1 STDP Workshop - Leigh McCullough Ph.D. Restructuring the Sense of Self by Building Self Compassion Leigh McCullough Ph.D. Associate Clinical Professor, Harvard Medical School Slides from the IEDTA Conference (International Experiential Dynamic Therapy Association UCLA, Los Angeles, CA., September 2005The point of this lecture was to demonstrate that compassion canbe dealt with similarly to grief and anger in Short Term Dynamic Psychotherapy; i.e., patients who are self attacking or self destructive need to be desensitized to positive feeling for self by exposure to feelings of care, concern, compassion for self and by the prevention of defensive and inhibitory responses. This approach is presented in detail in the following books (on the next two slides) and the website,Steinbeck appears to have been a soulmate of those of us doing this very challenging affect focused therapy.STDP Workshop - Leigh McCullough Ph.D.
2 Short Term Dynamic Psychotherapy STDP Short Term Anxiety-Regulating Psychotherapyfor Restructuring Defenses, Affects and AttachmentsBasic Books, 1997To Order:The priinciples taught in this workshop are drawn from Changing Character and our next book…..
3 Treating Affect Phobias: A Manual for Short Term Dynamic Psychotherapy Each chapter presents:1) Basic concepts of STDP, and2) Exercises for reader practiceTo order: 800 –Much of the material shown in this workshop are described in Treating Affect Phobia and Changing CharacterSTDP Workshop - Leigh McCullough Ph.D.
4 STDP Workshop - Leigh McCullough Ph.D. Go to our Website:For information on our Training Programs in in the Boston Area(Details to be posted in the Fall of 2005)sSTDP Workshop - Leigh McCullough Ph.D.
5 STDP Workshop - Leigh McCullough Ph.D. COMPASSIONSynonyms: Sympathy, empathy, pity,concern, kindness, consideration, caresofthearted, tenderheartedAntonyms: Hardhearted, stoneyhearted,callous, insensitive, pitilessLooking up antonyms for compassion was illuminating. ‘Hardhearted’ led me to add ‘softhearted’, and ‘tenderhearted’ to the synonym list…and those words seem a good representation of the feeling we are trying to achieve in compassionate action.STDP Workshop - Leigh McCullough Ph.D.
6 Thoughts on Compassion Compassion is the antitoxin of the soul:where there is compassioneven the most poisonous impulsesremain relatively harmless.Eric HofferU.S. PhilosopherIt occurs to me that if murderous rage can be held toward someone at the same time that one holds compassion for that person, then the positive component of the rage (e.g., setting right a wrong; ensuring limits) would be more likely to be enacted in a wise and humane way.STDP Workshop - Leigh McCullough Ph.D.
7 The Triangle of Conflict David Malan DEFENSESBehaviors, Thoughts,and FeelingsINHIBITION Anxiety, Guilt, Shame, Emotional PainACTIVATING FEELINGSAdaptive forms of grief, anger, closeness,And...POSITIVE FEELINGS FOR SELF ( Interest/excitement, Enjoyment-joy)The emotional bases of self-care, concern, compassion, pride, and esteemPositive feelings for self operate similarly to grief anger on the Triangle of Conflict: e.g., defenses and anxieties block the inner experience and outward expression of all of these activating feelings.STDP Workshop - Leigh McCullough Ph.D.
8 Compassion and its’ Blocks on the Triangle of Conflict DEFENSESSelf Attack,Self-HateLow Self EsteemANXIETY/ CONFLICTI am afraid to be too big.I am ashamed to feel proud.It is too painful to feel good about myself.These defenses and anxieties are typical mechanisms that block a healthy sense of self compassion..or of positive feelings for the self in general, as noted above.ADAPTIVE FEELINGJOY OR INTEREST IN SELFSelf Compassion, Self Care, Self Esteem, Pride,Self Confidence, Self Worth, Self Respect, Trust in SelfSTDP Workshop - Leigh McCullough Ph.D.
9 Desensitization of Affect Phobias in STDP INHIBITORY AFFECTSSHAME, Guilt, PainDEFENSIVE AFFECTSSelf HateRESPONSE PREVENTIONInterventions that achieve desensitization; e.g., exposure and response prevention are drawn from learning theory, but are mechanisms that can be observed to be operative in the working through of psychodynamic conflict…as described here on the Triangle of Conflict. Preliminary research is lending support to the efficacy of these mechanisms in STDP.ACTIVATING AFFECTSEXPOSUREPositive Self Feeling, Self Interest, Self Care, Self CompassionSTDP Workshop - Leigh McCullough Ph.D.
10 A Bit of Exposure from Grapes of Wrath Steinbeck, Chapter 6 Muley Graves: (After talking about wanting to kill the people whothrew his family off their land;)“Fella should maybe keep stuff like that in his head.”Casey (Former Preacher): “Yes, you should talk,” he said.“Sometimes a sad man can talk the sadness right outthrough his mouth.Sometimes a killin’ man can talk the murder right out of his mouthan’ not do no murder.You done right. Don’t you kill nobody if you can help it.”This is the more detailed quote from Steinbeck, when the Preacher exposed and normalized Muley Graves experience of violent feelings….but not endorsing the expression of those feelings.STDP Workshop - Leigh McCullough Ph.D.
11 Triangle of Person David Malan Identify the Adaptive and Maladaptive Relationships at each poleExposure to care & concern (or lack thereof) from each person;CHANGING PERSPECTIVES ON THE SELFCURRENT PERSONS (Spouse, boss, friends, etc.)THERAPISTSome interventions that are very useful for restructuring the sense of self are noted above: Identify defenses, and expose the patient to care, compassion and concern for the self. Interventions such as changing perspectives and distinguishing the origin versus the maintenance of the defenses are used again and again to achieve these goals. They are described in detail in Changing Character and Treating Affect Phobia.ORIGIN VERSUSMAINTENANCEOF DESTRUCTIVEDEFENSESPAST PERSONS(Family of Origin, Lost Loves,Teachers, Friends )STDP Workshop - Leigh McCullough Ph.D.
12 Interventions to Restructure the Sense of Self Insight: Identify the self attacking defensesMotivation to change the self attackOrigin versus Maintenance of Defenses(You didn’t cause the problem, but you have to resolve it.)Exposure & DESENSITIZATION to compassion/care by:Changing Perspectives- THERAPIST (How do I feel about you?/Shared feeling.)- others (What do they feel for you?)- self (How do you feel about yourself?)Expression of Compassion: The ability to treat self with compassion and care outside the sessionFor more detailed discussions of these interventions see Changing Character and Treating Affect PhobiaSTDP Workshop - Leigh McCullough Ph.D.
13 Theory in Restructuring the Self Retranscribing the Memory TraceChanging patients’ world view about the self …or ”Self View”Building new neuronal networksSTDP Workshop - Leigh McCullough Ph.D.
14 STDP Workshop - Leigh McCullough Ph.D. CaveatsThere are inevitable problems that arise when you work with positive feelings.What might those be?STDP Workshop - Leigh McCullough Ph.D.
15 STDP Workshop - Leigh McCullough Ph.D. Problems(More frequently occurring as GAF becomes lower, especially. under 50)Sexual feelings that arise with closeness(Need exposure and desensitization when conflicted, but take care not to let sexual feelings act as defenses to closeness with the therapist.Fear of boundaries being violated(There are clear boundaries here, remember that we imagine murderous feelings, but no one actually is murdered.)Over-idealizing the therapist(Sometimes a necessary phase with more regressed patients, but eventually the therapist must been seen as fully human.)Never wanting to leave therapy(We need to set you free…Can you take me with you?…Can you take these feelings with you? Generalize to caring feelings of others.)…..OTHER EXAMPLES?The more we work with positive feelings between the patient and therapist, the more we need to be mindful of such problems as noted above, and skilled in handling them.STDP Workshop - Leigh McCullough Ph.D.
16 SELECTING TREATMENT FOR PATIENTS BASED ON LEVEL OF FUNCTIONING More Expressive treatmentGAF100Short term Restructuring of FeelingsShort Term Restructuring of Defenses75Build defenses Cognitive Rx Supportive Rx Restructuring self/others50Build supports, Inpatient CareDifferent levels of the Global Assessment of Functioning Scale suggest different forms of treatment as outlined above. For patients with GAF scores below 50, Self Restructuring is virtually always necessary. But more and more I am realizing that some degree of impairment in the sense of self occurs in most patients, and thus the Restructuring of the Sense of Self may always need to be address to a greater or lesser degree. ( These are rules of thumb to guide us, but not laws of nature.)25More Supportive treatmentSTDP Workshop - Leigh McCullough Ph.D.
17 Some Old Things & Some New Things COMPASSION follows the same principles as other affects, (e.g.,desensitization)but has some different mechanisms.There seem to be no “breakthroughs” to compassion as with grief or anger.One builds, or develops this capacity incrementally.There can be no full sense of compassion without comparable acceptance of grief and rage.I am not certain about there being no breakthroughs to compassion, that is just a current observation.STDP Workshop - Leigh McCullough Ph.D.
18 Global Functioning, Affective Competence, and underlying Ego Strength Patient Adm GAF 1st Grief 1st Anger GAFSESSION SESSIONLesser Twin TBACaged Man 55 ~ TBASpiritual Chemist ~ (FU) 89Grandmother ~ 75Tortured StudentLady Cloaked in FogIn comparing some recent cases I noted that the higher the GAF score, the more rapidly I was able to reach grief about destructive patterns begun in childhood.STDP Workshop - Leigh McCullough Ph.D.
19 Are There Stages in Achieving Compassion? Denial and AngerBargainingAcceptanceAs I noted my own struggle to reach a compassionate stance with some more difficult patients, I noted working through these stages within myself. I was intrigued to find them similar to the often cited stages of death and dying.STDP Workshop - Leigh McCullough Ph.D.
20 STDP Workshop - Leigh McCullough Ph.D. The Spiritual Chemist37 year old divorced female; fired from job as a lab technician, estranged from sonCame to Rx for help during divorceInitial GAF: Current GAF: 89 (7 year follow-up)Sense of Self: “An amino acid with legs”Session 3: Exposure to closeness with and acceptance from me.This case was shown in LA. Session 3: exposure to closeness to me, shown here growing anxiety to the closeness, but then a gentle breakthrought to the sorrow of not having these feelings in her life.STDP Workshop - Leigh McCullough Ph.D.
21 The Superior Unchanging Grandmother 68 year old married female; 45 years of therapy, and almost as long on anti-depressants.Admission GAF: Current GAF: 75 (2yr F-U)Sense of Self: “There’s something horrible about me.”Sessions 1, 5, 10 and 12Off anti-depressants by Session 11This case was shown at the LA Confernece.STDP Workshop - Leigh McCullough Ph.D.
22 STDP Workshop - Leigh McCullough Ph.D. Goals that I work toward in therapy with my patients, and in my personal life.I think this is the Secret to the Art of Living and to emotional intelligence.If one can respond to life in the above ways, most things in life are manageable, and there does not seem to be much need for therapy.STDP Workshop - Leigh McCullough Ph.D.
23 STDP Workshop - Leigh McCullough Ph.D. IT TAKES COURAGE TO BE KINDIT TAKES COURAGE TO BE… COMPASSIONATE… SOFTHEARTEDAlways good to keep this in mind! Don’t take this for granted!STDP Workshop - Leigh McCullough Ph.D.
24 STDP Workshop - Leigh McCullough Ph.D. When time is limited:Point out self-attacking defensesBuild compassion for selfFind loves that have been lost (people who found them special): ’Whose eyes lit up when they saw you?’’Explore positive feelings in the therapist-patient relationshipUse Socratic dialogue; What do you think I...Feel for you?Want for you?Hope for you?This can save years of time if done in a heartfelt way that the patient is able to resonate to. This would be particularly helpful in inpatient settings where the sense of self is typically so impaired and needs to be worked on before other issues can be brought up. .STDP Workshop - Leigh McCullough Ph.D.
25 Three Treatment Objectives DefenseRestructuringAffectRestructuringSelf/OtherRestructuringDefense Recognition(Can the patient see the self attack?)Giving Up Defenses(Is the patient motivated to give up self attack?)Affect Experiencing(Degree of felt care or compassion for self)Affect Expression(Can the patient treat self compassionately?)Sense of Self(Positive and compassionate?)Sense of Others(Realistic, adaptive?)This is a good overview of the treatment goals that the patient is helped to achieve in STDP.FOCUS:RELATIONSHIP & ANXIETYFOCUS:DEFENSES & ANXIETYFOCUS:FEELINGS & ANXIETYSTDP Workshop - Leigh McCullough Ph.D.