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Case Nicole
Vulnerability Neglect Physical aggression
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
Allen, J.G.(2001). Traumatic Relationships and serious Mental Disorders. Chichester, UK: Wiley.
Attachment trauma
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 .
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
(self)destructive behavior
Reminders of trauma
Post-traumatic symptoms
Psychic equivalence mode: flashbacks Teleological mode: (self)destructive behavior Pretend mode: dissociation
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
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.