Transcript Slide 1

April 3, 2014
Dr Mark Schwartz
Avalon Malibu
&
Monterey Institute of Mental Health
[email protected]
314.378.6832
[email protected]
• Love is willingness and ability to be affected by another
human being and to allow that effort to make difference
in what you do, say, become.
• Compulsion is the act of wrapping ourselves around an
activity, a substance, or a person to survive, to tolerate
and numb our experience of the moment.
• Love is a state of connectedness, one that includes
vulnerability, surrender, self-valuing, steadiness, and
willingness to face, rather than run from, the worst of
ourselves.
• Compulsion is a state of isolation, one that includes self
absorption, invulnerability, low self-esteem,
unpredictability and fear that if we faced our plan, it
would destroy us.
• Love expands; compulsion diminishes
People go to great lengths to maintain the illusion of
connection. Many select mates who remind them of
their parents to try to recreate their past. They ignore
their children’s individuality and try to mold them into
an image of themselves in an attempt to achieve a
kind of immortality. Others work compulsively, taken
refuge in routines, or choose addictions to avoid real
experiences that threaten their illusions. In contrast,
individuals living a self-actualized existence discover
what lies beyond defenses and illusions of
connection. They make real contact and establish
genuinely loving relationships with actual people in
real life in spite of the awesome spectre of existential
aloneness and interpersonal pain.
Fireston, Robert W., Creating a Life of Meaning and Compassion
Love is not primarily a relationship to a specific
person; it is an attitude, an orientation of character
which determines the relatedness of a person to the
world as a whole, not toward one “object” of love. If
a person loves only one other person and is
indifferent to the rest of his fellow men, his love is
not love but a symbiotic attachment, or an enlarged
egotism... If I truly love one person I love all persons,
I love the world, I love life. If I can say to somebody
else, “ I love you,” I must be able to say, “I love in you
everybody, I love through you the world, I love in you
also myself.”
From “The Art of Loving”, 1956, Erich from
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Start with the assumption that every symptom is a valuable
piece of data
Use psycho educational material to make educated guesses
about the meaning of symptoms, as a symptom-memory or
a valiant attempt to cope.
Ask her,” how would this ___ have helped you to survive in a
unsafe world? Helped you to feel less overwhelmed? Less
helpless? More hopeful?
Look for what the symptom is still trying to accomplish: i.e.,
chronic suicidal feelings might offer comfort or a “bail-outplan;” cutting might help modulate arousal; social avoidance
could be an attempt to avoid “danger”
Once it is clear what the symptom is trying to accomplish,
then the therapist and patient can look for other ways to
accomplish the same goal in a context that describes the
patient as an ingenious and resourceful survivor, rather than
a damaged victim.
The concept of “burdens” is brilliant in its
widespread application. It sidesteps the need to
compare, contrast, count symptoms to diagnose,
and postulates instead more of a “no one
escapes unscathed” framework. Thus, “burdens”
can encompass beliefs, feelings, and energetic
residue of events and experiences that
overwhelmed the internal and/or external
accessible resources of the organism and its
attachment environment at the time, thereby
creating constraint.
Developmental deviation of ontogenetic process,
failure of adaptations, pattern of adaptation
reflecting the totality of the developmental
context to that point. Maladaptation can be the
result of different developmental pathways,
which are probabilistically related to
disturbance. Individuals beginning in similar path
may diverge, showing different pathology.
Fear activates the attachment system but, if the
primary attachment figure is the source of fear,
the result is the collapse strategies for dealing
with stress, preparing the capacity to regulate
arousal by using others for self-soothing and
delayed use of self-controlling behaviors.
1. Attachment is an organizational construct not a
causal agent.
2. Disorganized attachment correlates 34 percent with
global pathology and 36 percent with dis-associative
disorder .
3. Anxious attachment is uniquely and specifically
associated with anxiety disorders while avoidant
attachment with conduct disorders.
4. Both physical and sexual abuse increased incidence
of conduct disorder to 73 percent and was the
greatest predictor of adult depression.
5. 40 percent of parents who experienced childhood
abuse maltreated infants.
Sexual and physical abuse at the hands of family
members cause the child to split off experiences,
relegating them to an inaccessible part of self.
Dissociation of one’s experience sets the stage
for loss of one’s true self. The true self becomes
corroded with inner badness and is concealed at
all costs. Persistent attempts to be good, thus
leading to a socially acceptable self, are
experienced as non-authentic. The adolescent is
compelled with demand to create multiple
selves in different contexts.
Because their caretakers have been routinely
available to them, sensitive to their signals, and
response with some degree of reliability (though by
no means is perfect care required), these develop a
confidence that supportive care is available to them.
They expect that when a need arises, help will be
available. If they do become threatened or
distressed, the caregiver will help them regain
equilibrium.
Such confident expectations are precisely what is
meant by attachment security.
L. Alan Stroufe, 2000
• Excessive worry about relationships
• Worry partner won’t care as much as s/he does
• Obsessive preoccupation & rumination about
relationships
• Excessive need for approval
• Ignoring signs of trouble in relationship
• Fear will scare people away
• Fear of abandonment/rejection/criticism
• Resentment when partner spends time away from
relationship
• Angry withdrawal
• Frustration if partner not available or if don’t get what
need
• Feel extremely bad in face of disapproval
• Easily upset; intensified displays of distress or anger
• jealousy
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Fear of being alone
Compulsive care-taking
submissive, acquiescent, suggestible
Attachment at expense of autonomy
Work, school or friends get less attention
Compulsive care-seeking
Partner describes as “smothered” or “suffocated”
Eager to be with partner all the time
Need excessive reassurance
Clinging, demanding, nagging, or sulking
Desire to merge
Proactive attempts to win favor or impress
Forcing response from partner
Self-centeredness, showing off, center of attention
Dan Brown, 2008
Peter Fonagy and colleagues have described this
ability as a product of the adults’ “reflective
function” in which parents are able to reflect
(using words) on the role of states of mind
influencing feelings, perceptions, intentions,
beliefs and behaviors. For this reason, reflective
function has been proposed to be at the heart of
secure attachments, especially when the parent
has had a difficult early life.
The avoidant infant actively restricts attention to mother – as
if to distract from the anxiety and distress of wanting
mother’s comfort.
The preoccupied actively seek and confines self to monitoring
mom’s whereabouts, ignoring the toys and exploring the
environment. Gives up the development of self to survivor.
The disorganized capitulate in external relationships, they
also extend internal relational exchanges between parts of
the self, leading to chronic inner conflict, internal
abandonment of parts of self holding traumatic affect and
ruthless self-criticism.
Outpatients actively live by the rules of attachment.
Dismissive client find attention focused on needs of others,
denying their own needs. Preoccupied are consumed with
doubts about self and others and yearnings. They store up
strategies to justify and maintain pre-existing beliefs.
• Self-regulation (security, control) - look, listen,
attend, feel calm, modulate affect and behavior
• Forming intimate relationships ( optimism,
security, dependence)
• Engaging in boundary-defining communication
(self-other)
• Representing internal experience (wishes,
intentions, affects, complex sense of self)
• Feeding without nutrition
• Treated like an infant, rather than as a capable adult.
• Parents preoccupied with work and themselves, and
at the same time are over-focused on children.
• Parents irresponsible and over-responsible:
– Absent and hovering
– Give little of themselves and shower with material
goods.
– Uninvolved with homework or do homework for kids.
• Child raising child. Parenthood is ego dystonic.
• Only as good as last accomplishment: Don’t derive
mastery and efficacy from last accomplishment.
• Such behaviors include:
– Installing guilt
– Installing anxiety
– Withdrawing love
• Excessive achievement demand
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Avoiding tenderness
Affective punishment
Hostile detachment
Interfering with decision-making
Excluding outside influence
Not fostering self-reliance
Place child as subordinate to confirm completely
• Inhibiting child’s discovery
• Inhibiting expression of self
• Excessive parental expectations
Daily alcohol
consumption
Low Desire
Arousal
Disorder
Sexual Pain
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1. Men 50-59 are 3x as likely to have erection
problems and low desire than younger men.
Impotence 9.6% in older men.
2. Non married women 112 times more likely to
have climax problems and sexual anxiety.
3. High educational attainment negatively
associated with sexual problems. Women
graduated from college are half as likely to
experience low desire or orgasm problems.
4. Male college grads half as likely to report nonpleasurable sex and sex anxiety.
5. Arousal disorder highly associated with sexual
trauma history in men and women.
WOMEN
Unaffected – 58%
MEN
Unaffected – 70%
Low desire – 22%
Low arousal – 14%
Premature ejaculation –
21%
Erectile dysfunction – 5%
Sexual pain – 7%
Low desire – 5%
I don’t know that we’ve ever experienced true
sexual arousal, only fear arousal; Arousal driven
by terror, anxiety or excitement that is basically
over-stimulation. “When I feel tense, it
translates into a physical response in the vaginal
area.”
Abused children discover they can produce
release through temporary alterations in their
affective state by voluntarily including autonomic
crisis or extreme autonomic arousal. Purging and
vomiting, compulsive sexual behavior,
compulsive risk taking or exposure to drugs, and
the use of psychoactive drugs become vehicles
which abused children regulate their internal
state.
Judith Herman, M.D.
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Calmness
Curiosity
Clarity
Compassion
Confidence
Courage
Connectedness
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Joy
Gratitude
Humor
Equanimity
Perspective
Peace
Kindness
self punitive voice
out of control /over
perfectionism
control
Avoidance of anxiety
regular schedule
inability to take action
eat /sleep /exercise
harm avoidance
overly self /other focus
social inhibition emotional- self care
recognition tolerance
sexuality
expression
destructive relationships
saying no/ yes
showing up
shame binds keep
surrender
commitments
self forgiveness
self compassion
formulating meaningful life
chaotic lifestyle
coherence
clean house files papers- dissociation
mail
INTER-PSYCHIC INTIMACY
(between the couple)
vs.
INTRA-PSYCHIC INTIMACY
(within the individual)
Self and relational Dysregulation. The child exhibits impaired
normative developmental competencies in their sense of personal
identity and involvement in relationships, including at least three of
the following:
1. Intense preoccupation with safety of the caregiver or other loved
ones (including precocious care giving) or difficulty tolerating
reunion with them after separation.
2. Persistent negative sense of self, including self-loathing,
helplessness, worthlessness, ineffectiveness, or defectiveness.
3. Extreme and persistent distrust. Defiance or lack of reciprocal
behavior in close relationships with adults and peers.
4. Reactive physical or verbal aggression towards peers, caregivers,
or other adults.
5. Inappropriate (excessive or promiscuous) attempts to get contact
(including but not limited to sexual or physical intimacy) or
excessive reliance on peers or adults for safety and reassurance.
6. Impaired capacity to regulate empathic arousal as evidenced by
lack of empathy for, or intolerance of, expressions of distress of
others, Or excessive responsiveness to the distressed of others.
The National Child Traumatic Stress Network (NCTSN)
The internalizing of the attentive,
validating, caring relationship to oneself. This
involves helping the client articulate her
experience and bring it into her own internal
relational context.
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Unconditionally loving and accepting.
Affirming.
Takes responsibility.
Sets and teaches healthy boundaries.
Is protective.
Values play.
Is forgiving mistakes.
Encourages growth
Listens to child in open and receptive
way.
These are the qualities of the ideal “self-parent”
Low threshold for sexual responsiveness, often
with obsessive-compulsive rituals of sexual
expression that displace the unfolding of
connection or caring for the partner. The rituals
may also revolve around masturbation rather
than partnered sex, or paraphilic sex,
accompanied by a great deal of shame with
primary emphasis on relief or anxiety or tension.
It is therefore, quite common for one individual
to be both hypersexual and hyposexual within
the same or different periods of their lives. Their
extremes of responsiveness seem contradictory,
but are actually a predictable adaptation to a set
of complex overwhelming contradictory internal
cognitive-affective, behavioral structures,
evolved in a response to original rejection,
abandonment, neglect, assault and resultant
recreations and misappraisals.
• Sexual response is consistently inhibited.
• Low initiatory behavior.
• States, “I don’t enjoy sex very much and would
prefer to have less than once a month.”
• In relationships, often one partner is
hypersexual and the other feels pressured and
thereby hyposexuality and this dynamic
becomes amplified, creating labels “too much –
too little” which becomes disposition.
In sex therapy, entitlement refers to the
therapist giving the client permission to not to
be sexual. For example, a therapist might say: “ it
is understandable that, given what happened to
you and what you’ve done to yourself as a result
of what was done to you, and the destructive
influences on your choice of partner and the
relationship you’ve each created, you do not feel
sexual. It would be a miracle or even
dysfunctional if anyone could feel sexual under
these circumstances!’
• Re-enactments of past conflicts or traumata,
with underlying motive to resolve unfinished
business.
• Perversion: Turning childhood tragedy into
triumph.
• Illusion of being wanted/desired
• Illusion of having power and control
• Management of dissonance and paradox
1.
Authority Over Memory - Can take event from
past, talk about it with sense of empowerment.
2.
Integration of Memory and Affect - Can feel
appropriate affect with cognition. New affect
(adult-oriented)(1995).
3.
Affect Tolerance and Trauma - Related Affect Feelings no longer overwhelmed, get
overwhelmed and back into the trauma, ignore
and walk into danger.
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Symptom Mastery – Hyper vigilant, anxiety,
depression, dissociation, somatic, compulsivity,
how much do we need to measure remission.
5. Self-Esteem - Capacity for self-care and regard,
properly eat, exercise, sleep, self soothe.
6. Self-Cohesion - How one experiences oneself,
fragmented, compartmentalized, self-trust
7. Safe Attachment - Negotiate and maintain
safety in relationships.
8. Making Meaning - Making meaning of their
experiences.