Allan A. Abbass, MD, FRCPC

Bringing Structural Changes in Anxiety and Defenses using ISTDP

In the 1990's Dr Davanloo adapted his method of ISTDP to treat a broad range of patients including those with somatization, depression and fragile character structure. Each of these groups of patients requires preparatory work prior to helping them to safely face their unconscious feelings about broken attachments in the past. Davanloo developed a psychodiagnostic process to assess anxiety tolerance and physical manifestations along with the specific formats of defense. Through this process a “roadmap” to the unconscious is derived. As the patient develops capacity, there are specific markers of changes in anxiety and defenses. These are indeed character changes demonstrable on serial videotapes.

In this presentation, Dr Abbass will use videotape vignettes to illustrate the psychodiagnostic assessment and some of these changes as they take place in the early phase of treatment.

See presentation

See Article in Ad Hoc Bulletin

Jentine ten Broeke, PsyD, Angela van Driel, MD, Ria Meerhoff, PsyD

Instant Repression with a Dysthymic and a Psychosomatic Patient: Overcoming Blocks at Stimulus and Response

The concept of Instant Repression stems from Davanloo's clinical observations with patients, suffering from depressive, functional and psychosomatic disorders. According to Davanloo the unconscious defense mechanism of instant repression implies direct and instantaneous internalization of the sadistic Impulse, preventing it from coming into the patient's consciousness. One of the consequences is that these patients have difficulties in distinguishing between the poles of the triangle of conflict.

The presentation will elaborate on parts of the therapeutic process with two patients (a dysthymic and a psychosomatic patient), that were essential to establish a conscious/unconscious working alliance, and the undoing of the defenses of instant repression.

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Patricia Coughlin (Della Selva), PhD

From Detached Observer to Engaged Participant in Life

In this presentation I will be illustrating the process of character change in a man with a life long detachment and isolation. His initial presentation was that of a schizoid personality, as if he had no feelings. This was the result of massive defenses against the experience of his own anguish and rage, rather than a true absence of feeling. Once those defenses broke down, it was clear that he was an avoidant character. He satisfied all the diagnostic criteria for this condition, from an utter lack of any close friends or confidants – including first-degree relatives, to an unwillingness to extend himself and establish any new relationships. When he entered treatment, at the age of 27, he wasn't working or going to school but living in isolation, and was loath to reveal himself to anyone – including the therapist. He had been in a serious auto accident 3 years prior, which left him a quadriplegic. Of note, he told the therapist in the very first session not to make the mistake of assuming the accident was the cause of his difficulties. Rather, he had suffered from isolation and detachment since childhood. Even when able bodied and a gifted athlete, he did not interact with team mates or respond to the attention he got from girls. He turned down scholarships to college and went to a community college instead – not willing to venture far from home.

The treatment began by identifying his characterological detachment – both from his own inner world and from others, including the therapist. A head on collision with the resistance to closeness was necessary to break through his wall and activate the unconscious alliance, which then becomes very strong. We will observe the process of transformation in which his detachment is replaced with active engagement. Ten-year follow up substantiated the depth and maintenance, as well as deepening levels of change and development.

Kees L.M. Cornelissen, SocD

Being at the Crossroads: Aiming for Lasting Character Change

The therapeutic center "De Viersprong" (Halsteren, the Netherlands ) offers a residential treatment program that is based on Davanloo's Intensive Short-Term Dynamic Psychotherapy.

All patients who are admitted in this ISTDP program suffer from character or personality disorders.

In this audiovisual presentation parts of the therapy process with a couple of patients will illustrate specific aspects of their character disorder and the specific interventions that had been important to effectuate turning points in their therapy process on their way to character change.

Research data, collected from interviews of a cohort of patients (N=110) treated with our ISTDP program by means of follow-up from 1 to 10 years after treatment will give scientifically based evidence of the results over time.

Manuela Fontolan, MD

Is Everything Illuminated? Obscure Places and Characters in Fairy Tales and Reality.

Is it possible to explore the most obscure and frightening corners of an individual? Perhaps not always and not completely. This difficult and painful search, however, does often play a crucial role in fairy tales as well as in life, and it can bring about deep and irreversible change.

This EDT presentation illustrates the character change of a young, brilliant woman, extremely obliging and seductive in order to be always accepted. Special emphasis will be given to working with body-and-mind, in order to throw light onto the most obscure inner experiences of a girl, terrified and overpowered by violence in the family and the shady attention, paid to her by an almost demented grandfather. A dissociative, quasi-hypnotic state, populated by vivid images and memories called for the techniques of anxiety regulation and emotional maieutics, lifting the inhibitory forces and making a close and empathic interaction possible. The real personal relationship, fostered in this way was able to facilitate and subsequently consolidate the patient's character change from a prevailingly passive and obliging attitude to being genuine, self-confident and capable of sharing joyful feelings.

NOTE: the title is a tribute to J.S. Foer's wonderful novel “Everything is Illuminated”

Jon Frederickson, MSW

Awakening the Ego of the Highly Resistant Patient

In fairy tales we often read of someone who has been cast under a spell. Asleep for decades while life goes on, someone appears who says the right words which awaken this person from the spell. Patients who suffer from personality disorders suffer from a kind of ‘spell” in which their ego is not awake. They are not aware of their feelings, their anxiety, their defenses, nor of the destructive function of their defenses. As a result, they go through life emotionally blind, unaware of what is causing the destruction in their lives. Therefore, before any deep feelings can be experienced in therapy, the ego of the highly resistant patient must be awakened.

This presentation will analyze in depth a session during which we see interventions which awaken the patient's ego from the spell cast by his superego.

See Article in Ad Hoc Bulletin

Arno Goudsmit, PhD

By Way of “Cold Fusion”: Combining Challenge and Anxiety Regulation in Dealing with Character Defenses

Challenging character defenses usually raises the patient's anxiety, and this may lead to great discomfort before the resistances are overcome. This is “hot fusion”, where atomic particles fuse under extreme pressure and temperature. Alternatively, it is possible to look for “cold fusion”, that is a combination of challenging the defenses and regulating the patient's anxiety. As a result, restructuring the defenses proceeds in accordance with the patient's capacity to manage his anxiety. This procedure is especially suitable for fragile patients.

The presented video vignettes will focus on sessions in which the patient's dilemma between her (defended) longing for being cared for and her fear of rejection is explored. The therapist addresses this dilemma by challenging the patient's defenses while moderating her anxiety.

Josette ten Have-de Labije, PsyD

The Man, Who Tried not to be a Jew: the “Deal” with a Second Generation War-Traumatized Patient

The agony of children of Holocaust survivors often remains hidden if the limelight is taken by their severely war-traumatized parents.

Parts of the 1 st , 2 nd , 4 th , 5th and 6th sessions and one follow-up session with a second generation war-traumatized patient, suffering from high superego pathology and character disorder will be shown.

The first time I had seen this patient had been about one year before the therapy started. At that time he was paranoid, highly anxious and suicidal. As it then appeared that he was regularly seen by a psychiatrist, I had told him that he would be welcome as soon as he and his psychiatrist had agreed to end their contacts.

We will witness parts of the therapy process that are focused upon establishing a conscious and unconscious working alliance with the patient in order to uncover his painful feelings and to get access to traumatic experiences from his past.

Parts of a follow-up session will show the patient's view on his therapy.

Whether character change has been brought about is up to the judgement of the conference participants.

Allen Kalpin, MD

Mindfulness and Experiential Dynamic Therapy

Four years ago at the Second International IEDTA Conference in Washington DC my presentation was entitled “ The Use of ‘Being Present' in Facilitating Emotional Closeness and Emotional Experience” In that presentation I drew parallels between this use of “being present” in EDT and approaches that are used in the emerging field of mindfulness-oriented psychotherapy. Since then I have continued to expand the use of mindfulness in my work, moving toward the development of a Mindfulness-Informed Experiential Dynamic Therapy (MI-EDT). In this presentation I will explore this topic and present audio-visual vignettes showing this approach in treatment sessions.

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Nat Kuhn , MD

The Helpful Son: Confrontation of In-Session Defense and Exposure to Adaptive Affects

The 47 year-old patient we are about to see had had a lifelong history of chronic depression, chronic anxiety and a very poor sense of self. His psychopathology can be understood against a background of neglect, emotional and sexual abuse. He had had a brief therapy with the presenter in 2000 with some symptomatic relief; he returned in January of 2002 when his symptoms recurred.

The therapy focused on conflicts around grief, anger, closeness and positive feelings toward the self. His self-attacking defenses were very dense and he was not able to engage effectively in anger exposure, referring to it as “play-acting”. He eventually - in December of 2003 - attended an intensive nine-day workshop (known as the Hoffmann Process), which focuses on affect experiencing. This gave him some symptomatic relief, which faded after a few months. However from that point onward he was more able to engage in therapy and his defenses were more malleable.

The video-presentation consists of four segments which demonstrate work with defenses, anxiety and adaptive affects (mostly positive feelings about the self and grief). The fifth segment demonstrates a significant change in his character style.

Leigh McCullough, PhD

Research Skills and Research Results: Using Psychotherapy Research Tools to Enhance Your Clinical Practice

Part I: A brief overview of some of the exciting, new research results on STDP that are coming from the Norwegian process research program in Trondheim .

Part II: Teaching basic skills for assessing tapes of therapy as they do in the Norwegian program. This rating system, the Achievement of Therapist Objectives Scale (ATOS Scale on line at www.affectphobia.com. and online training on www.jakobsladder.com ) is used not only in research, but is a powerful form of clinical training. Participants will be taught some preliminary techniques for evaluating patient progress in treatment. Videotaped examples of therapy will be shown so that participants may practice rating various clinical objectives; e.g., patients degree of insight, motivation, or depth of feeling. By the end of the presentation participants should have acquired a heightened understanding of how to assess specific change mechanisms as well as a new way to assess their own therapy sessions.

Robert Neborsky, MD

The Crippled Bully: The AB/ISTDP Treatment of a Patient with Severe Ego Fragility

This presentation will outline the sequential therapeutic transformation of a patient with a highly rigid narcissistic and paranoid character structure into a person with a well integrated functional personality. The patient had sabotaged prior psychotherapy by terrorizing his psychotherapist and sought ISTDP out of desperation. He suffered from rage outbursts that destroyed his professional and personal life. At the beginning of treatment, he idealized the infliction of pain on others. He evolved into a man who valued his own feelings and learned to respect the feelings and rights of others. The case will demonstrate the power of AB/ISTDP to alter severe character pathology.

See presentation

See Article in Ad Hoc Bulletin

Ferruccio Osimo , MD

Loving and Leaving

It could perhaps be argued that from an experiential dynamic perspective, our main emotional endeavor in life has to do with loving and leaving – the two sometimes being simultaneous. An EDT therapist should then be capable of facilitating and sharing the emotional experiencing related to both loving and leaving. This man in his 60s, previously diagnosed as bipolar, came for therapy after a recent breakdown, unsuccessfully treated with neuroleptic and antidepressant medication. He had indeed suffered from episodes of total paralysis, lasting from a few weeks to 2-3 months, a “wave of darkness” taking him over completely. On closer examination, however, these symptoms appeared to be the tip of the iceberg of a lifelong character problem. The patient was actually imprisoned by the rigid rules of a strict and demanding superego, constantly forcing him to be good and to please others, to avoid at all costs love being withdrawn. This presentation will focus on parting ways with some aspects of his character and improving his ability to love himself and others.

Albert (Terry) Sheldon, MD

Changing Character: via an Evolving Complex Integration of Multiple Brain Systems Recent research in neuroscience is revolutionizing the way we understand how the mind functions and the nature of psychopathology. This research invites new explorations in how we approach psychotherapy. Traditionally, Davanloo used Freud's hydraulic theory directing us to "drain the unconscious reservoir." For example, now we know we can not "drain" anxiety out of the Amygdaloid Complex; (which is part of the Limbic System, that is involved in regulating anxiety and emotions). Those amygdala circuits cannot be extinguished.

Following the research of Panksepp and Grawe, we look at conflict as taking place between brain systems, such as seeking/approach systems and the fear/avoidance systems.

From a neuroscience perspective "resistance" is understood as the hypoactivation of the brain systems associated with approach and hyperactivation of the brain systems associated with avoidance. The therapist must identify those systems and regulate them in order for the patient to have the complex integration of multiple capacities necessary for overriding resistances and other conditioned neural pathways. From a neuroscience point of view, the emphasis in therapy must be on implicit learning. Repeated exposure to previously feared experiences within a range of low anxiety, readiness for approach (Grawe) develops new neural pathways and over time will actively inhibit previously conditioned maladaptive neural pathways. This differentiation of separate brain systems and then simultaneous activation will give rise to the complex integration of multiple brain systems in vivo .

Objectives:
1] Careful focus on the attentional capacities and the activation of the seeking/approach brain systems of the patient.
2] The process of identification and then differentiation of brain systems will reduce symptoms, build a stronger alliance and set the stage for further implicit learning.
3] Constant work in the present (here and now) relationship between the therapist and the patient will enable constant monitoring of psychophysiological shifts in the patient as evidence of ongoing implicit learning.
4] The combination of focused attention, activation of seeking/approach brain systems, differentiation of multiple brain systems, and psychophysiological shifts/ongoing implicit learning will take us to our goal: an evolving complex integration of multiple brain systems.
This presentation will demonstrate this process by showing the first therapy session in which the work can be witnessed, that gives rise to the changes we are seeking. The presentation will show how to identify hypoactive brain systems, how to activate them, how to address unconscious anxiety, and how to work within the implicit realm. That we are increasing integration of multiple neural networks within the patient will be evidenced in the way the patient appears, relates, and experiences himselve .

See presentation

Susan Warren Warshow, LCSW

Finding the Self in the Tornado of Betrayal
A Woman’s Courageous Journey

The breathtaking capacity of the individual to overcome massive traumas can be seen in this videotape presentation. The patient was terrorized by her raging, schizophrenic mother, abandoned by her divorced father (a registered sex offender) and molested by her older brother. Yet she was able to find fulfillment in her life and reconciliation with her family. In order to recover from chronic and debilitating symptoms of anxiety and depression, she had to confront and transcend the submissive, self-abusing and terrorizing parts of herself that were perpetuating her suffering. The curative process involved not only attention to anxiety, compassionate defense interruption and the therapeutic alliance, but also to the less easily defined qualities of relationship that enabled this patient to take the consummate risk of being “seen” by another in the deepest possible way. This presentation aims to emphasize the significance of the emotional engagement of the therapist, which heightens the patient’s experience of caring and safety in intimacy.