INTIMACY, SEXUALITY OF ATTACHMENT ISSUES OR ADDICTION - PowerPoint Presentation

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INTIMACY, SEXUALITY OF ATTACHMENT ISSUES OR ADDICTION

Dr Mark SchwartzAvalon Malibu&Monterey Institute of Mental HealthMfs96@aol.com314.378.6832drmarkschwartz.net@gmail.com

April 3, 2014Slide2

IntroductionSlide3

Love and Compulsion Cannot Coexist

Love is willingness and ability to be affected by another human being and to allow that effort to make difference in what you do, say, become.Compulsion is the act of wrapping ourselves around an activity, a substance, or a person to survive, to tolerate and numb our experience of the moment.Love is a state of connectedness, one that includes vulnerability, surrender, self-valuing, steadiness, and willingness to face, rather than run from, the worst of ourselves.Compulsion is a state of isolation, one that includes self absorption, invulnerability, low self-esteem, unpredictability and fear that if we faced our plan, it would destroy us.Love expands; compulsion diminishesSlide4

People go to great lengths to maintain the illusion of connection. Many select mates who remind them of their parents to try to recreate their past. They ignore their children’s individuality and try to mold them into an image of themselves in an attempt to achieve a kind of immortality. Others work compulsively, taken refuge in routines, or choose addictions to avoid real experiences that threaten their illusions. In contrast, individuals living a self-actualized existence discover what lies beyond defenses and illusions of connection. They make real contact and establish genuinely loving relationships with actual people in real life in spite of the awesome spectre of existential aloneness and interpersonal pain.

Fireston, Robert W., Creating a Life of Meaning and CompassionSlide5
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Love is not primarily a relationship to a specific person; it is an attitude, an orientation of character which determines the relatedness of a person to the world as a whole, not toward one “object” of love. If a person loves only one other person and is indifferent to the rest of his fellow men, his love is not love but a symbiotic attachment, or an enlarged egotism... If I truly love one person I love all persons, I love the world, I love life. If I can say to somebody else, “ I love you,” I must be able to say, “I love in you everybody, I love through you the world, I love in you also myself.”

From “The Art of Loving”, 1956, Erich fromSlide7

Re-Framing the Meaning of Symptoms

Start with the assumption that every symptom is a valuable piece of dataUse psycho educational material to make educated guesses about the meaning of symptoms, as a symptom-memory or a valiant attempt to cope.Ask her,” how would this ___ have helped you to survive in a unsafe world? Helped you to feel less overwhelmed? Less helpless? More hopeful?Look for what the symptom is still trying to accomplish: i.e., chronic suicidal feelings might offer comfort or a “bail-out-plan;” cutting might help modulate arousal; social avoidance could be an attempt to avoid “danger”Once it is clear what the symptom is trying to accomplish, then the therapist and patient can look for other ways to accomplish the same goal in a context that describes the patient as an ingenious and resourceful survivor, rather than a damaged victim.Slide8

Burdens

The concept of “burdens” is brilliant in its widespread application. It sidesteps the need to compare, contrast, count symptoms to diagnose, and postulates instead more of a “no one escapes unscathed” framework. Thus, “burdens” can encompass beliefs, feelings, and energetic residue of events and experiences that overwhelmed the internal and/or external accessible resources of the organism and its attachment environment at the time, thereby creating constraint.Slide9

AttachmentSlide10

Developmental Model of Disturbance

Developmental deviation of ontogenetic process, failure of adaptations, pattern of adaptation reflecting the totality of the developmental context to that point. Maladaptation can be the result of different developmental pathways, which are probabilistically related to disturbance. Individuals beginning in similar path may diverge, showing different pathology.Slide11

Fear activates the attachment system but, if the primary attachment figure is the source of fear, the result is the collapse strategies for dealing with stress, preparing the capacity to regulate arousal by using others for self-soothing and delayed use of self-controlling behaviors.Slide12

Stroufe Longitudinal Study

Attachment is an organizational construct not a causal agent.Disorganized attachment correlates 34 percent with global pathology and 36 percent with dis-associative disorder .Anxious attachment is uniquely and specifically associated with anxiety disorders while avoidant attachment with conduct disorders.Both physical and sexual abuse increased incidence of conduct disorder to 73 percent and was the greatest predictor of adult depression.    40 percent of parents who experienced childhood abuse maltreated infants.Slide13

Dissociation and Self-Development

Sexual and physical abuse at the hands of family members cause the child to split off experiences, relegating them to an inaccessible part of self.Dissociation of one’s experience sets the stage for loss of one’s true self. The true self becomes corroded with inner badness and is concealed at all costs. Persistent attempts to be good, thus leading to a socially acceptable self, are experienced as non-authentic. The adolescent is compelled with demand to create multiple selves in different contexts.Slide14
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Secure Attachment I

Because their caretakers have been routinely available to them, sensitive to their signals, and response with some degree of reliability (though by no means is perfect care required), these develop a confidence that supportive care is available to them.They expect that when a need arises, help will be available. If they do become threatened or distressed, the caregiver will help them regain equilibrium.Such confident expectations are precisely what is meant by attachment security. L. Alan Stroufe, 2000Slide16

Clinical Manifestations of Anxious Preoccupied Attachment

Excessive worry about relationshipsWorry partner won’t care as much as s/he doesObsessive preoccupation & rumination about relationshipsExcessive need for approvalIgnoring signs of trouble in relationshipFear will scare people awayFear of abandonment/rejection/criticismResentment when partner spends time away from relationshipAngry withdrawalFrustration if partner not available or if don’t get what needFeel extremely bad in face of disapproval

Easily upset; intensified displays of distress or anger

jealousySlide17

Clinical Manifestations of Anxious Preoccupied Attachment, cont.

Fear of being aloneCompulsive care-takingsubmissive, acquiescent, suggestibleAttachment at expense of autonomyWork, school or friends get less attentionCompulsive care-seekingPartner describes as “smothered” or “suffocated”Eager to be with partner all the timeNeed excessive reassuranceClinging, demanding, nagging, or sulkingDesire to merge

Proactive attempts to win favor or impress

Forcing response from partner

Self-centeredness, showing off, center of attention

Dan Brown, 2008Slide18

Fonagy: Attachment & Mentalization

Peter Fonagy and colleagues have described this ability as a product of the adults’ “reflective function” in which parents are able to reflect (using words) on the role of states of mind influencing feelings, perceptions, intentions, beliefs and behaviors. For this reason, reflective function has been proposed to be at the heart of secure attachments, especially when the parent has had a difficult early life.Slide19

Active Implementation

The avoidant infant actively restricts attention to mother – as if to distract from the anxiety and distress of wanting mother’s comfort.The preoccupied actively seek and confines self to monitoring mom’s whereabouts, ignoring the toys and exploring the environment. Gives up the development of self to survivor.The disorganized capitulate in external relationships, they also extend internal relational exchanges between parts of the self, leading to chronic inner conflict, internal abandonment of parts of self holding traumatic affect and ruthless self-criticism.Outpatients actively live by the rules of attachment. Dismissive client find attention focused on needs of others, denying their own needs. Preoccupied are consumed with doubts about self and others and yearnings. They store up strategies to justify and maintain pre-existing beliefs.Slide20

Developmentally Based Psychotherapy

(Mobilized Developmental Process) Self-regulation (security, control) - look, listen, attend, feel calm, modulate affect and behaviorForming intimate relationships ( optimism, security, dependence)Engaging in boundary-defining communication (self-other)Representing internal experience (wishes, intentions, affects, complex sense of self)Slide21

Over Indulgence

Feeding without nutritionTreated like an infant, rather than as a capable adult.Parents preoccupied with work and themselves, and at the same time are over-focused on children.Parents irresponsible and over-responsible:Absent and hoveringGive little of themselves and shower with material goods.Uninvolved with homework or do homework for kids.Child raising child. Parenthood is ego dystonic.Only as good as last accomplishment: Don’t derive mastery and efficacy from last accomplishment.Slide22

Over Indulgence vs. Control

Such behaviors include:Installing guiltInstalling anxietyWithdrawing loveExcessive achievement demandAvoiding tendernessAffective punishmentHostile detachmentInterfering with decision-makingExcluding outside influence

Not fostering self-reliance

Place child as subordinate to confirm completely

Inhibiting child’s discovery

Inhibiting expression of self

Excessive parental expectationsSlide23

SexualitySlide24

Sexual Dysfunction for Women (1999)

Low DesireArousal Disorder

Sexual Pain

Daily alcohol consumption

.46

.87

.58Slide25

Sexual Dysfunction

Men 50-59 are 3x as likely to have erection problems and low desire than younger men. Impotence 9.6% in older men.Non married women 112 times more likely to have climax problems and sexual anxiety.High educational attainment negatively associated with sexual problems. Women graduated from college are half as likely to experience low desire or orgasm problems.Male college grads half as likely to report non-pleasurable sex and sex anxiety.Arousal disorder highly associated with sexual trauma history in men and women.Slide26
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Sexual Disorder

WOMENMENUnaffected – 58%Unaffected – 70%Low desire – 22%Premature ejaculation – 21%

Low arousal – 14%

Erectile

dysfunction – 5%

Sexual pain – 7%

Low desire –

5%Slide28

Trauma Bonding

I don’t know that we’ve ever experienced true sexual arousal, only fear arousal; Arousal driven by terror, anxiety or excitement that is basically over-stimulation. “When I feel tense, it translates into a physical response in the vaginal area.”Slide29

Affect and Compulsive Behavior

Abused children discover they can produce release through temporary alterations in their affective state by voluntarily including autonomic crisis or extreme autonomic arousal. Purging and vomiting, compulsive sexual behavior, compulsive risk taking or exposure to drugs, and the use of psychoactive drugs become vehicles which abused children regulate their internal state. Judith Herman, M.D.Slide30

Treatment of Intimacy DisorderSlide31
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Seeding Development of SelfSlide33

Qualities of Self

CalmnessCuriosityClarityCompassionConfidenceCourageConnectednessJoy

Gratitude

Humor

Equanimity

Perspective

Peace

KindnessSlide34

Coaching Issues

self punitive voiceperfectionismAvoidance of anxietyinability to take actionharm avoidancesocial inhibition emotional- recognition tolerance expressionsaying no/ yesshame binds keep commitments

self compassion

chaotic lifestyle 

clean house files papers-mail

out of control /over control 

regular schedule 

eat /sleep /exercise   

overly self /other focus 

self care  

sexuality   

destructive relationships 

showing up 

surrender 

self forgiveness

formulating meaningful life 

coherence 

dissociationSlide35

INTER-PSYCHIC INTIMACY

(between the couple) vs.INTRA-PSYCHIC INTIMACY (within the individual)Slide36

Consensus Proposed Criteria for “Developmental Trauma”

Self and relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:Intense preoccupation with safety of the caregiver or other loved ones (including precocious care giving) or difficulty tolerating reunion with them after separation.Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness.Extreme and persistent distrust. Defiance or lack of reciprocal behavior in close relationships with adults and peers.Reactive physical or verbal aggression towards peers, caregivers, or other adults.

Inappropriate (excessive or promiscuous) attempts to get contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance.

Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, Or excessive responsiveness to the distressed of others.

The National Child Traumatic Stress Network (NCTSN)Slide37

Self-Empathy

The internalizing of the attentive,validating, caring relationship to oneself. This involves helping the client articulate her experience and bring it into her own internal relational context.Slide38

Self – parenting: according to survivors, qualities of ideal parent

Unconditionally loving and accepting.Affirming.Takes responsibility.Sets and teaches healthy boundaries.Is protective.Values play.Is forgiving mistakes.Encourages growthListens to child in open and receptive way. These are the qualities of the ideal “self-parent”Slide39

Hypo/Hyper SexualitiesSlide40
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Hypersexuality

Low threshold for sexual responsiveness, often with obsessive-compulsive rituals of sexual expression that displace the unfolding of connection or caring for the partner. The rituals may also revolve around masturbation rather than partnered sex, or paraphilic sex, accompanied by a great deal of shame with primary emphasis on relief or anxiety or tension.Slide42

Contradictory Aspects of Sexual Arousal (cont)

It is therefore, quite common for one individual to be both hypersexual and hyposexual within the same or different periods of their lives. Their extremes of responsiveness seem contradictory, but are actually a predictable adaptation to a set of complex overwhelming contradictory internal cognitive-affective, behavioral structures, evolved in a response to original rejection, abandonment, neglect, assault and resultant recreations and misappraisals.Slide43

Hypo Sexuality

Sexual response is consistently inhibited.Low initiatory behavior.States, “I don’t enjoy sex very much and would prefer to have less than once a month.”In relationships, often one partner is hypersexual and the other feels pressured and thereby hyposexuality and this dynamic becomes amplified, creating labels “too much – too little” which becomes disposition.Slide44

Relationships & Sexuality

In sex therapy, entitlement refers to the therapist giving the client permission to not to be sexual. For example, a therapist might say: “ it is understandable that, given what happened to you and what you’ve done to yourself as a result of what was done to you, and the destructive influences on your choice of partner and the relationship you’ve each created, you do not feel sexual. It would be a miracle or even dysfunctional if anyone could feel sexual under these circumstances!’Slide45

Cybersex as Dissociative Re-enactment

Re-enactments of past conflicts or traumata, with underlying motive to resolve unfinished business.Perversion: Turning childhood tragedy into triumph.Illusion of being wanted/desiredIllusion of having power and controlManagement of dissonance and paradoxSlide46

Trauma Recovery Domains (Mary Harvey, Ph.D.)

Authority Over Memory - Can take event from past, talk about it with sense of empowerment.Integration of Memory and Affect - Can feel appropriate affect with cognition. New affect (adult-oriented)(1995).Affect Tolerance and Trauma - Related Affect - Feelings no longer overwhelmed, get overwhelmed and back into the trauma, ignore and walk into danger.

Symptom Mastery – Hyper vigilant, anxiety, depression, dissociation, somatic, compulsivity, how much do we need to measure remission.Slide47

Trauma Recovery Domains (Mary Harvey, Ph.D.)

Self-Esteem - Capacity for self-care and regard, properly eat, exercise, sleep, self soothe.Self-Cohesion - How one experiences oneself, fragmented, compartmentalized, self-trustSafe Attachment - Negotiate and maintain safety in relationships.

Making Meaning - Making meaning of their experiences.