Transcript Assessing for Time Limited Psychodynamic Psychotherapy (TPP-A)

TIME LIMITED PSYCHODYNAMIC
PSYCHOTHERAPY WITH
ADOLESCENTS AND YOUNG
ADULTS (TAPP)
Professor Stephen Briggs
SESSION 1: INTRO TO
TAPP AND THE COURSE
10am- 10.30am
WHY DO WE NEED NEW THERAPEUTIC
APPROACHES FOR YOUNG PEOPLE?
Adolescent mental health is
a major concern nationally
and world-wide
There are very few
evidenced psychological
interventions for young
people
Adolescent problems are not
‘neat diagnoses’ but complex
psychosocial predicaments
(Cottrell and Kroom 2005) in
changing, diverse social
contexts
50% of all lifetime mental
disorders begin before 14
and 70% by age 24
(MHG/DH 2011 page 50)
More intensive interventions
in adolescence may reduce
longer term problems
(Patton et al 2014)
Adolescents need ‘adolescent-centred’
approaches through therapies designed for
their needs, and which they can ‘buy into’
to increase engagement and good
outcomes
Why do we need TAPP?
• TAPP was developed to meet the needs of young people who
present at mental health services
• These young people present not with ‘neat diagnoses’ but with
‘predicaments’
• Which often combine social vulnerability with mental health needs
• Thus, a psychosocial approach is helpful
• TAPP has been developed to:
• Respect the capacity for growth and development during
adolescence
• Ensure young people’s involvement through ‘adolescent centred’
therapy
• Ensure relevance to young people’s social and cultural contexts
• Provide a therapeutic modality which has a focus on emotions,
relationships and relatedness
Where is TAPP being used?
• TAPP has been developed in CAMHS and in services
specialising in adult mental health services for young
people (e.g. Tavistock)
• Current applications include:
• CAMHS in England (e.g Leicester, Tower Hamlets, Kent)
• School counselling services
• HE counselling services
• Training to individuals and organisations to use TAPP
• TAPP has been manualised, and research to evidence its
effectiveness is in preparation
What issues can be worked with using
this model?
• The focus on development means TAPP can be
considered for many young people.
• It is particularly useful for
• Complex presentations (social vulnerability plus m/h diagnoses)
• Difficulties in relationships (including e.g. (self)destructive
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relationships and self-harm/suicidal thoughts)
Anxieties and difficulties around separation
Anxieties around external events
Depression
Second treatments
When there is an external time-limit
When presentation is post-trauma
Transitions from CAMHS to AMS
What is TAPP?
TAPP’s structure
• TAPP is a manualised time-limited psychodynamic therapy for young
people between 14 and 25 (30)
• It has a usual structure of 4 sessions assessment followed by 16
sessions treatment, with a follow up-review session 6-8 weeks after
the end of treatment
• TAPP’s rationale
• The developmental process in adolescence is a powerful force for
change and growth
• Therapeutic focus on developmental difficulty/disturbance can recover
the individual’s capacity to meet her/his developmental challenges
• Therapeutic structures of time and focus can help young people
manage development and transitions in their social and cultural
contexts
Key features of TAPP
• TAPP is based on
• Psychoanalytic approaches to understanding and conceptualising
adolescent development
• Psychodynamic approach to therapeutic relatedness – including
• focus on the transference and counter transference
• working in depth
• It is adolescent centred – notably through
• active engagement of young people in establishing the focus for
therapy,
• contracting processes and
• working with their narratives of themselves
• It is rooted in understanding the young person’s negotiation of
their transitions through adolescence within their social and
cultural contexts
• Time-limits provide a structure for working with processes of
engagement, relating, change, ending, and reviewing
The therapist’s priorities when using TAPP
• Working with a developmental focus
• Working in depth, particularly with the transference and
counter-transference, and thus accessing deep anxieties
• Adopting a stance that provides a containing therapeutic space
• and which is thus both supportive and promoting possibilities for
exploration
• Support for the therapist is through supervision/seminar group,
focussing on the meaning of the therapist’s emotional
experiences
• Working with time-limits
The values and challenges of the timelimited approach: pros and cons?
In favour of time-limit
• Provide structure in complex
and confusing socio-cultural
transitional contexts for young
people
• Provide a focussed
intervention
• Help therapists through
structuring therapy
Against time-limit
……or feel like an oppressive
imposition on freedom
…….or make it difficult to work
through more
problematic/pathological aspects
of development
……… or put therapists under
pressure to work within a
timescale
Exercise
• In Pairs
• Share thoughts about working with young people
• Complete the questionnaire and use this to discuss:
• The kinds of issues that young people have and that you work with in
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your work setting
Issues that arise for you in working with them
Sharing the examples of your work you have reflected on before the
course and/or
Examples of your work that you are thinking about now
Thoughts about your hopes and expectations for the course
• Followed by feedback to whole group
SESSION 2: UNDERPINNING
PRINCIPLES OF TAPP
11.00 - 11.30am
11.45- 12.45
Development, change and growth in
psychodynamic therapies
• What are the key concepts in psychodynamic practice?
• Past relatedness and experiences affect the present
• We defend against experiences that make us anxious
• Past aspects of relatedness are attributed to others in the present
(transference)
• These are received by the ‘other’ as emotional experiences which if
recognised can help understanding (of the client)
• Therapy aims to increase self- understanding and the capacity to
sustain (rather than discharge) emotions
Psychodynamic therapeutic action
• Recovering past memories and patterns of relatedness
• Working through in the transference
• Containment of anxieties to increase the capacity to think about
feelings rather than discharging them
• Healing power of the narrative
• Integrating accounts from the past to achieve narrative coherence
and authenticity
• The corrective emotional experience
• Making implicit relational models explicit
• Mutative exchanges
A.Lemma (2003) Introduction to the Practice of Psychoanalytic Psychotherapy (page 82)
The process of container-contained
Infant projects
overwhelming
feelings
Infant takes in
named experiences
and mother’s
thinking capacity
Mother takes in
infant’s feelings,
makes sense of
them
Mother returns
feelings, named, in
modified form
Internalisation in infancy
Qualities of internalisation depend on qualities in the containercontained relationship (Bion 1962)
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Infant’s overwhelming experiences are projected into the mother
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Mother’s ‘reverie’ makes sense of infant’s emotional experiences
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Infant’s anxieties are modified, named, made bearable
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Infant internalises named emotional experiences and a mother who can bear
to think about emotions and modify anxieties
Internalisation when infants are in vulnerable situations:
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intense anxieties may not be mediated and will overwhelm the infant
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the infant defends against painful experiences
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the infant’s internalisations will include internal relatedness in which
dependency, intimacy and capacity to be separate will be disturbed
Contemporary Adolescence
• Contemporary adolescence is organised around two
distinct phases.
• The transition from childhood to early adolescence,
• through the impact of puberty,
• is a period of intense growth and far reaching changes- physically,
cognitively, emotionally.
• This is followed by a long transition into adulthood,
• which, though inclusive of diverse ‘pathways’ is usually extended,
lasting approximately for a decade from mid/late teens until the mid
twenties.
‘Becoming-a-Subject’
• During adolescence, the young person moves from being
a ‘child in the family’ to being ‘ a person in the world
• To accomplish this, the adolescent has to achieve:
• Separation from parental figures
• Ownership of new, adult, sexual body – and its role in the social
world
• Ownership of capacity for thought; thinking one’s own thoughts,
separate from others
• Ownership of drives, sensations, impulses, feelings and powers
• Problems in adolescence stem from problems in the
adolescent developmental process – in ‘becoming a
subject’
The entanglements of early adolescence
the ‘extraordinary entanglement, in the young adolescent’s
world, of internal and external, and of bodily and mental forces
and factors” (Waddell 2002)
The aim with early adolescence is to get past it – and then not
look back! (Jacobs 1990)
“though he was growing it was not a problem for him, but he had
two friends who did have problems, because for one of them his
bones were growing faster than his muscles and ligaments, and
with the other friend it was the other way round; his muscles
were growing faster than his bones. One of them was very stiff
and the other was very floppy.”
The adolescent process… it cannot be
hurried, but it can be undermined…
“The cure for adolescence belongs to the passage of time
and to the gradual maturational processes; this process
cannot be hurried or slowed up but it can be broken into
and destroyed, or it can wither up from within” (Winnicott
1971)
The power of the adolescent body
Leaving the ‘quiescence’ of latency, acquiring adult (physical)
power: In latency
‘‘It is the very balance of a relatively weak child and
relatively strong parents which, whatever the impulses
and anxieties is a background bedrock of reality which
allows for a sense of safety.” (Anderson 1999)
In adolescence, with the acquisition of the adult sexual body
‘S/he can really attack, destroy, rob, murder or commit
suicide, and he can really have sexual experiences of a
or homosexual kind’ (Hoxter 1964 page 13).
Adolescence: a second chance (Blos)
• ‘Dickie’ Bird (1989): assessing adolescents involves the question of
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identifying to whom pain and anxiety belong and are attributed
(projective processes).
A H Williams (1978) explored the dynamic meaning of depression in
adolescence – as a force for development as well as a painful
situation
R. Anderson and A. Dartington (1998) “If the adolescent is to
successfully achieve adulthood, he (sic) must re-negotiate every
aspect of his relationship with himself, and with his external and
internal objects in a new context”
Margot Waddell (2002) the ‘extraordinary entanglement, in the
adolescent’s world, of internal and external, and of bodily and mental
forces and factors” and
(2006) ‘‘the swiftness with which what seem to be deeply entrenched
narcissistic structures may be modified or modulated in response to
even quite small internal or external change’
The developmental process
• Development is formulated as the working through of the
dynamic effects of puberty for the individual, necessitating
reworking of relatedness to self and others
• It is significantly affected by the qualities of close relationships
with parents, authority figures outside the family, peers,
emerging love relationships, and those of social and cultural
contexts
• It requires:
• establishing the integration of the adult sexual body as essential
to individual identity,
• the ownership of one’s own thoughts, drives, sensations,
impulses, feelings and powers
• accepting the emotional experience and meaning of increasing
emotional, mental and/or physical separateness from parental
figures
• …as experienced in diverse social and cultural contexts
‘Catastrophic change’
• Development in adolescence and early adulthood generates
‘catastrophic change’ (Bion 1963) through the disjuncture of
past, present and future.
• It involves intense emotional experiences which disturb
• previous qualities and patterns of containment,
• ways of defending against anxiety that worked in childhood,
• it puts pressure on the individual to manage and make sense of
emotional experiences.
• This leads to new defences against anxiety, including splitting,
projection, denial, idealization, projective identification.
• Development is therefore characterised by powerful
progressive and regressive trends and involves rapid shifts of
states of mind, moving between paranoid schizoid and
depressive functioning (Ps<->D)
Development in current contexts
‘Developing subjectivity in particular domains of experience
more accurately describes these changes than does the
more traditional concept of identity formation” (2011 p418)
• Pathways into adulthood have become more complex,
extended, less structured, ‘desequenced’, disembedded
• These create a deeply contradictory situation and
generate new and different psychological tasks
• thinking flexibly about future plans,
• making decisions,
• responding to changing contexts,
• generating narratives to make sense of these experiences
• Fast-track and slow-track ‘routes’
Inequalities increasing: Fast Track and
Slow Track transitions
Slow track
• Staying on in education (until
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30 or later)
Many semi-independent
statuses requiring parental
support
Problematic for those without
middle class models of parental
support
Can result in ‘broken’ or
‘fractured’ transitions
Mental health issues arise
Acquiring social capital
Fast track
• Leaving education on or before
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min. age
Risks of unemployment, poor
wages
NEET
Early family formation
Higher anti-social behaviour
rates
Social exclusion
(Early achievement of adulthood
more likely to mean premature
loss of childhood)
Lack of social capital
Becoming a subject in adolescence
SeparationIndividuation
Self-esteem/
competence
States
of mind
Fear of
failure
Subject
to
Subject
of
Power
Dependence
Death
Life
Regression
SESSION 3: ASSESSING
FOR TAPP
1.45-3.00
Working with
First young person
adolescents is
Therapist: the plan is
different!
that we will meet weekly
Questions of
for 16 weeks
time, balance….
Young person1 : Really?
and ambiguity
As long as that? Am I
really that ill then?
Third young person
Second young person
Therapist: the plan is
Therapist: the plan is
that we will meet weekly
that we will meet weekly
for 16 weeks
for 16 weeks
Young person 3: It’s
Young person 2: Oh no –
down to you is it – what if
what will I do after that?
I don’t agree? It’s my life
The psychodynamic pyramid/prism
(for adolescence)
Development
Past Relationships
Current relationships
Transference
The Assessment
“The offer of therapy is primarily a process which
requires discussion, negotiation and containment of the
emotional experiences involved….the therapist suggests
discussing together the kind of treatment that will be
most helpful and appropriate and seeks the active
involvement of the young person in this process”
Assessment is usually four weekly interviews
Engaging young person in weekly sessions
Establishing modes of learning/relating
(including attributions of pain/anxiety –Bird
1989) (e.g. thinking between sessions)
Making a treatment offer in 3rd session,
including articulation of the developmental
focus
Offer reviewed, and contracted in 4th
session
SESSION 4: FORMULATING:
MAKING A TREATMENT
OFFER: THE
DEVELOPMENTAL FOCUS
3.15-.4.30
Formulations
• includes a focus on the qualities of change that occur
during the assessment
• contrasting more free flowing, discovery-laden interactions with
those that are more stuck, rigid or repetitive.
• Through this process, the therapist arrives at a view of the
developmental trajectories of the young person, the
anxieties and defences he has, and the qualities of
internalisation/inner object relations that support or disturb
the process of development.
• These are characteristically experienced in relation to the
therapist;
• emergent patterns of transference –counter-transference are
elucidated – initially provisionally
The treatment offer
• An offer of TAPP is usually made during the third
assessment session, and this is discussed and negotiated
in the fourth session
• the offer of 16 sessions treatment (plus a review session after the
therapy), which can be stated as therapy continuing up to a
specified time, e.g. the end of a specific month, or in relation to an
acknowledged future event in the YP’s life
• the formulation of the purpose of the brief therapy in terms of a
developmentally based focus – e.g.
• ‘working to understand more how these problems affect you whilst you
are changing and growing’ or
• ‘getting to grips with how (a particular event, a current set of
relationships, a current task) these affect you as you go through a
period of development and change’ or
• An agreement of a suitable regular time for the therapy
The Young Person’s response
• The offer is primarily a process which requires discussion, negotiation
and containment of the emotional experiences involved.
• Initially, either in the first or second session, the therapist suggests
discussing together the kind of treatment that will be most helpful and
appropriate and seeks the active involvement of the young person in
this process.
• The young person may respond with a thoughtful response which
creates the opportunity of a genuine negotiation, or, alternatively, by
omnipotent assertion, eager acceptance which needs no discussion
or pre-empts it, or passive deference to the therapist’s authority and
knowledge.
• At this point some ambivalences frequently emerge and can be
expressed in terms of contradictory wishes for treatment – e.g.
• the young person says he wishes for weekly therapy but does not have the
availability to attend regularly –
• or wishing for something that will not involve effort and work, an instant
‘prescription’ which can be taken away and ingested.
The developmental focus
• Theorisation of the developmental process in adolescence
underpins the formulations of a developmental focus for each
case:
• The presence of anti-developmental factors that reduce the capacity to
engage with current life tasks and relationships, and/or
• The absence or weaknesses of resources that can promote growth and
development
• The developmental focus relates closely to the young person’s
own account of themselves and their struggles and anxieties,
• and to encompass a sense of becoming, of encouraging curiosity about
self and others.
REVIEW OF THE DAY
4.30-5.00
“one of the outcomes of TAPP is
the young person’s engagement
with the continuous project of
themselves, the development of
their subjectivity, and awareness
of their emotionality” (2011
p423)
TAPP training courses
• Practitioner TAPP training consists of 3 elements:
• 2 day introductory (this can be taken as ‘stand alone’ e.g. for CPD)
• Supervision of TAPP cases
• 3 one day workshops
• Accreditation as a TAPP practitioner additionally involves
assessments
• The training is in process of accreditation by the British
Psychoanalytic Council (BPC)
Contact and further information
Stephen Briggs
• [email protected]
• [email protected]
• www.stephenbriggsconsulting.co.uk
Please contact me for further information including
• Copy of the manual for TAPP
• Training and supervision in TAPP
• Research of the application of TAPP
• Service consultation for introducing and using TAPP