T he c linic a l ma tc hing : inte r ac tions be twe e n patie nt’s and the r apist’s attac hme nt str ate gie s in a DMM pe r spe c tive . F ra nc o Ba ldoni, MD, PhD Attac hme nt Asse ssme nt L ab, De par tme nt of Psyc hology, Unive r sity of Bologna (Italy) fr anc o.baldoni@unibo.it
Atta c hme nt, Working Allia nc e a nd the ra pe utic re la tionship: Wha t ma ke s a psyc hothe ra py work? F r anc o Baldoni & Ale ssandr o Campailla (2017) Gio rnale italiano di psic o lo g ia, 4 (De c ): 823-846. do i: 10.1421/ 88770 • De spite me tho do lo g ic a l limita tio ns a nd so me c o nflic ting re sults, re se a rc h ha s e vide nc e d tha t a tta c hme nt pa tte rns o f the pa tie nt a nd the the ra pist sig nific a ntly influe nc e the the ra pe utic pro c e ss a nd the o utc o me o f the tre a tme nt. Me ta -a na lyse s Pa tie nt sa fe ty a nd tre a tme nt e ffe c tive ne ss a re re la te d to the de ve lo pme nt o f a va lid wo rking a llia nc e (Do zie r e t a l. 1994; Die ne r, Hilse nro th & We inb e rg e r, 2009; Mo nro e & Die ne r, 2011). T he c ha ra c te ristic s o f the the ra pist e xpla in 5-7% o f the the ra pe utic va ria nc e (e ffe c t o f 5-8 time s hig he r tha n the type o f tre a tme nt) (Ba ld win & I me l 2013) T he ma tc hing b e twe e n the a tta c hme nt pa tte rns o f the pa tie nt a nd the the ra pist influe nc e s the wo rking a llia nc e , the the ra pe utic pro c e ss a nd its o utc o me (Mo hr, Ge lso e Hill, 2004; Ro ma no , Ja nze n e F itzpa tric k, 2009; Ba ldo ni, 2008, 2013; Hill, 2015). the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
F a c tors tha t influe nc e the ra pe utic e ffic a c y (Wa mpo ld , 2014, c o urte sy o f the a utho r; Ba ldo ni & Ca mpa illa , 2017) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
How the DMM wor ks (in psyc hothe r apy) The DMM pays attention to the attachment patterns of the patient and the therapist and considers their matching The therapist may organize the most appropriate relational and therapeutic interventions by considering the patient’s (and his family) specific ability to process cognitive and affective information The therapist needs to be B in the clinical relationship (whatever his attachment pattern is) becoming a transitional attachment figure and offering a secure base that supports the exploration of mental processes and encourages new experiences (Hill, 2015) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
T he r apists’ Attac hme nt patte r ns T e nd to diffe r fro m tho se o f the g e ne ra l po pula tio n, with mo re fre q ue nt e xpre ssio n o f A+ a nd C+ E xtre me Atta c hme nt Pa tte rns DMM-AAI - I ta lia n sa mple , N: 279 pa tte rns a nd, in pa rtic ula r, unr e solve d tr auma or losse s (suc h a s illne ss o r de a th o f a fa mily me mb e r) tha t ma y b e the b a sis o f the ir mo tiva tio n to c ho o se a he lping pro fe ssio n (Do zie r, Cue & Ba rne tt, 1994; Wilkinso n, 2003; Unre so lve d T ra uma s L a mb rusc hi, 2008; Ding e r e t a l., 2009; Unre so lve d L o sse s Ho lme s, 2009; Wilkinso n 2003, 2008; Ba ld o ni, 2010; Ba ld o ni & Ca mpa illa , 2017). (L a mb rusc hi, 2008; L a mb rusc hi e t a l., unpulishe d) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
T he c linic al matc hing (Ba ldo ni, 2008, 2013) In A+ and C+ the r e sults c o uld be ve r y c o mple x
A T he r apist vs A Patie nt • T he ir a tta c hme nt stra te g ie s will pro b a b ly c o llude • Mo re dire c tive inte rve ntio ns fo c use d o n ra tio na l a spe c ts (rig id te c hnic a l-c o g nitive a ppro a c h, c o g nitive -b e ha vio ra l pre sc riptio ns, inte lle c tua l e xpla na tio ns o f diso rde rs, fo c using o n the so ma tic dime nsio n) • Avo ida nc e o f pro b le ma tic a re a s tha t re ma in po o rly e xplo re d (re la tio na l pro b le ms, de pre ssio n, fa nta sie s o f de a th o r suic ida lity, unre so lve d lo sse s o r tra uma s) • Syste ma tic dismissing o f ne g a tive e mo tio ns with the te nde nc y fo r b o th to e xpre ss fa lse po sitive a ffe c ts (suc h a s smiling o r jo king whe n fa c ing pa inful o r sc a ry to pic s) (Ba ldo ni, 2008, 2010; Ro ma no , Ja nze n & F itzpa tric k, 2009; Ba ldo ni & Ca mpa illa , 2017). the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
C T he r apist vs C Patie nt • T e nde nc y fo r b o th to e mpha size the e mo tio ns a nd fo ste r e xc e ssive a nd unre a listic e xpe c ta tio ns o f tre a tme nt. • I t will b e diffic ult to ma inta in re la tio nships within pro pe r limits, with the te nde nc y to e xte nd the c o nsulta tio ns a fte r a c o rre c t time . • At the b e g inning the y c o uld ha ve the impre ssio n o f b e ing o n the sa me wa ve le ng th (a s if the y we re frie nds), b ut, o ve r time , inte nse tra nsfe re nc e ne uro sis will te nd to ma nife st (due to the disa ppo intme nt o f mutua l e xpe c ta tio ns), with c o ntro ve rsy, q ua rre ls, re la tio na l c o nflic ts a nd po ssib le inte rruptio n o f the ra py (Ba ldo ni, 2008, 2010; Ro ma no , Ja nze n & F itzpa tric k, 2009; Ba ldo ni & Ca mpa illa , 2017). the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
A T he r apist vs C Patie nt (or C vs A) • A pa rtia l c o mpe nsa tio n c a n o c c ur. Studie s ha ve sho wn, in fa c t, tha t this c o nditio n is o fte n re la te d to a sa tisfa c to ry the ra pe utic re la tio nship, e spe c ia lly if the the ra pist is dismissing (Me ye r & Pilko nis 2001; Bruc k e t a l. 2006). • Co unte rtra nsfe re nc e e na c tme nts ma y a lso o c c ur, a lo ng with o missio ns a nd misunde rsta nding s c o nc e rning the ne g le c te d o r pro b le ma tic a re a s o f mutua l a tta c hme nt pa tte rns (suc h a s a ffe c tivity fo r dismissing sub je c ts a nd c o g nitio n fo r pre o c c upie d), with the c o nse q ue nc e tha t diffic ulty a rise s in unde rsta nding a nd sha ring o f the re sults (Mo hr, Ge lso & Hill 2005). • Co nse q ue nc e s ma y b e po o r the ra pe utic c o mplia nc e o r e ve n the a b rupt withdra wa l o f tre a tme nt. (Ba ldo ni, 2008, 2010; Ro ma no , Ja nze n & F itzpa tric k, 2009; Ba ldo ni & Ca mpa illa , 2017). the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
B T he r apist vs A or C or B Patie nt • I nte g ra tio n o f me nta liza tio n, c o g nitive info rma tio n, a ffe c ts a nd c o mmunic a tive skills with a g o o d a b ility to a na lyze pro b le ms • T he the ra pist will a ddre ss the c linic a l re la tio nship in a mo re c o nsc io us wa y a nd will wo rk to a da pt b e tte r to the pa tie nt’ s stra te g y a nd its spe c ific c ha ra c te ristic s a nd re q uire me nts (T a ilo re d tre a tme nt) • T his is pa rtic ula rly true with e a rne d B the ra pists (Do zie r, Cue & Ba rne tt 1994; Sho re y & Snyde r 2005; Ro ma no , F itzpa tric k & Ja nze n 2008; Ba ldo ni, 2008, 2010; Ba ldo ni & Ca mpa illa , 2017) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
A taylor e d attitude • Dismissing patie nts (A) ne e d to re c e ive c le a r info rma tio n a nd o rg a nize tho ug hts in a re la tive ly ra tio na l wa y, b ut a lso b e he lpe d in the e xpre ssio n o f e mo tio ns, e spe c ia lly ne g a tive o ne s. • e oc c upie d patie nts (C) the the ra pist ne e ds to b e mo re c a re ful no t to c o llude with his Pr me nta l sta te a nd a c ts mo re firmly ma inta ining a c o nsta nt psyc ho lo g ic a l c o nta inme nt a ttitude to impro ve the re g ula tio n o f e mo tio ns (Me ye r e t a l., 2001; Purne ll, 2010; Ba ldo ni, 2008, 2010). • At the b e g inning , the the ra pist pro po se s himse lf a s a tra nsitio na l a tta c hme nt fig ure , his re la tio na l a ttitude is o rg a nize d in a re la tive ly c omple me ntar y style , b y a vo iding e xpo sing the pa tie nt to o e a rly to e xc e ssive ly a nxio us o r o ve rly c o nfusing c o nditio ns. • Sub se q ue ntly, the pa tie nt's ma la da ptive e xpe c ta tio ns ne e ds to b e g ra dua lly disc o nfirme d ( symme tr ic al style ) “Sure , b ut no t to o sure ” (Bro mb e rg , 2006). • T re a tme nt pro duc e s c ha ng e s thro ug h re o rg a niza tio n a fte r mo me nts o f c risis ( Ruptur e and Re pair ) (Winnic o tt, 1956 ; De Be rna rt & L a ndini, 2015 - Bumps in the Road to Change ) (Millinckrodt, Porter & Kivlighan 2005; Holmes, 2009; Baldoni & Campailla, 2017) the inte rna tio na l a sso c ia tio n fo r the stud y o f a tta c hme nt
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