Treating Dissociative and Personality Disorders

A Motivational Systems Approach to Theory and Treatment

Antonella Ivaldi, Antonella Ivaldi

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317267591
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Treating Dissociative and Personality Disorders draws on major theorists and the very latest research to help formulate and introduce the Relational/Multi-Motivational Therapeutic Approach (REMOTA), a new model for treating such patients within a clinical psychoanalytic setting.

Supported by her fellow contributors, Antonella Ivaldi provides an overview of existing theories and evidence for their effectiveness in practice, sets out her own theory in detail and provides rich clinical detail to demonstrate the advantages of the REMOTA model as applied in a clinical setting. The narratives in this book show how it is possible to integrate different contributions within a multidimensional aetiopathogenic treatment model, which considers the mind as a manifestation of the relationship between body and world. From a conceptual perspective, according to which consciousness emerges and develops in the interpersonal dimension, this book shows how it becomes possible to understand, in the therapeutic space, what stands in the way of sound personal functioning, and how to create the conditions for improving this.

Treating Dissociative and Personality Disorders will be highly useful in addressing the particular clusters of symptoms presented by patients, stimulating therapists of different backgrounds to explore the complexity of human nature. On reading this book, it will become clear that theories can truly become useful instruments, if approached with a critical mind and with humbleness, in order to venture into what we do not know and will never know completely: the relationship with the other, unique and irreplaceable.

Treating Dissociative and Personality Disorders provides an integrative and comparative new approach that will be indispensable for combining relational clinical knowing and motivational theories. Itwill appeal to psychoanalysts and psychotherapists, especially those in training, clinicians of different backgrounds interested in comparative psychotherapy, as well as social workers and graduate and postgraduate students.

Chapter 1

Theorizing about theory

Joseph D. Lichtenberg

Is a theory necessary to practice psychoanalysis? Why not approach each event in the therapy of individuals, couples, or groups with an ‘open mind’ guided only by the observable phenomenon that emerges. To answer: an ‘open mind’ is a myth. Open mindedness is a valuable cultivated attitude. Humans (and higher animals) process experience by making implicit and explicit inferences about the affects, intentions, actions, and goals of others and themselves. Being human we can’t not make inferences. And having a theory, however simple or complex, is a prerequisite for forming an inference. Sometimes, actually very often, we make our inferences, assumptions, conjectures, hypotheses, estimates, assessments, and appraisals so rapidly that we are not aware we have made them, and generally are not aware of the theory we are using. We hit the brake to avoid a pedestrian who started across the street before we ‘know’ we have made an assessment and constructed an action response or that we have based our action on a conception of safe driving practices. We feel the ‘Oh my God’ relief after the moment in which the inference, action, and goal have played out. The phenomena in psychoanalysis we recognize as transference involve assumptions patients make about their analysts – our theory tells us that affectively strong past events trigger dispositions to form expectations of repetitions. And transferences involve the inferences that analysts draw about an implicit or explicit attribution a patient is making about them – our theory alerts us to the subtlety of metaphoric references to the analyst protectively encased in speech and gesture. Additionally, analysts time their interpretations of transference based on inferences, often implicit, about when the patient might be receptive – our theory tells us that affect, speech and gesture patterns provide clues to openness or turn off to information or influence.

A clinical example: His face animated, Mr. T. enters and immediately begins to talk about a phone conversation with his parents. His tone conveys his usual skepticism about their ‘foolishness’ in reference to his troubled dependant older brother. But he adds how come his parents assume all information goes from his brother to them or him to them. Why would they believe that he and his brother would not exchange information?

I infer he is in an animated state, eager to tell me the latest evidence that supports his chronic attitude of skepticism. My posture changes (out of my awareness) to a higher degree of alertness. As I listen, I contrast his current state with his affectless state in the last session when he had droned on and on and I could barely stay awake. His reactions to the phone call are a familiar theme with some new details that hold my interest, but my level of interest peaks when I hear him ask ‘how come’ his parents do not assume he and his brother have a relationship that does not centre on them. The content of the question is not what ‘grabs’ me – it is the fact that he is asking a question! Two sessions before I had challenged him on his lack of curiosity about both an unexpected sexual pattern he had followed in college, and later a variant of the pattern kept secret from his wife and from me for a long time into his treatment. I had conjectured that the subsequent affectless session that followed was an aversive response to my challenge and the shame my comment probably triggered. Now I conjectured that he had absorbed my challenge and was ready to explore a peripherally related aspect of the problem. With his curiosity now available implicitly, I inferred he would be open to my expanding my comments. As the session progressed, his further receptivity confirmed my positive expectation.

What place did theory occupy as I did my work as a psychoanalyst with Mr. T? As a psychoanalyst I have a theory that every mind state involves motives and emotions. My theory holds that different emotions or emotional attitudes are commonly associated with different intentions and goals. For example, persistent preoccupation with parents indicates unresolved attachment intentions and skepticism represents the negative aspect of an ambivalent attachment. Interest and curiosity are associated with the problem solving aspects of exploratory intentions. An analytic session characterized by avoidant dissociated affects or ‘deadness’ indicates the presence of an aversive intention of withdrawal and may further indicate a rupture in the transference–countertransference dyad. Each of these theory constructs guided my witnessing, my recognizing, my empathic listening and my self-reflection as I acted as a participant observer/interpreter during the session and when I reviewed it in my mind afterward.

If a theory is necessary for psychoanalysis, what particular qualities recommend a motivational systems theory? Central to Freud’s considerations were theories that explained what motivates human behaviour in general and what goes awry in the psychoneuroses and other mental illnesses. Libidinal and aggressive instinctual drives (or Eros and the death instinct) provided an explanation for the symptomatic neuroses and war trauma respectively. Levels of awareness, a dynamic unconscious, executive functions, a defensive organization, values, moral guides, and ideals had to be accounted for. An internal world of self and object representations and modes of regulating the drives and affects became a later focus. The principle of adaptation moved the explanation from an exclusive intra psychic focus to a greater account of interactions with the animate and inanimate environment. Differing analytic theories described a holding environment, object relations, interpersonal relationships, attachment theory, a self–selfobject matrix, intersubjectivity, and the relational perspective. With the shift of emphasis from intrapsychic dynamics to an interactive perspective, clinical theory took on a new vocabulary pointing to other dynamics. The analyst is brought more directly into the interplay of transference and countertransference, in concepts such as providing a container function, in the recognition of enactments as both negative and positive, and in attachment seeking. Even more contemporary concepts point to implicit relational knowing, a selfobject experience of vitalization and/or soothing, new relational experience, and the building of a dyadic realm of safety and positive ambiance (a ‘third’).

I argue that a theory of motivational systems includes and integrates the seminal elements of these shifts in theory and therapeutic approach (Lichten berg, Lachmann, and Fosshage, 1992, 1996, 2002, 2011; Lichtenberg and Kindler, 1994; Lichtenberg, 1989, 2005). Additionally, motivational system further integrates modern non-linear systems and complexity theory, and a contemporary non-linear development theory integrated with findings derived from neuroscience.

When does ‘theory’ enter the process of inference making? A theory is the necessary template out of which an inference is selected. Both template and inference may remain implicit or be brought into awareness. Humans are continuously processing information and using a simple or complex template (theory) to draw the inferences needed for navigating their pro cedural, social, conceptual, and affective experiential worlds. Social operational theories may be simple and personal. An example would be an experience Tom, an elementary school age child, described: ‘When I came home from school, my mother was cranky, not her usual glad to see me. When I left for school she was in a happy mood so I figured something had upset her and it wasn’t me.’ Tom drew his inferences from a series of templates he had formed from prior experience. First, when a person has a change of emotional state, the change is the result of some occurrence, and second, when the shift is from a positive affect to a negative affect the occurrence was disturbing. In inferring (concluding) that he was not the responsible source, Tom drew on a theory (belief) that his mother was very fond of him and he was solidly in her good graces. His operant theory (reasoning) was that when a person is in the good graces of a person fond of him, he is not apt to be a negative factor unless evidence is revealed to the contrary. Were he to scan his mind and remember that he had left his room a mess or failed to take out the garbage as promised and/or he saw his mother looking in the direction of his room or the garbage, he would have an instantaneous shift in inference – based on a simple cause–effect theory. From this example and countless others from ordinary daily life, I aver that as humans we form templates, maps, or schemas from which we draw ad hoc theories to orient ourselves about every lived experience and use these theories to form the inferences that guide our expectations and choices.

A reexamination of empathy offers a further example. The conventional view of empathy is that it is a mode of perception by which we place ourselves as much as possible into the state of mind of another person. As we listen to our patient empathically we sense her state of mind, her emotions, her thoughts and her perspective including us. This delineation is correct but incomplete. We don’t just sense into another’s state of mind, we also make inferences about what we believe we perceive. We infer the patient’s intentions and goals as well as the context that is most relevant to those intentions and goals. In addition we also implicitly ‘theorize’ about past and present determining influences and make predictions about what associations will come next – where the session, the patient and we are going next. This places empathy in our broader clinical theory.

Each valued psychoanalytic theory – Freudian, Kleinian, Winnicottian, Jungian, Laconian, Sullivanian, ego psychological, Mahlerian, Kohutian, intersubjective, evolutionary, and attachment – has tended to privilege one or another group of affects, intentions, and goals. With awareness and respect for these many theories, motivational systems theory attempts to offer a flexible inclusive integrated account of the diversity of human emotions, intentions, and goals. A point of departure for motivational systems theory is the continuous interplay between each individual and the human and inanimate environment in which he and she develop and live from birth (and before) to the end of life. No single motivational system is privileged as more significant for human functioning and survival, rather intentions and goals continuously shift in their dominance as mental states and contexts fluctuate. In this way the theory is concordant with the shifting associations and themes representing implicit and explicit motivations in each clinical session. Each system self-organizes based on a principal or paramount grouping of affects, intentions, and goals we indicate by the designations we have chosen: a system for the regulation of physiological requirements, for attachment to individuals, for affiliation with groups, for caregiving, for exploration and the assertion of preferences, to react to aver sive experience via antagonism and/or withdrawal, and for sensual excitement and sexual excitement. Beyond the verbal designators that epitomize the needs and motives of each of the seven systems, world pic tures and event stories in each system help analysts to evoke an infant and older child’s dyadic and triadic experience, a school aged child’s peer and widening experience, and an adolescent and adult’s more complex intentions and goals. A therapist attempting to infer un folding motivational themes utilizes the affective/metaphoric power of the picture-stories that animate the more abstract system verbal designators. Word and imagistic picture-stories provide the orienting sensitivity for analysts to feel themselves empathically into the mind state of analysands. The necessary knowledge is of what to observe. I believe that the pictures and stories derived from motivational systems theory contribute to the necessary knowledge of what to observe for optimal therapeutically pro ductive infer ences. Analyst and analysand sharing on-target word pictures and meta phoric connections derived from motivational systems theory builds a sense of intimacy, a mutual sense of understanding and being understood, a co-created positive affective state the dyad can share, and an easily re-created sense of safety and trust after disruptions. These positive effects of the use of motivational systems theory (or any effective theory) are the sine qua non of successful analysis.

Chapter 2

Theoretical foundations

Antonella Ivaldi

Where this model fits among other theoretical perspectives in psychotherapy

Dear Angie,

Reading the book that you picked for me was very moving. I think that you have uncommon intuitive skills and a likewise unique sensitivity. Your gift came at a difficult and painful moment in my life and it was like receiving a warm embrace. As I read it, I felt ever more grateful to you for what you were communicating to me. It is an honour for me to be compared to Dr Semmelweiss, not just for his undeniable value, but especially for his great ability to love – as Celine says, to be moved. While reading, I thought that you were communicating to me something very intimate and important about yourself, Angie. What is Dr Angie like? I wondered. Does she not conduct her work with love? And is it not true that her insights are extremely helpful to the people who turn to her? And in your case, those people are children, so your sensitivity is all the more valuable.

And what is Angie like as a woman? She is thoughtful with everyone she meets, is never false, is willing to expose herself, sometimes too much and in a dangerous way; she gives herself completely, selflessly.

So why does she suffer so much? What is wrong? Dear Angie, you have done a lot for me with this book and I want you to know how much I care about you. And that is why I am going to tell you something that you may not want to hear but that you will appreciate later on, I am sure. As I said, you are incapable of being false; however, at times you are unable to be authentic, essentially because your state of consciousness is altered. I mean to say that sometimes you are not clear-headed, self-aware, enough to understand and handle your emotions well. One might say that you appear to be ‘possessed’ by your emotions, or rather, by your emotional chaos. That is why you seek help. We have been exploring together the roots of your problem for some time now, and of course we can carry on this work and complete it.

However, there is an aspect that cannot be disregarded in your therapy. I am referring to your self-destructive behaviour. Dear Angie, in order to reach significant results in your treatment we have to address this aspect at the behavioural level. In other words, you must use your will power to change some bad habits, some behaviours that prevent you from making faster progress in your therapy and that continue to have harmful consequences, which you and I have to deal with constantly, diverting our attention from deeper and more significant interventions that would get to the core of your distress.

Dear Angie, you have to stop drinking! You must follow the drug therapy with perseverance and get help from your psychiatrist, from me and from those who are close to you and can help. This will require commitment on your part, and at times it will be very painful, but you have no other choice if you really want to make it. I am quite convinced of what I am saying and I hope you will think it over. If you should not accept these conditions, I am afraid that this therapy would not be very effective and, at any rate, it would not proceed as it should.

With great affection,

A.

Every now and then someone still comes up to me and says that, in order to practice psychotherapy, I must surely be trained to keep the necessary ‘emotional detachment’. This letter is a good example of the quality of the relationship that is established with patients who suffer from a personality disorder, or from disorders that do not fit into one single diagnostic category and present a particularly complicated polysymptomatic clinical picture.

In order to work with such patients, therapists must have undergone extensive training: indeed, they must be capable of carefully monitoring the emotional course of the relationship and must be flexible enough to tap into all of the patient’s resources, life, and therapeutic context. The ‘emotional detachment’ many people evoke when they talk about our work is not possible, since in our effort to understand the other we are guided precisely by our emotions. Rather, a psychotherapist and psychoanalyst must explore those very emotions at the time they are experienced, in order to engage in a joint reflection with the patient regarding what is happening in the relationship.

The point is, how are we to explore? We inevitably need theoretical foundations that we can refer to when we go about exploring and explaining phenomena. In psychological and clinical work, I believe it is indispensable to reflect on the need for and the choice of a theory which, in attempting to explain how the mind works, helps to identify the disorder, how it is expressed and how it can be treated. This has direct clinical consequences: if the main tool used in psychotherapy is the relationship and the means of communication are emotions, a theory that tries to explain how humans function necessarily informs us about the meaning of our emotions, which channel our intentions and mental life, and about the nature of the relationship we are living.

On the need for theories

Many fascinating developments have characterized psychiatry and psychology, since their inception and up until today. Influenced by the advances in scientific and philosophical thinking, every development has been the result of the culture that characterized the historical period during which it came into being (Ellenberger, 1970). By and by, sickness and healing have been interpreted on the basis of the knowledge available, sometimes of the ‘trends’ of the moment, of the opportunities afforded by the economic and political systems in force. Psychopathology too appears to be influenced by the historical context within which it evolves and...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Contributors
• Foreword Giovanni Liotti
• Foreword Joseph D. Lichtenberg
• Acknowledgements
• Introduction
• 1 Theorizing about theory
• 2 Theoretical foundations
• 3 The therapeutic relationship from the theoretical perspective of motivational systems
• 4 Complex trauma theories and psychopathology: the difficult patient
• 5 Personality disorders: diagnosis and treatment
• 6 The relational/multi-motivational therapeutic approach (REMOTA)
• 7 Some methodological considerations on outcome research in psychotherapy and results of a naturalistic study in the treatment of patients with severe axis I/II comorbidity disorders
• 8 Group psychotherapy: addressing impediments to engaging the affiliative motivational system
• References
• Index