Coping and complaining

1. Coping and complaining The language of dis-ease

2. Why?Behaviour shown at a particular moment • Why now? • Proximal cause • How grown to respond this way? • What is the general function of this behaviour? • How did it evolve phylogenetically? After Nico Tinbergen (1951) Simon R Wilkinson, Ullevål University Hospital, Oslo

3. My intentions for today Children learn a language of dis-ease, primarily in their family of origin (first 3 years). It is learnt implicitly and not immediately open to reflection – its origins are lost to them. Their lives depend on this illness language being effective for complaining and subsequently coping. They do more of what they have done before when desparate. We do not start learning a new language when we are in crisis – those who hear the symptoms need to be multilingual. This language develops according to the same principles which form attachment strategies. Simon R Wilkinson, Ullevål University Hospital, Oslo

4. All languages are strategic and dependent on mind-reading skills. Clinicians’ biases in mind-reading skills are likely to be central ingredients in system errors in medical practice which cost society more than the combined costs for treating all cancer and heart disease. Simon R Wilkinson, Ullevål University Hospital, Oslo

5. Validating symptoms Adapted from Dialectic behaviour therapy • Find the wisdom, correctness or value in patients’ symptoms • emotional expression, • cognitive understanding • associated behavioural responses • Ecological validity (context of current events) Simon R Wilkinson, Ullevål University Hospital, Oslo

6. Levels of validationafter DBT • Genuine presence and interest • Accurate reflection to the patient of her feelings, thoughts, assumptions and behaviour – being understood • Conveying understanding of aspects which have not been directly communicated – articulated mind reading • Behaviour shown to be justifiable in terms of its causes • Search for inherent appropriateness/ reasonableness of response + comment on dysfunctionality if necessary • Validation of individual as reasonable and effective Simon R Wilkinson, Ullevål University Hospital, Oslo

7. Outline1 • Components of dis-ease • Discriminating and identifying ’emotions’ • Memory: basis for remembering an illness language • Effectiveness of symptoms: from behaviour to strategies • Attachment strategies Simon R Wilkinson, Ullevål University Hospital, Oslo

8. ‘Dis-ease’ • Illness • Sickness • Disease • Disorder • Predicament Simon R Wilkinson, Ullevål University Hospital, Oslo

9. Illness • Experienced • Something counts as illness if it has influenced a meaningful element in relation with another important person in early childhood - and been labelled as ‘illness’ • ”I feel as if I have no bones in me” Simon R Wilkinson, Ullevål University Hospital, Oslo

10. Sickness • Attributed • Something counts as sickness when one is excused the normal expectations of a social role, and it is labelled as sickness • “You are ill/hyperactive/depressed” Simon R Wilkinson, Ullevål University Hospital, Oslo

11. Disease/Disorder • Observed • An expert finds pathognomonic signs of disease • or symptoms which tend to be found together without the underlying causal processes being identified in disorders • ”He has a known disease/disorder”. In psychiatry I work with disorders – without validity but with utility. Kendell & Jablensky, 2003 Simon R Wilkinson, Ullevål University Hospital, Oslo

12. Predicament • Acknowledged • An uncomfortable/difficult condition which has to be lived with • Congenital abnormalities • Depressed parent • Genetic vulnerability • Challenges presented by the course of the disease Simon R Wilkinson, Ullevål University Hospital, Oslo

13. The failure of modern medicine is that it cures disease without healing ‘dis-ease’. Simon R Wilkinson, Ullevål University Hospital, Oslo

14. Outline2 • Components of dis-ease • Discriminating illness from other ’emotions’ • Memory basis for remembering an illness language • Effectiveness of symptoms: from behaviour to strategies • Attachment strategies Simon R Wilkinson, Ullevål University Hospital, Oslo

15. Feelings and emotionsIllness & Disease Simon R Wilkinson, Ullevål University Hospital, Oslo

16. Proto-self The proto-self is an interconnected and temporarily coherent collection of neural patterns which represent the state of the physical structure of the organism in its many dimensions, at multiple levels of the brain. We are not conscious of proto-self. [Damasio, 2000] p.154/174. • Somatotopy core self & autobiographical self - conscious Simon R Wilkinson, Ullevål University Hospital, Oslo

17. Feelings and emotionsIllness & Disease Simon R Wilkinson, Ullevål University Hospital, Oslo

18. Background emotions Index of momentary parameters of inner state • Smooth muscle status and striated muscle of heart and chest • Chemical profile of internal milieu • Chemical profile signifying threat • to optimal homeostasis • integrity of living tissues i.e. disease included Simon R Wilkinson, Ullevål University Hospital, Oslo

19. From emotion to feeling the emotion from disease to illness Recognising the background feeling/illness Fatigue, relaxation,‘under the weather’ Background emotion/disease Backgroundfeeling Simon R Wilkinson, Ullevål University Hospital, Oslo

20. Subjectivity is reading a sundial – using a pocket torch. Piet Hein Simon R Wilkinson, Ullevål University Hospital, Oslo

21. Source of inducer internal Focus of response – internal milieu Source of inducer external Focus of response – musculoskeletal and visceral systems which can then function as an internal inducer Background cf Conventional emotions Simon R Wilkinson, Ullevål University Hospital, Oslo

22. Stress components • Physiology • Behaviour • Subjective experience • Words available to convey the feeling • That which is conveyed about the feeling There is no a priori reason for these to be coherent. Each level depends on ’interpretation’ and is open to both misattribution and self-deception. Simon R Wilkinson, Ullevål University Hospital, Oslo

23. Mirror neurones and emotional contagion • referential decoupling ”Brains are built to map the minds of another person. They are social organs …” Daniel Siegel, Sundvollen 2006 Simon R Wilkinson, Ullevål University Hospital, Oslo

24. Outline3 • Components of dis-ease • Discriminating and identifying ’emotions’ • Memory basis for remembering an illness language • Effectiveness of symptoms: from behaviour to strategies • Attachment strategies Simon R Wilkinson, Ullevål University Hospital, Oslo

25. The only information that we have is information about the pastwhereasThe only information that we need is information about the future. Simon R Wilkinson, Ullevål University Hospital, Oslo

26. Not knowing • All you know that you do not know • All that you do not know that you do not know • All that you think you know, but do not know • All that you do not know that you know • All that you do not know because it is too painful • Taboos, the dangerous and forbidden knowledge University of Utah course in Not-knowing for medical students Simon R Wilkinson, Ullevål University Hospital, Oslo

27. Information and memory systems after Pat Crittenden Context Context Simon R Wilkinson, Ullevål University Hospital, Oslo

28. Confidence in memory is totally unrelated to veracity of it There is no information in confidence Simon R Wilkinson, Ullevål University Hospital, Oslo

29. All you know that you do not know, All that you do not know that you do not know, All that you think you know, but do not know, All that you do not know that you know, All that you do not know because it is too painful, Taboos, the dangerous and forbidden knowledge Correct identification of lack of source memory Lack of integration of memory systems Mistaken reliance on semantic memory Implicit learning Dissociation Not-knowing Simon R Wilkinson, Ullevål University Hospital, Oslo

30. Nothing is so difficult as not to deceive oneself. Ludwig Wittgenstein Simon R Wilkinson, Ullevål University Hospital, Oslo

31. Outline4 • Components of dis-ease • Discriminating and identifying ’emotions’ • Memory basis for remembering an illness language • Effectiveness of symptoms: from behaviour to strategies • Attachment strategies Simon R Wilkinson, Ullevål University Hospital, Oslo

32. Anger Fear Need to be cared for Revealed to VIP anger+aggression Formed on basis of functionality rather than ‘chosen’ Partially hidden, exaggerated or distorted false positive affect Central feelings Simon R Wilkinson, Ullevål University Hospital, Oslo

33. We don’t see things as they are, we see things as we are.Anaïs Nin 1969 ”There is no such thing as immaculate perception”.

34. Reading the tears: our lenses • Hopes • Fears • Fantasies • Family traditions and myths • Personal experience • Current situation etc Simon R Wilkinson, Ullevål University Hospital, Oslo

35. The heart has its reasons that reason knows not of. Blaire Pascal Simon R Wilkinson, Ullevål University Hospital, Oslo

36. Dancing with a VIP: Attachment dynamic • Synchronised mother-infant affect • Mirror neurones • ’Emotional contagion’ or ’Referential decoupling’ • Adapt social awareness and reciprocal stimulation • Depends on • VIP’s attention to infant’s state & own state • With sympathy for infant’s attributed inner state rather than visible behaviour • VIP’s ’theory of mind’ in relation to her child • Mind reading skills and mind-talk • Reflective function • Co-construct a reciprocal regulating system with contingent responsiveness Simon R Wilkinson, Ullevål University Hospital, Oslo

37. Relaxation and modulation of arousal VIP is • Available • Sensitive • Acknowledges / validates • Collaborates • ‘Referential decoupling’ • Prevented when ignored, insensitive, rejecting, intrusive and lack of discrimination between own and other’s feelings. Simon R Wilkinson, Ullevål University Hospital, Oslo

38. Feedback hum Amplifier Simon R Wilkinson, Ullevål University Hospital, Oslo

39. Reciprocal VIP/child relation Recognise, find out about and understand • Own and others’ feelings • Association between their own feelings and own behaviour • How behaviour of others influences their own feelings • How own feelings and behaviour appear to influence the feelings and behaviour of others Appreciate that feelings are associated with and mutually affect behaviour Simon R Wilkinson, Ullevål University Hospital, Oslo

40. Fases in development of attachment: first 2-3 years1 · 0-2 m. Pre-attachment: prior to reliable coordinated access to implicit memory · 2-6 m. Discriminate social responsiveness · 9-14 m. Attachment behaviour: without taking into consideration the other’s awareness about their attunement with them, and consequences of the other’s motives. Simon R Wilkinson, Ullevål University Hospital, Oslo

41. Natural social biofeedback training • Detecting and maximising contingency • Likelihood that something that is about to happen is result of their behaviour • Sufficiency index • Likelihood that something which did happen was preceded by something they had done • Necessity index • related to how we use diagnoses? • Part of structural coupling Simon R Wilkinson, Ullevål University Hospital, Oslo

42. Fases in development of attachment: first 2-3 years2 • 15+ m.Attachment strategies: • approaches based on an understanding of the biases in VIP’s behaviour • development of parasympathic nervous system  capacity to self-soothe • meta-cognitive skills. • 30+ m. Goal corrected partnerships: • depends on’autonoetic’consciousness and frontal lobe development. Simon R Wilkinson, Ullevål University Hospital, Oslo

43. Loss and trauma • Trauma and alexithymia • Secondary alexithymia on intensive care units • Parental trauma effect on child’s experience of VIP predictability • Modifiers of attachment strategies • Ul; Utr • Dp as learnt helplessness • Confuses child’s development of strategy and symptoms become confusing for everyone Simon R Wilkinson, Ullevål University Hospital, Oslo

44. ’Do not mistake a child for his symptom’ Erikson Simon R Wilkinson, Ullevål University Hospital, Oslo

45. Reflection Examine the difference between what you think you do and what you actually do • Self-deception • Knowing-in-action • Personal knowledge based on experience • Espoused-knowledge • Explicit public knowledge believed to be the basis for action Including self-observation as a component of every perception Simon R Wilkinson, Ullevål University Hospital, Oslo

46. Outline • Components of dis-ease • Discriminating and identifying ’emotions’ • Memory basis for remembering an illness language • Effectiveness of symptoms: from behaviour to strategies • Attachment strategies Simon R Wilkinson, Ullevål University Hospital, Oslo

47. The greatest invention of the 20th Century DW Winnicott’s ’The good enough mother’ Smith, 2003 (previous editor of British Medical Journal to new medical students) How do you elicit enough care from a mother who falls short? The corollary: The good enough mother needs also to be ’poor enough’. Simon R Wilkinson, Ullevål University Hospital, Oslo

48. Central concepts in the Dynamic- Maturational Modelof Attachment • 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. Their language of dis-ease is how they do it. Simon R Wilkinson, Ullevål University Hospital, Oslo

49. Central Concepts in the DMM • Learn about behavioural contingencies (interpreted as causal information) and signs of dangerous contexts (based on interpretation of intensity of stimulus) • Cognitive and affective information • Leading to modulation of fight, flight or freeze responses • Attachment behaviour organizes into strategies for elicting protection and comfort • through development of structural coupling • developmental pathways - ‘mindreading’ skills Simon R Wilkinson, Ullevål University Hospital, Oslo

50. Paternalism, Maternalism and OLBs • Clinician centred practice • power • defining of another’s subjective state • smothering with ’care’ • Patient centred practice • Goal corrected partnerships • solicited paternalism What sorts of experience of personal effectiveness and illness language arise in the different scenarios? Simon R Wilkinson, Ullevål University Hospital, Oslo