INTEGRATING RELATIONAL PATTERNS INTO PSYCHOTHERAPY

1. HAMM CLINIC March 21. 2014 • Anne R. Gearity, PhD, LICSW • Helen Kim, MD INTEGRATING RELATIONAL PATTERNS INTO PSYCHOTHERAPY

2. PART I: RELATIONSHIPS • Romantic ideal: in sync harmony • Finding rhythm and pace • Soothing melody • Union and reunion

3. THE METAPHOR OF JAZZ • Starts with chaos -- where is this music going? • Individual improvisation that gradually moves towards increasing collaboration. • Work to find moments of harmonious meetings that then move off again towards discovery, even if discovery means returning to chaos and confusion. • Jazz musicians who are good listen very carefully to each other, so what may seem like cacophony to the unenlightened is actually the process of finding that sweet collaboration.

4. WHAT DO YOU HEAR?

5. TODAY • Part II: Understanding biology and neurology of relationship experiences, mentalizing and how disruptions like post partum depression changes the energy. • Part III: Revisiting attachment patterns to appreciate the profound influence of early experiences and representation. • Part IV: the Mother/ Baby project as applied mentalizing intervention • Part V: Relationship- informed psychotherapy/ paying attention the clinician's mind and mindsight. • Part IV: Using cases from the Mother/ Baby project, examine how relationship experiences are perpetuated with parenting and re- examined within clinical interventions. • Throughout our day, please be active participants. Questions and discussion are welcome.

6. PART III EARLY PATTERNS OF RELATING Dorothea Lange

7. ATTACHMENT PATTERNS PERSIST ACROSS CULTURES: STYLE MAY DIFFER BUT FUNCTION IS CONSTANT

8. Early relationships construct biological and psychological experiences that: • Assure survival • Provide necessary ingredients for regulatory learning • Form internal representation of live action: what happens and will happen (needand intention). • Facilitate exploration/ and movement towards a sense of self = mind awareness, mindsight.

9. ATTACHMENT When attachment goes well Care is reliable and predictable enough that parent and child discover rhythms and pace to find each other with enough harmony, So that the baby can feel secure about care (expectancies) And signals (strategies) when he needs company or feels distressed. Soothing is trusted, even when experiences can be hard, So that the baby can know what happens (and can eventually know myself). • When attachment is compromised • Parent and child struggle to find reliable expectations: parents provide confusing care and the child must work harder to maintain needed connection. Some children maximizeefforts and others minimizeneeds to assure some help at hard times. • In some circumstances, care is so unpredictable that the child can't know what to expect, and can't know how to respond so they remain disorganized. Disorganized means that relationships cannot become soothing enough to manage hard times.

10. ATTACHMENT AND MENTALIZING • As the child feels regulated, then she starts to regulate herself. • Move from parent regulation -- to dyadic regulation (co- regulation) -- to guided regulation -- to self- regulation. Self- regulation is about body, emotions, mind. • Within this process, the "whole idea of thinking about thinking is that we learn about ourselves through being understood by other people. Babies learn about their feelings by having their feelings understood by someone else." (David Wallin, quoted by Helen Kim)

11. MIND AWARENESS • To Wallin, I would add: babies and children also learn about their minds -- their intention, desires, needs, and thoughts that connect with feelings. I have a mind because my parent sees my mind. This is how mindsight develops. • Mentalizing is the active process of discovering, within the security of a primary relationship, that my feelings can be recognized and connect with my mind: that my actions (behaviors) are about my feelings and thoughts.

12. PERSISTING INTO ADULTHOOD... • Secure attachment = autonomous sense of my own mind • Anxious ambivalent attachment (maximizing effort) = preoccupied style of relating to self and others who are close. • Anxious avoidant attachment (minimizing need) = dismissive style of relating to self and others who are close. • Disorganized attachment becomes an unresolved sense of others, self, and what to do in relationships; chronic and persisting dysregulation because I remain reactive vs. reflective.

13. THESE PATTERNS BECOME ESPECIALLY ACTIVATED WITH PARENTING • Representations are conscious and unconscious -- like musical tracks laid down in memory, when you don't recall a song until it starts playing again. • But more than the actual song, there is the beats, the rhythms, the pace that quietly emerge as experiences of care. The parent returns to the experience of finding rhythms -- that support (or not) this new relationship.

14. MOTHER AND CHILD REUNION • Being in rhythm requires effort on both parent and baby. The parent brings her own earlier experiences, repeated over and over in subsequent relationship encounters but also activated by both biological and psychological processes. • The infant also brings potential -- and vulnerabilities: temperament, illness or "system immaturity," inevitable periods of dysregulation, overstimulation. • Three principles of salience (Beebe and Lachman, 3001) : homeostasis, moments of intense emotion, disruption and repair. • Emotional attunement -- or emotional improvisation/ to find the common rhythm once again.

15. A caution: If forced, a child will abandon self to hold onto the other -- for perceived survival.

16. Development and exploring GRADUAL EMERGENCE OF MEAND: YOU AS LIKE ME BUT DIFFERENT FROM ME.AND AN EMERGING SENSE OF SELF THAT INTEGRATES AND CARRIES MEMORIES OF THESE EARLIEST RHYTHMS A

18. “If I needed you, will you come to me, will you come to me to ease my pain? If you needed I would come to you, I would swim the sea to ease your pain... Baby's with me now, since I showed her how to lay her little (lilly) hand in mine. Who could ill agree she's a sight to see, a treasure for to fortify (the poor to find). –Emmy Lou Harris and Don Williams

19. WHAT DO YOU HEAR?

20. PART IV: STRONG TIES • WHAT HAPPENS IN PSYCHOTHERAPY? STATES OF MINDINTERSUBJECTIVITYREFLECTIVE CAPACITYSELF/ OTHER EXPERIENCESHARED NARRATIVE CLINICIAN STATE OF MIND

21. AT THE CORE OF RELATIONSHIP INFORMED PSYCHOTHERAPY • While we often assume it is about what we say...the change process in psychotherapy may be much more about how we relate-- which is how "what we say" gets remembered. • Therapy outcome research: the central influence of therapeutic alliance and the client's perception of the clinician's intention. (Wampold, 2010)

22. WHAT ALLOWS FOR THIS SWEET RELATIONAL COLLABORATION? • Trust that company feels safe, soothing, helpful. • Parental improvisation (reflective capacity). • Predictability and reliability, structure that allows the relationship to be. • Affective energy and tolerance for feelings. • Experiential opportunities --in the moment learning

23. AND ... • Acceptance of differences and confusion (tantrums). • Willingness to negotiate ideas and reciprocate/ back and forth action. • Awareness of my mind/ your mind / shared minds/ different perspectives. • Permission to explore -- to move out, to examine different possibilities about self, other and come back to safe base.

24. "I hurt you, you hurt me, we both bruise so easily, too easily to let it show... All my plans depend on you to help them grow... Ending always come at last, endings always come too fast, they come too fast but the past too slow. I love you and that's all I know. Art Garfinkel

25. WHERE BRUISING CAN HAPPEN (TO THE PARENT, THE CHILD, THE CLINICIAN) • CASES THAT LOOK AT THERAPY PROCESS