September 28th, 2010 admin
Sitting in silence in an anonymous hotel room in Vancouver, I contemplated my presentation for the 5th International Experiential Dynamic Therapy Association Conference (IEDTA). I planned to present a videotape of work with a patient with chronic, sometimes vegetative and ego-syntonic depression, and I was looking for a central theme. Suddenly, a key factor in the session jumped out at me: the emergence of HOPE. By “hope,” I refer to hope that is generated by a heightened sense of one’s own capacity to act or feel in an entirely new way as opposed to a passive stance of hoping for something to happen without our active engagement. This patient lacked hope in his ability to feel, to relate, and also to overcome his avoidant and depressive character traits. He also lacked hope in the healing aspects of relationship.
There was a startling moment, occurring in a millisecond and easily undetected, when hope as defined above arose within this patient and shifted the entire course of the initial session. It illustrated that hope is not as an end point but rather a dynamic process that both initiates and propels therapeutic movement. In J. Weinberger’s review of hundreds of outcome studies validating key curative factors in psychotherapy, “revival of hope” is among the most important.
Treatment success requires that the patient first be able to declare what he wants, then to experience hope in the possibility of achieving these desires. As hope grew in this patient, he risked greater emotional intimacy with me and there was a positive impact on his mood. The ability to self-reflect is one factor that is central to the development of hope. Jon Frederickson, MSW, whom I admiringly refer to as the “Maestro,” demonstrated the process of strengthening the observing ego in his transformational work with “A Man with 17 Therapies”:
(Transcribed according to my imperfect note taking).
Th. As soon as you say what you want, it’s like this worry station, this channel, comes on. You become anxious. This internal anxiety and guilt channel drowns out everything else. Some sadness comes up around differentiating yourself from this channel. It’s been your whole life.
(It’s not enough that the patient recognize his defenses; it’s his healthy desires that will win the battle).The doubt channel, doubting me, doubting you. You’re not liking what your mind is doing. Your brain has an automatic doubt circuit… Is this what you want?
When Jon’s patient could connect with his will and also observe the sabotaging part of himself, he was empowered to overcome it. The Impact of Desire and Hope in Defeating Resistance will be the focus of my presentation with Dr. Thomas Brod at the New Center of Psychoanalysis on Nov. 13, 2010. Register at http://www.n-c-p.org/edu-event.asp?id=160&the_type=Course. Thanks to NCP and also the Southern California Society for ISTDP for sponsoring this event.
This is also the topic of my article in the September, 2010, issue of “The Ad Hoc Bulletin of Short-Term Dynamic Therapy.” Subscribe to this excellent journal at http://www.iedta.net/.
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September 24th, 2010 admin
Further reflections from the 5th International Experiential Dynamic Therapy Association Conference (IEDTA) in Vancouver, B.C. this past July…
Patricia Coughlin, Ph.D., pointed out that Klaus Grawe, the eminent German psychologist who integrated neuroscience with psychotherapy, made therapists aware that we can’t focus on the problem alone but also on the healthy part of the patient; that we must speak to the healthy part while blocking defense at the same time.
Thought I’d share part of a session I had with a fragile, depressed patient with suicidal ideation and severely regressive defenses that I hope will illustrate this principle. The patient had described a bubbling energy in her stomach and then suddenly slumps and experiences a heavy feeling,
Th: So there’s this energy that wants to move up but there’s something blocking it. The heaviness holds it down (her depressive defenses).
Pt: I think sometime I shouldn’t show any emotion.
Th: Any anger. (Her narrative is highly suggestive of this emotion).
The pt. talks about how her family reinforced this repression of feeling and the therapist turns to the reality between the two of them.
Th. “Do you perceive any danger now, with me?”
The pt. recognizes there is no real danger, but she fears that the feelings inside her will be like soap bubbles endlessly rising from the mouth, coming and coming until they essentially drown her. Therapist comments that if we could make more room for her feelings, they would likely resolve themselves.
Th: “Do you want us to do that (make more room for her feelings)?”
Pt: Yes!
When the pt. emphatically responds affirmatively, the therapist feels moved by her. Smiling, she says, ”You’re a courageous lady.” The patient wonders why? “I think you have a wonderful spirit. There’s a very healthy spirit in you. Even when things are very difficult for you, you’ll say, ‘No, I want to go forward.” The patient recognizes this is true about her. Therapist goes on, “And I admire that.” Both patient and therapist share a sense of delight.
Th: “It takes courage. It isn’t easy.”
The patient has a moment of appreciation for herself and heightened hope, a primary curative factor in therapy.
Th. A part of you wants to release it (your anger), but another part wants to keep it inside.
Pt. But I know I don’t want that. So I’m kind of fighting inside, two of me.
Th. And then there’s the part that can observe with me this struggle inside. Would you say there is the part that wants to… keep you down…and then there’s the part that wants you to be freer.
The power to perceive these conflicting parts of herself activates a sense of hope and also her will. She then becomes aware of more bubbling up of feelings, with the ‘bubbles” getting bigger and rising up from her stomach but then getting stuck in her throat. The therapist views the “bubbles” as a mix of anxiety and also rage. This sign of the patient’s feelings moving up rather than being trapped in her stomach or under a weight of heaviness is viewed positively and is used to encourage the patient:
Th: But that’s progress!
With each step towards awareness of her strengths, this patient took another risk towards discovering and declaring herself. Eventually, she was able to access the full force of her rage as well as profoundly loving feelings towards her deceased father
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September 23rd, 2010 admin
At the 5th International Experiential Dynamic Therapy Association Conference (IEDTA) in Vancouver, B.C., I found Dr. Patricia Coughlin’s comments fascinating regarding the correlation of therapist attributes with successful treatment, possibly more significant than the approach being applied! Findings show that these attributes are found in 10-20% of therapists, and she plans to write about this in her upcoming book. These qualities include being passionate and engaged, flexible, humble, approachable, confident, and courageous. These therapists are lifelong learners open to feedback who push themselves and their patients to get the best results possible. I’m eager to hear more about this in her upcoming book! It makes much sense to me that the therapist qualities noted above would enhance results. I also commented at the conference that the work we were viewing showing depth emotion processing leading to relief from trauma seemed to additionally require a highly effective skill set, but this of course is developed through being “lifelong learners open to feedback.”
The quality of courage struck a chord because facing my fears has been necessary to any success I’ve had with Short-Term Dynamic Psychotherapy. I’m thinking of those times when I was on the verge of backing off a piece of defense work or making an observation that would raise the patient’s anxiety or resistance, when with perseverance, something profound opened up for the patient! Do we not all know what it is to stay in a safe zone versus making a difficult intervention that requires more of us and carries no guarantee?
I developed a teaching section on “The Warrior Therapist” when I presented at the Washington School of Psychiatry Fourth Annual Summer School in 2009, referring to the ways therapists sometimes have to gird themselves when helping patients to access intensely painful feelings… so that we can stay present… and not run away… and persist with that next intervention that we believe, to the best of our knowledge, will help the patient. Special thanks to Leigh McCullough, Ph.D., who raised my awareness of widespread affect phobia. Josette ten Have-de Labije, PsyD, made some great comments in her “Letter from the Editor” in the next Ad Hoc on the perceived “tragedy of failure” that can deprive us of learning opportunities. Cannot our own resistance be as formidable as that of our patient’s?
This blog is meant to encourage us all! I welcome your comments.
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September 4th, 2010 admin
“Convinced He Couldn’t Feel”
In July 2010, it was my great pleasure to speak at the 5th International Experiential Dynamic Therapy Association Conference (IEDTA) in Vancouver, B.C. Presenters included Dr. Jaak Panskepp, who coined the term “affective neuroscience,” the field that studies the neural mechanisms of emotion. Master clinicians Dr. Patricia Coughlin, Jon Frederickson, MSW, Dr. Robert Neborsky, Dr. Allan Abbass, Dr. Josette ten Have-de Labije, Dr. Thomas Brod, Dr. Allen Kalpin and others showed profoundly moving session videotape on overcoming resistance.
My topic was the impact and process of awakening hope and strengthening desire in a patient who had been “Convinced He Couldn’t Feel” for much of his life. In the first session, this man achieved a level of intimacy with me that he had believed impossible… which has important implications for his future relationships. I have just completed an article elaborating on this, including the 1st session transcript, which will appear in the next issue of the Ad Hoc Bulletin Of Short-Term Dynamic Psychotherapy. (Subscribe through the Southern California for ISTDP or the IEDTA website).
By Susan Warren Warshow, LCSW, MFT, BCD
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