ed patient: innocent or complicitous victim? an exploration of self-protective strategies in ed pm...

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


Three Aspects of Attachment

• Inter-personal: Strategies for eliciting protection and comfort

• Intra-personal: Information processing

• Familial: Array of interacting strategies


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.


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


Attachment Models

• Ainsworth: A B C

• Main & Solomon: A B C D (disorganized)

• In practice: Secure (B) versus Insecure

• Dynamic-Maturational Model (DMM, Crittenden)


Ainsworth Patterns of Infant Attachment

Predictability Negative Affect

Integration


Ainsworth Patterns of Infant AttachmentPlus Main & Solomon’s Disorganized

↑← Disorganized → ↓

Predictability Negative Affect

Integration

Secure


DMM: Transforming Information

• Serves a self-protective function

• Becomes more sophisticated with maturation of brain

• Appearance ≠ reality


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


Psychological Advances

• Implicit (non-verbal) causality

• Implicit affective states

• Being together:

- in temporal contingency and

- affective attunement


DMM in the Preschool Years

False Positive 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



• Verbal statements of what causes what

• Words for feeling states

• Construction of interpersonal episodes

• Or the absence of these


DMM in the School Years


Integrated True Information

True Cognition True Negative Affect

False Cognition



A1-2

A3-4

ComfortableB3

ReservedB1-2 B4-5

Reactive

C5-6

C3-4

C1-2Threatening/

Disarming


Punitive/Seductive





• 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?


DMM in Adolescence



False Cognition

Compulsively Promiscuous/Self-Reliant

ComfortableB3

ReservedB1-2 B4-5

Reactive

A5-6 C5-6

C3-4

C1-2Threatening/

Disarming


Punitive/Seductive



A1-2

A3-4



Sexual desire



• Wordless communication:

– Type A: Borrowed words & ideas

– Type C: Sullen wordlessness, behavioral communication


DMM in Adulthood


Delusional Idealization/Externally

Assembled Self



ComfortableB3

ReservedB1-2 B4-5

Reactive

A1-2

A3-4

A7-8

A5-6

C7-8

C5-6

C3-4

C1-2Threatening/

Disarming


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



Strategies for Dangerous Caregivers

Type A:

• Do the right thing from the perspective of others.

• Inhibit displays of negative affect.


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.)


DMM in Adulthood


Delusional Idealization/Externally

Assembled Self



ComfortableB3

ReservedB1-2 B4-5

Reactive

A1-2

A3-4

A7-8

A5-6

C7-8

C5-6

C3-4

C1-2Threatening/

Disarming


Punitive/Seductive

Menacing/ParanoidAC

Psychopathy

A/C

Very severe pathology Very severe pathology

No psychopathology

Extreme pathology

Apparently not clinical, sometimes somatic

Inexplicable & troublingpsychopathology


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.


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.


• No model is stored.

• DRs are always generated anew in the present.

• The presence, and probability of firing, of synapses reflects past experience.


• Parallel processing yields:

– Many different DRs;

– Each processed differently by the brain;

– Multiple solutions to each problem.


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.


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.


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.


Safety in the face of danger requires a fast response at the

cost accuracy of response.

Hence, exposure to danger reduces integration.


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.


Defining Crazy

Doing again what failed every time before -

and expecting a different outcome this time.


Three hypotheses:

• ED girls are trying to protect themselves.

• Parents of ED girls are trying to protect the girls.

• Appearance does not equal reality.


Three Examples of Appearance/Reality Discrepancy

• Ringer & Crittenden findings with DMM

• Case study from in-patient treatment

• Case study of family process & politics:


Adult Attachment Interview

• DMM classifications & method

• Assess strategy & information processing

• Multiple DRs assessed

• Strategy, trauma, modifiers


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


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?


Ringer Sample

• 19 Anorectics (restricting)

• 26 Bulimics

• 17 Anorectics (binging)


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


Common DMM strategies for ED

• C5-6

• C3-4 (bulimic)

• A1/C5-6

• [A] C5-6 (false A1)

• A3-4

(Ringer & Crittenden)


Ringer & Crittenden Results, Con’t

• Few Utr; most imagined (erroneous causation)

• Almost no modifiers – very strategic (not Dp)


Transformations

• Exaggerated affect

• Non-verbal communication

• Strategy employed without regard to outcomes

• Strategy can be used self-destructively without regard to results


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.


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.


Why use deception?

Adolescents’ perspective:

1. To avoid losing contact with a protective parent;

2. To communicate with the skills that one has.


Deception Scale

• Lie

• Intentional deception

• Self-deception

• Involving self-deception

• Reciprocal & involving self-deception

• Reciprocal, involving, & intentional self- and other-deception


Familial Processes

Two cases of ED adolescents & parents:

- Exploration of AAIs

- In-patient clinical experience.


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.


A Developmental Perspective on “Truth”

• Truth about the past is not predictive truth.

• The brain is evolved to use information to predict the future.


The only information that we have is information about the past

whereas

The only information that we need is information about the future.


Consequently, information from the past must be transformed to maximally

predict danger in the future.


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).


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.


Psychological & Strategic Effects

• Causal information is omitted.

• Affect is exaggerated.

• Child is Type C2-4 and maybe also idealizing of M (A1/C2-4)


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.



• 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.


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.



• 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.


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.


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.


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.


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


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?


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.


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.


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


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.


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.


To contact us:

• [email protected] or www.patcrittenden.com

• [email protected]

http://www.patcrittenden.com/

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