toward a dmm based dynamic psychotherapy (dmm …...franco baldoni attachment assessment lab...
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TOWARD A DMM BASED
DYNAMIC PSYCHOTHERAPY
(DMM-DP)
Franco Baldoni
Attachment Assessment Lab
Department of Psychology, University of Bologna, Italy
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)
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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)
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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
Confronting models in Dynamic Psychotherapy Contemporary
Psychoanalysis
Attachment
A-B-C+D
Attachment
DMM
Key
concepts
Relationship, unconscious,
transference, countertransference,
conflicts, resistances, defenses
(less importance of drives)
Attachment relationships,
secure base, IWM, mentalization
Danger, adaptation, cognition,
emotion, memory systems, patterns,
self-protective strategies,
dispositional representations
Motivations Meeting the needs,
limiting suffering
Searching for Safety Protection from danger
Models
Conflict, symbol,
personality structure
Secure and insecure attachment,
IWM: A-B-C+D / Ds-F-E-U
Pattern: A-B-C, low and high index,
mixed patterns, modifiers
Defenses Neurotic or primitive Attachment behaviors, defensive
exclusion, ambivalence
Strategies for
self-protection from danger
Pathology Psycho-neurosis, perversion,
personality disorders, psychosis
Dysfunctional attachment,
loss, trauma
Dysfunctional adaptation,
Modifiers (U/Tr, U/l, Dp, DO, ina)
Assessment Clinical interview, projective tests,
Manual: PDM, OPD
Clinical interview, SS, AAI,
Self-report questionnaires
Clinical interview, CARE-Index, SS,
PAA, SAA, TAAI, AAI
Technique 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)
Promote a secure base
Encourage exploration
Identify the IWM
Analysis of transference
and of attachment behaviors
Interpretation
Mentalization
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
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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
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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
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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
Clinical relationships examples
Clinician Patient Results
A (dismissing)
A
Rigid technical-cognitive approach
Unexplored and avoided areas
Dismissing negative emotions
False affects
C (preoccupied)
C Emotional emphasis
Excessive expectations
Extended consultations
Relationship conflicts
A
C
C
A
B (secure or balanced)
A, B, C Mentalization
Affective and cognitive communication
Tailored to the patient strategies
Partial compensation
Difficulty in understanding
Therapy interruption
(Baldoni 2012)
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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
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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)
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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
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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
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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 socio-cultural 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
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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
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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)
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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)
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For information
Prof. Franco Baldoni
Attachment Assessment Lab
Department of Psychology
University of Bologna – Italy