1. ED Patient: Innocent or complicitous victim? An exploration of self-protective strategies in ED PM Crittenden & SR Wilkinson

2. 4th April 2005Crittenden & Wilkinson2 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

3. 4th April 2005Crittenden & Wilkinson3 www.ssbu.no Three Aspects of Attachment Inter-personal: Strategies for eliciting protection and comfort Intra-personal: Information processing Familial: Array of interacting strategies

4. 4th April 2005Crittenden & Wilkinson4 www.ssbu.no 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.

5. 4th April 2005Crittenden & Wilkinson5 www.ssbu.no 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

6. 4th April 2005Crittenden & Wilkinson6 www.ssbu.no Attachment Models Ainsworth: A B C Main & Solomon: A B C D (disorganized) In practice: Secure (B) versus Insecure Dynamic-Maturational Model (DMM, Crittenden)

7. 4th April 2005Crittenden & Wilkinson7 www.ssbu.no Ainsworth Patterns of Infant Attachment Predictability Negative Affect Integration

8. 4th April 2005Crittenden & Wilkinson8 www.ssbu.no Ainsworth Patterns of Infant Attachment Plus Main & Solomon’s Disorganized ↑ ← Disorganized → ↓ Predictability Negative Affect Integration Secure

9. 4th April 2005Crittenden & Wilkinson9 www.ssbu.no DMM: Transforming Information Serves a self-protective function Becomes more sophisticated with maturation of brain Appearance ≠ reality

10. 4th April 2005Crittenden & Wilkinson10 www.ssbu.no DMM in Infancy Integrated True Information True CognitionTrue Negative Affect pre- compulsive Avoidant Comfortable B3 Reserved B1-2B4-5 Reactive A1-2 A+ C1-2 Resistant/ Passive A/C pre- coercive C+ Balanced

11. 4th April 2005Crittenden & Wilkinson11 www.ssbu.no Psychological Advances Implicit (non-verbal) causality Implicit affective states Being together: - in temporal contingency and - affective attunement

12. 4th April 2005Crittenden & Wilkinson12 www.ssbu.no DMM in the Preschool Years False Positive Affect Integrated True Information True Cognition True Negative Affect Compulsively Caregiving/ Compliant Socially Facile/ Inhibited A1-2 A3-4 Comfortable B3 Reserved B1-2B4-5 Reactive C3-4 C1-2 Threatening/ Disarming Aggressive/ Feigned Helpless A/C Distorted Cognition Omitted Neg. Affect Distorted Neg. Affect Omitted Cognition

13. 4th April 2005Crittenden & Wilkinson13 www.ssbu.no Psychological Advances Verbal statements of what causes what Words for feeling states Construction of interpersonal episodes Or the absence of these

14. 4th April 2005Crittenden & Wilkinson14 www.ssbu.no DMM in the School Years False Positive Affect Integrated True Information True CognitionTrue Negative Affect False Cognition Compulsively Caregiving/ Compliant Socially Facile/ Inhibited A1-2 A3-4 Comfortable B3 Reserved B1-2B4-5 Reactive C5-6 C3-4 C1-2 Threatening/ Disarming Aggressive/ Feigned Helpless Punitive/ Seductive A/C Distorted Cognition Omitted Neg. Affect Distorted Neg. Affect Omitted Cognition

15. 4th April 2005Crittenden & Wilkinson15 www.ssbu.no Psychological Advances 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?

16. 4th April 2005Crittenden & Wilkinson16 www.ssbu.no DMM in Adolescence False Positive Affect Integrated True Information True Cognition True Negative Affect False Cognition Compulsively Promiscuous/ Self-Reliant Comfortable B3 Reserved B1-2B4-5 Reactive A5-6 C5-6 C3-4 C1-2 Threatening/ Disarming Aggressive/ Feigned Helpless Punitive/ Seductive Compulsively Caregiving/ Compliant Socially Facile/ Inhibited A1-2 A3-4 A/C Distorted Cognition Omitted Neg. Affect Distorted Neg. Affect Omitted Cognition Sexual desire

17. 4th April 2005Crittenden & Wilkinson17 www.ssbu.no Psychological Advances Wordless communication: –Type A: Borrowed words & ideas –Type C: Sullen wordlessness, behavioral communication

18. 4th April 2005Crittenden & Wilkinson18 www.ssbu.no DMM in Adulthood Compulsively Caregiving/ Compliant Delusional Idealization/ Externally Assembled Self Compulsively Promiscuous/ Self-Reliant Socially Facile/ Inhibited Comfortable B3 Reserved B1-2B4-5 Reactive A1-2 A3-4 A7-8 A5-6 C7-8 C5-6 C3-4 C1-2 Threatening/ Disarming Aggressive/ Feigned Helpless Punitive/ Seductive Menacing/ Paranoid AC Psychopathy A/C CognitionNegative Affect False Positive AffectFalse Cognition Integration of True Information Integration of False Information Distorted Cognition Omitted Neg. Affect Distorted Neg. Affect Omitted Cognition

19. 4th April 2005Crittenden & Wilkinson19 www.ssbu.no Strategies for Dangerous Caregivers Type A: Do the right thing from the perspective of others. Inhibit displays of negative affect.

20. 4th April 2005Crittenden & Wilkinson20 www.ssbu.no 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.)

21. 4th April 2005Crittenden & Wilkinson21 www.ssbu.no DMM in Adulthood Compulsively Caregiving/ Compliant Delusional Idealization/ Externally Assembled Self Compulsively Promiscuous/ Self-Reliant Socially Facile/ Inhibited Comfortable B3 Reserved B1-2B4-5 Reactive A1-2 A3-4 A7-8 A5-6 C7-8 C5-6 C3-4 C1-2 Threatening/ Disarming Aggressive/ Feigned Helpless Punitive/ Seductive Menacing/ Paranoid AC Psychopathy A/C Very severe pathology No psychopathology Extreme pathology Apparently not clinical, sometimes somatic Inexplicable & troubling psychopathology

22. 4th April 2005Crittenden & Wilkinson22 www.ssbu.no 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.

23. 4th April 2005Crittenden & Wilkinson23 www.ssbu.no 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.

24. 4th April 2005Crittenden & Wilkinson24 www.ssbu.no No model is stored. DRs are always generated anew in the present. The presence, and probability of firing, of synapses reflects past experience.

25. 4th April 2005Crittenden & Wilkinson25 www.ssbu.no Parallel processing yields: –Many different DRs; –Each processed differently by the brain; –Multiple solutions to each problem.

26. 4th April 2005Crittenden & Wilkinson26 www.ssbu.no 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.

27. 4th April 2005Crittenden & Wilkinson27 www.ssbu.no 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.

28. 4th April 2005Crittenden & Wilkinson28 www.ssbu.no 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.

29. 4th April 2005Crittenden & Wilkinson29 www.ssbu.no Safety in the face of danger requires a fast response at the cost accuracy of response. Hence, exposure to danger reduces integration.

30. 4th April 2005Crittenden & Wilkinson30 www.ssbu.no Peter 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.

31. 4th April 2005Crittenden & Wilkinson31 www.ssbu.no Defining Crazy Doing again what failed every time before - and expecting a different outcome this time.

32. 4th April 2005Crittenden & Wilkinson32 www.ssbu.no Three hypotheses: ED girls are trying to protect themselves. Parents of ED girls are trying to protect the girls. Appearance does not equal reality.

33. 4th April 2005Crittenden & Wilkinson33 www.ssbu.no Three Examples of Appearance/Reality Discrepancy Ringer & Crittenden findings with DMM Case study from in-patient treatment Case study of family process & politics:

34. 4th April 2005Crittenden & Wilkinson34 www.ssbu.no Adult Attachment Interview DMM classifications & method Assess strategy & information processing Multiple DRs assessed Strategy, trauma, modifiers

35. 4th April 2005Crittenden & Wilkinson35 www.ssbu.no 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

36. 4th April 2005Crittenden & Wilkinson36 www.ssbu.no 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?

37. 4th April 2005Crittenden & Wilkinson37 www.ssbu.no Ringer Sample 19 Anorectics (restricting) 26 Bulimics 17 Anorectics (binging)

38. 4th April 2005Crittenden & Wilkinson38 www.ssbu.no 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

39. 4th April 2005Crittenden & Wilkinson39 www.ssbu.no Common DMM strategies for ED C5-6 C3-4 (bulimic) A1/C5-6 [A] C5-6 (false A1) A3-4 (Ringer & Crittenden)

40. 4th April 2005Crittenden & Wilkinson40 www.ssbu.no Ringer & Crittenden Results, Con’t Few Utr; most imagined (erroneous causation) Almost no modifiers – very strategic (not Dp)

41. 4th April 2005Crittenden & Wilkinson41 www.ssbu.no Transformations Exaggerated affect Non-verbal communication Strategy employed without regard to outcomes Strategy can be used self-destructively without regard to results

42. 4th April 2005Crittenden & Wilkinson42 www.ssbu.no 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.

43. 4th April 2005Crittenden & Wilkinson43 www.ssbu.no 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.

44. 4th April 2005Crittenden & Wilkinson44 www.ssbu.no Why use deception? Adolescents’ perspective: 1.To avoid losing contact with a protective parent; 2.To communicate with the skills that one has.

45. 4th April 2005Crittenden & Wilkinson45 www.ssbu.no Deception Scale Lie Intentional deception Self-deception Involving self-deception Reciprocal & involving self-deception Reciprocal, involving, & intentional self- and other-deception

46. 4th April 2005Crittenden & Wilkinson46 www.ssbu.no Familial Processes Two cases of ED adolescents & parents: - Exploration of AAIs - In-patient clinical experience.

47. 4th April 2005Crittenden & Wilkinson47 www.ssbu.no 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.

48. 4th April 2005Crittenden & Wilkinson48 www.ssbu.no A Developmental Perspective on “Truth” Truth about the past is not predictive truth. The brain is evolved to use information to predict the future.

49. 4th April 2005Crittenden & Wilkinson49 www.ssbu.no The only information that we have is information about the past whereas The only information that we need is information about the future.

50. 4th April 2005Crittenden & Wilkinson50 www.ssbu.no Consequently, information from the past must be transformed to maximally predict danger in the future.

51. 4th April 2005Crittenden & Wilkinson51 www.ssbu.no 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).

52. 4th April 2005Crittenden & Wilkinson52 www.ssbu.no 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.

53. 4th April 2005Crittenden & Wilkinson53 www.ssbu.no Psychological & Strategic Effects Causal information is omitted. Affect is exaggerated. Child is Type C2-4 and maybe also idealizing of M (A1/C2-4)

54. 4th April 2005Crittenden & Wilkinson54 www.ssbu.no 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.

55. 4th April 2005Crittenden & Wilkinson55 www.ssbu.no Psychological & Strategic Effects 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.

56. 4th April 2005Crittenden & Wilkinson56 www.ssbu.no 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.

57. 4th April 2005Crittenden & Wilkinson57 www.ssbu.no Psychological & Strategic Effects 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.

58. 4th April 2005Crittenden & Wilkinson58 www.ssbu.no 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.

59. 4th April 2005Crittenden & Wilkinson59 www.ssbu.no 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.

60. 4th April 2005Crittenden & Wilkinson60 www.ssbu.no 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.

61. 4th April 2005Crittenden & Wilkinson61 www.ssbu.no 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

62. 4th April 2005Crittenden & Wilkinson62 www.ssbu.no 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?

63. 4th April 2005Crittenden & Wilkinson63 www.ssbu.no 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.

64. 4th April 2005Crittenden & Wilkinson64 www.ssbu.no 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.

65. 4th April 2005Crittenden & Wilkinson65 www.ssbu.no 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

66. 4th April 2005Crittenden & Wilkinson66 www.ssbu.no 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.

67. 4th April 2005Crittenden & Wilkinson67 www.ssbu.no 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.

68. 4th April 2005Crittenden & Wilkinson68 www.ssbu.no To contact us: pmcrittenden@att.net or www.patcrittenden.comwww.patcrittenden.com simonroger.wilkinson@uus.no