Mental Health, Ill Health and Personality Disorder
Mental Health, Ill Health and Personality: The Role of Maladaptive & Adaptive Defence Mechanisms
Professor George Vaillant Psychiatrist and Professor, Harvard Medical School, and Director of Research for the Department of Psychiatry, Brigham and Women’s Hospital
Professor Vaillant’s extended keynote address focused on one of the most profound lessons from his ground-breaking research on development across the lifespan; namely, that any exploration of the links between positive mental health and psychopathology requires an understanding of adaptive involuntary coping – the so-called ‘mature defence mechanisms’.
Dr. Vaillant is a Professor of Psychiatry at Harvard Medical School and the Department of Psychiatry, Massachusetts General Hospital. He is graduate of Harvard College and Harvard Medical School; Dr. Vaillant did his psychiatric residency at the Massachusetts Mental Health Center. He has spent his research career charting adult development, the importance of involuntary coping mechanisms, and recovery from alcoholism. From 1970 to 2005 he was Director of the Study of Adult Development at the Harvard University Health Service. The study is arguably the longest (75 years) prospective psychosocial and medical study of males in the world. At age 80 he is now the beneficiary of his own research.
More recently Vaillant has been interested in positive emotions and their relationship to Positive Psychology. In 2000 he became a founding member of Positive Psychology. He has been a Fellow at the Center for the Advanced Study in the Behavioral Sciences, a past Class A (nonalcoholic trustee) of Alcoholics Anonymous and is a Fellow of the International Positive Psychology Association. He has received the Jellinek Memorial Award and American Psychiatric Association Distinguished Service Award. His published works include Adaptation to Life, 1977, The Natural History of Alcoholism-Revisited, 1995, Aging Well, 2002, Spiritual Evolution, 2008 and Triumphs of Experience, 2012
In his presentation Professor George Vaillant stated:
"Anticipating danger and rehearsing it is a defence mechanism."
"Our brains can take a situation and turn it into something magic – example going on a rollercoaster, rationally you know they are safe, but you still feel fear, but some people turn into an exciting, rewarding experience."
"Freud – emotion could be isolated but could also be reattached to other ideas (displacement), or forgotten (repression)."
"Projection, fantasy, dissociation, hypochondriasis, acting out, passive aggression – spells ‘borderline’ in American."
"Immature vs mature defences – scoring use of either across lifespan can help predict outcomes in later life."
"Sadly good health doesn’t necessarily correlate with good psych defences."
"WT Grant 1936 – What I have in mind is to assist, by some means, people…through a better knowledge of how to use and enjoy all the good things that the world has to offer them."
Mental health and ill health in Primary Care: Psychodynamic perspectives on mind-body links
Dr Julian Stern Director of Adult and Forensic Services & Consultant Psychiatrist in Psychotherapy Tavistock and Portman NHS Foundation Trust
In his presentation Dr Stern stated:
“Controlling countertransference – immature defenses are contagious. Hypochondriac provokes passive aggression.”
“How can this apply to our primary care situations in UK ? We would see reduced cost of service use and be seen as good value for money if we adopted this approach as more successful.”
Dr Julian Stern Full Presentation
Pre-event Abstract: A New Model for Primary Care Psychotherapy-the Tavistock model : And some psychodynamic perspectives on mind-body links
In this paper I will discuss the Model for Primary Care Psychotherapy which is being developed by the Tavistock and Portman NHS foundation Trust ,and epitomised in the 2 primary care services the Trust manages in London i.e. in City and Hackney, and in Camden. Some of the origins, developments and achievements of the services will be described, as well as the importance of research and outcome monitoring.
2 cases will be presented bringing the clinical work of the service to life, and I will link these cases with the ideas and work of George Vaillant, especially in relation to his paper (1992) “The beginning of Wisdom is never calling a patient a Borderline, or, The Clinical management of defences, in the Treatment of Individuals with personality disorders” , where he describes 3 principles for enabling patients to replace immature defences with more mature defences namely stabilising the external environment, altering the internal environment and controlling counter-transference.
Antisocial Personality Disorder (ASPD): Using mentalisation-based approaches
Dr Jessica Yakeley Consultant Psychiatrist in Forensic Psychotherapy, Director of Medical Education and Associate Medical Director Tavistock and Portman NHS Foundation Trust
In her presentation Dr Yakeley stated:
'Primitive defence mechanisms - projection and projective identifaction, acting out through violence, idealization and denigration (predator/prey), splitting, dissociation, somatization.'
'Why MBT? Has been developed for ASPD patients therapy. Psychotropic medication only for co-morbid conditions, not ASPD per se.'
'Principles of treatment - promote mentalizing, focus on violent and aggressive behaviours and link to mental states. Focus on self regard, social and interpersonal awareness. Actively avoid victim empathy, it doesn't work with these patients. Promote curiosity not certainty.'
'Hierarchy and power - ASPD patients experience relationships in terms of power and control. Avoid assuming position of power in relation to patient, by readily apologizing for perceived errors, see their point of view.'
'Shame and disrespect - try not to trigger feelings of humiliation and shame.'
'The future, commissioned by NHS England and MoJ in 2014 to develop new MBT services in probation service for violent men with antisocial personality disorder as part of the National Offender Personaltiy Disorder pathway.'
Dr Jessica Yakeley Full Presentation
Antisocial personality disorder (ASPD) is a complex condition carrying high rates of co-morbidity and mortality for individual sufferers as well as harmful consequences for their families and society. Despite the publication of NICE guidelines for ASPD in 2009, the evidence base and provision of effective treatments for patients with this costly disorder remain inadequate, and the belief amongst psychiatrists and other professionals that the condition is untreatable remains widespread. A Cochrane review of psychological treatments for ASPD in 2010 concluded that ‘further research is urgently needed for this prevalent and costly condition’
In this talk I view the mind of the antisocial person from a psychodynamic perspective, emphasising the role of primitive affects and defenses. I will highlight current diagnostic controversies and summarise the evidence for conceptualising ASPD as a disorder of attachment. This developmental perspective provides the rationale for adapting mentalization-based therapy (MBT), a treatment based on attachment theory, for individuals with ASPD. Violence can be seen as a defensive response to feelings of shame and humiliation exposed via failures in the capacity to mentalize, which have their roots in disorders of attachment.
I will then describe the framework we have developed in a pilot adapting MBT for men with ASPD in the community at 2 sites (St Ann’s Hospital and the Portman Clinic), highlighting the importance of creating a safe setting and the adaptations of therapeutic technique necessary to facilitate the engagement of this ‘treatment-rejecting’ patient population.
Following this pilot the Tavistock and Portman NHS Foundation Trust were commissioned by NHS England and the Ministry of Justice in 2014 to develop new community MBT services in National Probation Service across 13 sites in England and Wales for violent men with antisocial personality disorder as part of the Government’s National Offender Personality Disorder Pathway, with the Anna Freud Centre providing training and supervision. University College London is leading a multi site randomised controlled trial funded by NIHR across all sites comparing MBT versus ‘Probation as Usual’ in the reduction in violent behaviour in men with ASPD.
I will conclude with a video clip of an MBT group session of men with ASPD, which illustrates the psychodynamics of treatment.
Also of interest:
Improving Physical Health for People with Mental Health Conditions
Psychological Therapies for Severe & Prolonged Mental Illness
Psychosis & Schizophrenia in Adults
Medically Unexplained Symptoms/Somatic Symptom Disorder
23 June 2016