Let’s start by sharing with you our happiness that James Paul Walker, PhD, has joined our Editorial Board. In a former life, Jim Walker has been assistant professor of psychology at the University of Southern California and the author of several journal articles and book chapters on brain and behavior. He has been Director of Training at the Southern California Society for the Advancement of Attachment Based ISTDP. Now, he spends most of his professional time working with patients in his private practice and supervising colleagues. Our inter-continental-to-and-fro-efforts to co-operate have resulted in a solid Holland-America-Connection, (with the American end being covered by Robert Neborsky and Jim Walker) and this is what we had hoped for!

Entering relationships, living them and the unavoidable farewell always induces images of anticipation. “Those Happy Few”, whose past experiences guaranteed the memory storage of happy images, are able to anticipate on images, expressing a fulfillment of their need for mutual understanding, compassion, and respect. This kind of anticipation, we call hope.

Many of our patients, however, in their struggle with the daily constraints, spend much of their time dwelling on all other Days of Doom, that for sure are to come. Any understanding of what Happiness might lie outside this State of Continuous Concern with the Fatal Future must remain unthinkable and invisible - at least - to their conscious minds.

In their common quest for Happiness, therapist and patient begin their arduous journey towards those atrocious experiences which are stored as mental images in the patient’s cortical and subcortical limbic structures. It is only after reliving these memories, (but this time with the full intensity and extent of all accompanying painful feelings and impulses), that the patient’s Longing and Hope are freed from this heavy burden. But with the prospect of the end of this journey, past victories suddenly no longer seem so glorious to the patient. Unfortunately, the vividness of past victory has vanished from the patient’s inner eye and conscious experience. And sometimes, it even seems as if our patient is migrating again toward that “State of Continuous Concern with the Fatal Future”.

Announcing the end of a therapy, and the upcoming farewell, will trigger still unresolved issues (not only in the patient) and gives the therapist the opportunity to see what work still has to be done. Of course, the more a patient experiences himself as adequate to cope with his problems and feelings, the less the approaching end of his journey with the therapist will lead to the resonance of unresolved past.

Diana Shulman, JD, PhD, describes in her article “The Delayed Termination” that in a prior therapy of twelve sessions, she had failed to unmask her patient’s “concern” for his little sister as part of his superego pathology. As a consequence, the patient’s murderous impulses, guilt, grief and love remained buried in the unconscious and the issues around past traumatic experiences with this sister and his parents remained unresolved.

That is ……. until about one year later when the second series of five sessions took place.
This linkage of termination of therapy with the rise of transference and countertransference issues will also be found in the article of Joy A. Oonk, PsyD. “Terminating Therapy: when is the time to say goodbye?”

“When Patients Enter with Anxiety on the Forefront”, the last article in this issue of the Ad Hoc Bulletin, is from Josette ten Have-de Labije, PsyD. After focusing on some aspects of the neurobiological regulation of anxiety and the operational steps to be carried out when assessing a patient’s anxiety, transcripts of five different patients are given as an illustration.

Till we read and write again !

Josette ten Have-de Labije

We really are of a ruthless kind and we did it again! The same futile cycle will forever repeat itself. From bad to worse. All wars look miserably familiar. Some wars have a winner, but do remember: all wars have losers. The shattering of lives, war victims desperately guarding their territory or homeless refugees, using all their wits and courage to escape from a nightmarish situation. But they all are traumatized. And their pain - physical and emotional - is aching and stinging and pounding and burning and lasting. And even opiates or cutting nociceptive nerves may not work. And when there is no other option the persistent and aching, stinging, pounding, burning pain is borne stoically. Whether little-t-trauma or Big-T-Trauma, all pain and memory of pain - physical as well as emotional - is perceived by the mind. Pain, a phantom in the brain.

Extinguishing the traces of pain by transforming noxious memories into innocuous ones, that is how we try to be of help. We attempt to alter pain's future by recollecting when it began, how it began, by helping our patients to experience the repressed rage, guilt and grief. By recollecting the pre-pain period. By recollecting love and happiness. This is easily said but we all know that the process of becoming a skilled psychotherapist is lifelong. There has to be the willingness to continuously re-examine the interventions we did during the interaction with our patients and to re-evaluate our own interfering thoughts, impulses, feeling, defenses. We do not increase our professional expertise through repetition of our failures, isn't it! Diane Anderson'article “Student driver: the bumpy detour to the patient's unconscious and the driving lessons of the supervisor” evidences her readiness to learn from her supervisor and her unsparing honesty to face her “right and wrong interventions” with complete objectivity. Her patient, suffering from severe eating disorders and alcohol abuse, was referred for psychotherapy sessions prior to her admission to an intensive 4-month residential program for patients with eating disorders. The therapist was also asked to have ongoing psychotherapy sessions (frequency once per month) with the patient parallel to the residential program. The author will first focus on the 3 preparatory sessions and subsequently the transcript of the 4th session is given including the comments of the supervisor.

The second article is from Josette ten Have-de Labije and the title speaks for itself: “ISTDP in Couples Therapy: unlocking marital collusion by experiencing the murderous impulse towards the partner and the accompanying guilt, grief and love”. Under our section “Having Read” you will find Emanuel Peluso's review of the book “Lives Transformed”. The book is written by David Malan and Patricia Coughlin Della Selva. According to the reviewer the authors have produced a book that gives both a beautifully concise explanation of how and why ISTDP works, and enough analyzed case material to be a very serviceable training guide. Emanuel Peluso is generous with his compliments, however he also has some criticisms. The last contribution to this issue comes from Pablo Altieri and Bruce Pickle. These two colleagues attended June 4 - June 9, 2005, the Summer School which was organized by the Washington School of Psychiatry. Read their sojourners reflections on the Summer School in “Two Roads to Syria: a time and place to grieve”.

Till we read and write again !

Josette ten Have-de Labije

The inner life of emotions seems more or less inaccessible to all of our patients. To some of them, e.g. to those on the right side of Davanloo's spectrum of structural neuroses, inner emotional life has become equal to Terra Incognita. Those are the patients who - amongst others - habitually bring their defenses of ignoring, denying and physical immobility into operation. With these syntonic defenses they have succeeded in interfering and interrupting the myriads of interaction and feedback systems between sensory modalities (like vision, hearing and proprioception) and the brain's subcortical limbic structures, that are involved in the regulation of emotion.

Although it may happen that these patients, especially the verbally gifted ones, entertain us with their conversation, neither the well-ordered flow of their words, nor their face or body reflect any emotion other than perhaps anxiety. Often, the facial muscles are frozen, due to tension, that accompanies anxiety. The lack of gestures, due to the defense of physical immobility, reflect that their inner world has become Terra Incognita as well as Terra Prohibita under the dictate of their superego.

As it turns out however, Terra Incognita can become visible once the therapist knows how to lift the prohibition, knows how to proceed step-by-step and knows how to look at physiological phenomena that give inner life away.

Our three Dutch colleagues: Jentine ten Broeke, PsyD, Angela van Driel-Corthals, MD and Ria Meerhoff, PsyD joined forces to write their article. “Instant Repression with a dysthymic and a psychosomatic patient: overcoming blocks at stimulus and response”.

You will learn how the borders of Terra Prohibita were thrown open and how, step-by-step, the therapists uncovered Terra Incognita with a dysthymic (case 1) and with a psychosomatic patient (case2).

Another evidence of Inner Life deciphered and revealed is “The Girl Who Played “Perfect” for her Father” by Joal Ann Bennett-Stenzel, LCSW.

The therapy with this patient focused first on helping the patient to undo her identification with her judgmental, devaluing superego part, helping the patient to cope with her anxiety, to restructure her ego adaptive capacity before in the 27th session the therapist and patient could go for the patient's breakthrough of her murderous impulse, guilt, grief and an unlocking of the patient's unconscious.

The readers of the Ad Hoc Bulletin shouldn't miss the fourth International IEDTA Conference on August 24-26, 2007 that will take place in Aarhus , Denmark . See the information and the registration form in this issue.

This issue ends with the Index of all articles that were published in the Ad Hoc Bulletin up till now.

The Editors wish you good health, laughing, singing and dancing in 2007 !

Till we read and write again !

Josette ten Have-de Labije

The concept of instant repression stems from Davanloo's clinical observations with patients, suffering from depressive, functional and psychosomatic disorders. According to Davanloo (1987 a, b) 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.

This article will elaborate on parts of the therapeutic process with two patients, that were essential to establish a conscious/unconscious working alliance, and the undoing of the defenses of instant repression. After the Introduction a transcript of part of the therapy process with a dysthymic (and alcoholic) patient (Case 1) will be given. This will be followed by a transcript of part of the therapy process with a patient, suffering from - what appeared to be - a psychosomatic disorder (Case 2).

Physiological effects of (childhood) trauma can be severe. The degree, frequency and duration of cruelty, the age of the victim, the absence of a social network acknowledging the (full enormity of the) trauma and it's devastating effects, all have impact on the extent of havoc on the (developing) brains of the victims.

Broken minds and scattered souls, that are captured in the victim's damaged and deformed brains! Imprisoned because the damage to the respective brain areas and to the interconnecting neuronal pathways inhibit amongst others a (constructive development of the growing child's brain and) a constructive regulation of perception, behavior and emotion.

Broken minds and broken dreams! Imagining the future as hopeful and imagining oneself as successfully coping in that future is - in this editor's view - based on the possibility of looking back to at least one or two interactions with the loving eyes and voice of some caretaker. In fact, the same brain regions are involved when imagining the future as when recollecting the past.

To help his patients recollect the atrocities of their past, to bear their painful feelings and to work them through, Davanloo devised his Central Dynamic Sequence. Every psychotherapist - and not only the ISTDP therapist - knows that if the sequence of selection of problem targets and of interventions is not properly followed accidents will happen. Prematurely pressure to feeling and challenge to the patient's defenses with patients suffering from high superego pathology will result in a misalliance.

The therapist's first task is to help the patient to undo his identification with his sadistic superego and to separate it from his constructive ego part. The therapist functions therewith as an external loving superego part in focusing the patient's attention on the fact that “he has come on the basis of his longing to understand his thoughts, feelings and the processes that he put into operation with love, care, precision and strict honesty”. The target of this intervention is of course the patient's memory that once upon a time in his life there had been a hopeful future when he still had access to this longing to be understood with love, care, precision and honesty. The aim of this intervention is to awaken this longing. (see e.g. the teachings of J. ten Have-de Labije, the VKDP Summer Schools on superego pathology, the VKDP courses and workshops on superego pathology, all since 1998).

Without a longing for better times, a longing to be understood with love, care, precision and honesty no human being nor any therapy will flourish. It is therefore that the first task of the therapist is to go back to the future, to help the patient recollect the future, the time that the patient still had this longing to be loved and had happy and curious expectations of the future. This editor said it before: remember the future! Remember that once there was this longing!

This April 2007 issue is all about compassion!

There is no other way than on the basis of the loving and expert eyes of Ferruccio Osimo, MD and his wife Claudia Ferrandes, Dietician and Therapist of Eating Disorders. that their borderline patient could have (re)gained psychological health. Their article, “the Octopus and the Little Girl: Sex, Bingeing, Dissociation and Closeness”, offers us insight into their joined forces to help their patient to become strong enough to free herself from her sabotaging superego and to flourish again. The setting of two therapists, more or less working in parallel with the same patient, requires excellent timing of which problem targets to tackle and excellent communication of what happened in the parallel processes. If these requirements are met then one process can accelerate and deepen the other as we will notice. It is often that we see that working in the transference is avoided by the therapist. Not by these two therapists, who held out their hands to the patient in more than one way.

In “Self Compassion: an Important Key to Emotional Well-Being” Leigh McCullough, PhD and Kaare Thornes, Clin.Psychol. describe the process of restructuring the sense of self by focusing specifically on the feeling of self compassion. The term self compassion is defined, and the theoretical basis of this construct is presented. Self compassion is seen as one of the “true or activating feelings” at the bottom of Malan's triangle of conflict, and an outgrowth of a growing interest in restructuring a general category of “positive feelings for self.”

A case example is presented of a severely self-attacking man who did not respond to five years of previous treatment. You may read and admire the seemingly “yes-of-course-steps” that are so elegantly taken by the therapist during the process of desensitizing the patient's “phobic avoidance” (or “warding off”) of self compassion. Strong improvement was seen in 35 sessions.

“The Triangle of the Perpetrator: a Potential Framework to Help Accelerate the Restructuring of Severe SuperEgo Pathology” is written by Stephen Arthey, PhD and Margaret Ross, DPsychCand. By locating the Perpetrator/sadistic superego part at one corner on a new triangle, with the Ego and the “Loving SuperEgo part” at the other corners, the authors have developed an intra-psychically focused Triangle of the Perpetrator which offers a potential framework to help to restructure the relationships between the patient's Ego, Perpetrator/Sadistic SuperEgo and Loving SuperEgo parts. Therapy vignettes from the 6th session with a 50 year old patient will illustrate that working in this triangle enables the patient to rapidly turn against the Perpetrator while his syntonic masochistic defenses become more dystonic and the relationship between the patient's Ego and his Loving SuperEgo part intensifies. The editors, however think that our Australian colleagues have taken an unnecessary complicated road to help their patients undo their identification with their sadistic superego. If the therapist functions as an external loving superego, reminding the patient of his once-upon-a-time-longings and expectations of a hopeful future and if this procedure is properly administered, then the patient will tell the therapist which former aggressor(s) he has internalized as his sadistic superego part(s), which will be followed by grief because of the self-destructive function of this identification.

Anyway, the editors thought that this interesting article undoubtedly will stimulate the reader to lots of intercollegial discussion!

Till we read and write again !

Josette ten Have-de Labije

Summary
This case was treated by both authors, endeavoring to help a patient presenting with dissociation, splitting and complex symptoms to achieve a higher level of integration. The therapy was first presented at the 2005 IEDTA International Conference in Los Angeles. It is described in this article with further theoretical discussion and follow-up material from subsequent sessions.

Summary
This article describes the process of restructuring the sense of self by focusing specifically on the feeling of self compassion. The term self compassion is defined, and the theoretical basis of this construct is presented. Self compassion is seen as one of the “true or activating feelings” at the bottom of Malan's triangle of conflict, and an outgrowth of a growing interest in restructuring a general category of “positive feelings for self.” Blocks to self compassion are defensive responses such as self hate, self attack, or lack of self care. To effect change in these destructive responses, avoided self compassion is conceptualized as an “Affect Phobia.” Principles of “exposure” to the feeling of self compassion and prevention of defensive, self-attacking responses are described. A case example is presented of a severely self-attacking man who did not respond to five years of previous treatment. The process of desensitizing his “phobic avoidance” (or “warding off”) of self compassion resulted in strong improvement in 35 sessions. Impairment in feelings of self compassion may be considered universal, relevant not only for patients but for therapists as well.

Summary
Many therapists have difficulty treating patients with high superego pathology. These patients demonstrate a strong alliance or identification with a punitive/sadistic superego part or - as Davanloo calls it - they have more or less identified with the Perpetrator of the Unconscious. Turning these patients against the Perpetrator is often a complex and lengthy task in the initial stages of treatment. By locating the Perpetrator/sadistic superego part at one corner on a new triangle, with the Ego and the “Loving SuperEgo part” at the other corners, we have developed an intra-psychically focused Triangle of the Perpetrator which offers a potential framework to help to restructure the relationships between the patient's Ego, Perpetrator/Sadistic SuperEgo and Loving SuperEgo parts. Therapy vignettes from the 6th session with a 50 year old patient will illustrate that working in this triangle enables the patient to rapidly turn against the Perpetrator while his syntonic masochistic defenses become more dystonic and the relationship between the patient's Ego and his Loving SuperEgo part intensifies. This procedure offers the possibility of accelerating the ISTDP treatment process for patients with severe superego pathology.

“Changing Character: Fairy Tale or …?” is the theme of the 4th international IEDTA Conference (organized in co-operation with the Danish Academy for Integrative Psychotherapy, the AIP). The conference takes place on August 24, 25 and 26, 2007 at the Lakeside Lecture Halls, situated on the Aarhus University Campus.

Robert Neborsky, MD, Allan Abbass, MD and Jon Frederickson, LCSW, contributed to this issue of the Ad Hoc Bulletin, and they also will present their work at the IEDTA Conference. Their articles and presentations are about helping their patients to overcome their character and superego pathology. And that is no Fairy Tale! Although - as you probably know - Fairy Tales with very similar plots, characters and motifs are cross-culturally found in oral folktale and in literary form and very often the hero/heroine-victim is rescued by a helper or donor (e.g. the fairy godmother gives Cinderella the dress she needs to attend the ball,. Gerda, who manages to liberate Kay from the Snow Queen's chill is on her turn helped by Bae, the reindeer, the Lapp woman and the Finn woman).

Signs of character and superego pathology often resemble the symptoms of a frozen vegetative state. While awake there is barely any awareness. Many of our patients are trapped in the territory of the Snow Queen, like Kay in the famous Fairy Tale by Hans Christian Andersen.

Patients, who have suffered severe and extensive physical trauma to the brain can slip into a coma. In coma the patient is neither awake nor aware. Only a few of those patients regain consciousness, mostly within days. Others will awaken from their coma but they will remain unconscious and they will enter a vegetative state (awake but unaware). The vegetative state may be a transitory one and the patient might enter the minimally conscious state in which the patient is awake and aware. The patient responds to stimuli but has a limited capacity to take willful actions. The minimally conscious state may be chronic and permanent or it may be a transient condition on the way to further recovery of consciousness (Laurey S in the Scientific American, 296, 5, 2007). A study, conducted by Owen, A; Coleman, M.R. et al, (Science, 313, 8, 2006), using functional MRI found that their 23-year old brain-damaged patient showed activity in the supplementary motor area of her brain when she was asked to imagine playing tennis. There was activation of the premotor, parietal and parahippocampal cortices (involved in spatial tasks) when she was asked to envision walking through her house. At the time of the experiment the patient was already beginning the transition from the vegetative to the minimally conscious state.

Our inner-eye-ability to envision, estimate and simulate future courses of action while previewing their consequences enables us to survive, to learn from mistakes and to avoid making them in the future.

Some of our life's lessons are learned in the very next split-second (yes, it is true one shouldn't have put his hand into that dog's mouth), others only become apparent some time after the fact (yes, there are some men/women that come to see that they should have given their companion a compliment about their help, their loyalty, their smile …).

Sadly enough, other life-lessons will never become learned although images of atrocity like massacres, ethnic cleansing, (collective) rape, mental and physical abuse etc. etc. etc. are deeply engraved into our memories.

The efficiency of our memory, our inner-eye-capacity (or incapacity) to foresee and simulate action and reaction and our capacity (or incapacity) to forget are important factors to the quality and degree in which we enjoy life, shuffle through it or simply do our best to endure it. When we merely endure, we make time rigid and endless in such a way that there is no past, no future but only empty present. We remain stranded in an endless minute, unable to remember what was or envision what will be next.

Some of our patients, having suffered psychological trauma also have the ability (by means of their defenses) to slip into a psychological coma, a vegetative or minimally conscious state. By using their defenses they have been able to disrupt the neuronal pathways from thalamus to the cortical regions, to the subcortical limbic structures, therewith preventing that they e.g. become aware of this specific sensory, or emotional input and its meaning.

Luckily we have come to realize that our brain retains considerable power of “neuroplasticity”, the ability to change its structure and function in response to experience.

Thus it is certainly no fiction that we have the possibility of “repairing” the damaged wiring and structure of our brain that underlies character and superego pathology. Only, we as well as our patients, (like Cinderella, Kay and little Gerda from the Fairy Tales) need the help of some Very Wise colleagues, teachers and researchers.

Till we read and write again !

Josette ten Have-de Labije

Summary
In this article the authors review the historical roots of the concept of the superego from an analytical perspective. They articulate specific criterion for diagnosing a punitive superego and outline a system for de-identifying patients from their punitive superego part. They discuss the different points of view about the origin of the punitive superego and the importance of making the unconscious feelings of guilt, conscious as early in therapy as possible. An illustrative clinical case is summarized and annotated with vignettes following a modified central dynamic sequence in a 15 hour block therapy case with good clinical results. Finally the authors suggest a metaphor for the metapsychology of clinical cure from Greek Mythology.

Summary
Davanloo has discovered and operationalized a means of direct assessment of character structure, including both discharge pathways of unconscious anxiety and specific manifestations of defenses. This psychodiagnostic process provides a roadmap to the unconscious buried feelings which generate the anxiety and defenses. This roadmap tells the therapist how much of which interventions are required to bring sufficient structural changes in unconscious anxiety and defenses to enable smooth, direct access to the unconscious. In following the map, changes in character structure begin to take place and are thereafter cemented by repeated unlocking of the unconscious and working through the underlying feelings. In this article, this process of psychodiagnostic evaluation, and the graded format of bringing structural changes will be overviewed and illustrated by vignettes from a course of treatment.

Summary
This artikel shows portions of a fifty session treatment of a fragile 52 year old man who suffered brutal childhood abuse for years followed by a traumatic series of 70 electroshock treatments which caused some brain damage. The vignettes will illustrate aspects of Davanloo's graded technique which gradually increase the patient's ego adaptive capacity.

Our personal life history provides us with a vast reservoir of experiences that inform and guide our view about ourselves, about the world around us, about our longings, feelings and actions. And, as it is very easy in this world to get hurt, our viewpoints as well as those of our patients aren't always so sunny. Trauma as part of one's life history is very common. Don't be too confident that Fate will overlook you. If you haven't experienced natural disaster (Tsunami, volcano eruption, flooding, fire), there is always the chance you will become involved in a serious vehicle accident (motorcycle, car, train, aircraft, boat). Or to become the victim of interpersonal violence (war, combat, terrorist attack, murder, human trafficking, kidnapping, hostage taking, discrimination). Or of mental or physical (e.g. sexual) abuse. And what about “only” witnessing violence and abuse? Not traumatic enough?

In case I forgot to mention some disaster it will not be difficult for you, dear colleague, to add to the list. Is it also your experience that sexual abuse is nowadays booming and scoring high on the global trauma market?

Studies and surveys indicated in 1999 that one in three girls and one in six boys are sexually abused in childhood. But if a broader definition of sexual abuse is used (1995 findings from the Women's Safety Project), including unwanted kisses, non-genital sexual touching or e.g. having to watch someone masturbating then 54 % of women reports unwanted sexual experience before age 16. CNN reported in 2001 that an estimated two million women and children are sold into the sex trade every year. Up to 120.000 women are smuggled into Western Europe and forced into prostitution. More than 15.000 women are trafficked into the USA every year, many of them young girls from Mexico. Almost 200.000 girls from Nepal, many of them under the age of 14, are working as sex slaves in India. 60.000 Thai children have been sold into prostitution and in 2007 The Independent, UK, reports that more than 5.000 children are being forced to work as sex slaves in the UK, including thousands trafficked to the UK by criminal gangs.

This December 2007 issue of the Ad Hoc Bulletin contains vignettes of two ISTDP therapies with adult women-survivors of incest.

Some 1999 statistics: did you know that of sexually abused girls, 53% are abused by their biological fathers, 15% by stepfathers, and 8,8% by uncles. In case of incest between siblings, 26% are between siblings of the same sex.. Force and violence may be used during incest, however 68 % of victims report no physical force, 29% report mild physical force, 2% involve hitting, 1% involve beating. Adult women survivors of incest are 4 times more likely than non-abused women to work as prostitutes, 66% of all prostitutes are victims of child sexual abuse Having been a victim of incest creates of course long lasting (till into adulthood) problems on Axis I and II of the DSM. Among the somatic complaints we often find pelvic pain, migraines and sleep disturbances.

Incest is only one form of sexual abuse. It is a horrendous crime that goes on behind closed doors, where the vulnerable and immature prey is easy to stalk and the child is trapped in repetitive, obscene tragedy. A child, being used as a sexual slave - free of charge - for their predator father or mother. Predator parents, who don't take the trouble to raise their child, to understand their child. They “keep” a child, they feed and clothe their possession, that they call their child. Like one grows for instance potatoes. They water and feed the potato in order to consume it! And the free-of-charge-sexual-slave-victim-child quickly learns that the ultimate betrayal of her/his trust doesn't matter to the rest of society either. Because we, the rest of the society, do not like to interfere into “family business”. Because we don't think it our business. Because we first want to have “hard proof of what happened and what didn't happen” before going directly to some kind of legal or social organization, which has at least some power of protecting such a victim. But the free-of-charge-sexual-slave-victim-child, who has already lost trust and already has become an expert in dissociation, de-personalization, instant repression, and idealization of her/his predators will keep silent.

The 1926 Slavery Convention described slavery as “… the status and/or condition of a person over whom any or all of the powers attaching to the right of ownership are exercised…”. We haven't made much progress since 1926.

“Slaying the serpent of shame” is the title of Susan Warren-Warshow's article, in which she highlights her patient's unhealthy guilt and shame that invaded all of the patient's important relationships .The author describes the stepwise undoing of her patient's identification with her punishing superego part, helping the patient to understand and to undo her projection and to quit her defenses in the relationship with the therapist. It is no surprise that during the process the patient reveals her damaged trust in the relationship with her highly abusive mother, her father, who left his wife and children ,and de-represses her painful memories of the relationship with her incestuous brother.

Kees Cornelissen, in his article “The invisible woman” gives us insight into the suffering of his patient, an adult survivor of incest. We follow the author helping his patient to become aware of her projections, understanding their roots, helping his patient to relate with the therapist, in accordance with her growing degree of ego adaptive capacity and anxiety. Stepwise, the dynamics are revealed with which this patient has made herself invisible so as to survive the incest by her perpetrator father and his partner in crime, his closed-eyed-wife.

Luckily, both therapists were successful in helping their patient. And that Changing Character is possible, that's what we also saw and heard at the 4 th IEDTA conference in Aarhus, Denmark.

James P. Walker gives us his view on that conference. Just read his review on the “International Conference on Experiential Dynamic Psychotherapy: Changing Character: Fairy Tale or ..?”

Last but not least the editors of the Ad Hoc Bulletin wish that all the happiness you hope for will become reality in 2008 !

Till we read and write again !

Josette ten Have-de Labije

Toxic shame had permeated the life of the female patient who is the subject of this article. The process of being “seen” by the therapist and also being “seen” by herself was like stepping onto a glass surface that could shatter at any moment and lead to unbearable aloneness. The therapist communicates to the patient both implicitly and explicitly that shame is something she is doing to herself as one of the activities of her abusive superego, which is intent upon attacking, humiliating and defeating the self. As the therapist conveys both compassion for the patient and faith in her healthy capacities, the patient becomes aware of her own agency to either activate or deactivate shame. In alliance with the therapist, she is enabled to effectively neutralize toxic shame and replace it with compassion for self and caring attention to her feelings.

Key elements in the process of character change will be highlighted, involving a fundamental shift in the patient's lifelong patterns of relating to self and others.

This article focuses on helping a severely traumatized patient to make acquaintance with her inner world and the complex of painful feelings which were associated with severe parental abuse. The patient was in the residential ISTDP program of the “Viersprong” and vignettes of the 1st, 14th and 19th individual ISTDP-sessions are given.

When the mirror of attachment shatters, the shards penetrate, blinding and disheartening our patients. They are locked in their icy prisons until we, the therapists, help to free them from the illusory cold which has trapped them in despair.

“Changing Character: Fairy Tale or…?” was the theme of the fourth Conference of the International Experiential Dynamic Therapy Association (IEDTA) on August 24 – 26, 2007.

This IEDTA conference was organized in co-operation with the Danish Academy for Integrative Psychotherapy (AIP) and it was held at the University of Aarhus, Denmark.

Dear colleagues,

It is April, skies are grey and Spring proceeds still in slow motion. Summer is obviously hesitant to leave her pleasant bed and change it for her full-time job and put her Sun at work and have it shine to warm up the million souls of those who have the blues, are feeling down or low and not quite themselves. How long or short the hours or days appear to us is not only influenced by external time cues but also by our physical and emotional states. Time is elastic and passes very quickly when we are in the middle of happy adventure. In contrast Time orders her minutes to crawl very slowly when we are not feeling very well. Be it because of high fever, of extreme anxiety, of deprivation of external stimuli, because of boredom, because of little-d-depressed or of capital-D-Depressed. It is the editor's opinion that it should have been the other way round: Time should run quickly when unhappiness is the rule, and crawl at a snail's pace to prolong experiencing happiness. Well, Injustice shall reign!

The first article “Working with a patient whose bipolar II was mistaken for a Major Depressive Disorder” is written by Linda C. Gilbert The author describes that with the establishment of a growing working alliance with her patient it became evident that the diagnosis of a recurrent major depressive disorder should be changed into a bipolar II disorder. Indeed, we don't need much imagination to understand how difficult pharmacotherapy and psychotherapy can be, due to the complexity of the disorder and its effect on our patient's cognition, judgment and behavior. It is a known fact that bipolar disorder patients have a relatively high rate of non-adherence to pharmacotherapy. and Linda Gilbert's patient was no exception. The reader is given some insight into the therapist's difficulties in helping the patient to accept this diagnosis, and not to tough out the side effects of her medication, to be also honest in her interaction with her psychiatrist. The patient's healthy part must have been more than happy being in psychotherapy with a therapist who knows that professionalism includes the constant minute-to-minute loving and honest evaluation of one's own clinical perception and never to lose curiosity. This is what the editor calls an attentive ego and in a successful therapeutic encounter it is not only up to the patient to take that responsibility.

Also in the Introduction of his article Allen Kalpin reminds the reader that the various schools of Experiential Dynamic Therapy (EDT) make use of mindfulness, whether or not the actual word is used. “In all schools of EDT patients are encouraged to pay attention to their emotions along with the physical manifestations of these emotions, as well as to manifestations of anxiety, and to the moment by moment shifts and changes in the workings of the defensive system.”

Allen Kalpin's article is exactly what its title says “Implementing Mindfulness in Experiential Dynamic Therapy with a Depressed Patient.”

Allen Kalpin gives us insight into his way of helping his patient to become progressively mindful or self-aware of her own thoughts, feelings and behaviors and to reveal and share these with the therapist. But what the author doesn't point out is that his own “mindful attitude” to his patient's problems provided the base as well as the catalyst for beneficial change and growth in his patient.

“Unfinished Serenade” , the title of Geoffrey Sternlieb's article refers to the patient's most intense layers of grief that broke through (in-between some swearing to cease the pain) into his conscious experience when singing his father's favorite song. The patient, whose extensive somatization overlaid actual coronary disease, had entered therapy upon the insistence of his internist. The moment the patient realized his positive feelings towards the therapist, he switched into Spanish and the therapist followed seamlessly. It is a pity that the Ad Hoc Bulletin is only printed because the session that is described by Geoffry Sternlieb is a very moving one.

Our Danish colleagues Merete Boje, Denise Daval Ohayv and Dorrit Yde look back on the post-conference Summer School that last year was held in Tisvilde, Denmark. Just read their enthusiastic report in: “Highlights from the Tisvilde ISTDP Summer School, 27th - 30th of August 2007” and if you look in the Ad Hoc Bulletin's Agenda you will find some 2008 Summer Schools.

Till we read and write again!

Summary
This article describes that during the working alliance with a 58 year old woman it became evident that her diagnosis of a recurrent major depressive disorder should be changed to a bipolar disorder. The reader is given some insight into the therapist's difficulties in helping the patient to accept this diagnosis, and in being honest in her communications with her psychiatrist without toughing out the side effects of her medication. The session that resulted in an end of the patient's denial of the side effects of her medication and her evasiveness in her interactions with the psychiatrist and the psychotherapist is transcribed.

Summary
This article illustrates the author's use of the concept of mindfulness in EDT. Vignettes of the first and fifth sessions with a depressed patient illustrate how the therapist used this concept to draw the patient's attention to her self-devaluation, her ego-syntonic defenses, and the self-destructive function of these defenses. Both sessions can be understood as contributing to the foundation upon which the therapist created the working alliance with this patient, an alliance which once formed, could then be maintained throughout the whole therapy process.

Summary
The author presents select portions of an initial ISTDP session with a highly resistant patient, who only entered treatment at the insistence of his internist During a prior psychopharmacological evaluation with the author it became clear that the patient's extensive somatization overlaid actual coronary artery disease and that it had been difficult to the patient to distinguish between his cardiac symptoms, his anxiety pathways and his somatization. The patient had never been in psychotherapy and was unaware of any possible link between his multifocal development trauma and his current symptomatology. During the psychopharmacological evaluation of the previous week an early conscious and unconscious working alliance with the patient was established and the patient made the decision to enter psychotherapy with the therapist. During this first ISTDP session, a rise in the patient's positive feelings towards the therapist triggered a switch into Spanish, his native language. The remainder of the session, leading to a major breakthrough of the patient's Impulse and feelings, was conducted entirely in Spanish, the language of the patient's childhood.

Once upon a time a queen and three knights of ISTDP decided to gather a group of people in Denmark for a Summer School out in the country by the sea. They found a beautiful old house surrounded by apple trees and flowers with delicious food and some old beds. The weather was windy, sunny, and rainy just as were the feelings of the group members as they immersed themselves into the content of the workshop.

The group members came from different countries - Italy, USA, Canada, The Netherlands and Denmark - all eager to experience the art of ISTDP.

Dear colleagues,

Now that Summer is almost meeting Autumn we have time to reappraise our ways of spending our (always too short) summer holidays. Many amongst us took the opportunity to further their process of learning ISTDP by participating in a Summer School, or by reading some textbooks and/or articles.

To be honest: becoming a skilled and effective psychotherapist is a lifelong process that requires honesty and endurance. It is not only that we must be willing to study (and enjoy) our successes , we also must be ready to (sadly) assess our failures. We must be willing to study and understand theory. Study, understand and practice technique. And - very important - we must be very alert to keep on experiencing each and every patient a new and unique stranger. We must take care not to fall into the trap of misusing our experience, where we tell ourselves that we have seen these problems over and over again. This might lead to the danger of doing diagnosis and therapy interventions too automatically, to the danger of forgetting that we need new and fresh eyes to do justice to our patients, to stay sensitive to their painful feelings, their suffering. We must be willing to assess our counter transference reactions, to increase our own introspective capacities in order to unmask our own maladaptive interventions as maladaptive defenses and to go for our own underlying painful impulses and feelings.

The setting of psychotherapy is such that it is all about the patient's destructive and constructive processes, about the patient's needs, successes, failures, painful and happy feelings. And -of course- in these therapeutic encounters the needs and feelings of the psychotherapist are not the issue of mutual scrutiny. Therefore, for the therapist, psychotherapy can be a lonely enterprise. Because of the patient's privacy the therapist cannot share his therapeutical experiences with friends or family. And thus psychotherapists need colleagues for sharing experiences, exchange opinions or need elder colleagues for help and answering theoretical and technical questions. And what about the importance of having a good laugh with the colleagues ? Luckily there are Summer Schools! Luckily there are text books!

In this September issue of the Ad Hoc you will find Nancy Reder's review of the Summer School that was organized by the Washington School of Psychiatry and the review that was written by Monica Urru and Agnese Frau of the Dutch VKDP's Summer School. Esther Rosen-Bernay has read for you the book of our Swiss colleague Paul Troendle on ISTDP. May these reviews stimulate you to keep being motivated for continuous education.

The contributions of Kees Cornelissen, Robert Neborsky and Emanuel Peluso could also be witnessed by those colleagues, who attended one of the Summer Schools or the “Maastricht presentation” of Robert Neborsky.

“Making the Difference Apparent”, the article of Kees L.M. Cornelissen, SocD, focuses on the assessment of high and mild superego pathology.

Vignettes of two different patients are presented to highlight these differences. Both patients were in the residential ISTDP program of the “Viersprong”, all vignettes are from the initial interview that took place in the first week after admission.

“Understanding and Overcoming Double Projective Identification in ISTDP - Part I” is written by Robert J. Neborsky, MD and Emanuel Peluso, MFT .

In this article the initial interview of an illustrative case is presented wherein the mechanism of projection, projective identification and double projective identification is central to the origin and maintenance of the patient's symptoms. The authors emphasize how the techniques of affective experiencing in ISTDP and Attachment Based Interventions help the patient free himself from the cycle of projection and projective identification.

Till we read and write again !

Josette ten Have-de Labije

Summary
This article focuses on making the difference apparent between high and mild superego pathology. Demonstrating these differences might be helpful for therapists diagnosing and evaluating superego pathology.

Vignettes of two different patients are presented to highlight these differences. Both patients were in the residential ISTDP program of the “Viersprong”, all vignettes are from the initial interview that took place in the first week after admission.

Summary
In this article the authors describe the mechanism of projection and projective identification as described by Davanloo and others. An initial interview of an illustrative case is presented wherein the mechanism of projection, projective identification and double projective identification is central to the origin and maintenance of the patient's symptoms. The authors emphasize how the techniques of affective experiencing in ISTDP and Attachment Based Interventions help the patient free himself from the cycle of projection and projective identification. The authors demonstrate how to prevent it or deal with it as it occurs.

(Part II, to be published later will address the working through phase of the therapy).

Summary
The Washington School of Psychiatry hosted its third annual ISTDP Summer School at Graves Mountain Lodge, nestled in the Shenandoah Mountains of Syria, Virginia June 8 through 13. Jon Frederickson, MSW, Allen Kalpin, MD and Robert Neborsky, MD taught a wonderfully eager and collegial group of 30 students from three continents and seven countries. The teachers brought their expertise to bear upon the topic, “Addressing Superego Pathology in ISTDP.” They elucidated with lecture and videotape conceptual and technical aspects of this crucial part of defense restructuring.

Summary
The enchanting scenery of the Tuscany landscape was the theatre of the VKDP Summer School 2008, where again the theme was the everlasting fight between the darkest forces of the punitive Superego and the light of the therapeutic alliance.

Honoring Dante Alighieri's poem “la Divina Commedia” the inspiring theme was the Ninth Circle of Inferno.

Here Dante (symbol of mankind) and Virgil (symbol of reason) are confronted with the representatives of the most wicked crime: the group of ultimate traitors, who have betrayed people with whom they had very special relationships.

Summary
Anything you ever wanted to know about ISTDP, - “Intensive Short Term Dynamic Psychotherapy” – the “ins and outs” of this fascinating psychotherapeutic treatment approach, you find it in this very comprehensive book. It is published by Psychosozial Verlag (ISBN-10: 3898064794) and it is written in German. Our Swiss colleague, Paul Troendle provides a rich foundation of philosophical thought and scientific findings from areas such as anthropology, Freud's psychoanalysis, developmental psychology as well as neurosciences which he sees Habib Davanloo's work to be based on. Troendle's vast and detailed knowledge of the classical as well as the contemporary psychoanalytic thinking provides a strong context in which he presents us with the ideas of Habib Davanloo, the founding theorist and clinician of ISTDP. His rendition of theory and technique of this captivating paradigm of psychotherapy is precise, rich and clear. Yet at once this book carries the potential of leading the reader into a morass of factoids where she might lose sight of the forest for the trees.

Dear colleagues,

As our brains and minds are continuously interacting with each other, they are mutually influencing and modifying each other's structures and processes. A change of interaction patterns of our mind will influence change of brain activity patterns and vice versa.

Today, science and technology are still limited in their ability to detect the activity patterns within and in-between the different regions of our brain. More specifically, notwithstanding developments in brain research and technology, we are still limited to detect the precise meaning of 1) these activity patterns, 2) the changes in these patterns, 3) their function and 4) their influence on the structures and processes of our minds. And in reverse we don't have yet precise insight in how the structures and processes of our mind influence these specific brain activity patterns.

As human beings, while in continuous interaction with our environment, we are able to represent the outer world symbolically in our minds by means of verbal and non-verbal symbols, concepts and we are able to communicate these concepts and ideas to ourselves and others.

Thus as perceiver we are not only a simple receptor of a series of stimuli but at the same time we create our own inner and outer world by means of the above-mentioned verbal and non-verbal symbols and concepts, and therewith we influence how and what we will communicate to ourselves and to others.

What we call consciousness is the “that, when and how of what exactly” we are aware of ourselves as perceiving, thinking, experiencing, acting individuals. What we call unconsciousness is the “that, when and how of all what” we are not aware of ourselves but what is nevertheless influencing at each time the outcome of our consciousness.

Thus the unconscious is Terra Incognita to our conscious. To the conscious the continuous flow of interacting processes within and in-between the structures of the unconscious and in-between unconscious and conscious are Secret and Unknown.

However, isn't it fascinating to realize ourselves that within the domain of the unconscious itself there are no secrets!!. The different structures of our unconscious have no secrets to each other and on top of that to the unconscious the conscious is Terra Cognita.

This is what we have learned from wise men and women in e.g. the field of psychology, psychotherapy (psychoanalysis, behavior therapy, cognitive therapy, ISTDP etc), psychophysiology, brain research as well as from our patients. Our patients, who have come to us as the prisoner of their unconscious while punishing and defeating themselves. These are our patients that come to us with superego pathology. These are our patients who, while craving for freedom ask for our help in exploring and understanding Terra Incognita. Asking for our help in liberating themselves from the Secrets of Terra Incognita. The Secrets of Terra Incognita that constitute their prison. And if and when the therapist succeeds in establishing a working alliance with the constructive conscious and unconscious parts of the patient then together they will actually unlock his prison. Unlock his unconscious and in the current both patient and therapist will see through the eyes of the child that the patient once was. In the current the aggressor(s) of the past are seen and experienced again, the harm and pain are seen and experienced again and the reactive rage, guilt, grief and love are seen and experienced again. And both patient and therapist understand that the unconscious does not make a difference between murder, guilt, grief and prison in the external reality and that of the inner experience.

And in the current the therapist and patient suddenly understand that all of his life, the different structures of the patient's unconscious mind knew that murder had been committed and therefore Justice had to be done and therefore the verdict had to be a life sentence, in order to protect the outer world from repetitive murder. And as the patient and therapist come to experience and understand what was well-known to the unconscious but not to their conscious, and as the patient comes to forgive himself his reactive internal murders, the patient's lifelong sentence will be changed into amnesty. And going this process, in the patient's mind the interaction patterns of the patient's conscious and unconscious structures have been modified to more constructive patterns. In turn these modified activity patterns of the mind will influence the flow of activity patterns of the patient's brain in a constructive way.

This December 2008 issue of the Ad Hoc Bulletin is all about unlocking, assessment, unveiling of Secrets. This issue is all about assessment of a patient's superego pathology, assessment of his ego adaptive capacity, assessment of core neurotic structure and complex transference feelings. It is about assessment of the conscious and unconscious structures of the mind and conscious and unconscious interaction patterns between present and past external and inner world, about unlocking the patient's unconscious and modifying structures and processes, about experiencing reactive murder, fused with guilt, grief and love, and about forgiveness.

The reader will undoubtedly notice how Jon Frederickson's excellent work with a drug addicted patient had become the turning point on the patient's road to forgiveness of her own internal murderous crimes, some of which she also had partly acted out via her defenses.

The article of Josette ten Have-de Labije describes the subsequent steps on the road to a patient's unconscious. Like Jon's patient this extremely anxious patient also had a very low ego adaptive capacity and an extremely high superego pathology.

The editors of the Ad Hoc Bulletin wish you and your dear ones a good health and many open and constructive interactions with family members, friends, colleagues and pets. We wish you and your patients many successful travels to Terra Incognita!

Till we read and write again !

Josette ten Have-de Labije

Summary
The following case illustrates the importance of separating the ego and superego in the establishment of a working alliance with a drug addicted patient. During this process the patient's ego adaptive capacity was assessed, restructured and mobilized in such a way that it became possible to the patient to experience her unlocked impulses and feelings. The session, described in this article, proved to be the turning point in the patient's struggle to overcome her severe problems.

Summary
An incorrect assessment of nature and degree of a patient's superego pathology, nature and degree of his ego adaptive capacity and of his anxiety regulation are often at the basis of a non-successful therapy. This article focuses on the subsequent steps to establish a conscious/unconscious working alliance with a patient, who was heavily identified with her pathological superego, had a very low ego adaptive capacity and an extremely high and generalized anxiety.

Dear colleagues,

The global bad economic situation will surely continue to have a negative impact on the provision of governmental and insurance benefits for psychotherapeutic treatment. Refusal to authorize payment or reimbursement for medium and long-term psychotherapy will increase and even the cost of short term psychotherapy may also influence the decision to set limits to the number of sessions to be reimbursed/paid for. However , psychotherapy is not of a fixed and predetermined duration. Any given psychotherapy is as long or as short as it takes until the patient's psychological health is markedly improved (or - this is also reality - until the patient drops out). And to the editors' knowledge there is no evidence of abuse of therapy duration by either patient-consumer or therapist-provider.

We - mental health professionals - think psychotherapy works. However our purported efficacy and efficiency has been regularly criticized for not having been scientifically documented. So two questions have been raised: “Is any one therapy school better than another ?” and “How well or how bad is the therapy working for the patient ?”

The main focus of “efficacy” studies has been the demonstration of the usefulness of specific psychotherapy schools or of specific packages of techniques for specific patient's disorders. On the other hand “efficiency” studies concentrate on exactly how well or how bad a specific therapy works. There may not be an answer to the question whether one therapy school produces better or worse results than another. This is amongst others due to the fact that the different therapy schools share an emphasis on common curative ingredients as e.g. the emphasis on the quality of the relationship between therapist and patient. A patient does not care if therapy school X does better or worse than therapy school Y. Effective and high quality psychotherapy needs to be tailored to the problems and needs of the patient. Patients will assess the effectiveness and the efficiency of their psychotherapy going the process, as it is actually performed and on the basis of their particular therapy results. The outcome of any given therapy is multiple determined. Are the specific techniques that are devised to target specific aspects of problems really effective? What is the influence of intermediate results on subsequent changes of the interrelations of the patient's problems? Is the therapist really skillful enough to assess when and how to use the particular technique? Does the therapist really understand underlying theory? Learning to become a competent and wise psychotherapist is a challenging and ongoing task that takes time, effort, frustration and hard work. But it also takes high quality education and training to meet the therapist's needs. It takes high quality supervisors and trainers. It takes high quality supervision and perhaps more emphasis on supervision-on-the-job (as e.g. live supervision in a closed-circuit TV-setting)?

Let us please not forget that providing funds for a high quality of education of mental healthcare therapists would not only facilitate high quality psychotherapists offering high quality psychotherapy but would also influence a reduction of mental health care cost.

Allan Abbass,MD; Michel Joffres, MD and John Ogrodniczuk, PhD open this April 2009 issue of the Ad Hoc Bulletin: ISTDP trials of therapy: qualitative description and comparison to standard intake assessment. Already in an earlier study Allan Abbass et al showed that doing an Initial Interview (or trial therapy) along Davanloo's lines effectuated symptom reduction in a range of patients. But would one see similar effects when a standard intake interview would have been done?

The Trial Therapy showed consistent benefits on the Brief Symptom Inventory where the standard Intake model showed less such changes. Although further research is needed the authors concluded that their study advances the testing of the hypothesis that the ISTDP trial therapy is superior to traditional intake assessment.

Determining the optimal treatment approach for a patient is often a difficult task. Variables as the competence or e.g. the personality of individual therapists have also to be considered significant factors in therapy outcome. Variables as the competence of psychotherapists to establish a working alliance with their patients or e.g. the competence of helping the patient to experience painful feelings. Anyway, ISTDP and IEDP psychotherapists agree that the effectiveness and efficiency of psychotherapy depends to a large extent on the quality of the working relationship of patient and therapist and thus on the abilities of the therapist to establish such a relationship with his patient.

Ferruccio Osimo, MD, our Italian colleague has developed his therapeutic approach (Intensive Experiential Dynamic Psychotherapy((IE-DP)) on the basis of Davanloo's ISTDP. Those who have seen his work know that Ferruccio Osimo regards the personal relationship between therapist and patient and the conscious physical experience of emotions as crucial curative ingredients. The title of Osimo's article “Character Hologram” refers to his technique of helping the patient to undo his identification with his pathological superego. His transcript illustrates the use of the “character hologram” in the initial phase of IE-DP with an axis II and I disordered patient, taken on for IE-DP within the Italian National Health Service.

All of our patients that come for help have lost a healthy and constructive capacity to deal with their emotions. One of the aims of each ISTDP therapist will be to help a patient to experience emotions in a constructive way and to change an unhealthy regulation of emotions into a healthy one. A failure to come to an optimal conscious and unconscious working alliance that is such a prerequisite for helping a patient to put an end to his unhealthy emotion regulation, is often due to the therapist's inadequate understanding of the precise role of defenses in the emotion regulatory process.

Josette ten Have-de Labije, PsyD is the third and last author of this April 2009 issue. The article is titled: Helping our patients to experience feelings: understanding the role of defenses in emotion regulation and the implication for ISTDP practitioners - Part I.

Till we read and write again !

Josette ten Have-de Labije

Summary
Objective: To compare Intensive Short-Term Dynamic Psychotherapy (ISTDP) trial therapy consultations to standard intake interviews.

Design: Non-randomized clinical trial design.

Methods: Thirty sequential ISTDP trial therapies were compared to 20 traditional intake assessment interviews using blind ratings of videotape samples. Brief Symptom Inventory and Inventory of Interpersonal Problems scores were compared pre and post interview. Need for follow-up treatment, medication use and work functioning were also compared between groups.

Results: Trial therapies were clearly distinguishable from standard intake assessments. The trial therapy resulted in statistically significant improvements on all BSI subscales. In the follow-up interview, one third (10) of individuals in the trial therapy group required no further treatment, 7 were able to stop 11 psychotropic medications, and 2 were able to return to work.

Conclusions: ISTDP trial therapy appears to be a distinct therapeutic assessment procedure that results in superior benefits compared to traditional intake assessments. Confirmation of these findings will require a randomized trial.

Key words : consultation, short-term, psychodynamic, psychotherapy

Summary
Defenses may block a patient's healthy experiencing and/or expression of emotions at various stages in the emotion regulatory processes. After focusing on the emotion regulatory processes, the author elaborates on the role defenses have in these regulatory processes and at what level they are put into operation.

Summary
In this article the author describes Intensive Experiential-Dynamic Psychotherapy (IE-DP), a therapeutic approach mostly originating from Davanloo's ISTDP. IE-DP regards the personal relationship between therapist and patient and the physical experience of conflicting emotions as the basis of therapeutic change. Various aspects of IE-DP are touched upon and a new one, the character hologram, is introduced and specifically addressed here. The transcript illustrates the use of the character hologram in the initial phase of IE-DP with an axis II and I disordered patient, taken on for IE-DP within the Italian National Health Service. The rest of this therapy from session 2 to session 26 is summarized and the clinical picture of the patient at 6-month follow-up is described.

This August 2009 issue of the Ad Hoc Bulletin is - in so many words - all about similarities and differences between some Short-Term Dynamic Psychotherapy schools (and therapists).

Our colleagues Leigh McCullough, PhD and Nat Kuhn, MD open with “The Varieties of STDP Experience: Taking Our Theories Lightly”. They compare Leigh McCullough's Affect Phobia Therapy with their view on “the current version of Davanloo's ISTDP”. The focus is on similarities and differences in handling of defenses, anxieties and emotions.

The second article is Allen Kalpin's (MD): “Mindfulness, Experiential Dynamic Therapy, and a Case

of Somatization Disorder”. Our colleague first focuses on the concept of mindfulness, then he gives a thorough overview of brain research on mindfulness and in the remainder of his article Allen Kalpin illustrates his particular use of the concept of mindfulness to enhance the psychotherapeutic process with a patient, who amongst others, suffered from a somatization disorder.

José Verpoort, MD allows us to witness how she and her patient travel together “In Search of the Ego to End the Supremacy of the Superego.” The patient had been in the residential ISTDP program of the Viersprong (Crossroads), Halsteren, The Netherlands.

Most of us will undoubtedly agree with Leigh McCullough and Nat Kuhn that we are all comrades-in-arms trying to heal our patients on the deepest levels. Where techniques and theories differ - so they conclude - ongoing research may clarify some points of difference.

In the editors view, the issue of differences and similarities between the different psychotherapy schools within the IEDTA (International Experiential Dynamic Therapy Association) gives rise to the following four questions: 1) Which ingredients are supposed to make that particular school of psychotherapy effective? 2) Which of these effective ingredients are unique for that particular psychotherapy school? 3) Which are the common effective ingredients that are used in all schools within the IEDTA? and 4) To what degree are the competence, level of experience and personal qualities of the psychotherapist distinctive for the effectiveness of that a) therapy-school-unique-effective ingredient and/or b) common effective ingredient?

Isn't it so that irrespectively of theoretical orientation and irrespectively of psychotherapy school it is always the therapist that “delivers” the ingredients or the interventions to the patient. If a therapist is not competent in that particular method or if the therapist's personal problems prevent him/her from adequately applying the method, then no therapy will work. Irrespectively of theoretical orientation and psychotherapy school it is always the therapist, who has to establish a working alliance with his/her patient. Irrespectively of theoretical orientation it is always the therapist , who has to assess which of the patient variables obstruct such an establishment and it is always the therapist , who has to reinforce the patient to become aware of these particular variables and to understand their defeating function. It is always the therapist, who has to help the patient to become aware of his/her therapeutic task in the common enterprise of dealing with the patient's problems and going for overcoming them.

The psychotherapist's road to competence and to overcome his/her own unhealthy intrapsychic processes is lifelong and sometimes very frustrating. Only willingness to look critically at oneself, to admit mistakes, both in a loving and honest way can help us to become competent. And in order to do so we need colleagues, we need each other!

Till we read and write again,

Josette ten Have-de Labije

Summary
This article compares two therapy models that have evolved from the pioneering work in Short Term Dynamic Psychotherapy, particularly that of David Malan and Habib Davanloo: McCullough's Affect Phobia Therapy (APT) and Davanloo's Intensive Short Term Dynamic Psychotherapy (ISTDP). These two models represent some of the major variations in STDP regarding the handling of defenses and feelings. After noting the large areas of similarity between these closely-related therapies, we explore five particular areas of differences: (1) conceptualization of the unconscious, (2) working with defenses, (3) management of anxiety, (4) the role of guilt and shame, and (5) the role of anger/rage in the transference. Finally, we examine factors that might influence how easy it is to disseminate these therapies. This diversity within these two models gives us an opportunity to learn from one another and can help us discover which aspects of various therapeutic approaches contribute to making therapy as effective and brief as possible.

Summary
There is much controversy in the scientific literature regarding the etiology of cases of multiple chemical sensitivity and atypical food allergy. It is believed by some clinicians that many such cases are examples of Somatization Disorder. Cases of complex Somatization Disorder are notoriously difficult to treat. In this article the author will use detailed case transcript to illustrate the first stage of treatment of one such patient using techniques of Experiential Dynamic Therapy, enhanced by selected use of a focus on mindfulness.

Summary
When a patient with high superego pathology enters psychotherapy, it is important that the therapist realizes that it is specifically this dictate of the sadistic superego to the patient's ego part which will prevent the patient from being successful. In this article the author describes the therapy process with a patient , who had a very sadistic and powerful superego, which almost suffocated the patient's ego part. The transcript illustrates how the patient and the therapist cooperate to separate ego and superego, to establish a conscious and unconscious working alliance, to restructure the ego adaptive capacity before unlocking the patient's unconscious. The transcript also illustrates where patient and therapist were stuck because superego manifestations were overlooked or underestimated.

Dear colleagues,

Questions give rise to answers (– some satisfactory, some disappointing) give rise to new questions to new answers and so on, and so on. Inability of the several therapeutic approaches to help our patients effectively in overcoming their problems is a source of dissatisfaction that compels mental health workers and researchers to revise theory, goal, and technique. In this way, luckily, clinical psychology and clinical practice as a discipline is still growing. In this way. (luckily ??) through the development of new knowledge, new findings, new technology the therapist is confronted with the everlasting need for continuous education. At this moment thanks to new technology as e.g. functional magnetic resonance imaging (fMRI) of brain activity there is an explosion of knowledge related to e.g. specific tasks or sensory processes. And it is such an interesting field! And it raises so many new questions! And answers! And new research! And new implications for method and techniques of psychotherapy! How much do we still have to absorb, assimilate ? Is there some point at which we therapists say “enough is enough” ?

Not so Monica Urru, MD, PhD and Agnese Frau, PhD, our two enthusiastic Italian colleagues! The Los Angeles conference (October 25-26, 2009) “Treating the difficult patient using attachment-based ISTDP to overcome resistance” inspired them to understand their patients at a deeper level, to implement what they had learned and … very important … to review the conference for us. Bravissima !

Robert J. Neborsky, MD and Emanuel Peluso, MFT, give their view on how to help the patient to quit his defense of projective identification. We are sure that reading their article and reading the transcript of “The man with the ghost in the basement and in the nursery” will give you courage to establish a conscious and unconscious working alliance and to help your patient saying goodbye to his whole repertoire of regressive defenses, including that of projective identification.

Electro-convulsive therapy (ECT) was originally developed in the 1920s and was used widely during the 1950s and 1960s for a variety of conditions. This editor – obviously – mistakenly believed that nowadays ECT was not used anymore. This editor mistakenly believed that it wasn't used anymore because the hypothesis that ECT would be curative for severe depression and schizophrenia by altering neurotransmitters (e.g. serotonin), endorphins and adrenalin had never been proved. This editor was and is wrong because ECT is still being practiced!

Thanks to Allan A. Abbass MD, FRCPC and Ravinder Bains, MD, FRCPC, their article “ISTDP and electro-convulsive therapy” and the internet this editor has learned that ECT is used for patients, suffering from severe depression accompanied by psychosis, suicidal intent, refusal to eat. For patients, whose mania did not improve with medication. For schizophrenic patients when their symptoms are severe or medication is not sufficient.

Thanks to the internet this editor learned that ECT treatments are usually done 2 to 3 times a week for 2 to 3 weeks. Maintenance treatments may be done once a week, tapering down to once a month. These treatments may continue for several months to a year to reduce the risk of relapse. One would suppose that with the growing effectiveness of psychotherapy ECT would only be thought of as an indication when other treatments like e.g. psychotherapy and/or medication have failed to help.

Thanks to the work of Allan Abbass, Ravinder Bains and their team there is some evidence that ISTDP could be effective in reducing the need for ECT. Therefore an ISTDP Initial Interview is warranted prior to considering ECT . We agree with Allan Abbass and Ravinder Bains that the ideas, stated in their article need more research . Also only describing a therapy process does not give us that objective information which would have been supplied by a plain transcript. A transcript of the subsequent steps (and their effects on the patient variables) in the therapy process during the Initial Interview would have been our preference. It may be evident that we invite Allan Abbass and Ravinder Bains.to keep us posted on their research. And of course ... next time: we want your transcript, transcript, transcript!

This is the last issue of 2009, although it appears in 2010. We take the opportunity to wish you all good physical and mental health for the coming year.

Till we read and write again !

Josette ten Have-de Labije

Summary
Monica Urru and Agnese Frau review the conference (Los Angeles, USA, October 24, 25, 2009).

Summary
This is part two of a two-part article on projective identification. The authors discuss the mechanism of projective identification and its role in creating, maintaining and sustaining character pathology.

Summary
In this article, we review Intensive Short-Term Dynamic Psychotherapy (ISTDP) as an alternative to electroconvulsive therapy (ECT) or as treatment for patients not responding to ECT. Based on our clinical observations, we conclude that ISTDP can be used as a preventive treatment in selected patients. Furthermore, failure to respond to ECT may suggest that psychotherapeutic issues are prominent and predict response to ISTDP. We conclude with clinical and research recommendations.