Experiencing Love and Guilt about Rage: the central change agent in Davanloo's ISTDP Allan Abbass MD, FRCPC Professor and Director of Education, Director, Centre for Emotions and Health Dalhousie University, Halifax, Canada allan.abbass@dal.ca www.istdp.ca (c) Dr Allan Abbass

Overview Davanloo’s “new metapsychology of the unconscious” Clarifications of major technical interventions Case example: The Angry Scientist (c) Dr Allan Abbass

“The ISTDP therapist must have the utmost respect for the patient while at the same time no respect for the resistances that have paralyzed his or her functioning” (c) Dr Allan Abbass

“The ISTDP therapist must have the utmost respect for the patient while at the same time no respect for the resistances that have paralyzed his or her functioning” These 2 processes should happen simultaneously: otherwise the process is splitting and can have negative effects (c) Dr Allan Abbass

ISTDP Papers Since 1995 Specific diagnosable patient categories Central focus on the T Specific interventions and timing Specific responses relates to specific therapy events How to identify and use specific unconscious signals Specific techniques for fragile, somatizing and other patients The somatic pathways of rage, guilt and grief The need for continuous positive regard Central role of love and forgiveness (c) Dr Allan Abbass

The evolving Davanloo: 2012 + He still teaches Others teach for him He cites published research Acknowledges, including by letter, contributions of others Is much clearer about technique, how it works and how to teach it. Is clearer about the central role of love, attachment and forgiveness (c) Dr Allan Abbass

Metapsychology of ISTDP Genesis of Psychoneurotic Disorders BOND Trauma PAIN RAGE, GUILT about the Rage Character problems Symptoms (c) Dr Allan Abbass

Spectrum of Psychoneurotic Disorders Spectrum of Patients with Fragile Character Structure Severe/ Borderline Low R Moderate R High R Mild Moderate These are diagnosable and have different treatment pathways (c) Dr Allan Abbass Davanloo, 1995, Abbass 2002

Metapsychology of ISTDP Triangle of Conflict Unconscious Defence Isolation Repression Projection Superego Unconscious Anxiety Striated Muscle Smooth Muscle Cognitive-perceptual Unconscious Feelings Pain, Rage, Guilt, Grief (c) Dr Allan Abbass

Psychodiagnosis  Roadmap Clamp Resistance Unconscious Anxiety Unconscious Defenses Monitor Response Unconscious Feelings Pressure (c) Dr Allan Abbass

3 Categories of major resistance Isolation of Affect Talk about it without somatic experience Repression Shut down emotions unconsciously into the body or depression etc Projection and Projective Identification (c) Dr Allan Abbass

Resistance of the Punitive Superego Davanloo 1988 a and b Manifestations: Repeated/chronic self defeat and self sabotage. Origins: Violent and murderous rage toward loved ones and guilt about this rage. Countless modes of presenting to psychology, medical, social and legal systems IT is protective of others AND self-constrictive and self-punitive (c) Dr Allan Abbass

Complex Transference Feelings (CTF) I Includes positive feelings and irritation toward the therapist which link to past feelings about the bond, trauma, pain, rage and guilt Mobilizing CTF is the engine to the Unconscious Therapeutic Alliance. The essential element of ISTDP is rise in CTF  UTA Mobilized by having an increasing lack of respect for the resistance in the service of assisting the patient to overcome these behaviors. (c) Dr Allan Abbass

The central task of the ISTDP Therapist is to reach through the Resistance to the person stuck underneath (Pressure) If the patient is too weak to reach back then build capacity (Graded work and other elements) If they involuntarily resist in the transference help them see and overcome that barrier (Clarify, challenge and Head on collide) (c) Dr Allan Abbass

This can only happen with continuous positive regard for the patient Coupled with this is a continuous negative regard for the resistances that are destroying the patient and his relationships (c) Dr Allan Abbass

Interventions in 30 ISTDP Trial Therapies (Abbass, Joffres & Ogrodniczuk, 2009) Rate per hour Percent of all Pressure 97 59% Recapitulation 29 19% Clarification/challenge 23 14% Inquiry 9 5% Dynamic Exploration 6 3% (c) Dr Allan Abbass

Pressure Davanloo 1999 The mainstay intervention of ISTDP Encouraging the patient to connect to his true feelings and be open with the therapist about these feelings. = Reaching through resistance to the person underneath Psychodiagnosis and Road map Pressure increases CTF, UTA and Resistance (c) Dr Allan Abbass

Technique of Unlocking the Unconscious Davanloo 1988-2001 UTA R CTF R UTA “Unlocked” Pressure (c) Dr Allan Abbass

Challenge Davanloo 1999 This is done only when the resistances are crystallizing in the therapeutic relationship (transference), when they are an obstruction to the therapeutic bond and task First, clarify the defences with the Patient Then pressure: encourage the patient to overcome the resistances with you Finally, challenge the defences in concert with the patient. (c) Dr Allan Abbass

Technique of Unlocking the Unconscious Davanloo 1988-2001 UTA R Resistance is in T Clarify and Challenge Keep up Pressure CTF R UTA “Unlocked” (c) Dr Allan Abbass

Head on Collision Davanloo 1999 With the resistances crystallized in the transference this most powerful intervention highlights the reality of the limits of the therapist, effects of resistance potential of the alliance And encourages the patient to do his or her best Again, seldom used with low capacity patients. (c) Dr Allan Abbass

Technique of Unlocking the Unconscious Davanloo 1988-2001 UTA R Resistance in T Head on Collision Pressure Challenge CTF R UTA “Unlocked” (c) Dr Allan Abbass

Unlocking of the Unconscious CTF are experienced: anxiety and defence are removed or reduced UTA is greater than resistance Partial versus major versus extended unlocking Partial: Link to past Major: Image changes to the past person Extended: During breakthrough of rage the image is the past person (c) Dr Allan Abbass

Central Dynamic Sequence Systematic Analysis of the Transference Extensive Cognitive Recap of findings Collaborative and repetitive Extremely important in patients with panic, somatization, depressive disorders and fragile character structure (c) Dr Allan Abbass

Resistance goes into the T Inquiry Experience Feelings Low Resistance Resistance goes up Pressure Experience Feelings Moderate Resistance Resistance goes into the T Experience Feelings High Resistance Clarify and Challenge Depression, Somatization, Fragile Graded Format to build Capacity Go flat at any point (c) Dr Allan Abbass

Eg. threshold to cognitive disruption Anxiety Graded Format: 1. Pressure to feelings or to defences 2. Rise in complex feelings and anxiety 3. Intellectual recap to bring down anxiety Eg. threshold to cognitive disruption 1 Anxiety 2 (c) Dr Allan Abbass

Summary ISTDP takes place via continuous positive regard for the patient Out of that positive regard there is a continuous pressure on or disrespect for the resistances that paralyze his or her functioning. This complex stance brings the UTA Specific diagnostic system and treatment system Specific interventions, timed and dictated by the format of unc anxiety, resistance, state of complex feelings and UTA Pressure vs Challenge vs Head on Collision (c) Dr Allan Abbass

Immersion Training Halifax Canada September 24-27: Focus on detecting mobilzation of the Unconscious. Plus 6 quest speakers Stockholm: October 18-21, 2012: Overview and psychodiagnosis across spectrum Norway June 10-13, 2013: The Highly Resistant Patient Contact Jennifer at abbass@bellaliant.net (c) Dr Allan Abbass