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MBT and trauma

Ab Hesselink 27 april 2012, Haarlem

Case Nicole
Vulnerability Neglect Physical aggression

PTSD and BPD

PTSD

Objective nor subjective stressor criteria predict the development of complex PTSD Needed: a person-oriented model instead of a symptom-oriented Model

Allen, J.G., Lemma, A. & Fonagy, P. (2012). Trauma. In: Bateman, A.W. & Fonagy, P. (ed.) Handbook of Mentalizing in Mental Health Practice (pp.419-444). Washington, DC: American Psychiatric Publishing

Traumatic stressors
Spectrum of interpersonal involvement
Impersonal stressors Interpersonal Attachment trauma

PTSD

Complex PTSD / Axis II

Allen, J.G.(2001). Traumatic Relationships and serious Mental Disorders. Chichester, UK: Wiley.

Attachment trauma

Trauma in an attachment relationship Trauma reduced mentalizing capacity

Reduced mentalizing capacity trauma is fixed

Attachment trauma
Abuse - Physical abuse - Sexual abuse - Antipathy - Psychological abuse Neglect - Physical neglect - Psychosocial neglect
Bifulco et al (1994). Treating Attachment Trauma. In: Allen, J.G., Fonagy, P. & Bateman A.W. Mentalizing in Clinical Practice (pp.214). Washington, DC: American Psychiatric Publishing .

Non - mentalizing modes

Psychic equivalence, f.e. flashbacks Teleological mode, f.e. (self)destructive behaviors Pretend mode, f.e. dissociation

Psychic equivalence
Mental reality = outer reality: Concrete understanding Flashbacks Extreme rigid thoughts Intolerance of alternative perspectives Self-related negative connotations may be felt too real

Trauma related symptoms: f.e. flashbacks, extreme alertness, irritability Nicole: fits of rage

Teleological mode
Mental states are expressed by actions Only actions and their concrete effects count. Idea that the only way of influencing another person is by action, f.e. seduction, (self)destructive behavior Nicole: demanding concrete action

Pretend mode
Mental world is decoupled from external reality Detachment and alienation Linked with emptiness, meaninglessness and dissociation Frequently affects do not match the content of thougts

Trauma related symptoms: f.e. dissociation, self-destructive behavior


Nicole: cutting herself

Re-enactment en posttraumatische symptomen


Re-enactments

(self)destructive behavior

Reminders of trauma

Post-traumatic symptoms
Psychic equivalence mode: flashbacks Teleological mode: (self)destructive behavior Pretend mode: dissociation

Re-enactment and post-traumatic symptoms


Re-enactments: Nicole: injustice Team: irritated

(self)destructive behavior: Scolding the team

Reminders of trauma: Misunderstood

Post-traumatic symptoms: Rages


Allen, J.G.(1994). Treating Attachment Trauma. In: Allen, J.G., Fonagy, P. & Bateman A.W. Mentalizing in Clinical Practice (pp.222). Washington, DC: American Psychiatric Publishing .

Treatment
Aim is not to bring up traumatic memories Aim is to help the patient to develop perspective on the past by reworking current experience

By supporting mentalizing the meaning and the effect of the trauma on the present, including the effects on relationships, especially the relation with the therapist
Re-enactments are inevitable

Treatment

Emphasis is on process not on the content To regulate the level of arousal is essential for mentalizing the emotion and to prevent re-traumatisation To balance mentalizing the trauma and containment

Nicole
Mentalizing the re-enactment Therapist accept enactment Connection trauma and re-enactment

Attachment trauma

Hyperactivation of the attachment-system Arousal reduces mentalizing capacity Projection

Projection

Feeling bad = being bad May result in (self) destructive behavior The function of projection is stabilization of the Self Projection has to be contained by the therapist

Conclusions

1. 2.

Mentalizing is the way to tackle the intrusive symptoms of PTSD Mentalizing is the pathway out of the re-enactments of trauma

Allen, J.G., Lemma, A. & Fonagy, P. (2012). Trauma. In: Bateman, A.W. & Fonagy, P. (ed.) Handbook of Mentalizing in Mental Health Practice (pp.419-444). Washington, DC: American Psychiatric Publishing

Conclusions

By mentalizing the trauma, and especially the meaning and effect on the current life, the patient will be able to have the traumatic experience in mind as a meaningful and emotionally endurable part of his or her life.