Download Mindfulness and Experiential Dynamic Therapy

ISTDP Overview
and
Application for Chronic
Relational Trauma
Allen Kalpin, MD
Introductory Comments
• Bioenergetic Analysis – inclusiveness
• ISTDP – “Short-Term”
• Commonalities
- Psychodynamic
- Character analysis
- Focus on the Body
• Differences
History - Overview
• Psychoanalysis
• Attempts to shorten analyisis
• Short-Term Dynamic Psychotherapy
(STDP)
• Intensive Short-Term Dynamic
Psychotherapy (ISTDP)
• Experiential Dynamic Therapy (EDT)
Classical Psychoanalytic
Concepts
• Psychodynamic: unconscious; conflict;
transference/countertransference;
defense; resistance; childhood
experiences
• Structural Theory: Id, Ego, Superego
Shortening Psycoanalytic
Treatment
• Freud
• Firenczi, Rank and Adler
• Reich – character analysis
• Alexander and French – 1946 – “corrective
emotional experience”
Short-Term Dynamic
Psychotherapy (STDP)
• Michael Balint and David Malan – 1960s
• Peter Sifneos and James Mann – 1960s –
1970s
• Habib Davanloo: Intensive Short-Term
Dynamic Psychotherapy (ISTDP)
Experiential Dynamic Therapy
(EDT)
1. Based on psychodynamic principles as expressed in
2.
3.
4.
5.
the two triangles.
Important focus on the physiological experience of
emotions as a major healing factor.
Use of the therapeutic relationship as a central force
in assessment and treatment.
Recognition of the human relationship - attachment as being central to causes of pathology and to
healing.
Identification and countering of the inner selfsabotaging forces.
Intensive Short-Term
Dynamic
Psychotherapy
(ISTDP)
ISTDP – Time Frame
• 40 hours or less
• Severe borderline psychopathology: up to
150 hours (3 years)
ISTDP – Assessment
• Trial Therapy
• Reaction to intervention
• Observation
• Audio-visual recording
• Dynamic formulation
The Two Triangles
The Triangle of Persons
Transference (T)
Current (C)
Past (P)
The Triangle of Conflict
Defense (D)
Anxiety (A)
Impulse/Feeling (I/F)
Impulse/Feeling
• Core emotions vs. anxiety and defense
• Somatic pathways of emotion
• Action tendencies
Somatic Pathways of Emotion
• Love: Warmth in chest; urge to embrace
• Grief: Tears, waves, sobbing; no physical
pain; desire to be held
• Anger: Upward and outward-moving
energy; urge to lash out
• Guilt: Neck/chest pain; urge to apologize,
make amends
Discharge Pathways of Anxiety
(Davanloo)
Conscious Anxiety
Unconscious Anxiety
• Striated Muscle
• Smooth Muscle
• Cognitive/Perceptual Disruption
• Motor conversion (muscle weakness)
• Psychosomatic
Discharge Pathways of Anxiety
Conscious Anxiety
• Awareness of “feeling afraid,” etc.
Discharge Pathways of Anxiety
Unconscious Anxiety
• Little or no awareness that the symptoms
are from anxiety
• Little or no awareness of the connection
between triggers and the symptoms
Discharge Pathways of Anxiety
Striated Muscle
• Muscle tension +/- movement
• High ego adaptive capacity
• Anxiety is closest to consciousness
• Striated muscles are muscles of action
• Most compatible with good functioning
Discharge Pathways of Anxiety
Smooth Muscle
• e.g. IBS, migraine, asthma
• Low ego adaptive capacity
• Anxiety is farther from consciousness
• Smooth muscles are not muscles of action
• Less compatible with good functioning
Discharge Pathways of Anxiety
Cognitive/Perceptual Disruption
• e.g. blank mind, blurry vision, tinnitus
• Ego fragility
• Anxiety is even farther from consciousness
• Muscles are not involved
• Very incompatible with good functioning
Discharge Pathways of Anxiety
Psychosomatic
• e.g., autoimmune disorders
• Anxiety is farthest from consciousness
• Muscles are not involved
• Very incompatible with good functioning
• Potentially dangerous
Projective Identification and
Symptom Formation
• Identification with the victim (attachment
figure) – of violent fantasies
• Psychosomatic symptoms that correspond
to targets of attacks
• Chronic pain and/or weakness in arms or
legs – that would carry out the attacks
Restructuring
• Instant Repression – Depressive Mechanism
Gradually bringing awareness of aggressive
impulse to consciousness
• Ego Adaptive Capacity
Gradually increasing the ego’s capacity to
tolerate anxiety by repeated cycles of
exposure and integration
- Low EAC – e.g., IBS
- Ego fragility
- Psychosomatic
Defenses – Major Resistances
• Isolation of affect: Can talk and about emotions
•
•
without physically experiencing them; Striated
muscle
Repression: Associated with depression and/or
motor conversion; Smooth muscle
Primitive defenses: Splitting, projection,
projective identification, dissociation,
externalization, regressive defenses;
Cognitive/Perceptual Disruption
Spectrum of Structural Neurosis
(Davanloo and Abbass)
________________
Resistance, SEP, REC, Amount of Problems, Character
Pathology, Complexity of Core Neurotic Structure
Low
Moderate
High
Spectrum of Structural Neurosis
(Davanloo and Abbass)
________________
Striated muscle + isolation of affect-----------------------Smooth muscle + repression
Low
Moderate
High
Spectrum of Fragility
(Davanloo and Abbass)
________________
Degree of disability in tolerating anxiety and painful
feelings, tendency for CPD, use of primitive defenses
Mild
Moderate
Severe-Borderline
Spectrum of Fragility
(Davanloo and Abbass)
________________
Smooth muscle + repression (+ Str m. if mild)----------Cognitive/perceptual disruption + primitive defenses----
Mild
Moderate
Severe-Borderline
Punitive Superego
Analysis Terminable and
Interminable: Freud 1937
“Nothing impresses us more strongly in
connection with the resistances encountered
in analysis than the fact that there is a force
which defends itself by all possible means
against recovery and clings tenaciously to
illness and suffering. We have recognized
that part of this force is the consciousness of
guilt and the need for punishment, and this is
undoubtedly correct; we have localized it in
the ego's relation to the super-ego.”
Analysis Terminable and
Interminable: Freud 1937
“If we bear in mind the whole picture
made up of the phenomena of the
masochism inherent in so many people, of
the negative therapeutic reaction and of
the neurotic's consciousness of guilt, we
shall have to abandon the belief that
psychic processes are governed
exclusively by the striving after pleasure.”
Analysis Terminable and
Interminable: Freud 1937
“For the moment we must bow to those
superior powers which foil our attempts.
Even to exert a psychic influence upon a
simple case of masochism is a severe tax
on our skill.”
What is the Punitive Superego?
• (SE = conscience; PSE = unhealthy functioning of
conscience)
• a defensive system
• which defends the ego against the pain of remorse
• by means of a process of atonement by selfpunishment
• “I don’t have to feel the pain of remorse – I can atone
for it instead.”
The Role of Guilt in Human
Functioning and Psychotherapy
• Freud: Superego – Conscience
• Religion: “Sin”
• Popular Psychology: “Low Self-Esteem”
• Gestalt Therapy: “Internal Critic”
• CBT: Core Belief: “Unlovable”
• Alcoholics Anonymous: “Making Amends”
The Central Role of the
Superego in ISTDP
• Freud’s Conceptualization
• Davanloo’s Technique
Deficit vs. Inhibition
• Developmental Psychopathology
• Structural Psychopathology
The Origin of the Guilt
• Learning
• Conflictual Feelings
Guilt as a Feeling vs.
Guilt as a Defense
• Unhealthy guilt: “I am bad” – self-hatred,
self-punishment
= Defense
• Healthy guilt: “I am sorry” – remorse
= Painful feeling
Important Change Mechanism in
ISTDP
• Replacing unhealthy guilt with healthy
guilt
• Replacing “I am bad” with “I am sorry”
• Replacing a defensive system with the
capacity to experience a feeling
Attachment Trauma – No Ego
Fragility
• Attachment Trauma ->
• Pain ->
• Rage Toward Attachment Figures ->
• Guilt about the Rage ->
• Superego Pathology – Self-Punishment ->
• Character Pathology ->
• Resistance to Emotional Closeness
Attachment Trauma – No Ego
Fragility
• Major Resistance – Isolation of Affect
Anxiety – Striated Muscle
-> No Restructuring
• Major Resistance – Repression
Anxiety – Smooth Muscle
-> Some Anxiety and Defense
Restructuring
Chronic Relational Trauma
• Associated with ego fragility
• The more severe the childhood relational
trauma, the more severe is the fragility
• The farther “to the right” on the spectrum
of fragility, the more borderline pathology
Attachment Trauma – With Ego
Fragility
• Attachment Trauma ->
• Pain ->
• Rage Toward Attachment Figures ->
• Guilt about the Rage ->
• Superego Pathology – Self-Punishment ->
• Character Pathology +
• CPD and Primitive Defenses
Attachment Trauma – With Ego
Fragility
• Major Resistance – Repression
Anxiety – Smooth Muscle
-> Some Anxiety and Defense
Restructuring
• Major Resistance – Primitive Defenses
Anxiety – Cognitive/Perceptual Disruption
-> Major Defense and Anxiety
Restructuring
Restructuring of Severe Fragility
• Defense restructuring – undoing splitting,
projection, etc.; increasing capacity for
intellectualization (isolation of affect)
• Anxiety restructuring – increasing capacity
to tolerate anxiety -> striated muscle
• Building self-observation capacity
• Reality testing re: view of self and others
– especially re: the therapist
Restructuring of Severe Fragility
• As defenses and anxiety become
restructured, there is gradually more and
more ability to tolerate underlying
emotions.
• Process gradually moves toward more and
more experiencing and working through of
complex memories and feelings from the
past.