1. ISTDP Overview and Application for Chronic Relational Trauma Allen Kalpin, MD

2. Introductory Comments
Bioenergetic Analysis – inclusiveness
ISTDP – “Short-Term”
Commonalities
- Psychodynamic
- Character analysis
- Focus on the Body
Differences

3. History - Overview Psychoanalysis Attempts to shorten analyisis
Short-Term Dynamic Psychotherapy (STDP)
Intensive Short-Term Dynamic Psychotherapy (ISTDP)
Experiential Dynamic Therapy (EDT)

4. Classical Psychoanalytic Concepts
Psychodynamic: unconscious; conflict; transference/countertransference; defense; resistance; childhood experiences
Structural Theory: Id, Ego, Superego

5. Shortening Psycoanalytic Treatment
Freud
Firenczi, Rank and Adler
Reich – character analysis
Alexander and French – 1946 – “corrective emotional experience”

6. Short-Term Dynamic Psychotherapy (STDP)
Michael Balint and David Malan – 1960s
Peter Sifneos and James Mann – 1960s – 1970s
Habib Davanloo: Intensive Short-Term Dynamic Psychotherapy (ISTDP)

7. Experiential Dynamic Therapy (EDT)
Based on psychodynamic principles as expressed in the two triangles.
Important focus on the physiological experience of emotions as a major healing factor.
Use of the therapeutic relationship as a central force in assessment and treatment.
Recognition of the human relationship - attachment - as being central to causes of pathology and to healing.
Identification and countering of the inner self-sabotaging forces.

8. Intensive Short-Term Dynamic Psychotherapy (ISTDP)

9. ISTDP – Time Frame 40 hours or less
Severe borderline psychopathology: up to 150 hours (3 years)

10. ISTDP – Assessment Trial Therapy Reaction to intervention Observation
Audio-visual recording
Dynamic formulation

11. The Two Triangles

12. The Triangle of Persons
Transference (T) Current (C)
Past (P)

13. The Triangle of Conflict
Defense (D) Anxiety (A)
Impulse/Feeling (I/F)

14. Impulse/Feeling Core emotions vs. anxiety and defense
Somatic pathways of emotion
Action tendencies

15. Somatic Pathways of Emotion
Love: Warmth in chest; urge to embrace
Grief: Tears, waves, sobbing; no physical pain; desire to be held
Anger: Upward and outward-moving energy; urge to lash out
Guilt: Neck/chest pain; urge to apologize, make amends

16. Discharge Pathways of Anxiety (Davanloo)
Conscious Anxiety
Unconscious Anxiety
Striated Muscle
Smooth Muscle
Cognitive/Perceptual Disruption
Motor conversion (muscle weakness)
Psychosomatic

17. Discharge Pathways of Anxiety
Conscious Anxiety
Awareness of “feeling afraid,” etc.

18. Discharge Pathways of Anxiety
Unconscious Anxiety
Little or no awareness that the symptoms are from anxiety
Little or no awareness of the connection between triggers and the symptoms

19. Discharge Pathways of Anxiety
Striated Muscle
Muscle tension +/- movement
High ego adaptive capacity
Anxiety is closest to consciousness
Striated muscles are muscles of action
Most compatible with good functioning

20. Discharge Pathways of Anxiety
Smooth Muscle
e.g. IBS, migraine, asthma
Low ego adaptive capacity
Anxiety is farther from consciousness
Smooth muscles are not muscles of action
Less compatible with good functioning

21. Discharge Pathways of Anxiety
Cognitive/Perceptual Disruption
e.g. blank mind, blurry vision, tinnitus
Ego fragility
Anxiety is even farther from consciousness
Muscles are not involved
Very incompatible with good functioning

22. Discharge Pathways of Anxiety
Psychosomatic
e.g., autoimmune disorders
Anxiety is farthest from consciousness
Muscles are not involved
Very incompatible with good functioning
Potentially dangerous

23. Projective Identification and Symptom Formation
Identification with the victim (attachment figure) – of violent fantasies
Psychosomatic symptoms that correspond to targets of attacks
Chronic pain and/or weakness in arms or legs – that would carry out the attacks

24. Restructuring Instant Repression – Depressive Mechanism
Gradually bringing awareness of aggressive impulse to consciousness
Ego Adaptive Capacity
Gradually increasing the ego’s capacity to tolerate anxiety by repeated cycles of exposure and integration
Low EAC – e.g., IBS
Ego fragility
Psychosomatic

25. Defenses – Major Resistances
Isolation of affect: Can talk and about emotions without physically experiencing them; Striated muscle
Repression: Associated with depression and/or motor conversion; Smooth muscle
Primitive defenses: Splitting, projection, projective identification, dissociation, externalization, regressive defenses; Cognitive/Perceptual Disruption

26. Spectrum of Structural Neurosis (Davanloo and Abbass)
________________
Resistance, SEP, REC, Amount of Problems, Character Pathology, Complexity of Core Neurotic Structure
Low
Moderate
High

27. Spectrum of Structural Neurosis (Davanloo and Abbass)
________________
Striated muscle + isolation of affect
Smooth muscle + repression
Low
Moderate
High

28. Spectrum of Fragility (Davanloo and Abbass)
________________
Degree of disability in tolerating anxiety and painful
feelings, tendency for CPD, use of primitive defenses
Mild
Moderate
Severe-Borderline

29. Spectrum of Fragility (Davanloo and Abbass)
________________
Smooth muscle + repression (+ Str m. if mild)
Cognitive/perceptual disruption + primitive defenses----
Mild
Moderate
Severe-Borderline

30. Punitive Superego

31. Analysis Terminable and Interminable: Freud 1937
“Nothing impresses us more strongly in connection with the resistances encountered in analysis than the fact that there is a force which defends itself by all possible means against recovery and clings tenaciously to illness and suffering. We have recognized that part of this force is the consciousness of guilt and the need for punishment, and this is undoubtedly correct; we have localized it in the ego's relation to the super-ego.”

32. Analysis Terminable and Interminable: Freud 1937
“If we bear in mind the whole picture made up of the phenomena of the masochism inherent in so many people, of the negative therapeutic reaction and of the neurotic's consciousness of guilt, we shall have to abandon the belief that psychic processes are governed exclusively by the striving after pleasure.”

33. Analysis Terminable and Interminable: Freud 1937
“For the moment we must bow to those superior powers which foil our attempts. Even to exert a psychic influence upon a simple case of masochism is a severe tax on our skill.”

34. What is the Punitive Superego?
(SE = conscience; PSE = unhealthy functioning of conscience)
a defensive system
which defends the ego against the pain of remorse
by means of a process of atonement by self-punishment
“I don’t have to feel the pain of remorse – I can atone for it instead.”

35. The Role of Guilt in Human Functioning and Psychotherapy
Freud: Superego – Conscience
Religion: “Sin”
Popular Psychology: “Low Self-Esteem”
Gestalt Therapy: “Internal Critic”
CBT: Core Belief: “Unlovable”
Alcoholics Anonymous: “Making Amends”

36. The Central Role of the Superego in ISTDP
Freud’s Conceptualization
Davanloo’s Technique

37. Deficit vs. Inhibition Developmental Psychopathology
Structural Psychopathology

38. The Origin of the Guilt
Learning
Conflictual Feelings

39. Guilt as a Feeling vs. Guilt as a Defense
Unhealthy guilt: “I am bad” – self-hatred, self-punishment
= Defense
Healthy guilt: “I am sorry” – remorse
= Painful feeling

40. Important Change Mechanism in ISTDP
Replacing unhealthy guilt with healthy guilt
Replacing “I am bad” with “I am sorry”
Replacing a defensive system with the capacity to experience a feeling

41. Attachment Trauma – No Ego Fragility
Pain ->
Rage Toward Attachment Figures ->
Guilt about the Rage ->
Superego Pathology – Self-Punishment ->
Character Pathology ->
Resistance to Emotional Closeness

42. Attachment Trauma – No Ego Fragility
Major Resistance – Isolation of Affect
Anxiety – Striated Muscle
-> No Restructuring
Major Resistance – Repression
Anxiety – Smooth Muscle
-> Some Anxiety and Defense
Restructuring

43. Chronic Relational Trauma
Associated with ego fragility
The more severe the childhood relational trauma, the more severe is the fragility
The farther “to the right” on the spectrum of fragility, the more borderline pathology

44. Attachment Trauma – With Ego Fragility
Pain ->
Rage Toward Attachment Figures ->
Guilt about the Rage ->
Superego Pathology – Self-Punishment ->
Character Pathology +
CPD and Primitive Defenses

45. Attachment Trauma – With Ego Fragility
Major Resistance – Repression
Anxiety – Smooth Muscle
-> Some Anxiety and Defense
Restructuring
Major Resistance – Primitive Defenses
Anxiety – Cognitive/Perceptual Disruption
-> Major Defense and Anxiety

46. Restructuring of Severe Fragility
Defense restructuring – undoing splitting, projection, etc.; increasing capacity for intellectualization (isolation of affect)
Anxiety restructuring – increasing capacity to tolerate anxiety -> striated muscle
Building self-observation capacity
Reality testing re: view of self and others – especially re: the therapist

47. Restructuring of Severe Fragility
As defenses and anxiety become restructured, there is gradually more and more ability to tolerate underlying emotions.
Process gradually moves toward more and more experiencing and working through of complex memories and feelings from the past.