approaches to complex pa1ents intensive short-term dynamic

ApproachestoComplexPa1ents

IntensiveShort-termDynamicPsychotherapyAustenRiggsGrandRounds,October2017

AllanAbbassMD,FRCPCDalhousieUniversity,Halifax,Canada.

www.allanabbass.com

Dr Allan Abbass

ReferenceMaterialsn  ReachingthroughResistancen  DetailedmanualonISTDPpsychodiagnosisand

treatmentwithcaseexamplesn  www.allanabbass.comn  AvailableonAmazon:hHp://a.co/3UGMWx0OtherarOclesunderpublicaOonsatwww.allanabbass.com

3

Plan

n  Evidencebasen  Metapsychologyn  PaHernsofResistancen  ISTDPforFragilepaOents

Dr Allan Abbass

ISTDP

n  DevelopedbyDavanlooandMalanwithvideotapelargecaseseriesresearch

n  BroadapplicaOon:madeforresistantpopulaOons

n  EmphasisonbuildingcapaciOesenablingtheexperienceandworkingthroughofaHachmenttrauma

n  11studiesofcomplexpopulaOons:meanEffectSized=1.59

Dr Allan Abbass

Cornelissen KLM, Smeets D, Willemsen SP, Busschbach JJV, Verheul R.

ResidenOalISTDPMax6monthadmissionsfortreatmentresistantpersonalitydisorders.N=155

Dr Allan Abbass

8weekISTDPInpa1entTreatmentRefractoryServiceNorway:Allhadfailed3ormoretreatments

SolbakkenandAbbass2016

Dr Allan Abbass

RCTofISTDPinTreatmentResistantDepression

ISTDP 36% Remission

Community Mental Health 3.7% Remission

Town et al, 2017

Dr Allan Abbass

Adjunc1veISTDPinpsychosis

Abbass et al, 2015

For residual anxiety, depression and interpersonal problems and some psychotogenic cycles N=38, Mean 13 sessions Large Significant Health care Cost reductions

Dr Allan Abbass

SelfreportOutcomes

Dr Allan Abbass

Metapsychology

Dr Allan Abbass

BOND With

Parents

Dr Allan Abbass

BOND With

Parents PAIN FEAR

Dr Allan Abbass

BOND With

Parents PAIN FEAR

Rage, Guilt about the Rage

Dr Allan Abbass

BOND With

Parents PAIN FEAR

Rage, Guilt about the Rage

Self-destruct Symptoms

Somatization Dr Allan Abbass

Currentperson

Transference(Therapist/Doctor)

Pastperson

Dr Allan Abbass

UnconsciousAnxiety

UnconsciousDefense

UnconsciousImpulses&Feelings

Dr Allan Abbass

UnconsciousAnxiety

UnconsciousDefense

UnconsciousImpulses&Feelings

1.PressureonFeelingsorDefenses

2.MonitorAnxiety&Defenseresponses

Psychodiagnosis

Dr Allan Abbass

UnconsciousAnxiety

n  StriatedMuscle:Voluntarymuscletensionn  SeewithisolaOonofaffect/selfreflecOononbodyandaffect

n  SmoothMuscle:Bodyorgansn  Seewithrepression

n  CogniOve–perceptualDisrupOonn  SeewithprimiOvedefenses

Dr Allan Abbass

SpectrumofPsychoneuro1cDisorders

(NONFRAGILE)Low Resistant

Highly Resistant

Moderate Resistant Mild Severe/

Borderline Moderate

SmoothMuscle/Conversion+Repression

CogniOve-PerceptualDisrupOon+PrimiOveDefenses

SpectrumofPaOentswithFragileCharacterStructure

StriatedMuscle+IsolaOonofaffect

All these are specifically diagnosable and each have a different treatment pathway Dr Allan Abbass

ComplexTransferenceFeelings(CTF)andUnconsciousTherapeu1cAlliance

n  MixedFeelingsmobilizedbytryingtotherapeuOcallyaHachtopaOent

n  Linkedtothepastbond,trauma,pain,rageandguiltaboutrage

n  AcOvatesthe“unconscioustherapeuOcalliance”:deepdesiretohealbyseeingandworkingthroughfeelingsaboutthetrauma:producesimagesandlinkagestopasttrauma

n 

Dr Allan Abbass

FragileCharacterStructurePa1ents

n  Earlyneglect,abuse,invalidaOonn  Absenceofparentalfigurewithanxietytolerance:usuallyfragileparentswhoprojectonchild

n  CogniOve-perceptualdisrupOonatsomelevelofriseinanxiety

n  ProjecOon,spligng,projecOveidenOficaOonn  Needcapacitybuilding

n  Anxietytostriated/voluntarymusclen  DefensetoselfreflecOononfeelings/isolaOonofaffect

Dr Allan Abbass

WEAK BOND

PAIN

Rage, Guilt about the Rage

Self-destruct Symptoms

Dr Allan Abbass

UnconsciousAnxiety

StriatedMuscleAnxietyIsolaOonofAffect

ConsciousFeelings

Mildfragile

Moderatefragile

Severefragile

Dr Allan Abbass

TreatmentPhasesinFragileCharacterStructure

n CapacityBuildingn RepeatedUnlockingn WorkingThroughn TerminaOon

Dr Allan Abbass

Accelera1oninISTDPn  Psychodiagnosistofindmaximumanxietytolerancethreshold(Findthecurve)

n  UsenonverbalcuestoopOmizedosageofemoOonacOvaOon(Hugthecurve)

n  AcOveinterrupOonofprojecOon(Stayontrackofinternalprocess)

n  PressureonGuiltaboutragetobuildanxietytolerance:psychicintegraOonathigherlevelsofanxiety

n  Repeatedunlockingoflovingfeelings,rage,guiltandgriefusingtheaHachmentrelaOonshipintheTransference(Lethimrun)

Dr Allan Abbass

UnconsciousAnxiety

StriatedMuscleAnxietyIsolaOonofAffect

ConsciousFeelings

1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.IntellectualrecaptobringisolaOonofaffect

1

3 2

3 2

1

Dr Allan Abbass

UnconsciousAnxiety

3

2

1

ConsciousFeelings

Dr Allan Abbass

IsolaOonofaffectStriatedmuscle

Mildfragile

Moderatefragile

Severefragile,borderline

Threshold

toCPDorp

rimiOvede

fenses

TherapeuO

cwindow

1

3

2 12

3

1.  Pressure 2.  Rise in CTF 3.  Recap

Unconsciousanxietyanddefense

Consciousfeelings

Dr Allan Abbass

CaseofModerateFragility/Psychosisn  60yearoldmanlivesinSalvaOonArmyapt.n  5years+ofschizophrenia:5admissionsover200days

n  JailedfewOmes:terrified.FearinHospital.n  Beganwhenfather‘becamedementedandstartedaHackinghim,hadhimjailed’

n MovedtoHalifaxunderdelusionsandthenlivingonstreet

Dr Allan Abbass

CogniOve

Perceptual

DisrupOon

Repression

SmoothMuscle

IsolaOonofaffectStriatedMuscle

MildFragileModerateFragileSevereFragileBorderline

Dr Allan Abbass

HowtoReduceAnxiety

n  Talkandlettheclient/paOenttalkn  ChangeStaOonsCàTorTàCorCàCn  Focusonbodilycuesn  RecapitulateonwhathappenedP-C-TandI/F-Anxiety-Defence

n  Stayofffeelingsforamoment

Dr Allan Abbass

MildFragility:Can“see”Psychosis

IsolaOonofaffectStriatedmuscle

Mildfragile

Moderatefragile

Severefragile,borderline

Threshold

toCPDorp

rimiOvede

fenses

TherapeuO

cwindow

1

3

2 12

3

1.  Pressure 2.  Rise in CTF 3.  Recap

Unconsciousanxietyanddefense

Consciousfeelings

Dr Allan Abbass

Projection of rage or punishment

Fear attack or punishment

Guilt about rage is repressed

Rage about the attack or punishment

Self Escalation in severe fragile and psychosis

Dr Allan Abbass

UnconsciousAnxiety

StriatedMuscleAnxietyIsolaOonofAffect

ConsciousFeelings

1.Pressuretorage2.Risetoabovethreshold3.PresstoGuiltandregulatedownanxietyasneeded4.ExtensiveRecapping

1

3

2

3

2

1

Immersive Approach to Building Capacity

Dr Allan Abbass

3laterphaseswithFragilePa1entn Manwithchronicdepression,paranoia,dysfuncOon.OnWelfareformanyyears

n Moderatetoseverefragility:prominentprojecOon

n  Historyalcoholismn  HadpsychoOcepisodeondexedrineforADHDthatpersisted

n  Paranoidfamily,sisterborderlinedisordern  Firstyearnovideoasfelthewastooparanoideventoask

Dr Allan Abbass

ResultsofCapacityBuildingPhase

n  Anxietyinstriatedmusclen  Abilitytoselfreflectn  Abilitytoreduceownanxietyn  Understandingofthetrauman  ReducOonofparanoia/projecOonandgriefaboutit

n  Emergingempathyforfamily

Dr Allan Abbass

RepeatedUnlockingPhase

n  Inlongercases,phaseisayearormorelongn  RepeatedparOalthenmajorunlockingoftheunconscious

n  Drainingthepathogenicreservoirofrageandguilt

n MobilizingposiOvefeelingswhichmobilizesmorerageandguilt

n  Inlongertermcasemaybe2-300unlockings

Dr Allan Abbass

UTAinRepeatedUnlocking

n  Spontaneousunlockingsinweekn  Imagerypopsinheadn  Deadbodiesn  SensaOonsinbodyn  Dreamsthatarebreakthroughsn  Vividcontentallowstrongguilttobefeltn  SenseofPresence:UTA

Dr Allan Abbass

Resultsofrepeatedunlockingphase

n  Nexttonosignsoffragilityn  EmoOonsareseparated:de-fusedn  Compassionforselfn  Empathyandloveforothers:survivorguiltn  Griefaboutpsychopathologyn  FuncOonalgainsn  Growingmasteryofpsychodynamicsn  Altruism:wishtogivetoothers

Dr Allan Abbass

WorkingThroughPhase

n  MobilizaOonofgriefandselfcompassionasguiltisremoved

n  DefusionofpuniOvesuperegofromselfn  DrivesforaHachmentn  HealthyacOvityinlifen  ReturntofuncOonn  PocketsofrageandguiltsOllemergen  Griefisdominantn  Empathy/loveforfamilymembers

Dr Allan Abbass

CourseofIntensive“Long-term”DP

Start End

Capacity Building

Repeated Unlocking

Working Through Termination

Dr Allan Abbass

Pressure ModerateResistance

Striatedmuscleanxietyplusfeelcomplex

transferencefeelings

HighResistance

Depression,smoothmuscleanxietyormotorconversion

HighResistancewithRepression

CogniOve-perceptualdisrupOonorprimiOvedefenses

FragileCharacterStructure

GOFLAT:Nostriatedmuscleanxietyandcantselfreflect

CapacityBuildingFormats

Repeatedunlocking,workingthrough,terminaOon

Striatedmuscleanxietyplusfeelcomplex

transferencefeelings

Breakthroughofgriefaboutloss

LowResistance

Completetreatmentin1or2sessions

Inquiry

ResistanceRises

Resistancecrystallizesinthetransference

Clarify,Challenge,

HeadonCollision

Dr Allan Abbass