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Cmo manejamos las emociones negativas durante las

crisis en el proceso teraputico

F. Lana y C. Snchez


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Cmo manejamos las emociones negativas durante las

crisis en el proceso teraputico

Fernando Lana

Programa de trastorno lmite de la Personalidad

Director del Master en Trastorno Mental Grave, IL3-UB

Psiquiatra-Psicoanalista (CPM-IFPS)

Centre Emili Mira-INAD

Parc de Salut Mar de Barcelona

Carmen Snchez

Programa de trastorno lmite de la Personalidad

Master en Trastorno Mental Grave, IL3-UB

Psicloga Clnica-DBT

Centre Emili Mira-INAD

Parc de Salut Mar de Barcelona


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BorschmannBorschmannBorschmannBorschmann R

RRR,

,,, HendersonHendersonHendersonHenderson C

CCC,

,,, HoggHoggHoggHogg J

JJJ,,,, PhillipsPhillipsPhillipsPhillips R

RRR,

,,, MoranMoranMoranMoran P

PPP.

..

.

Cochrane Database SystCochrane Database SystCochrane Database SystCochrane Database Syst Rev.Rev.Rev.Rev. 2012 Jun 13;6:CD009353.

BACKGROUND:BACKGROUND:BACKGROUND:BACKGROUND:

People with borderline personality disorder (BPD) frequently present to health services in crisis, often involving suicidal thoughts or actions.

Despite this, little is known about what constitutes effective management of acute crises in this population.

OBJECTIVES:OBJECTIVES:OBJECTIVES:OBJECTIVES:To review the evidence for the effectiveness of crisis interventions for adults with BPD in any setting. For the purposes of thereview, we defined crisis intervention as 'an immediate response by one or more individuals to the acute distress experienced byanother individual, which is designed to ensure safety and recovery and lasts no longer than one month.'

AUTHORS' CONCLUSIONS:AUTHORS' CONCLUSIONS:AUTHORS' CONCLUSIONS:AUTHORS' CONCLUSIONS:

There is no RCT-based evidence for the management of acute crises in people with

BPD and therefore we could not reach any conclusions about the effectiveness of

any single crisis intervention. High-quality, large-scale, adequately powered RCTs in

this area are urgently needed.

Crisis interventions for people withborderline personality disorder


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Cochrane Database Syst Rev. 2012 Aug 15;8:CD005652.

Psychological therapies for people with BPDStoffers JM, Vllm BA, Rcker G, Timmer A, Huband N, Lieb K.

ObjectivesTo evaluate the effects of psychological interventions for people with borderline personality disorder.

Search strategy

We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL(1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science CitationIndex (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011..

Selection criteria

Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specificpsychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects..

Conclusions:

There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensivepsychotherapeutic interventions for BPD core pathology and associated general psychopathology.

DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPSHowever, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality ofindividual studies.

Overall, the findings support a substantial role for psychotherapy in the treatment ofpeople with BPD but clearly indicate a need for replicatory studies..


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Crisis? What Crisis?Definicin(del latn crisis, a su vez del griego )

Diccionario de la Real Academia de la Espaola, significados:1. Cambio brusco en el curso de una enfermedad, ya sea para mejorarse, ya paraagravarse el paciente.2. Mutacin importante en el desarrollo de otros procesos, ya de orden fsico, ya histricos o espirituales.

3. Situacin de un asunto o proceso cuando est en duda la continuacin, modificacin o cese.

4. Momento decisivo de un negocio grave y de consecuencias importantes.

5. Juicio que se hace de algo despus de haberlo examinado cuidadosamente.

TLP-DBT(m):

Activacin/excitacin de las emociones.

Disfuncin del procesamiento cognitivo.

Disfuncin regulacin de la atencin (cappara manejarla voluntariamente)

TLP-DBT: Malestar insoportable (emocional).

No puedo pensar en otra cosa.

No habla de otra cosa


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Amor

Alegra/Gozo

Ira

TristezaMiedo

Vergenza

Segn los autores las emociones pueden ser diversas:

Izard (placer, sorpresa, tristeza, ira, asco, desprecio, miedo)

Ekman (miedo, ira, alegra,, tristeza, asco, sorpresa)

Plutchik (miedo, ira, alegra, tristeza, aceptacin, asco, anticipacin, sorpresa)

CLASIFICACION DE LAS EMOCIONES(DBT)


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According to Linehan's biosocial theory, individuals with BPD areemotionally sensitive from birth.

This sensitivity leads to a propensity to experience negative affect across

contexts and situations,


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Following Linehan's biosocial model, we conceptualize emotion dysregulationin borderline personality disorder (BPD) as consisting of four components:

emotion sensitivity,

heightened and labile negative affect,

a deficit of appropriate regulation strategies,

a surplus of maladaptive regulation strategies


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Emotion sensitivity in BPD has primarily been associated with negative mood states (e.g., anger, fear, sadness) and not positive emotions

Given the complexity of the construct of emotion dysregulation there is a need forresearch that specifies:

which components of emotion dysregulation are under study.

the interplay amongst these emotion dysregulation components.


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-La respuesta se ha ido formulando en torno a lo que NO-hacer.

-La historia de la evolucin de la psicoterapia del TLP, se ha escritomuchas veces subrayando lo que no es recomendable:

-NO utilizar divn (definicin TLP).

-NO invalidar.

-No actuar la contratransferencia, etc.

Cmo manejar las emociones negativas durante las

crisis?


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LO QUE NO HACER?

The therapeutic work is directed at:

=>The devaluation:

Youre afraid to want things from me which you cant control

=>The manipulation:

Youre trying exert control over me

=>The projection:

Youre mad at me for not always being available

Extracto: Manual de psicoterapia para el TLP. APA, 1984.


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C

RIS

IS

N

O


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NOaccidente


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LAS CRISIS SON MUY FRECUENTES EN EL TLP

lo extrao sera que no las hubiese

Estar prevenidos

Qu se puede hacer antes de quecomience la crisis?


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DBTTerapia dialctico-conductual

-Plan de crisis

-Qu hacer cuando el T noest disponible?

-El Tf, componente del tto

-HH para disminuir lavulnerabilidad emocional

MBTTerapia basada en la mentalizacin

LAS CRISIS SON MUY FRECUENTES EN EL TLP

-Plan de crisis

-Qu hacer cuando el T noest disponible?


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Crisis Strategies

(DBT)

-T attends to AFFECT rather than content.

-T explores the problem NOW.

-T focuses on PROBLEM SOLVING.-T focuses on AFFECT TOLERANCE.

-T helps P COMMIT herself to a plan of action.

-T T assess Ps SUICIDE POTENCIAL.

-T anticipates a RECURRENCE of the crisis.

MuyIMP


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Affect Storms

(MBT basic principles)

=>Interventions should be:

-AFFECT focused.

-Refer to CURRENT/Immediate context.

-Simple and Short.-Address CONSCIOUS content.

-Non-judgemental.

OJO

-Clarify the feeling WITHOUT interpretation.

-ONLY address possible causes (current, IP ) as the emotional state subsides.

-Link affect storm to therapy ONLY after it has receded.


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Es fcil acercarse, contactar, comunicarse, ayudar...

a una persona con un TLP en crisis?


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Alright . . . what do you want me to say? Do you want me to say its

funny, so you can contradict me and say its sad? Or do you want

me to say its sad so you can turn around and say no, its funny!!!

From Whos Afraid of Virginia Woolf?, by Edward Albee


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J Am Psychoanal Assoc June 2003 vol. 51 no. 2 517-545

The Management of Affect Storms inthe Psychoanalytic Psychotherapy ofBorderline Patients

Otto F. KernbergColumbia University Center for Psychoanalytic Research and Training, New York Presbyterian Hospital,Westchester Division, Joan and Sanford I. Weill Medical College, Cornell University,

[email protected] [email protected]

AbstractAffect storms are a frequent complication in the psychoanalytic approach to borderlinepatients. The descriptive, psychodynamic, and structural characteristics of these storms areexplored, and the verbal, nonverbal, and countertransference manifestations that permit theformulation of interpretations under such conditions are described, as are the interventionsrequired to maintain the treatment frame as a precondition for an analytic approach. Theprincipal theoretical formulations regarding the affect pathology of borderline patients are

reviewed and related to a proposed interpretive approach. An apparently oppositedevelopment, the utter absence of emotional developments in the sessions, is examined, andits defensive function of avoiding affect storms is explored. Clinical case material illustratesthe proposed approach to these storms, and clinical evidence is given to support theapproach, which centers on systematic analysis of the primitive internalized object relationsof these patients in the transference, the use of countertransference analysis withoutcountertransference communication to the patient, and the repeated restoration of technical

neutrality in the service of protecting the treatment frame.


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=>POR UN LADO: Estrategias potentes y bien definidas, sobre todo,

las DBT.

=>POR OTRO LADO: lograr que el paciente las utilice durante lacrisis.


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HABITUALMENTE

NO las va a utilizar (sobre todo, al inicio)

NO basta con recordrselas

NO ser nada fcil, muchas veces, el primeracercamiento al paciente

RIESGO de re-activacin emocional.


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DBTTerapia dialctico-conductual

-Validacin

-Dialcticas

-Estilsticas: equilibrar elestilo de comunicacin IP

MBTTerapia basada en la mentalizacin

Estrategias de acercamiento y comunicacin en las CRISIS

-Mentalizar (con el paciente)

-Postura: no-saber ycuriosidad

-Validacin


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-Existe investigacin al respecto?

-Puede ayudarnos a mejorar las terapias?


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La funcin evolutiva principal del sistema de apego es mantener la proximidad del nio a sucuidador (Nolte et al, FBN 2011).

Adulto: El apego es un sistema biolgico, fisiolgico-conductual, que facilita una respuestadinmica al estrs provocado por diversas amenazas ambientales para que el individuo se adaptelo mejor posible al medio (Mikulincer and Shaver, 2007).

APEGO, ESTRS Y MENTALIZACION


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AmenazaMiedo

Sistema de apego

ADULTO

Respuesta biopsicosocial(estrategias primarias de apego)

Modula la respuestaal estrs Estado de alerta

Conductas primarias de apego

(Buscan una respuesta de la figura de apego

que proporcione seguridad)


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Sistema de apego

DES-ACTIVACION

ADULTO

Sistema deactivacinemocional

Hipervigilancia

RESPUESTA FINAL*proporciona seguridad

(neuro)sistemas cognicin social:

Sospecha (confianza) interpersonal

*Combinacin de la respuesta de la persona y del ambiente


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Sistema de apego

ADULTO

activacinemocional

+++ hipervigilancia+++

RESPUESTA FINAL

NO proporciona seguridad

(neuro)sistemas cognicin social:

Sospecha +++

Anomalas en la capacidad dementalizacin

Respuesta biopsicosocial(estrategias secundarias de apego)


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Sistema de apego

Activacin crnica delsistema de apego

RESPUESTA FINALNO proporciona seguridad

Estrs +++Activacin emocional +++

NuevaAmenaza

Miedo

Re-acticacion


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Clinical evidence strongly implies that as the attachment bond

between therapist and client intensifies, the quality of BPDpatients mentalization will tend to deteriorate.

Psychotherapists of many orientations often attempt to provide understandingsfor issues that trigger intense emotional reactions (challenging interpersonal

situations, issues of shame, guilt, feelings of inadequacy, etc.) at a time when thecapacity for effective explicit mentalization is practically inaccessible.


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LO QUE NO HACER?

The therapeutic work is directed at:

=>The devaluation:

Youre afraid to want things from me which you cant control

=>The manipulation:Youre trying exert control over me

=>The projection:

Youre mad at me for not always being available

Extracto: Manual de psicoterapia para el TLP. APA, 1984.


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LO QUE NO HACER?

Intervenciones menos sofisticadas

=>Es que no pones nada de tu parte

=>Usted no quiere cambiar

=>Llegas tarde, no tomas la medicacin para qu vienes?


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LO QUE NO HACER?

Influencias:

=>El mdelo terico

=>La contratransferencia

Management of

Countertransference With

Borderline Patients.

Glen O. Gabbard, Sallye M. Wilkinson, 2000.


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-Autoobservacin.

-Auto-regulacin emocional

-Etc.

Manejo de la Contratransferencia con los personas con TLP

=>Teoras que ayudan a comprender a los seres humanos:

Ej. Las personas y los pacientes, primariamente, hacen todo loque saben para sufrir menos (validacin).

Contrarrestar mitos: el mito de la persona normal, madura.


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El mito de la persona madura:

Las persona normal (madura) es racional, estable, etc.


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we used transcranial magnetic stimulation (TMS) to disrupt neural activity in the temporoparietal junction (RTPJ) transiently.

TMS vs control, provoca que los participantes juzguen los intentos dehacer dao... moralmente ms permisibles... TMS altera la capacidad

para usar los estados mentales en el juicio moral.http://www.ted.com/talks/lang/es/rebecca_saxe_how_brains_make_moral_judgments.html


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Evid Based Mental Health doi:10.1136/eb-2012-100928

Therapeutics

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