SUBMISSIVE

(Anxiety/Frustration)

DOMINANT

(Fear/Anger)

AVOIDANT

(Sadness/Distrust)

Pleasing

Helpless

*Oscilatting

Agresive

Pasive-Agresive


Manifest

Emotional



3. Treatment:

www.arunmansukhani.com Edinburgh 2014

• Prerequisites:

• Attachment

• Dissociation

• Pharmacological

• Phased Treatment Plan

Treatment prerequisites

ATTACHMENT

THE NATURE OF THE CHILD'S

TIE TO HIS MOTHER1 By

JOHN BOWLBY, LONDON 1. An abbreviated version of this paper was read before the British

Psycho-Analytical Society on 19th June, 1957.

2. Although in this paper I shall usually refer to mothers and not

mother-figures, it is to be understood that in every case I am concerned

with the person who mothers the child and to whom it

becomes attached rather than to the natural mother.

The Nature of Love Harry F. Harlow (1958)[1]

University of Wisconsin

First published in American Psychologist, 13, 673-685

Address of the President at the sixty-sixth Annual Convention of the

American Psychological Association, Washington, D. C., August 31, 1958.

First published in American Psychologist, 13, 573-685.


http://psychclassics.yorku.ca/Harlow/love.htm

Attachment

• Primary dyadic bond between babies and their caretakers.

• One of the behavioral control systems (also action-motivation systems).

• A child can have different attachment bonds with different people, but needs at least one for a healthy developement.

• Each person developes an attachment style that influences how he relates to himself and others and what outcomes will occur in relationships


“The infant and young child should

experience a warm, intimate and

continuous relationship with his mother (or

permanent mother substitute) in which

both find satisfaction and enjoyment [and if

this should not occur] will result in sever

anxiety conditions and psychopatic

personality”

Bowlby, 1951 Maternal care and mental health


Attachment bond

Defining aspects

1. Proximity seeking. Availability

2. Separation anxiety-Attachment cry.

3. Safe Haven.

4. Secure Base.


Mary Ainsworth

-Strange Situation Procedure

-Convirts Attachment into a dimensional and interactive

variable (grades of emotional availability). Identifies:

•Secure Attachment

•Insecure attachment (divided into avoidant and

anxious ambivalent).

Mary Main

-Identifies Disorganized attachment

-Designs AAI.

-Extends attachment studies to adults.


SECURE AVOIDANT ANXIOUS DISORGANIZED

Attachment Types

(Ainsworth-Main classification)

A B C D AUTONOMOUS DISMISSIVE PREOCCUPIED UNRESOLVED


Attachment Types

SECURE

INSECURE

Organized

Disorganized

Hostile/Intrusv

Fearful

Hyper-activating

(Anx-Resistant)

De-activating

(An-Avoidant)


"Attachment theory regards the

propensity to make intimate emotional

bonds to particular individuals as a

basic component of human nature,

already present in germinal form in the

neonate and continuing through adult

life into old age."

Bowlby, 1988. A secure base.

“There is a strong continuity

between infant attachment

patterns, adolescent patterns

and adult attachment

patterns"

Main & Goldwyn, 1993 www.arunmansukhani.com

Secure

Autonomous

Dismissing

Deactivating

Preoccupied

Hyperactivating

Unresolved

Disorganized

• Secure-Autonomous (S2-F2)

• Somewhat dismissing (S1-F1)

• Somewhat preoccupied (S3-F3)

• Earned Secure (S4-F5)

• Inatentive (D1)

• Devaluating-Dismissing (D2)

• Restricted in feeling (D3)

• Fearful (D4)

• Passive-Submissive (E1) • Angry (E2)

• Enmeshed (E3)

• Controlling-Caretaking

• Hostile-Intrusive.

• Afraid.

A

D

U

L

T

T

Y

P

E

S www.arunmansukhani.com

Secure Attachment 1

(Parents)

• Positive affect (state of mind) towards

child

• Attention: Mindsight.

• Cooperatión (vs Interference).

• Availability and Continuity (Secure Base)

• Predictibility.

• Acceptance of the child’s needs.

• Mentalising Capacity (Fonagy & Steele)

Autonomous Attachment

(Adults) • Coherent narrative, explains largely, enters in

details. Not polarised. Realistic.

• Wide range of IWM of attachment. Flexible.

• Distinguishes healthy relationships

• Values positive interactions.

• Is cooperative and also self-protective

• Has in intuitive understanding of attachment:

considers attachment bonds very important.


Dismissing (Avoidant)

Attachment Avoidant parents or too intrusive

• Don’t give much details about childhood. Define childhoo as “good” or “excellent”

• Don’t see adults as regulating and comforting.

• Self-reliant. Good social analysis capacity.

• Covert or manifest hostility towards equals.

• Restricted emotional expression.

• Intimacy avoidant strategies.


Anxious-Resistant Attachment

Caregivers with selective and biased attention patterns. Self-centered or centered on their emotion.

• Gives a lot of details. Defines childhood as good but then enters into contradictions

• High emotion expression.

• Frequently express dependency overt patterns.

• Difficulties self-regulating. .

• Insecure. Low self-esteem


Disorganized Attachment

Fearsome or fearful caregivers.

• Very few memories. Disorgranized tales. May fabulate.

• No sense of security.

• Emotional swings.

• Contradictory behaviour.

• Impulsive.

• Difficulties with sefl-regulation.

• Bizarre behaviour: fearsome or fearful.


Attachment Types

(Ainsworth-Main classification)

A B C D AUTONOMOUS DISMISSIVE PREOCCUPIED UNRESOLVED



Attachment

Types

A B C D


SECURE

FEARFUL

Bonding patterns

AUTO

REGULT.

CO

REGULT.


Transition from:

CHILD

ATTACHMENT

PATTERNS

ADULT

ATTACHMENT

STYLES

ADULT-CHILD

ATTACHMENT

RECIPROCAL

ATTACHMENT

ATTACHMENT THROUGH

LIFE-SPAN • 0-6 MONTHS: Dual

Primary Attachment (Crow & Randolph, 2005).

• 6 M onwards: – Primary attachment

figures as agents too.

– Secondary attachment figures: elder siblings, grandmothers, grandfathers, pets, others (teachers, therapists).

• 2-3 years: growing

independence

• Adolescence: peer

group and first

romantic relations.

• Adulthood:

– Recirprocal

attachment to adults

– Children

– Resolved previous

attachments


CORTICAL

Meaning making and intersubjectivity

LIMBICAL

Attachment

(Care-seek)

Care-give

Social Rank

(Dom/Sub)

Cooperation

Affiliation

to social

groups

Sexual

Bonding

BRAIN ST.

Defense

Homeostati

c systems

Predatory

aggression

Exploration

Territory

Primordial

Sexuality

Liotti 2014

Behavioral (action-motivation) systems

Attachment

Social Ranking

Affiliation

Exploration

Defense

Sexuality

Adult (care-giving)

Child (care-seeking)

Dominance

Submission

Cooperation

Social play

Exploration

Fight/Flight

Freeze/Feigned death

Primordial Sexuality

Sexual Bonding www.arunmansukhani.com

SECURE

INSECURE

Organized

Insecure

DISORGANIZED


ATTACHMENT

BEHAVIOR

GOAL

To activate the care-

taking system in

the adult

Creating an atenttive

and positive state

of mind in the adult

SECURE

INSECURE

Organized

INSECURE

DisOrganized

CONTROLLING

STRATEGIES

“The activation of

alternative

behavioral

(motivational)

systems to maintain

closeness (sense of

security) that

hampers high

dysregulation that

leads to frank

disorganization.”

*Hilburn-Cobb 2004.


• Controlling punitive (domineering strategies)

• Controlling caregiving (inverted attachment)

Lyons-Ruth and Jacobwitz, 2008

• Controlling submissive.

• Sexualized behaviour.

Liotti 2014

• Instrumental supplies for protection and comfort. Others as “agents”.

Hilburn-Cobb 2014

“...as maturation proceeds, felt security can be obtained

through the operations of many other behavioural systems

besides attachment”. Mary Ainsworth 1990.


The search for Regulation (Crow and Randolph, 2005)

• Love, Affection.

• Care, Protection.

• Appreciation, Recognition.

• Admiration

• Control

• Cause Fear.

Needs Hierarchy

(Maslow, 2006)

SECURE

INSECURE

Organized

INSECURE

DISORGANIZED

CONTROLLING

STRATEGIES

“The collapse of the

controlling strategies

lead to DTD and

Complex PTSD

and, with later

cumulative traumas,

to Dissociation”

*Liottti 2014.


•Disorganized attachment (DA)

predicts dissociation as it activates

attachment and defense systems

simultaneously (Liotti, 2014)

• Infant DA predisposes to dissociation in

later years (Ogawa et al., 1997)

• Relational processes play a key role in

dissociation (Lyons-Ruth, 2003).

• Infant DA is by far a much more powerful

predictor of dissociation than later trauma

(Dutra et al, 2009)

Treatment prerequisites

DISSOCIATION

“Adult personality, as we know it in us and

our neighbours, is the result of a process

of integration” William McDougall (1926)

– Adult integrated personality is a construction.

– We have to have integrated diverse negative

experiences during our life.

– When don’t manage this, ir results in

dissociation.

– Unresolved attachment is cause of

dissociation.

Different parts of the self have:

• Different ideas about me and the world

(Nijenhuis 2008)

• Different needs

• Different functions

• Different action tendencies

And we can add:

Different attachment styles!

SECURE

FEARFUL

Bonding patterns

AUTO

REGULT.

CO

REGULT.


SOCIAL P (ANP)

CHILD AVOIDANT P

(EP)

CHILD BONDING P

(EP)

FEARFUL OR DESTRUCTIVE (EP)


SECURE

FEARFUL

AUTO

REGULT.

CO

REGULT.


Parts Adult Parts (ANP)

Child anxious-avoidant parts (EP)

Child afraid-agressive parts


SUBMISSIVE

(Anxiety)

DOMINANT

(Fear/Anger)

AVOIDANT

(Sadness/Empty)

Pleasing

Helpless

*Oscilatting

Agresive

Pasive-Agresive


Manifest

Emotional



SECURE

FEARFUL

AUTO

REGULT.

CO

REGULT.


Parts P. Adulta

P. Infantiles Ansiedad (protec/retraim)

P. Infantiles Enfadadas-Temerosas.

Treatment Phased

PLAN

PHARMACOLOGICAL TREAT.

*Cabello-Santamaría, 2013

SSRI: Paroxetine, 20-40 mg/d

TCA: Chlorimipramine: 25-150 mg/d

Propanolol (40 mg x 3)

Topiramate (25-200)

Lamotrigine (25-200)

Sulpiride

Quetiapine

Aripirazol

Risperidone (1 mg)

Pimozide www.arunmansukhani.com

Treatment – Basic Assumptions -Pathology expresses itself in intimacy relationships.

-Rigid interaction patterns reflect and create absorbing emotional states, due to neuroendocrine response patterns linked to the activation of behavioral systems.

-For many patients, the external world is suffused with the feelings belonging to the inner world (Fonagy and Target’s, 1997).

-Psychopathology is seen in terms of the persistence into adult life of earlier response patterns (Fonagy et al 2002) the activation of different behavioral systems simultaneously.

-There’s a high risk of decompensation and, therefore, retraumatization.


Treatment – Basic Assumptions -Emotions (states) are the center of change.

-People cope as optimally as they can, given their current circumstances and life history.

-Change involves a new undertsanding and experience of the self, of the other and the interaction.

-Therapy should be based on a solid and safe relationship that respects limits and is predictable. Many times, this will be the first healthy relationships the patient has experienced in his/her life.

-Work with subtlety and finesse (Janet), gradually helping the patients to expose themselves to manageable bits of disturbance and discomfort, specially with the most avoidant patients.


Treatment – Therapeutic Relationship

-Therapy is an “in vitro experiment in intimacy” (Holmes J, 2010). Intimacy is the core of problems of these patients. So:

-Conflicts are the norm, not the exception, in these cases, as patient and therapist encact emotional scenarios from his (patient’s) past.

Schore (2003): “The greatest challenge facing the therapist is the skillful managemente of enactments that often put the trerapist on the defensive evoke boredom, irritation, anger and hostility and in other respects put pressure on the therapist to behave in ways that are indompatible with empathic listening”.


-As an attachment figure must have worked on his/her attachment history and be able to interact safely and securely (Earned Secure Attachment, Mayn & Goldwyn, 1984; Hess 2008).

-As a interactive co-regulator should have the capacity of being in relational mindfulness

-Has to enter (and therefore validate) the clients’s worldview before challenging it. This implies understanding the patients bonding patterns and respecting them and accepting all parts, specially the “inner monsters”.

-Be sure that the past that is being re-created is not his (therapists) but the patients.

-Understand that conflicts in therapy, when correctly managed and interpreted, are the begining of therapeutic change.

Treatment – The therapist


Reminder of EMDR basics

• Image

• Cognition

• Emotion

• SUD

• Body Sensation

• Right Hemisphere

• Left Hemisphere

• Limbic System and

ANS

• Brainstem and ANS


DUAL FOCUS

Present

Past

Cognitive (adult)

Emotion+Sensation

When to do EMDR

In each session:

• Emotional impact has

been felt. There is no

numbness.

• It’s being articulated

• The person can stay

present with it.

Solomon, 2013

In therapy:

• Stability (stabilized or

has resources or

prepared to de-

stabilize).

• Security

• Understanding



Type 1: Symptomatic patiens : Axis I Symptomps

Dual attention easily

Type 2: Chaotic patients : BPD -PDNOS

Difficulties staying present:

Frequent abreactions (hyperactive dissociation)

Type 3: Stable unsymptomatic patients: no D-OCPD-APD

Difficulties conecting with past/sensations:

Frequent numbness or sleep or “getting off” (hypoactive dissociation)


(V: RV-1,2,3)

EMDR and Attachment Trauma

• Patients are mind-blind to their unresolved

attachment issues (Siegel, 2012). Including therapists.

• A lot of mentalising work to be done all along.

• Targets are not clear in initial therapy. Frequently new targets will appear during sessions, only when AS is activated.

• Images won’t come or will take long to come. Cognitions and body sensations help conect and lead the processing.


(cont.) • Targets appear in a hierarchical way (from

less to more important; i.e: school or

situations where the person felt insecure).

• Frequent use of symbolic images (face of

mother, inner child, etc.) and imagined

situations that allow to activate the AS.

• Frequent projection: children, children on

TV, pets, etc.)


(cont.) • Hypoactivation is linked to feeling of helplessness

• Dissociation is central even in not overtly dissociated patients (normally partial dissociations). Integration is progressive.

• Hypoactivation defences (dissociation) is more frequent than hyperactivation defences and is more difficult to notice, even by the patients. It will frequently seem that nothing is happening or the person is bored ant tired, etc.

• Initially negative emotions may appear with positive or neutral face/body language, disguising the feeling.

Phased Treatment

0. Reception:

– Tune one’s interaction to the attachment mode of the patient.

– Accept all parts, specially the “inner monsters”.

– Create a space of acceptance and calm from which exploration is possible and not fearful.

*With Avoidant/dismissive patients, help them to • Understand that the therapist is not going to be

invasive or manipulative.

• Be aware of their comfort zone and non-comfort zones

• To start understanding the reason behing extreme experiential avoidance (Hayes et al, 1996).


1. De-scalation and stabilization:

– Restore security: help understand and deal with the negative interaction cycle: • Initial self regulation techniques: window of tolerance.

• Start using parts language.

– Initial objective: conflict reduction.

– Relapse prevention/prescription: a chance to observe interaction and what failed. Before, during and after.

– Start differentiating correct responses from wrong ones.

Phased Treatment


Conflict cycle

Honeymoon

Crisis

Acumulation tension


2. Detect, understand and correct personal traits in safety and self regulation (underlying variables)

Phased Treatment


AUTO

REGULT. CO

REGULT.

SECURITY

(TRUST)

FEAR

(DISTRUST)

Phased Treatment

3. Endue and strengthen resources.

– Self-care abilities: Learn how to listen, respect and cover needs. (starting fr. homeostasic).

– Create rutines and structures.

– Initiate pleasurable activities: hedonic and eudaimonic.

– Strengthen ANP. Work with the Inner child

– Learn to regulate energy levels (even in sessions).

4. Solve current interaction and intimacy problems

– Work on limits.

– Comunication and interaction styles. Window of tolerance.

– Understand interactive and co-regulation.

– Understand dependence and it’s cycles.

– Solve specific couple therapy problems.

Phased Treatment


5. Work with parts: *Mosquera & González, 2012

– Co-conscienceness. Internal and external interaction types. Internal cooperation

– Understanding the needs of all parts.

– Phobia reduction. Acceptance of parts. Integration.

Phased Treatment


6. Analyze attachment patterns, and when and how they were formed.

– Progressive insights about attachment history

– Attachment styles of parents and relevant attachment figures. Combined effect.

– The role adopted in interaction with attachment figures.

– Mourning of the idealized family (Jung, 1967)

7. Learn healthy bonding patterns: – Capacity to self-regulate and co-regulate.

– Heal past relations.

– Generalize to other relations. Future relations

Phased Treatment


Thank you!


+34 607 803 803

+34 670 881 999

[email protected]

[email protected]

☻ www.arunmansukhani.com

interpersonal dependence and pathological bonding … · 2014. 12. 14. · patterns (id - pbp)...

Documents