1. LIVES TRANSFORMED The Art and Science of Experiential Dynamic Psychotherapy Stockholm August 2010 Patricia Coughlin, Ph.D.

2. Sullivan If you do not feel equal to the headaches that Psychiatry induces, you are in the wrong business. Skill in psychotherapy consists of doing as much with as little as possible.

3. Scientific Approach 1 – Must have a theoretical basis of understanding human functioning and unconscious processes 2 – develop skills/techniques that clinically effective and 3 - are consonant with theory and supported by empirical research

4. Today’s Program Introduce you to Davanloo’s method of Intensive Short Term Dynamic Psychotherapy: By laying a theoretical foundation Describing the method in detail Acquainting you with the research support Illustrating the method with videotape

5. DAVANLOO’S ISTDP Based on his understanding of psychoanalytic theory of neurosis Developed new techniques designed to accelerate and condense the process by precipitating an intrapsychic crisis, creating an opening into the unconscious Taped sessions and conducted follow to study outcome and bring scientific method to bear

6. PSYCHODYNAMIC PRINCIPLES Based on Freud’s Second Theory of Anxiety: Anxiety is a signal that some threatening feeling or impulse is on the rise. Defenses reduce anxiety and keep threatening feelings out of consciousness BUT Excessive reliance on these defenses causes the symptoms and difficulties the patient wants help with This creates conflict: patient wants help for relief of symptoms but doesn’t want to face feelings they have been avoiding

7. Attachment/Emotion Theory This is an attachment theory Feelings that are thwarted or punished become associated with anxiety and are avoided If there is significant or repeated rupture to the attachment, the child is overwhelmed with pain and reactive rage Rage toward loved one stimulates guilt Guilt drives self punishment and protects loved one

8. BOND With Parents

9. BOND With Parents Trauma

10. BOND With Parents Trauma PAIN Rage, Guilt about the Rage

11. BOND With Parents Trauma PAIN Rage, Guilt about the Rage Feelings avoided Self-destruct Symptoms

12. THE TWO TRIANGLES Triangle of Conflict A= Anxiety D= Defense I/F= Impulse/Feeling Triangle of the Person T= Transference C= Current Figures P= Past Genetic Figures I/F A D P T C

13. Same theory, new technique Only 20% respond to interpretation Developed techniques designed to create/intensify internal conflict Shift from defense and resistance to activation and alliance Experience of avoided feelings is key to unlocking the unconscious De-repressed material makes sense of patient’s suffering Awareness create choice

14. Central Dynamic Sequence Phase I: INQUIRY Phenomenological approach Survey of difficulties/symptoms Get example, usually regarding precipitant Focus on feelings Phase II: DEFENSE WORK Identify and clarify defenses Focus on negative consequences Pressure and challenge Turn the ego against defenses

15. Central Dynamic Sequence Phase III: BREAKTHROUGH OF FEELINGS Rise in complex feelings in C or T Signal from the unconscious that impulse is pre-cs Passing of the impulse with portrait De-repression of memories Obtain relevant history Phase IV: INTERPRETIVE PHASE Cognitive re-analysis of process Make T-C-P links Get consensus and form contract

16. Psychodianostic Procedure 1- Pressure to feelings toward significant other 2 - Monitor anxiety 3 - Block defense Only 3 responses possible Patient’s response to intervention is diagnostic and guides next step Each treatment tailor made

17. Two Forces within Psyche As Davanloo developed techniques to block defense and resistance and got to buried feelings he discovered There is a healing force within the unconscious This is our ally: unconscious therapeutic alliance Work to activate and strengthen healing capacity while blocking defenses that prevent growth and perpetuate suffering

18. Basic Human Feelings Love, fear, anger, sadness/grief, sexual desire Components of Affect 1 - cognitive label 2 - physiological activation 3 - impulse/action tendency

19. CHANNELS OF ANXIETY  STRIATED MUSCLE  SMOOTH MUSCLE  COGNITIVE DISRUPTION

20. FORMAL DEFENSES REPRESSIVE Intellectualization Rationalization Minimization Displacement Reaction formation REGRESSIVE Projection Denial Dissociation Acting out Somatization

21. TACTICAL DEFENSES VERBAL Vague and general Diversification Sarcasm Argumentative Contradictory Rate of speech NON-VERBAL Avoiding eye contact Arms and legs crossed Smiling Laughing Weepiness Temper tantrums

22. RESULTS OF WORKING THROUGH Reduction in anxiety/increased tolerance for conscious experience of anxiety Decreased reliance on defenses Increased emotional activation and expression Enhanced understanding of inner self with coherent life narrative Increasing tolerance for ambivalence and complexity

23. Early Research Efforts Alexander and French David Malan Davanloo Winston and Beth Israel Group Allan Abbass Leigh Mc Cullough & the Norwegians

24. Davanloo Amassed N=1 studies, all recorded on video tape Demonstrated that it is possible to expose core conflicts within first contact The emotional and visceral experience of feelings is key to cure Developed techniques to create an intrapsychic crisis, creating a therapeutic “emergency”, allowing for rapid re-organization of personality Long term follow-up revealing the sustained nature of changes achieved in therapy

25. Empirical Basis of ISTDP 1960-Present: Davanloo’s case studies Controlled Clinical Trials – 60 published studies finding strong evidence for efficacy in broad range of conditions Effective with treatment resistant depressives Effective with personality disorders Effective with somatic patients, movement disorders and fragile patients Huge cost savings to the health care system

26. Empirical Basis of ISTDP II Superior to wait list Superior to medication in long run Clinically effective in real world Cost effective One ISTDP session outperforms standard intake interview

27. ABBASS, 2002 89 consecutively referred patients treated on an average of 15 sessions Average age of 40 25% unemployed and on disability 46% on multiple meds 83% treatment resistant

28. Abbass Results 71% stopped all meds 18 of 22 back to work 17 of 18 off disability insurance Combined savings from prescriptions, disability, hospital and physician costs of $402,523 per year for three years following treatment

29. Process Research Weinberger’s Meta-analysis revealed: 1 – development of strong therapeutic alliance 2 – helping patient confront what they tend to avoid 3 – revival of hope 4 – increased sense of mastery & competence 5 – attribution of success to patient

30. Case Studies Possible for patients to serve as their own controls Lay down criteria for cure following the trial therapy Make predictions about issues to be dealt with and compare those to actual results at end of treatment Follow-up to assess whether changes hold over time

31. Neuroscientific evidence Our brains are wired interpersonally Neurons that fire together, wire together The brain is plastic and changes as the result of experience Psychotherapy changes the brain

32. How to change the brain Establish trust and collaborative alliance Focus, intensity and repetition Induce moderate levels of anxiety, alternate with periods of calm Activate multiple levels of experience:cogntive, emotional, somatic and interpersonal Facilitate profound moments of meeting Create meaning and coherence

33. The most vital element:YOU The person of the therapist is the most potent but understudied variable Top 15% do better than all the rest combined Passionate and enthusiastic Open and flexible/adaptable/approachable Masters at handling relationship Humble, life long learners Pressure themselves and patients to get extraordinary results Reflective - they ARE the change they want to promote

34. Take home message It is possible to become far more effective and efficient Self development Study Practice, Practice, Practice 10,000 hours to become a master