Separating the Ego and Separating the Ego and Superego: Working with a Superego: Working with a Fragile Recovering Drug Fragile Recovering Drug

AddictAddict

Jon Frederickson, MSWJon Frederickson, MSW

November 2011November 2011

Copenhagen, DenmarkCopenhagen, Denmark

www.ISTDPInstitute.comwww.ISTDPInstitute.com

Psychodiagnosis Psychodiagnosis

Unconscious Anxiety

Unconscious Defences

Unconscious Feelings

1) Invite feeling

3) Identify Defences 2) Monitor Anxiety

Levels of SE PathologyLevels of SE Pathology

• Fragile patientsFragile patients

• High Resistance High Resistance

• Moderate Resistance Moderate Resistance

• Low Resistance Low Resistance

ISTDP and the SuperegoISTDP and the Superego

• Pressure to FeelingPressure to Feeling

• Defense identificationDefense identification

• Challenge DefensesChallenge Defenses

• Resistance in the TResistance in the T

• Confront the Transference Confront the Transference ResistanceResistance

• BreakthroughBreakthrough

Modifications of ISTDP Modifications of ISTDP Technique ITechnique I

• Ten Have de Labije: mobilization of Ten Have de Labije: mobilization of ego adaptive capacity and separation ego adaptive capacity and separation of ego and superego prior to the of ego and superego prior to the phase of pressure. Immediately phase of pressure. Immediately point out the superego basis of point out the superego basis of defenses and the superego basis of defenses and the superego basis of the non-therapeutic relationship the the non-therapeutic relationship the patient tries to establish.patient tries to establish.

Ideal Ego Adaptive Ideal Ego Adaptive CapacityCapacity• Observing ego: anxiety, feeling and defenseObserving ego: anxiety, feeling and defense• Attentive ego: anxiety, feeling and defense.Attentive ego: anxiety, feeling and defense.• Ability to differentiate feeling from anxiety, Ability to differentiate feeling from anxiety,

feeling from defense, and anxiety from feeling from defense, and anxiety from defense.defense.

• Able to see causality: feeling evokes anxiety Able to see causality: feeling evokes anxiety which evokes defenses.which evokes defenses.

• Dystonic: able to distinguish healthy ego Dystonic: able to distinguish healthy ego from unhealthy part of the superego; able to from unhealthy part of the superego; able to feel guilt and grief over the cost of the feel guilt and grief over the cost of the defenses; able to turn against destructive defenses; able to turn against destructive defenses.defenses.

Do we see ego or Do we see ego or identification identification with the with the superego?superego?• I don’t observe my feelings or anxiety.I don’t observe my feelings or anxiety.

• I don’t pay attention to my F, A, or D.I don’t pay attention to my F, A, or D.

• I don’t differentiate feeling from anxiety: I don’t differentiate feeling from anxiety: I strangle and punish myself with anxiety.I strangle and punish myself with anxiety.

• I don’t differentiate myself from defense: I don’t differentiate myself from defense: I identify with my destructive defenses.I identify with my destructive defenses.

• Causality? My defenses don’t cause my Causality? My defenses don’t cause my presenting problems; other people do.presenting problems; other people do.

Do we see ego or Do we see ego or identification identification with the with the Superego?Superego?• I can’t help it = I’m identified with I can’t help it = I’m identified with

my superego, my healthy ego is in my superego, my healthy ego is in you, so get to work and see if you you, so get to work and see if you can overcome the team of me and can overcome the team of me and my superego against you.my superego against you.

• My defenses aren’t destructive; My defenses aren’t destructive; they’re what make me feel safe. they’re what make me feel safe.

Separation of Ego and Separation of Ego and SuperegoSuperego• Confront patient with her identification Confront patient with her identification

with the superegowith the superego• Differentiate the healthy part of the ego Differentiate the healthy part of the ego

from the unhealthy part of the superegofrom the unhealthy part of the superego• Restructure ego capacity; differentiate the Restructure ego capacity; differentiate the

triangle and see causalitytriangle and see causality• Challenge patient to stand up to the SEChallenge patient to stand up to the SE• Help patient bear increasing levels of Help patient bear increasing levels of

feeling with manageable anxiety.feeling with manageable anxiety.

Modifications of ISTDP Modifications of ISTDP Technique IITechnique II

• Robert Neborsky: distinguish between Robert Neborsky: distinguish between the superego based insecure attachment the superego based insecure attachment and the secure attachment offered by and the secure attachment offered by the therapist; point out the function of the therapist; point out the function of superego affects; point out the superego superego affects; point out the superego based relationship each defense invites; based relationship each defense invites; point out the superego basis of projected point out the superego basis of projected transference images; metaphors to help transference images; metaphors to help patients with problems of symbolization.patients with problems of symbolization.

Modifications of ISTDP Modifications of ISTDP Technique IIITechnique III

• Allen Kalpin: attention as the basis of a Allen Kalpin: attention as the basis of a secure attachment, inattention as secure attachment, inattention as evidence of superego activity; use of evidence of superego activity; use of cognitive therapy techniques to help cognitive therapy techniques to help patients differentiate feeling from patients differentiate feeling from defenses (pathological beliefs), see defenses (pathological beliefs), see correct causality, differentiate ego from correct causality, differentiate ego from superego habit. In other words, superego habit. In other words, develop all ego capacities necessary develop all ego capacities necessary prior to the phase of challenge.prior to the phase of challenge.

Modifications of ISTDPModifications of ISTDP Technique IV Technique IV

• Each of these innovators understands Each of these innovators understands the difference between a principle and the difference between a principle and a technique.a technique.

• Principle: separate ego and superego.Principle: separate ego and superego.

• Technique: any technique from any Technique: any technique from any school of thought may used as long as school of thought may used as long as it serves the fundamental principle. it serves the fundamental principle.

Viewing Defenses and the Viewing Defenses and the Alliance through the Prism of Alliance through the Prism of the Superegothe SuperegoDefense: patient talks over and ignores Defense: patient talks over and ignores

her anxiety. [identifies with superego]her anxiety. [identifies with superego]

Relationship: I invite you to join me in Relationship: I invite you to join me in ignoring my anxiety. [be a superego ignoring my anxiety. [be a superego to me]to me]

Object relation: dismissive parent and Object relation: dismissive parent and suffering, ignored child.suffering, ignored child.

Attachment pattern: insecure, avoidantAttachment pattern: insecure, avoidant

Superego based Superego based InterventionsInterventions• Defense: Do you notice you ignore your Defense: Do you notice you ignore your

anxiety right now?anxiety right now?

• Relationship: Do you notice that you are Relationship: Do you notice that you are inviting me to pay attention to your inviting me to pay attention to your friend instead of to you right now? That friend instead of to you right now? That you invite me to ignore you?you invite me to ignore you?

• Object relation: What kind of therapist Object relation: What kind of therapist would I be if I joined you in ignoring you?would I be if I joined you in ignoring you?

Superego based Interventions Superego based Interventions IIII

• ““I don’t know.” “Is that really true, or is I don’t know.” “Is that really true, or is that a way you have of ignoring that a way you have of ignoring yourself?”yourself?”

• ““Do you notice that you say that before Do you notice that you say that before you even give yourself a chance to pay you even give yourself a chance to pay attention to yourself, before you even let attention to yourself, before you even let yourself think? Is that a way you have of yourself think? Is that a way you have of not paying closer attention to yourself?”not paying closer attention to yourself?”

Task versus Superego Task versus Superego ActivityActivity• You will need to take a stand against You will need to take a stand against

that self dismissal of your emotions. that self dismissal of your emotions. Otherwise, we will not be successful.Otherwise, we will not be successful.

• So who is going to be in charge here---So who is going to be in charge here---you, or these destructive habits?you, or these destructive habits?

• Ego or superego?Ego or superego?• Secure attachment or insecure?Secure attachment or insecure?• New relationship or repetition of trauma New relationship or repetition of trauma

bond.bond.

Why the patient does not see Why the patient does not see the the superego: superego: Externalization!Externalization!• She obviously doesn’t care about me, She obviously doesn’t care about me,

because if she did she wouldn’t wear because if she did she wouldn’t wear perfume when I come to visit.perfume when I come to visit.

• You obviously don’t care about you, You obviously don’t care about you, because if you did you wouldn’t wear because if you did you wouldn’t wear her perfume by staying there for her perfume by staying there for hours while having that allergic hours while having that allergic reaction.reaction.

Externalization: Externalization: the superego’s best friend the superego’s best friend• Mistaken causality: she ignores me.Mistaken causality: she ignores me.• True causality: When angry, I punish myself True causality: When angry, I punish myself

by staying by her perfume and inflicting an by staying by her perfume and inflicting an allergy upon myself. Then I blame her for my allergy upon myself. Then I blame her for my choice to stay and have an allergic reaction. choice to stay and have an allergic reaction.

• As long as the patient projects his superego As long as the patient projects his superego onto others, he does not see how he creates onto others, he does not see how he creates his suffering. His suffering is “caused” by his suffering. His suffering is “caused” by people in the external world. The patient people in the external world. The patient remains blind to the ways the superego remains blind to the ways the superego inside him causes his suffering. Thus, the inside him causes his suffering. Thus, the patient chronically misunderstands causality.patient chronically misunderstands causality.

Externalization: Externalization: the superego’s best friend II the superego’s best friend II• Problem of causality:Problem of causality:• Mistaken causality: she made me put $100,000 Mistaken causality: she made me put $100,000

into her bank account.into her bank account.• True causality: I was angry with her, punished True causality: I was angry with her, punished

myself by putting $100,000 into her account, then myself by putting $100,000 into her account, then blamed her for my decision. blamed her for my decision.

• Anger; A; self punishment; projection of superego.Anger; A; self punishment; projection of superego.• If I accuse her of punishing me, I can ignore how I If I accuse her of punishing me, I can ignore how I

punish myself, thus allowing my suffering to punish myself, thus allowing my suffering to continue. This is why blame and complaining are continue. This is why blame and complaining are considered defenses in ISTDP.considered defenses in ISTDP.

Externalization: Externalization: The superego’s best friend III The superego’s best friend III

• Mistaken causality: He hit me twice!Mistaken causality: He hit me twice!

• True causality: enraged with his True causality: enraged with his brother, he punished himself by brother, he punished himself by accepting the second blow, then accepting the second blow, then blamed his brother.blamed his brother.

• Anger; A; self punishment; blame.Anger; A; self punishment; blame.

• He hit you once. The second time you He hit you once. The second time you hit yourself, using his arm. hit yourself, using his arm.

Impact of Superego Pathology Impact of Superego Pathology on on Ego Adaptive Capacity Ego Adaptive Capacity II• High anxiety prevents the mobilization of High anxiety prevents the mobilization of

an observing or attentive ego. Since she an observing or attentive ego. Since she can’t see her defenses, she can’t turn can’t see her defenses, she can’t turn against them.against them.

• Identification with a neglectful parent Identification with a neglectful parent leads patient not to pay attention to her leads patient not to pay attention to her anxiety or feelings. Since she does not anxiety or feelings. Since she does not pay attention to her anxiety, she can’t pay attention to her anxiety, she can’t regulate it. Thus, she remains tortured regulate it. Thus, she remains tortured by anxiety.by anxiety.

Impact of Superego Pathology Impact of Superego Pathology on on Ego Adaptive Capacity II Ego Adaptive Capacity II

• Since the defenses are so chronic and Since the defenses are so chronic and automatic, the patient believes that is who automatic, the patient believes that is who she is. Fusion of ego and superego.she is. Fusion of ego and superego.

• The patient cannot see causality: feeling The patient cannot see causality: feeling triggers anxiety which triggers defenses triggers anxiety which triggers defenses which cause her presenting problems. As a which cause her presenting problems. As a result, the patient has a mistaken theory of result, the patient has a mistaken theory of causality: defenses are the solution to my causality: defenses are the solution to my problem, not its cause.problem, not its cause.

Separating Ego and Separating Ego and SuperegoSuperego• Identification with the superego: “that’s the way Identification with the superego: “that’s the way

I am.” “No, that’s the way you deal with your I am.” “No, that’s the way you deal with your feelings.”feelings.”

• ““Do you remember when you saw your babies? Do you remember when you saw your babies? Did they hate themselves? Did they hurt Did they hate themselves? Did they hurt themselves? Right. See, you have to learn to do themselves? Right. See, you have to learn to do crazy stuff like that. So those babies? That’s crazy stuff like that. So those babies? That’s you. This self hate and all that, those are just you. This self hate and all that, those are just habits you picked up along the way. They have habits you picked up along the way. They have as little to do with you as a cancer tumor does.”as little to do with you as a cancer tumor does.”

Separating Ego and Separating Ego and Superego IISuperego II• Inability to differentiate observing ego Inability to differentiate observing ego

from superego affects. “I am anxious.” from superego affects. “I am anxious.” “Do you notice how it’s as if a “Do you notice how it’s as if a policeman comes in the room right now policeman comes in the room right now to paralyze you with this anxiety? How to paralyze you with this anxiety? How this anxiety comes in to attack you this anxiety comes in to attack you right now? This must be upsetting how right now? This must be upsetting how this anxiety does such a number to this anxiety does such a number to you.”you.”

Superego AffectsSuperego Affects

• Anxiety, guilt, and shame.Anxiety, guilt, and shame.

• The key is not the historical origin, but The key is not the historical origin, but the function of these affects in the here the function of these affects in the here and now: to paralyze and cripple the and now: to paralyze and cripple the patient.patient.

• The superego attacks the ego through The superego attacks the ego through these affects to prevent the patient from these affects to prevent the patient from using adaptive feelings in an adaptive using adaptive feelings in an adaptive way.way.

Separating Ego and Superego Separating Ego and Superego IIIIII

• Inability to differentiate conscious Inability to differentiate conscious choice of the ego from automaticity choice of the ego from automaticity of the superego. “It’s not a choice.” of the superego. “It’s not a choice.” Analogy of driving a car.Analogy of driving a car.

• Inability to distinguish the healthy Inability to distinguish the healthy ego from the unhealthy part of the ego from the unhealthy part of the superego. “Is that the healthy or the superego. “Is that the healthy or the unhealthy part of you?”unhealthy part of you?”

Separating Ego and Superego Separating Ego and Superego IVIV

• Problem in representation: “But that Problem in representation: “But that anxiety is not you. You are like this tree, anxiety is not you. You are like this tree, but it’s so covered up with this vine of but it’s so covered up with this vine of anxiety and shame that after awhile you anxiety and shame that after awhile you forgot there was a tree, you, underneath forgot there was a tree, you, underneath all those vines. So we are having to peel all those vines. So we are having to peel those vines of anxiety and shame off of those vines of anxiety and shame off of you so we can see who you really are you so we can see who you really are underneath all of that.”underneath all of that.”

Superego Theory Advances Superego Theory Advances within within ISTDP ISTDP

• Davanloo: pathological superego based Davanloo: pathological superego based on unconscious guilt due to murderous on unconscious guilt due to murderous rage in the context of a trauma to the rage in the context of a trauma to the bond.bond.

• Kernberg: superego comprised of Kernberg: superego comprised of internalized object relations.internalized object relations.

• Neborsky: each defense is an invitation Neborsky: each defense is an invitation to act out an internalized object relation to act out an internalized object relation in the superego which would lead to an in the superego which would lead to an insecure attachment.insecure attachment.

The Guises of the Superego The Guises of the Superego

• These pathological superego internalized These pathological superego internalized object relations take three forms:object relations take three forms:

• 1) I will be a superego to myself. [Patient 1) I will be a superego to myself. [Patient ignores her anxiety.]ignores her anxiety.]

• 2) Let’s both be a superego to me. [I 2) Let’s both be a superego to me. [I invite you to ignore my anxiety too.]invite you to ignore my anxiety too.]

• 3) I will be the superego to you. [I (as SE) 3) I will be the superego to you. [I (as SE) will ignore and dismiss your efforts and will ignore and dismiss your efforts and invite you to be my healthy part. invite you to be my healthy part. Therapist masochistically submits to the Therapist masochistically submits to the patient’s superego.] patient’s superego.]

PatientPatient

• African-American woman in her forties African-American woman in her forties who is in a drug rehabilitation facility who is in a drug rehabilitation facility to overcome her twenty year addiction to overcome her twenty year addiction to cocaine. She suffers from chronic to cocaine. She suffers from chronic depression, panic attacks, frequent depression, panic attacks, frequent migraine headaches, vomits as soon as migraine headaches, vomits as soon as she has a feeling, and hears a voice she has a feeling, and hears a voice that tells her to use drugs. that tells her to use drugs.

Smooth Muscle Pathway of Smooth Muscle Pathway of Unc. Unc. Anxiety Discharge Anxiety Discharge

• Exceeds threshold of anxiety Exceeds threshold of anxiety tolerance.tolerance.

• Regulate anxiety immediately.Regulate anxiety immediately.

• Identify anxiety.Identify anxiety.

• Differentiate observing ego from Differentiate observing ego from experiencing self.experiencing self.

• Recap the triangle of conflict.Recap the triangle of conflict.

Structure the Treatment: Structure the Treatment: Task ITask I• Patients with low ego adaptive capacity Patients with low ego adaptive capacity

can not maintain focused attention on can not maintain focused attention on therapeutic goals. Instead, their therapeutic goals. Instead, their defenses create unfocused sessions defenses create unfocused sessions which yield little benefit. And their which yield little benefit. And their defenses keep them in a physically defenses keep them in a physically dysregulated state! A disorganized, dysregulated state! A disorganized, inattentive, and non-collaborative inattentive, and non-collaborative relationship results because they are relationship results because they are unaware of the TASK.unaware of the TASK.

Structure the Treatment: Structure the Treatment: Task Task • The The therapeutictherapeutic task is for both patient task is for both patient

and therapist together to:and therapist together to:

• Pay continual, kind, and loving attention to Pay continual, kind, and loving attention to the bodily experience of feelings, the bodily the bodily experience of feelings, the bodily experience of anxiety, the shifts in feeling experience of anxiety, the shifts in feeling and anxiety, and shifts in the degree of and anxiety, and shifts in the degree of collaboration and relationship. That is a collaboration and relationship. That is a secure attachment. It also means a secure attachment. It also means a partnership where both therapist and partnership where both therapist and patient take a stand against the superego.patient take a stand against the superego.

The Task as Proposed by The Task as Proposed by the the Superego Superego

• We are here to ignore and dismiss my We are here to ignore and dismiss my feelings, anxiety, and defenses (and the feelings, anxiety, and defenses (and the therapist). We are also supposed to ignore therapist). We are also supposed to ignore how these defenses create my presenting how these defenses create my presenting problems, how they prevent any anxiety problems, how they prevent any anxiety regulation, and how they are destroying any regulation, and how they are destroying any possibility of a collaborative relationship. possibility of a collaborative relationship. You see, I am busy trying to recreate the You see, I am busy trying to recreate the insecure attachment I grew up with.insecure attachment I grew up with.

ProjectionProjection

• This wish frightens me. Therefore,This wish frightens me. Therefore,

• I attribute this wish to you. It is not I attribute this wish to you. It is not that I want to reveal myself to you; it that I want to reveal myself to you; it is that you want to ask questions and is that you want to ask questions and find out about me.”find out about me.”

• I don’t have a wish to reveal; you I don’t have a wish to reveal; you have a wish to invade.have a wish to invade.

• ““I want to reveal myself to you.”I want to reveal myself to you.”

Superego AffectsSuperego Affects

• Anxiety, guilt, and shame.Anxiety, guilt, and shame.• As soon as the patient wants to reveal As soon as the patient wants to reveal

herself, the superego uses these herself, the superego uses these affects to paralyze the patient.affects to paralyze the patient.

• Superego affects are the bars of the Superego affects are the bars of the cage which imprisons the patient.cage which imprisons the patient.

• We help the patient see the We help the patient see the FUNCTION of these affects: to inhibit, FUNCTION of these affects: to inhibit, paralyze, and sabotage.paralyze, and sabotage.

Differentiate Ego and Differentiate Ego and SuperegoSuperego• Differentiate observing ego and Differentiate observing ego and

superego affects.superego affects.• Differentiate observing ego and self Differentiate observing ego and self

attacking defenses (dis-attacking defenses (dis-identification): “this attacking identification): “this attacking anxiety must be upsetting to you.”anxiety must be upsetting to you.”

• Differentiate who she is from how Differentiate who she is from how she treats herself. she treats herself.

Deactivating Deactivating ProjectionsProjections• Splitting: I want this; I don’t want this.Splitting: I want this; I don’t want this.

• Projection: You want this.Projection: You want this.

• Redirect her attention inward.Redirect her attention inward.

• Remind patient of facts which she forgets Remind patient of facts which she forgets under the impact of projection: her will, her under the impact of projection: her will, her goal, her desire, her agency.goal, her desire, her agency.

• Indication projection is deactivated: drop in Indication projection is deactivated: drop in projective anxiety. Patient will relax, projective anxiety. Patient will relax, become present, thinking will clear.become present, thinking will clear.

Assessing ProjectionAssessing Projection

• Tactical defense: patient has access to Tactical defense: patient has access to striated, can mentate, and projection is striated, can mentate, and projection is merely a device to distract you from merely a device to distract you from pressure to feeling. Press for feeling.pressure to feeling. Press for feeling.

• Cognitive/perceptual disruption: little or Cognitive/perceptual disruption: little or no striated, drifting, can not mentate, no striated, drifting, can not mentate, patient fears you as the projected figure. patient fears you as the projected figure. Recap, regulate anxiety, restructure Recap, regulate anxiety, restructure projection.projection.

Anxiety vs. Projective Anxiety vs. Projective Anxiety IAnxiety I• CTF rising in the patient cause anxiety.CTF rising in the patient cause anxiety.

• When the patient projects her anger on When the patient projects her anger on you (her will to reveal herself, her wish to you (her will to reveal herself, her wish to know herself), she will fear you as the know herself), she will fear you as the “angry” one, the one who “wants to ask “angry” one, the one who “wants to ask questions”, the one who wants to get “in questions”, the one who wants to get “in her mind.”her mind.”

• Anxiety in response to her projection onto Anxiety in response to her projection onto you is projective anxiety.you is projective anxiety.

Anxiety and Projective Anxiety and Projective AnxietyAnxiety• If a patient is projecting and fearing you If a patient is projecting and fearing you

as the projection, you must clear up the as the projection, you must clear up the projection and the projective anxiety projection and the projective anxiety first.first.

• If a patient projects her anger onto you, If a patient projects her anger onto you, then is angry at you, do NOT pressure to then is angry at you, do NOT pressure to this anger. It is not anger at you, but this anger. It is not anger at you, but anger at a projection. This will lead to a anger at a projection. This will lead to a misalliance. misalliance.

Intervene before the Intervene before the DefenseDefense• Feeling anxiety defense.Feeling anxiety defense.

• One second concurrent two secondsOne second concurrent two seconds

• Mobilize attention to what is new and Mobilize attention to what is new and emergent before defenses derail the emergent before defenses derail the observing ego.observing ego.

• Mobilizes capacity to bear her wish and Mobilizes capacity to bear her wish and anxiety without having to resort to anxiety without having to resort to defense. Thus, building ego capacity.defense. Thus, building ego capacity.

Anxiety RegulationAnxiety Regulation

• Pause as soon as patient exceeds her Pause as soon as patient exceeds her threshold of anxiety tolerance.threshold of anxiety tolerance.

• Cognitive recap.Cognitive recap.

• Differentiate observing ego from Differentiate observing ego from experiencing self.experiencing self.

• Rebalance parasympathetic and Rebalance parasympathetic and sympathetic systems.sympathetic systems.

• Defenses increase anxiety in the body!Defenses increase anxiety in the body!

Mobilize Will to the TaskMobilize Will to the Task

• When I talk about me. “Do you want to talk When I talk about me. “Do you want to talk about you?”about you?”

• I’ll be vulnerable. “Are you willing to be I’ll be vulnerable. “Are you willing to be vulnerable and open?”vulnerable and open?”

• I’m scared of my feelings. “Do you want to I’m scared of my feelings. “Do you want to face your feelings or run from them?”face your feelings or run from them?”

• Mobilizing conscious will decreases projection Mobilizing conscious will decreases projection and projective anxiety, and defiance, and and projective anxiety, and defiance, and reminds patient of her therapeutic goal.reminds patient of her therapeutic goal.

• Mobilizing the ego to take a stand against the Mobilizing the ego to take a stand against the superego.superego.

Managing DefianceManaging Defiance

• Fragile patients project onto you their Fragile patients project onto you their will to do therapy. Then they will to do therapy. Then they experience you as if you want to experience you as if you want to control or dominate the patient. As a control or dominate the patient. As a result, the patient will defy you (as the result, the patient will defy you (as the projected will). The antidote to these projected will). The antidote to these projections and the resulting defiance projections and the resulting defiance is mobilization of the patient’s will.is mobilization of the patient’s will.

Mobilizing Will to Undo Mobilizing Will to Undo DefianceDefiance• Did you come here of your free will?Did you come here of your free will?

• Is it Is it youryour will to be here today? will to be here today?

• Is this a problem in Is this a problem in youryour opinion? opinion?

• Is this a problem Is this a problem youyou want help with? want help with?

• Do you want Do you want meme to help you with this? to help you with this?

• Is this a problem Is this a problem youyou want to overcome? want to overcome?

• Are you sure?Are you sure?

Mini-mobilizations of WillMini-mobilizations of Will

• Would you like to take a look at this?Would you like to take a look at this?

• Would you be willing not to put yourself Would you be willing not to put yourself down so we can look at this feeling?down so we can look at this feeling?

• Would you like to overcome this critical Would you like to overcome this critical system in your mind?system in your mind?

• Would you like to find out what’s going on Would you like to find out what’s going on underneath this anxiety?underneath this anxiety?

• What would you like to do about this What would you like to do about this distancing?distancing?

Differentiate Ego and Differentiate Ego and SuperegoSuperego• F, A, and D are all invisible.F, A, and D are all invisible.

• Use visible physical gestures and visual Use visible physical gestures and visual metaphors to help the patient visualize an metaphors to help the patient visualize an internal process, externalize, and dis-internal process, externalize, and dis-identify with the self attack. identify with the self attack.

• Mistaken causality. “I fear feeling.” “No, Mistaken causality. “I fear feeling.” “No, you fear how you attack yourself for you fear how you attack yourself for having a feeling.” Feeling is not the having a feeling.” Feeling is not the problem, the defense of self attack is.problem, the defense of self attack is.

Differentiate Ego and Differentiate Ego and SuperegoSuperego• Not: “Do you see how you attack yourself.” Not: “Do you see how you attack yourself.”

Premature Challenge will lead to self Premature Challenge will lead to self attack.attack.

• Instead: “Do you see how that anxiety Instead: “Do you see how that anxiety attacks you?” “Is there a critical system in attacks you?” “Is there a critical system in your brain that’s coming in now?” “Could your brain that’s coming in now?” “Could that be a self critical thought?” “Do you that be a self critical thought?” “Do you think it might be hurting you?” “Would you think it might be hurting you?” “Would you be willing to turn against that mechanism?”be willing to turn against that mechanism?”

Differentiate Ego and Differentiate Ego and SuperegoSuperego• ““Cruel” highlights the superego function.Cruel” highlights the superego function.• Differentiates her from how the voice Differentiates her from how the voice

treats her.treats her.• Separation of observing ego from Separation of observing ego from

superego causes a rise in self superego causes a rise in self compassion, pain, and anxiety. Help compassion, pain, and anxiety. Help patient integrate this new experience. patient integrate this new experience. Grief over cruelty to herself will help her Grief over cruelty to herself will help her turn against the defense of self attack.turn against the defense of self attack.

Differentiate Ego from Differentiate Ego from SuperegoSuperegoFeelings evoke anxiety which evokes Feelings evoke anxiety which evokes

defenses. Defenses create the defenses. Defenses create the presenting problems. If you can show presenting problems. If you can show the patient how her defenses are the patient how her defenses are creating her problems, she will be creating her problems, she will be motivated to turn against those defenses motivated to turn against those defenses and face what she has avoided. “These and face what she has avoided. “These defenses which originally were your defenses which originally were your friends are now your enemies.”friends are now your enemies.”

Steps in Differentiating Ego Steps in Differentiating Ego and and Superego at 23:50Superego at 23:50

• I am anxiety vs. anxiety attacks me.I am anxiety vs. anxiety attacks me.

• I am stupid vs. voice tells me.I am stupid vs. voice tells me.

• Voice has a name: Nadine.Voice has a name: Nadine.

• ““I want to break that voice.”I want to break that voice.”

MigraineMigraine

• Rise of feeling past capacity. Anxiety Rise of feeling past capacity. Anxiety no longer contained in striated no longer contained in striated muscles, goes into smooth muscles, muscles, goes into smooth muscles, leading to migraine.leading to migraine.

• Regulate: pause, mobilize attention Regulate: pause, mobilize attention to physical signs of anxiety, note to physical signs of anxiety, note triangle of conflict, introduce higher triangle of conflict, introduce higher level defenses if necessary.level defenses if necessary.

Differentiate Ego from Differentiate Ego from SuperegoSuperego• Distinguish healthy existential guilt from Distinguish healthy existential guilt from

unhealthy pathological guilt.unhealthy pathological guilt.

• Pathological guilt based on unc. primitive Pathological guilt based on unc. primitive murderous rage, the defense of identifying murderous rage, the defense of identifying with the perpetrating criminal, and with the perpetrating criminal, and punishing oneself. Healthy guilt mobilizes punishing oneself. Healthy guilt mobilizes a reparative response. Pathological guilt a reparative response. Pathological guilt mobilizes self punishment and self torture.mobilizes self punishment and self torture.

Differentiate External Reality Differentiate External Reality from from Internal Reality Internal Reality

We can not change what happened in the We can not change what happened in the past. We can change the way she handles past. We can change the way she handles her emotions internally in the present and her emotions internally in the present and future. [SE: since we can’t change the future. [SE: since we can’t change the past, let’s not change anything now.]past, let’s not change anything now.]

Establish an intrapsychic focus.Establish an intrapsychic focus.

Remind patient of the psychotherapeutic Remind patient of the psychotherapeutic task and her goal: to face emotions so she task and her goal: to face emotions so she doesn’t have to be sick.doesn’t have to be sick.

Origin of the SuperegoOrigin of the Superego

• Trauma to bond: pmr and mixed Trauma to bond: pmr and mixed emotions.emotions.

• Defense of identification with her Defense of identification with her mother’s cruelty to her.mother’s cruelty to her.

• Defense as gift of love (Benjamin).Defense as gift of love (Benjamin).

• Ignoring feelings and cruelty to self Ignoring feelings and cruelty to self as the pathways to connection.as the pathways to connection.

Building Ego Capacity 33-Building Ego Capacity 33-50”50”• 33: sees that she ignores her feeling like her 33: sees that she ignores her feeling like her

mother did. Understands origin of defense of mother did. Understands origin of defense of ignoring. With increase in observing ego and ignoring. With increase in observing ego and differentiation of defense from feeling, feeling differentiation of defense from feeling, feeling arises.arises.

• 41: anger toward mother---smooth muscle.41: anger toward mother---smooth muscle.• 45: Now differentiate feeling from anxiety. Sees 45: Now differentiate feeling from anxiety. Sees

conflict of feeling, anxiety and sick, and causality.conflict of feeling, anxiety and sick, and causality.• 49: With feeling differentiated from anxiety, feeling 49: With feeling differentiated from anxiety, feeling

becomes accessible again. She makes a becomes accessible again. She makes a spontaneous link to the children’s father. spontaneous link to the children’s father.

• 50: “I tried to kill him once.”50: “I tried to kill him once.”

Portrayal for the Fragile Portrayal for the Fragile PatientPatient• Let patient imagine the urge he wants to do.Let patient imagine the urge he wants to do.• Helps patient be aware of and isolate the Helps patient be aware of and isolate the

affect: desensitizes him.affect: desensitizes him.• Can be used with little or no experience of Can be used with little or no experience of

the rage.the rage.• Increases isolation of affect and brings Increases isolation of affect and brings

anxiety over time into the striated muscles.anxiety over time into the striated muscles.• Raises the threshold of anxiety tolerance so Raises the threshold of anxiety tolerance so

that he can use these defenses (isolation of that he can use these defenses (isolation of affect and intellectualization) and tolerate affect and intellectualization) and tolerate anxiety.anxiety.

Graded Portrayal: Graded Portrayal: The Projective Technique The Projective Technique

• Introduce the defense of displacement to Introduce the defense of displacement to grade the patient’s experience of guilt.grade the patient’s experience of guilt.

• If a wild animal attacked what would it If a wild animal attacked what would it do? If the beast in you came out….do? If the beast in you came out….

• If someone else felt this rage, how would If someone else felt this rage, how would it come out on me?it come out on me?

• If someone else felt this rage, how would If someone else felt this rage, how would it come out on another person?it come out on another person?

Graded Breakthrough for the Graded Breakthrough for the Fragile Patient Fragile Patient

• When strong rage and guilt arrive, When strong rage and guilt arrive, fragile patients may immediately fragile patients may immediately somatize, repress, project, or have somatize, repress, project, or have conversion.conversion.

• Grade the affective experience to bring Grade the affective experience to bring in isolation of affect, use a recap, and go in isolation of affect, use a recap, and go slowly to allow the breakthrough without slowly to allow the breakthrough without going over the patient’s threshold of going over the patient’s threshold of anxiety tolerance.anxiety tolerance.

Differentiation of Ego and Differentiation of Ego and SuperegoSuperego

• Sadistic, murderous rage toward the Sadistic, murderous rage toward the molester.molester.

• ““What he did was his fault. My fault I was on What he did was his fault. My fault I was on the streets.” Differentiation of her existential the streets.” Differentiation of her existential guilt from guilt over murderous rage.guilt from guilt over murderous rage.

• ““Feel fine, gut is fine.” Drop in anxiety. No Feel fine, gut is fine.” Drop in anxiety. No longer somatically identified with the longer somatically identified with the murdered figure who is strangled by his own murdered figure who is strangled by his own guts.guts.

Integration of Experiential Integration of Experiential InsightsInsights

• Unconscious guilt over murderous rage Unconscious guilt over murderous rage led her to identify with molester’s led her to identify with molester’s projections.projections.

• Dis-identifying with projections.Dis-identifying with projections.

• Link of rage to breakdown and Link of rage to breakdown and hospitalization: ego regression as a hospitalization: ego regression as a defense against experiencing her rage.defense against experiencing her rage.

• ““Not my fault.” Further differentiation.Not my fault.” Further differentiation.

Differentation of Ego and Differentation of Ego and Superego Superego at this Pointat this Point

• Guilt over daughter being molested.Guilt over daughter being molested.

• Fusion of existential guilt and Fusion of existential guilt and pathological guilt.pathological guilt.

• ““Lived in fantasy world.”Lived in fantasy world.”

• Anger re: mother, then to molester.Anger re: mother, then to molester.

• What he did was his fault, not my fault.What he did was his fault, not my fault.

• ““Want to stop punishing myself.”Want to stop punishing myself.”

Follow-up SessionFollow-up Session

• Anxiety was 8, now 4.Anxiety was 8, now 4.

• Depression was 9, now 6.Depression was 9, now 6.

• Had 12 migraines a month, now 2.Had 12 migraines a month, now 2.

• Week before first session tried to Week before first session tried to leave program to go back to use leave program to go back to use drugs. Compliant with drug rehab drugs. Compliant with drug rehab ever since session.ever since session.

Emergence of Coherent Emergence of Coherent NarrativeNarrative

• Trauma at age 8, experiencing Trauma at age 8, experiencing mother’s murderous rage and hatred.mother’s murderous rage and hatred.

• Identification with mother as defense Identification with mother as defense against loss of mother.against loss of mother.

• Validation of grief, loss, terror, rage, Validation of grief, loss, terror, rage, genuine helplessness, longing for genuine helplessness, longing for mother leads to increased capacity.mother leads to increased capacity.

• Her emotional life makes sense to her.Her emotional life makes sense to her.

Final Differentiation of Final Differentiation of Ego and SuperegoEgo and Superego

• Use of play with superego role.Use of play with superego role.

• Dis-identification with mother’s Dis-identification with mother’s defenses.defenses.

Change Processes Change Processes

• Build capacity: mobilize will, deactivate Build capacity: mobilize will, deactivate projections; observing and attentive ego; projections; observing and attentive ego; differentiate observing ego and differentiate observing ego and experiencing self; differentiate feeling, experiencing self; differentiate feeling, anxiety and defense; differentiate ego anxiety and defense; differentiate ego and superego; differentiate healthy guilt and superego; differentiate healthy guilt from neurotic self attack; build capacity from neurotic self attack; build capacity to bear feeling; restructure unconscious to bear feeling; restructure unconscious pathway of anxiety discharge; relational pathway of anxiety discharge; relational capacity.capacity.

OutcomeOutcome

• At nine month follow up, depression, At nine month follow up, depression, anxiety remain lowered. Drop in anxiety remain lowered. Drop in migraines was maintained. Successful migraines was maintained. Successful completion of rehab. Clean from drugs completion of rehab. Clean from drugs for first time in 20 years. Attends for first time in 20 years. Attends narcotics anonymous faithfully. Moved in narcotics anonymous faithfully. Moved in with daughter and cares for grand with daughter and cares for grand daughter. Now employed full time. daughter. Now employed full time. Manages a day care center.Manages a day care center.

LiteratureLiterature

• Intensive Short Term Dynamic Intensive Short Term Dynamic Psychotherapy by Patricia Della SelvaPsychotherapy by Patricia Della Selva

• Intensive Short Term Dynamic Intensive Short Term Dynamic Psychotherapy by Habib DavanlooPsychotherapy by Habib Davanloo

• Articles from Articles from www.ISTDP.no

• Google Allan Abbass or Centre for Google Allan Abbass or Centre for Emotions and HealthEmotions and Health

ReferencesReferences

• Davanloo, H. (1987) ISTDP with Davanloo, H. (1987) ISTDP with highly resistant depressed patients. highly resistant depressed patients. Part I---restructuring Ego’s regressive Part I---restructuring Ego’s regressive defenses. Int. J. Short term defenses. Int. J. Short term psychotherapy 2:99-132. Reprinted psychotherapy 2:99-132. Reprinted in Davanloo (1990).in Davanloo (1990).

ReferencesReferences

• Davanloo, H. (1989) The technique of Davanloo, H. (1989) The technique of unlocking the unconscious in patients unlocking the unconscious in patients suffering from functional disorders. suffering from functional disorders. Part I: Restructuring Ego’s defenses. Part I: Restructuring Ego’s defenses. Int. J. Short term psychotherapy Int. J. Short term psychotherapy 4:93-116. Reprinted in Davanloo 4:93-116. Reprinted in Davanloo (1990).(1990).

ReferencesReferences

• Davanloo, H. Clinical Manifestations of Davanloo, H. Clinical Manifestations of Superego Pathology. In Unlocking the Superego Pathology. In Unlocking the Unconscious (1990).Unconscious (1990).

• Havelaby, J. (2003) Red Lights and Green Havelaby, J. (2003) Red Lights and Green Lights on Davanloo’s Road to the Lights on Davanloo’s Road to the Unconscious. In: The Working Alliance in Unconscious. In: The Working Alliance in ISTDP: Whose Intrapsychic Crisis?ISTDP: Whose Intrapsychic Crisis?

ReferencesReferences

• Korff, P. von (1998) Early management Korff, P. von (1998) Early management of unconscious defiance in Davanloo’s of unconscious defiance in Davanloo’s ISTDP. Part I. Int. J. Intensive short ISTDP. Part I. Int. J. Intensive short term dynamic psychotherapy 12:183-term dynamic psychotherapy 12:183-208.208.

• Neborsky, R. and Peluso, M. Identifying Neborsky, R. and Peluso, M. Identifying and Overcoming the Punitive Superego and Overcoming the Punitive Superego in Short-Term Dynamic Psychotherapy. in Short-Term Dynamic Psychotherapy. In Ad Hoc J. of STDP, August, 2007.In Ad Hoc J. of STDP, August, 2007.

ReferencesReferences

• Whittemore, J. (1996) Paving the Whittemore, J. (1996) Paving the royal road: an overview of royal road: an overview of conceptual and technical features in conceptual and technical features in the Graded Format of Davanloo’s the Graded Format of Davanloo’s ISTDP. Int. J. Short term dynamic ISTDP. Int. J. Short term dynamic psychotherapy 11:21-39.psychotherapy 11:21-39.

ReferencesReferences

• Whittemore, J. (1998) The application Whittemore, J. (1998) The application of Davanloo’s ISTDP to a complex of Davanloo’s ISTDP to a complex masochistic patient with panic, masochistic patient with panic, functional and somatization functional and somatization disorders: From the ‘Frying Pan’ into disorders: From the ‘Frying Pan’ into freedom. Part I. Int. J. Short term freedom. Part I. Int. J. Short term dynamic psychotherapy 12:151-181.dynamic psychotherapy 12:151-181.

ReferencesReferences

• Whittemore, J. (1999) The application Whittemore, J. (1999) The application of Davanloo’s ISTDP to a complex of Davanloo’s ISTDP to a complex masochistic patient with panic, masochistic patient with panic, functional and somatization functional and somatization disorders: From the ‘Frying Pan’ into disorders: From the ‘Frying Pan’ into freedom. Part II. Int. J. Short term freedom. Part II. Int. J. Short term dynamic psychotherapy 13:17-48.dynamic psychotherapy 13:17-48.

ReferencesReferences

• Whittemore, J. (1999) The application Whittemore, J. (1999) The application of Davanloo’s ISTDP to a complex of Davanloo’s ISTDP to a complex masochistic patient with panic, masochistic patient with panic, functional and somatization functional and somatization disorders: From the ‘Frying Pan’ into disorders: From the ‘Frying Pan’ into freedom. Part I. Int. J. Short term freedom. Part I. Int. J. Short term dynamic psychotherapy 13:49-79.dynamic psychotherapy 13:49-79.

ReferencesReferences

• Troendle, P. (2003) Psychotherapie: Troendle, P. (2003) Psychotherapie: dynamisch-intensiv-direkt. dynamisch-intensiv-direkt. Psychosozial-verlag. Most Psychosozial-verlag. Most comprehensive textbook in ISTDP. comprehensive textbook in ISTDP. Currently available only in German.Currently available only in German.