approaches to complex pa1ents intensive short-term dynamic
TRANSCRIPT
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
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Plan
n Evidencebasen Metapsychologyn PaHernsofResistancen ISTDPforFragilepaOents
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ISTDP
n DevelopedbyDavanlooandMalanwithvideotapelargecaseseriesresearch
n BroadapplicaOon:madeforresistantpopulaOons
n EmphasisonbuildingcapaciOesenablingtheexperienceandworkingthroughofaHachmenttrauma
n 11studiesofcomplexpopulaOons:meanEffectSized=1.59
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Cornelissen KLM, Smeets D, Willemsen SP, Busschbach JJV, Verheul R.
ResidenOalISTDPMax6monthadmissionsfortreatmentresistantpersonalitydisorders.N=155
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8weekISTDPInpa1entTreatmentRefractoryServiceNorway:Allhadfailed3ormoretreatments
SolbakkenandAbbass2016
Dr Allan Abbass
RCTofISTDPinTreatmentResistantDepression
ISTDP 36% Remission
Community Mental Health 3.7% Remission
Town et al, 2017
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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
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Metapsychology
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BOND With
Parents
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BOND With
Parents PAIN FEAR
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BOND With
Parents PAIN FEAR
Rage, Guilt about the Rage
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BOND With
Parents PAIN FEAR
Rage, Guilt about the Rage
Self-destruct Symptoms
Somatization Dr Allan Abbass
Currentperson
Transference(Therapist/Doctor)
Pastperson
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UnconsciousAnxiety
UnconsciousDefense
UnconsciousImpulses&Feelings
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UnconsciousAnxiety
UnconsciousDefense
UnconsciousImpulses&Feelings
1.PressureonFeelingsorDefenses
2.MonitorAnxiety&Defenseresponses
Psychodiagnosis
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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
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WEAK BOND
PAIN
Rage, Guilt about the Rage
Self-destruct Symptoms
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UnconsciousAnxiety
StriatedMuscleAnxietyIsolaOonofAffect
ConsciousFeelings
Mildfragile
Moderatefragile
Severefragile
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TreatmentPhasesinFragileCharacterStructure
n CapacityBuildingn RepeatedUnlockingn WorkingThroughn TerminaOon
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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
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3 2
3 2
1
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UnconsciousAnxiety
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2
1
ConsciousFeelings
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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
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CogniOve
Perceptual
DisrupOon
Repression
SmoothMuscle
IsolaOonofaffectStriatedMuscle
MildFragileModerateFragileSevereFragileBorderline
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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
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RepeatedUnlockingPhase
n Inlongercases,phaseisayearormorelongn RepeatedparOalthenmajorunlockingoftheunconscious
n Drainingthepathogenicreservoirofrageandguilt
n MobilizingposiOvefeelingswhichmobilizesmorerageandguilt
n Inlongertermcasemaybe2-300unlockings
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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