Drs. Thomas Brod, Robin L. Kay and I had a marvelous afternoon presenting ISTDP this past 11/13 at the New Center for Psychoanalysis. 45 were in attendance and brought a very positive energy into a beautiful “Room with a View” with dark wood shelving throughout the book-lined scholarly setting. OK, I’m into ambiance as well as content! Dr. Kay offered an elegant overview of attachment theory and ISTDP principles and Dr. Brod presented lovely, transformational work with a highly anxious young woman. I’m excited to be teaching with both of them again very soon. Please check out www.warrenwarshow.com and read about the upcoming events, “Thwarting the Transmission of Trauma” with Dr. Kay with the choice of 1 or 2 afternoons beginning 12/17, and also an extended workshop for therapists on “Intensifying Deep Affective Processing” with Dr. Brod to be held on 5 Saturdays between Jan. & May 2011. We welcome our colleagues!

In response to a reader of this blog, we’ve embarked on the topic of whether we need to curtail intense emotion processing with clients/patients who have certain medical conditions? Dr. Allan Abbass, Professor of Psychiatry and Psychology, Director of Psychiatric Education and founding Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Nova Scotia, is gifting us with some additional invaluable and generous input on this subject. Thank you!!

He tells us that the exertion of emotion-focused ISTDP work should not be that physically demanding and should be safe for a patient who is able to walk up a flight of stairs. However, there could be risk factors with certain conditions, such as congestive heart failure, chronic lung disease, vasospastic angina and autoimmune syndromes (such as multiple sclerosis, rheumatoid diseases, ulcerative colitis, irritable bowel syndrome, asthma) and active depression “IF THE ANXIETY IS TOO HIGH AND THE RISE IN THE TRANSFERENCE IS TOO LOW.”

Given that ISTDP, an EDT therapy, does raise anxiety on the road to relief, we never want our patients to be experiencing UNRECOGNIZED anxiety of any significance because the lack of recognition will only increase it. When Dr. Abbass speaks of the transference being too low, he is indicating that underneath the patient’s anxiety is a build-up of complex feelings that are not being experienced. So, we may have a powder keg of emotion that’s held in check by rising anxiety…not good for the body! I remember a patient who appeared perfectly normal until I inquired what was happening in his body. He replied that he was “stiff as a board.” When I asked “where?” he answered “everywhere.” I was unaware that this patient was in such a state of extreme tension and thankfully was learning to track these changes at regular intervals.

Abbass cautions us not to practice ISTDP with the patients mentioned above for our first 25 or more cases. That being said, he adds  “We have to ask ourselves, ‘will this session be more stressful than life outside the office?’ The answer to this is virtually always no: how can therapy be more stressful than what happens in the cold, cruel and real world of many of our unfortunate patients?”  This is an intriguing comment because it is a reality that there are definite risk factors involved in maintaining the status quo for many of our patients. However, as Dr. Abbass indicates, it is possible to make matters worse with certain patients when our skills are not yet sufficient.

When we do attempt intense affective work with these patients, Dr. Abbass recommends a graded approach with “frequent recaps” (reflections on the process) and a reliance on more data, adding that input from the relevant medical specialist more than suffices. However, it is only the trained therapist and not the specialist who can determine whether a particular patient has the “ability to do the work of intensive psychotherapy without becoming problematically symptomatic vis a vis accurate psychodiagnostic evaluation and trial in the trial therapy.”

I believe an intervention that seeks “more data” might be, “As you were discussing your girlfriend, you became short of breath, which suggests anxiety as feelings towards her are rising inside of you. Are you experiencing anything that would suggest this symptom is related to your medical condition now.” If not, we could then ask, “Does it make sense to you that your anxiety is related to the rise of underlying feelings?” If the patient is unable to see this connection and reflect upon it, the therapy cannot progress.

Encouraging the client/patient to talk and self reflect will lower anxiety. We do not want to continue exploring feelings until anxiety level is optimal, perhaps 3-4 on a scale of 1-10. Sometimes I ask the patient to rate their own anxiety. Dr. Abbass tells us that when we see striated muscle activation, (such as in the neck, chest, arms, hands, legs or the muscle band around the stomach or head), this signals a healthy self-protective response that tells us it’s safe to continue exploring feelings. IF WE DON’T SEE THIS STRIATED MUSCLE ACTIVATION, WE NEED TO WORRY! Also, if there is smooth muscle activation (as in gastro-intestinal distress or migraine) or cognitive-perceptual disruption, we need to STOP all exploration of feelings until anxiety is again manageable. These are signs that the patient cannot tolerate anxiety at present and feelings and physical symptoms may worsen, perhaps to a dangerous level.

Another warning from Dr. Abbass: If these patients are talking about rage when they aren’t actually feeling it, their medical condition can worsen and fatigue from blocked guilt will increase. This defense (isolation of affect) is resistance that needs to be identified with pressure exerted to turn against it. (I prefer to do this in such a way that emphasizes compassion for self, i.e. “This defense is so HURTFUL to you! Would you agree?” The healthy results of turning against destructive defenses are, as Dr. Abbass informs us, “structural changes in anxiety discharge pathways and defenses.”

Those of us who like to be “supportive” should heed this note of caution from Dr. Abbass: “Being supportive in these cases can make everything worse, so this needs to be an educated supportive format, like “Graded Format,” applied with a lot of skill at recognizing unconscious anxiety and defenses. Just reassuring these patients will drive the rage and guilt down into the body and worsen anxiety and repression.” So, we don’t want to reassure the patient that he/she is doing fine when in fact the patient is experiencing an unacceptable level of anxiety that could trigger a medical event. The only way we know this is through a thorough exploration of what the patient is actually experiencing throughout their body at a given moment. Abbass says: “Develop 2 feedback loops to monitor: 1. Your eyes and ears and 2. Have the patient keep feeding back to you what they are noticing physically.” With both patient and therapist “watching,” Abbass says there are more reasons than not to do a trial (ISTDP) therapy.

This entry was posted on Wednesday, December 1st, 2010 at 12:16 am and is filed under Conference, Home, Treatment Process. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.