Intensive Short-term Dynamic Psychotherapy: Detecng and …al2898/columbia_psychosomatics/conference-2017... · Intensive Short-term Dynamic Psychotherapy: Detecng and treang somac

IntensiveShort-termDynamicPsychotherapy:Detec6ngandtrea6ng

soma6csymptomdisordersAllanAbbassMD,FRCPC

Professor&ProgramDirectorCentreforEmo:onsandHealth

DalhousieUniversity,Halifax,[email protected]

Allan Abbass MD 2017

ReferenceMaterialsn  ReachingthroughResistance.

DetailedmanualonISTDPpsychodiagnosisandtreatmentwithcaseexamples

n  www.reachingthroughresistance.comAvailableonAmazon:

hLp://a.co/3UGMWx0n  GradedFormatar:cleorcapacity

assessmentandbuilding:hLp://bit.ly/2gVT7iBAr:cleonResistancehLp://reachingthroughresistance.com/wp-content/uploads/2015/02/PsychodynamicPsychiatry2016.pdf

n  HiddenfromView:Aclinician’sguidetoPsychophysiologicalDisorders

n  WriLenwithaMindbodyexpertinternistHowardSchubinerandwriLenfordoctors

n  Howtoeducate,providefirstandsecondlinetreatmentsandbasicISTDPmethods.

n  Comingoutendof2017-early2018

n  www.unlearnyourpain.comAllan Abbass MD 2017

CentralPointsn  Thepresenceofemo:onalfactorscanbedirectlydetected

n  TherearespecificpaLernsofunconsciousanxietyanddefensewhichoccurtogether

n  Theactualsoma:cexperienceofunprocessedrage,guiltandgriefcanovercomesoma:za:on


MetapsychologyoftheUnconscious


BOND With

Parents


BOND With

Parents


BOND With

Parents


BOND With

Parents

BOND With

Others


BOND With

Parents


BOND With

Parents PAIN FEAR


BOND With

Parents PAIN FEAR

Rage, Guilt about the Rage


BOND With

Parents PAIN FEAR

Rage, Remorse about the Rage

Character Disorder + Symptoms


Currentperson

Transference(Therapist/Doctor/Den:st)

Pastperson


UnconsciousAnxiety

UnconsciousDefense

UnconsciousImpulses&Feelings


Whattodo?

n  Handlebarrierstoengagementn  Trytoformtherapeu:caLachmentn  Focusonunderlyingavoidedfeelingsn  Thisac:vatesalltheunresolvedcomplexfeelingsn  Thisac:vatestheanxietyanddefensesn  Buildanxietytoleranceasneededn  Helpexperiencetheavoidedfeelingsn  Linkeverythingtogether


UnconsciousAnxiety

UnconsciousDefense

UnconsciousImpulses&Feelings

1.PressureonFeelingsorDefenses

2.MonitorAnxiety&Defenseresponses


3paCernswewillstudy

n  1.Tenseupmusclesandintellectualize,usecharacterdefensesordetach

n  2.GoFlatwithrepressiontosmoothmuscleanxiety,conversionordepression

n  3.GoFlatwithcogni:veperceptualdisrup:onorprimi:vedefenses

n  4.Noresponse


StriatedMuscleUnconsciousAnxietyn  HandsClenchn  Arms,Shoulders,Neckn  Intercostal:Sighn  Abdomen,backn  LegsandFeet

àHyperven:la:on,Fibromyalgia,headache,chestpain,abdominalwallpain,tremor,:csn  SeewithIsola:onofAffect:intellectualiza:on


SmoothMuscleUnconsciousAnxietyn Gastrointes:naln  Vascular,CoronaryArteriesn  Bronchin  Bladder

n  AbdominalPain,IrritableBowelSyndrome,Dyspepsia,Migraine,PelvicPain

n Mediatedby(unconscious)Repressionoffeelings


Cogni:ve-perceptualDisrup:onn  Dissocia:on,losingtrackofthoughts,poormemory,fain:ng

n  Visualblurring,blindnessn  Dysfunc:onofothersensesn  Hallucina:onsinall5senses

n  SeenwithPrimi:vedefensesincludingProjec:onoffeelingsandimpulses


MotorConversion:Muscleweakness

n àNeurologyConsulta:onandEmergencyDepartments

n  SeenwithRepressionn  Nostriatedanxietywhenconversionisac:ve


Sympathysymptomsn  Guiltaboutragecausesthesamesymptomsasapersonunconsciouslywantedtoinduceinanother.

n  CommonExamples:n  StranglingàChokingn Headdamageàheadachen  Chestdamageàchestpainn  Tearing/rippingsensa:onsàPrimi:verage

n Management:pressuretofeelguiltabouttheragetoremoveorreducepain


SpectrumofPsychoneuro6cDisorders

Low Resistant

Highly Resistant

Moderate Resistant Mild Severe/

Borderline Moderate

SmoothMuscle/Conversion+Repression

Cogni:ve-PerceptualDisrup:on+Primi:veDefenses

SpectrumofPa:entswithFragileCharacterStructure

StriatedMuscle+Isola:onofAffect


SpectrumofPsychoneuro6cDisorders

Low Resistant

Highly Resistant

Moderate Resistant Mild Severe/

Borderline Moderate

ViolentRage

MurderousRage

Primi:veMurderousRage

SpectrumofPa:entswithFragileCharacterStructure

Primi:veTorturousRage

Grief


ComplexTransferenceFeelings(CTF)

n Mixedfeelingsintherapylinkedtothepastbond,trauma,pain,rageandguiltaboutrage.

n Includesapprecia:onandirrita:ontowardthetherapistbecauseofthechallengetodefenses


UnconsciousTherapeu6cAlliance(UTA)

n  Thisistheunconscioushealingforceinthepa:ent

n  UTAismobilizedinpropor:ontothedegreeofmobiliza:onoftheCTF

n  Bringsmentalimagesandclearlinkagestotrauma

n  “UnconsciousMobilized”meansmobiliza:onoftheUTA


SpectrumofUTA

R>>UTAWhispersfromtheUTA

R<<UTAImagesTransferGuiltandRageR<UTA

GriefandClearLinks

R>>UTANega:on&Dreams

After Davanloo, 2001. Abbass, 2012 Allan Abbass MD 2017

Pressure ModerateResistance

Striatedmuscleanxietyplusfeelcomplextransferencefeelings

HighResistance

Depression,smoothmuscleanxietyormotorconversion

HighResistancewithRepression

Cogni:ve-perceptualdisrup:onorprimi:vedefenses

FragileCharacterStructure

GOFLAT:Nostriatedmuscleanxiety

CapacityBuildingFormats

Repeatedunlocking,workingthrough,termina:on

Striatedmuscleanxietyplusfeelcomplex

transferenceFeelings

Breakthroughofgriefaboutloss

LowResistance

Completetreatmentin1or2sessions

Inquiry

ResistanceRises

Resistancecrystallizesinthetransference

Clarify,Challenge,

HeadonCollision




HighResistance










Breakthroughofgriefaboutloss

LowResistance

Completetreatmentin1or2sessions

Inquiry

ResistanceRises


Clarify,Challenge,

HeadonCollision




HighResistance










ResistanceRises


Clarify,Challenge,

HeadonCollision


Moderateresistantpa6ents

n  Buriedmurderousrageandguiltandgriefn  Anxietyisallstriatedn Maindefenseisisola:onofaffectandintellectualiza:on

n  Pressuretoseeunderlyingfeelingsmobilizestheunconscioustherapeu:calliance

n  Ifdefensescrystallizeintheroom,clarifyandchallengethem


PressureDavanloo1999

n  Themainstayinterven:onofISTDPn  Encouragingthepa:enttoconnecttohistruefeelingsandbeopenwiththetherapistaboutthesefeelings.

n  =Reachingthroughresistancetothepersonunderneath

n àPsychodiagnosisandTreatmentRoadmap

n  PressureincreasesComplexTransferenceFeeelings,UTAandResistance


ChallengeDavanloo1999

n Thisisdoneonlywhentheresistancesarecrystallizinginthetherapeu:crela:onship(transference),whentheyareanobstruc:ontothetherapeuHcbondandtask

n First,clarifythedefenceswiththePa:entn Thenpressure:encouragethepa:enttoovercometheresistanceswithyou

n Finally,challengethedefencesinconcertwiththepa:ent.


Unconscioustherapeu:calliance

ComplexTransferencefeelings

“Unlocked”

Resistance

Lowrise:inquiryandpressure

Midrise:Resistance

crystallizingintransference.ClarifyandChallenge,

Maintainpressure


Therapist Pa:ent

Therapist Pa:ent

Therapist Pa:ent

Lowrise

Highrise

Midrise

=DefenseAllan Abbass MD 2017



“Unlocked”

Resistance

Midrise:Resistance

crystallizingintransference.ClarifyandChallenge,

Maintainpressure

UTA, CTF AND RESISTANCE ARE RISING




“Unlocked”

Resistance Highrise:Resistanceintransference.Challenge,

Maintainpressure,Headoncollide

UTA, CTF AND RESISTANCE ARE ALL AT VERY HIGH LEVELS


StriatedMuscleAnxietyGoesDownBody

NeurobiologicalPathwayofRagegoesupSamesystem:Displacingsoma:za:on

AMAAtlasonlineAllan Abbass MD 2017

§  Firstbreakthrough:somepassageofgriefwithlinkagetopastorrecentperson

§  Par:alUnlocking:soma:cpathwayoflove,rage,guiltandgriefareexperiencedtosmalldegree:vividlinktopastperson.

Unlocking


StriatedMuscleAnxietyGoesDownBody

NeurobiologicalPathwayofRage:goesupsamesystemdisplacingsoma:za:on

AMAAtlasonlineAllan Abbass MD 2017

Pressure







Inquiry

ResistanceRises


UnconsciousAnxiety

StriatedMuscleAnxietyIsola:onofAffect

SevereRepression

ModerateRepression

MildRepression

ConsciousFeelings Threshold to experiencing impulse/feelings


UnconsciousAnxiety


ConsciousFeelings

1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.Intellectualrecaptobringisola:onofaffect

1

3 2

3 2

1


HowtoReduceAnxiety

n  Talkn  Lettheclient/pa:enttalkn  ChangeSta:onsCàTorTàCorCàCn  Focusonbodilycuesn  RecapitulateonwhathappenedP-C-TandI/F-Anxiety-Defence

n  Stayofffeelingsforamoment


WhentoResumePressure

n  Whentensionisbackinstriatedmusclesn  Whenpa:entisac:velyisola:ngaffectn  Whenthepa:entsuggestsweexplorethismoreorexpressescuriosityabout“whythathappens”

n  Whenheexpressesthatheisreadyformorepressure”canyouaskmethatonemore:me?


Portraying

n  Imageryofwhatanurgewantstodon  Ameanstoholdawarenessandisolatetheaffect:desensi:ze

n  CanbeusedwithliLletonoexperienceoftherage.n  Increasesisola:onofaffectandbringsanxietytostriatedmuscles

n  Raisesthresholdthathecanusethesedefencesandtolerateanxiety.


UnconsciousAnxiety

3

2

1

ConsciousFeelings


UnconsciousAnxiety


ConsciousFeelings


1

3 2

3 2

1


UnconsciousAnxiety


ConsciousFeelings


CTF UTA RESISTANCE


Threshold

Unconscious anxiety and

defense

Conscious feelings

Guilt

Rage

Grief


Pressure





Inquiry

ResistanceRises


FragileCharacterStructurePa6ents

n  Dissociate,losevision,losehearing,hallucinaten  Projec:on,splimngprojec:veiden:fica:onn  Needcapacitybuildingn  Preandpost:structuralchangesàStriatedmuscletensionandisola:onofaffect

n  Theregularbreakthroughofunderlyingfeelings,workingthroughandtermina:on

n  Treatment20-150sessionsdependingonseverity


WEAK BOND

PAIN FEAR

Rage, Remorse about the Rage, Craving Bond Severe Character

Disorder + Symptoms


Isola:onofaffectStriatedmuscle

Mildfragile

Moderatefragile

Severefragile,borderline

Threshold

toCPDorp

rimi:vede

fenses

Therapeu:

cwindow

1

3

2 12

3

1.  Pressure 2.  Rise in CTF 3.  Recap

Unconsciousanxietyanddefense

Consciousfeelings


Cogni:ve

Perceptual

Disrup:on

Repression

SmoothMuscle

Isola:onofaffectStriatedMuscle

MildFragileModerateFragileSevereFragileBorderline


ResultsofCapacityBuildingPhase

n  Anxietyinstriatedmusclen  Abilitytoselfreflectn  Abilitytoreduceownanxietyn  Understandingofthetrauman  Reduc:onofparanoia/projec:onandgriefaboutit

n  Emergingempathyforfamily


UTAinRepeatedUnlocking

n  Spontaneousunlockingsinweekn  Imagerypopsinheadn  Deadbodiesn  Sensa:onsinbodyn  Dreamsthatarebreakthroughsn  Vividcontentallowstrongguilttobefeltn  SenseofPresence:UTA


Resultsofrepeatedunlockingphase

n  Nexttonosignsoffragilityn  Emo:onsareseparated:de-fusedn  Compassionforselfn  Empathyandloveforothers:survivorguiltn  Griefaboutpsychopathologyn  Func:onalgainsn  Growingmasteryofpsychodynamicsn  Altruism:wishtogivetoothers


WorkingThroughPhase

n  Mobiliza:onofgriefandselfcompassionasguiltisremoved

n  Defusionofpuni:vesuperegofromselfn  DrivesforaLachmentn  Healthyac:vityinlifen  Returntofunc:onn  Pocketsofrageandguilts:llemergen  Griefisdominantn  Empathy/loveforfamilymembers


CourseofIntensive“Long-term”DP

Start End

Capacity Building

Repeated Unlocking

Working Through Termination


UsewhenbelowthresholdsEvokefeelingsAc:vatesoma:cpathwayofrageDevelopimagesFirelimbicareasincludingamygdala

UsewhenabovethresholdsSelf-reflectLinkphenomenaObservethebodyObservethoughtsFirebrainself-reflec:vecenters

Reflection: Recap

Pressure

Usetoop:mizerisewithoutbeingoverthresholdCombinebothself-reflec:onandpressureTrainbraintofirebothfunc:onalregionstogether

BRACING

Abbass, Reaching Through Resistance, 2015 Allan Abbass MD 2017

Cogni:ve

Perceptual

Disrup:on

Repression

SmoothMuscle

Isola:onofaffectStriatedMuscle

MildFragileModerateFragileSevereFragileBorderline


UnconsciousAnxiety


ConsciousFeelings

1.Pressuretorage2.Risetoabovethreshold3.PresstoGuiltandregulatedownanxietyasneeded4.ExtensiveRecapping

1

3

2

3

2

1

Immersive Approach to Building Capacity


Adjunc6veISTDPforPsycho6cDisorders

n  Forresidualanxiety,depressionandinterpersonalproblemsandsomepsychotogeniccycles

n  N=38,Mean13sessionsn  Sigreduc:oninselfreportParanoididea:on,Anxiety,Obsessive

Compulsive,andGlobalsymptomra:ng(BSI)

0

5000

10000

15000

20000

25000

30000

1 yr Pre 1 yr Post 2 yr Post 3 yr Post 4 yr Post

Hospital Costs

0

200

400

600

800

1000

1200

1 yr Pre 1 yr Post 2 yr Post 3 yr Post 4 yr Post

Doctor Billings

Abbass, et al, 2015 Allan Abbass MD 2017

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Intensive Short-term Dynamic Psychotherapy: Detecng and …al2898/columbia_psychosomatics/conference-2017... · Intensive Short-term Dynamic Psychotherapy: Detecng and treang somac