January 11th, 2012 admin
Spaces are still available for my new 1-3 year certification program, Intensifying and Integrating Deep Affect. Check out the link to my site. Please fax your registration form to 818-704-1986 ASAP. If you have a serious interest in the training but aren’t sure about committing due to lack of knowledge about it, you will have the option to come to the first meeting and then decide (fee: 195.00). The material is powerful, which is what inspired me to teach it. If you haven’t yet been exposed to it or if you have, you will benefit from this opportunity!
Save June 9, 2012, for a special one-day event to be announced soon. I’ll be teaching a model that I’m now calling Dynamic Emotion Focused Therapy. This is my personal blend of ISTDP’s Central Dynamic Sequence with an emphasis on empathic engagement and neurobiological attunement (attention to body language, facial expression, eye gaze, and tone of voice). It includes a style of defense interruption that emphasizes compassion for self, vivid language and metaphor to bring the therapeutic process to life, and interventions utilizing the latest research on hope.
I’ve been very curious at the small percentage of therapists who pursue post graduate training. I see talented therapists who develop exciting new skills and report the impact on their clients yet become debilitated and discouraged: “My patient had a breakthrough and got better and worked out big problems with her boss but then she got depressed again. I feel terrible.”
An accomplished therapist in STDP training who gave me permission to share his comments emailed: “I have struggled sometimes with what to do with resistance, though I have gotten better at recognizing it. I get breakthroughs to rage eventually sometimes, but often helping people to see the triangle of conflict clearly and realize that they spend a lot of time quite anxious but have been unaware of it, often leads to quite significant changes. Most clients seem to get to anger but have difficulty going past a portrait at best.”
“My dad often raged around me so I think that I have difficulty with patient’s rage some times. I have noticed difficulty in bringing out a patient’s feeling in the Transference, especially if it is rage. I feel I don’t know where to go with it to help them get to the impulse. So often their defenses quell the anger before I see a clear motoric impulse and I don’t seem to have the language to help spur them along at that moment.”
I was struck that his point that his new skill level “often leads to quite significant changes” was barely noticed or relished. He is saying that even without major breakthroughs, he is a far better and effective therapist. How sad that we take little notice or pleasure in the enormous gift of a therapeutic relationship growing deeper!
It was heartening that he could make the observation: “I could easily tell you whether I was seeing a response of Feeling, Anxiety, or Defense, which type, where we were in the Central Dynamic Sequence, whether or not the client was projecting will/Punitive,Superego or stuck in identification with a previous aggressor, etc. …So I expect too much sometimes of myself as I am learning.
Ah, yes…”expecting too much as I am learning.” Familiar anyone?? If I may free associate, one of the most riveting conferences I can remember was one I attended many years ago, “On “Death and Dying.” The presenters were some of the leading scientific researchers in the world on near death experiences (including Dr. Raymond Moody), who reported on studies of thousands of people of all ages from a great many cultures. I was especially fascinated with the “life review.” From Wikipedia, “A life review is a phenomenon widely reported as occurring during near-death experiences, in which a person rapidly sees much or the totality of his or her life history in chronological sequence and in extreme detail, a ‘flash before the eyes.’ …A reformatory purpose seems commonly implicit in accounts.” Significant numbers of survivors report a transformation after experiencing a “life review” when they recover because they were in a state of complete acceptance, without judgment, able to comfortably observe their life experiences. From a place of safety, they looked at how they hurt or overlooked people and how they missed opportunities to connect and to love and these revelations influenced their lives. Keywords: “From a place of safety.”
In our everyday lives, we often do not make it safe to look at our “messes.” To do so, we must pass through the halls of shame and self-degradation, being whipped by the Furies for our transgressions, blindness and unnecessary losses and we fear being banished. It’s painful to look, and yet how do we truly change anything if we don’t look? The STDP therapist is in the most uncomfortable position of drawing attention to the ways in which the elephant inside the patient stomps on him. As the therapist in training told me, ““I would say that learning ISTDP is far more provocative for the therapist than any other form of therapy I’ve learned. We so directly and pointedly violate a lot of social strictures and rules that it takes time to settle in and see the good that this kind of direct care does people and learn to trust it.”
He further observes how he can stomp on himself, “After all, ISTDP is very complex in its moment-to-moment perceptual tasks and decision-making. I also go after myself for not “seeing” what is happening with a client and then get stuck. I tend to want to see everything in the big picture and to talk with the client in that fashion when they just need their new understanding built up from here-and-now micro-observations done together. … I also see that this may be a defensive stance in which I don’t act until I feel I can excel. … I also tend to intellectualize too much; both a defense against intimacy that was prized in my family of origin, a badge of quality, and also just a habit borne of too much academic training (and probably the same basic defense).”
Yeah, I get it. It’s easy to see why therapy that works with our core is painfully activating and can be the “road less travelled” for patients and therapists alike. And so it becomes imperative that we do everything possible to create safety for our patients, our colleagues and ourselves… so that we can all continue to learn and grow and truly break through our self-imposed upper limits that hinder our professional advancement.
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June 28th, 2011 admin
See new photo gallery by clicking on the “Gallery” link at top of this page.
You’re invited to join my new 5 part extended workshop for therapists, “Intensifying Deep Affective Processing,” beginning August 13, 2011. Therapists will practice skill building exercises aimed at forming an alliance to penetrate defenses, attend to anxiety effectively and work through buried emotions. It will be held monthly on Saturdays, 11:00-4:00 p.m. (Aug. 13, Sept. 10, Oct. 15, Nov. 12 and Jan. 14) at the beautiful Skirball Cultural Center in L.A. Register soon as there are only a few remaining spaces!
I’ve missed blogging over the last few weeks as my readers do stay in my mind and I miss the contact! Whatever happened to the lazy, hazy days of summer laden with delicious excess time? It’s been more like a Santa Ana whirlwind in the last few weeks, with some amazing stuff getting stirred up at the Washington School of Psychiatry’s
6th Annual Summer Immersion Course
in Intensive Short Term Dynamic Psychotherapy this past June 5 -10, 2011 in Syria, VA. Check out the wonderful photos by clicking on “Gallery” at the top of the page. This event is the brainchild of Jon Frederickson and I was thrilled to be invited back as his co-presenter. Edward Weston wrote in his daybook that he’d spent the day in a “holiday of work, but work which was play.” This is the atmosphere that Jon created in our amazing week together as we journeyed to become better therapists, inspiring our hearts, our minds and our spirits.
As Monica Urru reminded us, we were a group of therapists meeting at a lodge on Graves Mountain, apropos of the central theme of our workshop… learning to help our patients to bury the pathological, punitive superego and thereby restore hope through the liberated self. This represents victory in a battle co-fought by the patient with the assistance of the therapist against all that had been associated with abuse, cruelty, neglect, devaluation, abandonment, irrational fear, toxic guilt and shame…destructive forces that had become internalized and were perpetuated within and against the self. “We have to learn to be our own best friends because we fall too easily into the trap of being our own worst enemies. ~Roderick Thorp, Rainbow Drive.”
As we sat at U-shaped tables, with our collective unconscious focused intently on all internal processes that are destructive to the self (perpetrator watch), I began to have images of a communal burial ground in the center of our spacious meeting room overlooking the majestic Shenandoah mountains. We were directing a fiercely bright spotlight on any perpetrator activity within the psyche and it was impossible not to become acutely aware of one’s own self-destructive parts as well. There was a shared vulnerability as self-doubts, self-criticism, shame and anxieties rose to the surface. Along with the excitement of learning powerful new healing tools and the joy of sharing the journey together, pain was also palpable in our group at times… tears as well as fears.
“Am I sufficiently smart and knowledgeable enough to become skilful at this approach? (Never mind the hard earned degrees after our names).
“Will I harm my patients?” (Do athletes fall and hurt themselves and each other in practice? Does it stop them? As one client said to me “It is the repair that matters.”)
“Do I have to abandon all that I already know and start over?” (Absolutely not! Please, integrate new skills slowly as they make sense, and continue to value your hard earned knowledge in other approaches).
“I’ll never be able to do it like _______(fill in the blank). (Shouldn’t we rejoice over our individuality? Do we really want clone therapists? And if I’m trying to be someone else, where is the authenticity?)
“There is one right way to do this.” (Then we’re all doomed).
“My heart is racing and my palms are sweating as I open to the unknown.” (Then let us beat back all that would prevent us from our birthright…to keep growing!)
“My dad abused me too. Can I myself handle the pain of revisiting such painful emotions?” (Yes, you can. It’s the price of freedom and we’re in this together!)
I felt sadness imagining a communal burial ground because that which lay beneath the dirt, while needing to be left behind, included destructive remnants of precious loved ones (who may have meant well or just been sadly limited and emotionally damaged) as well as some very old, familiar and seemingly self-protective parts of myself and others. Pruning is bittersweet. After all, those dead branches and parasitical vines that now sucked our life force were once a living part of our families and us. Yet, if the healthy tree (i.e. healthy self) is to produce new fruit, that which is anti-relationship, anti-growth and anti-joy simply has to be separated from the tree and discarded. In Gretchen Rubin’s delightful bestseller, The Happiness Project, (a book that I picked up in the Atlanta airport on the return to L.A. that is based on her personal application of happiness research), she reminds us that we have a responsibility to nurture happiness within ourselves… even when the going gets rough. Not surprisingly, strong personal bonds, mastery and an atmosphere of growth bring the most personal happiness to people (supplemented with an occasional fashion magazine, listening to drummer Danny Seraphine of Chicago fame as he jams with other local greats, and writing this blog…if you happen to be me).
Jon and I both placed a high priority on self-reflection, self-care and, as Jon put it, a “culture of compassion.” At the sunset gatherings arranged by Jon after the workshop, sitting on rocking chairs or leaning against old pillars on our porches, sipping wine and sometimes swatting bugs and watching our makeup melt in the humid air, I found myself just loving this community of deep sea divers of the unconscious. So much passion to learn and bravery too! There was lots of laughter, giggling, morning yoga and long walks about the hills and woods too… to work off the bowls of steaming Southern dishes that greeted us at each family style meal. But what made the experience especially extraordinary were the intimacy and our collective commitment to kindness to self and other. We could express anger in our group process but devaluing was off limits. We could acknowledge what we didn’t know and wanted to learn but putting ourselves down would be met with clear resistance. We could challenge each other’s ideas but only in an atmosphere of respect. This didn’t mean we might not have superego reenactment, being human after all, but this was a culture that would support each of us in our personal struggles to practice what we preached.
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April 23rd, 2011 admin
I’ve missed blogging with my friends and colleagues! Check out the video on the sidebar and remember that I love your questions and feedback. My new highly experiential, extended workshop for therapists, with clinical video illustrations, “Intensifying Deep Affective Processing” will be held on 5 Saturdays, 11:00 – 4:00 P.M., on August 13, Sept. 10th, Oct. 15th and Nov 12, and Jan. 14, 2012 with lunch and materials included. It’s been a terrific experience to have co-led a similar workshop with a highly motivated group of therapists with the superb Thomas Brod, MD. The new series will have a heavier emphasis on the experiential component. My intention is to devote significantly more time to role playing practice of specific interventions for different phases of treatment with a broad spectrum of psychoneurotic disorders. Please email me right away at swarshow@me.com or call 818-378-1418 to tell me of your commitment so that I can confirm the beautiful Skirball Cultural Center in L.A. for our location. The fee is $850. before May 27, 2011 and $1000. thereafter. More details to follow shortly on my website, www.warrenwarshow.com.
You’re invited to join my Monthly Mondays supervision/teaching group, which offers engaging experiential opportunities to learn the art and skill of reaching and processing deep affect. We’d welcome new members. Call Susan at 818-703-1145 for more information.
Don’t forget another terrific training opportunity with Jon Frederickson, MSW, and myself at the beautiful Graves Mountain Lodge in Syria, VA, on June 5-10, 2011 for the Washington School of Psychiatry’s 6th Annual Summer Immersion Course.
I will be speaking on “Awakening Hope to Defeat Resistance.” It’s been fascinating to reflect on the importance of therapist hope within the therapeutic dyad. We tend to focus on the client’s sense of hopefulness but not our own. We’re told to stay hopeful and to project hopefulness, but we are not told how to do this. I’ve been recently challenged myself when it seemed that no intervention was working and the client raged, “OK, I know I’m self-destructive and I know I act out, and I know I push people away, and I know that I’m anxious but so what that I know that? I make some progress and then I slide back and here I am out of control again! And I know what I need to do but I don’t do it!” Perhaps the patient adds, implicitly or explicitly, “And it’s your fault!” It’s especially delicious when the client projects all responsibility for the setbacks on the failures of the (dare I say beleaguered) therapist and refuses to stop ventilating and discharging and projecting and abandons all self-reflective capacity.There may have been a medication reaction exacerbating this particular client’s outbursts and curiously, he also reported having new recent successes. (Uh Oh, I just remembered that perhaps his relapse in session was DUE to perpetrator activity BECAUSE of the recent successes)!
Yes indeed, there are times when we lose hope…for all sorts of reasons. So, how do we sustain our sense of hope after a discouraging session or a treatment failure? And by the way, if anyone ever says they don’t have treatment failures, be very suspicious! I remember a great article in the Psychotherapy Networker magazine in which the author (don’t remember his name), an accomplished therapist, did research on his treatment outcomes and was amazed that some patients, whom he thought had positive reactions, in fact had not. And others, whom he thought did not respond positively, actually had! Also, his perceptions of what had occurred in session often did not match the patient’s! We also know of seemingly “successful” treatments in which the patient sought another therapist eventually or whose problems reoccurred.
At discouraging times, what can we do to sustain our sense of hope? We do need to remember, always, that a successful treatment takes two to tango. The client simply must have enough will, self-care and self-reflective capacity to actively engage in the treatment process. Yes, it is our role to attempt to mobilize these healthy forces within the patient, but we absolutely cannot do it singlehandedly. We also must be compassionate towards our own vulnerabilities and missteps. Don’t we all sometimes wish we’d selected a few phrases differently? Or maybe we mishandled a new skill we’re just getting the hang of? Sometimes a client just won’t make room for our attempts at repair and the forces of self-sabotage are too great. But will we be forgiving within ourselves? Or maybe a particular dyad simply is a misfit…who can be right for everyone? Will we allow for these personal limitations?
Self-compassion sustains my own sense of hope, and I sometimes need reinforcement from others to reconnect with that. I also need to be selective with the clients I work with as I must be with other relationships. A sense of progress in treatment is necessary for me to keep the hope flame burning within myself. It also helps me to remember the successful treatments in my practice, past and present, as well as the successful aspects of a very frustrating case. Sometimes we forget that even bad experiences can still contain good parts. Wonder if anyone has studied a patient’s positive memories or outcomes related to a disappointing therapy? Many patients who come to me, having been in therapy with someone else, will still tell me of important progress they made with that therapist. Rarely is it black and white, if we’re honest.
I wish you a very Happy Easter and Passover.’Til next time!
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March 5th, 2011 admin
Hope you’ll check out the “Special Events” section at the top of this page (it’s not up on my website yet) and join Jon Frederickson, MSW, (amazing clinician and teacher!) and myself in Virginia at the Washington School of Psychiatry’s 6th Annual Summer Immersion Course in Intensive Short Term Dynamic Psychotherapy from June 5 -10, 2011. Last time I did this with Jon a couple years ago, it was a breathtaking experience. Also, there’s still room in my intimate supervision/training group, “Monthly Mondays,” from 12:30-2:30 p.m. in my Woodland Hills office.
I had a recent email exchange with a therapist that I repeat here with her permission. She has the most heart-wrenching task of trying to help a young woman in her 20’s to find some internal peace as she faces death from cancer. The patient asks, “How can I not feel that I did something to deserve this?” The therapist says that in probing a little further it almost seems that this self contemptuous stance is defensive albeit masochistic as she said to me, “I cannot love myself…it would be harder to feel weak and accept death.”
This young woman, who I understand has felt self-hatred for a long time, lets her therapist know that she has anger/rage inside of her (see below). However, her terrible suffering is increased not by her rage but by rejected rage that is forced to turn against the self rather than have it’s natural trajectory, directed outwards. She is in fact “attached to anger” (see Dr. Clayton’s comment below) because she will not permit herself to experience it towards anyone or anything but herself, and once she opens that door, she fears or feels guilt about the feelings that would follow. It would also seem that her perpetrator has defined self-hatred as a source of strength and perhaps necessary for survival.
Were she to unleash her feelings, we can only imagine the grief to follow the rage involved in facing her death as well as other feelings towards significant others. I’m imagining that like many people, she has come to associate painful feelings with weakness and is not recognizing the great courage and strength involved in facing them. But I would want to ask her how it is that she associates acceptance of death with weakness? I will admit that my own fears and grief over death have never been worked through enough to arrive at the state of acceptance that Kubler-Ross describes as the final stage of grief…a state that I would see as a triumph…but I do believe it’s possible.
My husband, Donn Warshow, Ph.D., said to me, “Her self-hatred is a form of cancer.” My comments in the email exchange with her therapist are italicized below:
2/16 Th: “So I just had a very sad session with ____ who has relapsed with four new tumors in her pelvis (this is her fourth relapse.) She says something to me repeatedly which leaves me speechless. What she says is that she feels angry, but can’t focus the anger outside of her because the cancer is inside, so how can she not be angry toward her body/herself? Any thoughts?”
Susan: I’d ask, “Might you turn your anger on the cancer and hate it rather than yourself, your essence, your core? Your self-hatred is tragic as it inflicts more suffering upon yourself than you’re already enduring. I feel deep pain as I witness this lifelong rejection of yourself. Do you not want to have the experience of compassion and love for yourself while you live and sit here with me? For once in your life??” Also: “How do you experience that I feel towards you?” “Are you aware how profoundly affected I am by your pain? How deeply I feel compassion for you? How much I despise the part that withholds love from you?” If she does: “How is it for you to see that compassion in my eyes? What do you feel as you see my caring for you?” If she does not: “So, you need to push my caring away from you and to also withhold it from yourself? If it were your sister (or someone she loves), what would you say to her if she spoke to you of her self-hatred, especially at such a time as this?”
2/28 Th: “Thanks for letting me vent about …my cancer patient. She starts big guns chemo tomorrow and is filled with dread. She still can’t give herself any slack. I asked her if she could feel and take in my compassion. She said she was terrified that if she did that, I would find out something bad about her and reject her. I asked her what that might be and she had no response. My heart is breaking for her as I dont think she is going to come out of this alive (not according to her doctor.) Interesting side note; I spoke to her psychiatrist who is prescribing her anti-depressants. Her response to this relapse was to up the dosage of her meds and her words to me were, ‘Don’t get too close to her.’ Too late for that…”
Susan: I would suggest telling her something like, “Of course there is a risk that if you begin to treat yourself more compassionately and become freer to share yourself with me, there would be a possibility of experiencing feelings that I could reject. On the other hand, it is far more likely that you would reject yourself than I would…could we look at the track record? At your own experience with me? Nevertheless, you may choose to keep yourself at a distance from me, which I have no choice but to accept, but at the same time, you will tragically be inflicting even more pain and isolation upon yourself as well as a life not fully lived. I empathize with the struggle this involves for you and with the fear you’d have to face. But it is also possible that you might let me stand alongside you in facing your fears, that I will not reject you and that you will feel more at peace with yourself than ever before in you life. But of course, only you can make the choice to take that risk.”
Re. the psychiatrist’s comment:
Susan to therapist: “So, we should try to be close in life but not in death? Or perhaps never be close?” It is indeed an overwhelming prospect to allow all the torrential feelings to which we are exposed on a daily basis to resonate through our bodies. I used to wonder myself if I’d “make it” with this degree of exposure to emotion. Is this psychiatrist right that we do need defenses against closeness as we are exposed to so much human pain? (Another question for another time: Should we limit our caring feelings towards someone who may never let them in?).
Scroll down to the reference to an article written by forensic psychologist F. Barton Evans III, Bethesda, Maryland and Department of XX George Washington University Medical School on 10/13/10 that eloquently addresses this issue. My answer is that we need boundaries but not defenses, self-care and self-compassion, intermittent breaks like walks around the block and lunch with a friend. Behaviorists would say this is an exposure (to feelings) therapy and desensitization is part of the cure…for patient and therapist alike. Seems to me that there’s something magical inborn within us that makes this closeness thing seemingly boundless and infinite.
I was just rereading a wonderful comment to my blog from Dr. Rob Clayton in which he says, “We can also see how attachment to anger is counterproductive from both a Buddhist and a psychological perspective. We have all encountered clients who seem to be a seething mass of anger, with almost no ability to experience the pain of the (psychological) attachment wound that underlies it. The (dharmic)attachment to anger here is a defensive use of affect.” Along this line, McCullough (1991) tells us that “borderline rage…hides enormous sorrow over unmet, and natural, longings for validation of experience.” So, do we say that rage is a defense against grief and the experience of loss or do we say that rage is potentially a pathway to grief and subsequent empowerment? It is my perspective that we cannot arrive at the underlying attachment wound except THROUGH THE TUNNEL of rage, but at that point, there is generally fear and guilt that prevent curative processing. In other words, it is resistance to rage that blocks underlying grief over the attachment wound.
I believe it is fear and guilt over rage that is defensive, not anger itself, and that fear and guilt can cause us to become stuck in anger (i.e. “attached to anger.”) There are those who hold the belief that anger is a destructive, negative force to be gotten rid of as soon as possible. Rather I find that the shared experience of anger/rage, with an awareness of its physiological (bodily) manifestations, and also releasing guilt and fear about the emotion of anger, almost invariably leads to calmness, inner peace and greater capacity for relationship. And very importantly, it can lead to insight into old wounds; empowerment/newfound strength to defeat that which abuses and neglects in order to protect self and others in healthy ways; and more clarity in the decision-making process.
It is certainly vital to pay attention to our anger in a timely way, which does involve not only registering the degree of its internal intensity, i.e. “How great is the force of this rage?” but also sitting with it in order to become additionally aware of the following: “To whom is it directed?” and “Are these feelings in any way familiar and who comes to mind?” and finally “What other feelings follow upon it?”
A woman says, “I ran into Carol and Tom today and they’re going to the Getty museum with friends. But I don’t care because I don’t enjoy their friends anyway.” She cannot permit herself to experience anger…therefore she is unconsciously attached to it because there is no path for release. As she self-reflects, she becomes aware of disappointment, feeling left out. “Why did they tell me without inviting me?” Eventually anger comes to awareness…disappointment almost always having components of anger…then memories of being excluded from other groups as a child come to mind. I ask, “Who is it that has been excluding you, really?” “Who is it that bypasses your angry feelings instantly and drives them out of awareness?” “If these friends do in fact exclude you regularly, shall we look at the self-hurting part within you that has ignored your anger and remained attached to them for years?” Or “You tell me they often spend time with you, which is clearly inclusive, so what is the cruel part that will not allow you to take in their caring and uses the Getty comment to clobber you (anger turned against self)?” “But now that you are thankfully aware, certainly an achievement, that the anger is present… shall we follow it’s true course and see what it feels like inside your body?” Etc. Bottom line, I believe in embracing all emotions, trusting we have access to them for a purpose.
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December 15th, 2010 admin
I’m excited by readers’ responses to my blog, such as this one: (my comments are italicized): “Susan, I find your blog helpful, clarifying and inspiring—and I have a question/quagmire I would love to have addressed. I can wait and see if it answers itself after I take your class next year, but I thought I’d throw it out there in the event that others might be wondering about something similar.”
“What I have found at conferences, classes and study groups aimed at those interested in attachment theory is equal representation (among attendees) of the students of Davanloo and the students of the Dalai Lama (mindfulness folks, psychotherapists and mindfulness-based psychotherapists).” Perhaps the commonality between Davanloo and the Dalai Lama is that both practice meditative approaches and both awaken us to new realms of consciousness! “I initially struggled to resolve what seemed like a set of irreconcilable differences—the exploration of destructive impulses (STDP) and teachings such as, ‘a truly compassionate attitude toward others does not change even if they behave negatively or hurt you’ (Dali Lama).” I believe that both teachings illuminate truth but neither holds ALL truth.
I wish to make clear that I am in awe of the contributions of the Dalai Lama, the “Buddha of this era,” and I confess up front that I am no expert on sainthood! But I write this blog to express a point of view for the edification of other therapists. If the Buddhist teachings that reference “a truly compassionate attitude” mean that we should have only feelings of love and forgiveness with an absence of anger and rage towards the perpetrators of atrocities and abominable behavior, I do not see this as compassionate towards either the victims, the perpetrators or ourselves. John Bradshaw, who has written extensively on addictions and the family, tells us that most addicts put themselves under tremendous pressure to forgive and that this impedes their recovery…because it bypasses the processing of their feelings. I am aware of countless instances in which true and genuine feelings of love and forgiveness were made possible as a direct result of processing primitive murderous rage.
“I eventually realized my struggles were more over my need to figure out who was right—is ‘anger our real enemy’ as the Dali Lama says or is it more important to create space/acceptance for all human feeling? So I’m not trying to figure out who has it more figured out anymore, but I do wonder how [there are some] who truly do not believe animalistic rage is part of the human condition? Is that always a defense? Could it just be reality—someone with a well-developed “middle prefrontal cortex” might not experience rage?”” Perhaps the Dalai Lama views anger as the “real enemy” because he may associate it with the violent and brutal actions of humans towards each other. Yet I can’t imagine that he and the tragically slaughtered monks in Tibet would not have preferred a strong defense of their lives, which would have required considerable aggressive force with roots in feelings of outrage. Soldiers entering battle to protect those brutalized monks would not be feeling love in their hearts towards their enemy. Anger/rage originates as a PROTEST against abuse, cruelty, abandonment, wrenching loss, violations of freedom, exploitation and all that inflicts suffering upon humanity. Rage only becomes sociopathic when no successful connection is ever actualized and the feeling transmutes into self loathing and self punishment.
When rage is OBSERVED through the eye of pure awareness, as it is in ISTDP, we discover that it is a powerful, pure energy, fast and furious, that begins with the child’s desire to destroy cruel and rejecting forces that create separation from loved ones. Throughout life, it can serve to protect both oneself as well as innocent others. It is OUTRAGE that has led to civil rights and every freedom that we enjoy today. Anger and rage are emotions hard wired into our brains (I choose to believe not by accident) with impulses that flow through our bodies. Do we want to transcend the urges to ACT OUT these feelings in destructive ways? Absolutely! ISTDP will help us to do that! Do we want to turn away from all experience of anger as it occurs spontaneously within our bodies and completely detach from it? I wouldn’t want this in life as we know it. Anger has been my friend in more ways than I can count. I won’t bore you with the details, but take my word for it. Has it been a problem in my life? Yes, but only when acted out or insufficiently processed.
Daniel Goleman writes in his book, Emotional Intelligence,“Buddhist philosophy tells us that all personal unhappiness and interpersonal conflict lie in the ‘three poisons”: craving, anger and delusion. It also provided antidotes of astonishing psychological sophistication-which are now being confirmed by modern neuroscience. With new high-tech devices, scientists can peer inside the brain centers that calm the inner storms of rage and fear. They also can demonstrate that awareness-training strategies such as meditation strengthen emotional stability- and greatly enhance our positive moods.”
Davanloo’s ISTDP (Intensive Short-Term Dynamic Psychotherapy) is a meditative practice in that it instructs us to be fully attentive to our internal experience within the context of the present relational moment. Rather than repeating a mantra or visualizing a candle, we are paying exquisite attention to every nuance of feeling, bodily awareness, and relational phenomena occurring moment to moment in the therapy session. The Buddhist type of meditation is known to promote healing of various medical conditions and to reduce stress (i.e. anxiety). ISTDP is a type of meditation that also promotes healing, lessens anxiety and leads to greater relational fulfillment. In regards to the latter, it is unsurpassed by anything else with which I’m familiar. I know of no other practice that focuses so intently or investigates so thoroughly emotional phenomena and emotional closeness. A young client described her newfound closeness with friends in which the rawest part of herself are now able to be shared as “transformational” and leading to an embracing, secure kind of love.
If “craving,” as mentioned above, refers to our addictions and compulsive defenses, then I agree that such “craving” is a poison. If by “craving,” the reference is to that which causes us to long for (healthy) attachment and love, I do not view this as poison but rather as the greatest of all gifts. It is necessary to long for healthy attachment to make possible its fulfillment (ask anyone who has sought and worked on a relationship), while at the same time face grief to heal from its passing…i.e. letting go.
Another thought on anger as a poison or “the enemy”: A colleague of mine is a follower of the Dali Lama and sponsored an intimate evening at a home in the Hollywood hills to host one of the Lama’s monks, a close associate who was traveling with him while he was in L.A. As the monk sat erectly in crimson and gold robes on a living room sofa, we expected an amazing, intimate chat. Instead, the monk began a tedious, endless, dry, monotone treatise on Buddhist philosophy. The group became increasingly restless and bored, as bodies twisted and turned. The monk did not appear to be aware of the growing frustration in the room. I felt sad and disappointed that this monk was clearly unable to make a connection with the people present, appearing quite emotionally detached, and the group left downcast. I believe that there was loss for both the monk and the group. Had the anger been identified and responded to, an entirely different, life-enhancing experience might have occurred. Detachment does not foster relationship although quiet awareness does! I believe that the group’s anger was due to lack of contact, a PROTEST against emotional distance. Humans do crave connection to each other, but I shudder to imagine a world in which such cravings didn’t exist.
A friend also comes to mind who was heavily involved in transcendental meditation for years. When she experienced a traumatic loss, she turned to her meditation teachers and they became distant and detached which traumatized her further. She started a long road back to healthy relatedness through therapy.
There are many sublime realms to which we have the privilege to enter and one has only to attend a transcendent concert or surpassing theatrical production or read the words of Abraham Lincoln to experience this truth. But try to imagine any of these experiences without emotions? If you try to pick and choose the emotions you want, I predict they will ALL be STUNTED. Feelings like thoughts just ARE. We are always wise to observe them and to notice their manifestations in our bodies. We are then free to choose whether to act upon them or not and whether they deserve further focus or not. What a lifeless world this would be without our emotions, ALL of them…something like what I experienced with the detached monk! IN CONCLUSION, I FEEL PROFOUND GRATITUDE TO BOTH THE DALAI LAMA AND DAVANLOO FOR IMMENSELY ENRICHING OUR LIVES.
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December 10th, 2010 admin
Check out Susan’s Special Events for 2 exciting offerings, one next weekend with Dr. Robin L. Kay on “Thwarting the Transmission of Trauma with Deep Affective Processing.” Not too late to register!
I really like hearing from fellow therapists who invite feedback on compelling issues, such as this one: “My referrals have increased dramatically since doing this (ISTDP, an intensive experiential, emotion-focused dynamic therapy) so something is going right. However, I feel drained, exhausted, stressed and more porous to all my patients’ distress.”
This is naturally the case. When I began learning ISTDP, it began to feel like training to become a surgeon (with the patient/client as part of the team)…in the sense that I was being handed very powerful tools that could bring about remarkable healing and in some cases, save lives. As thrilling as it was to be acquiring these skills, it was simultaneously terrifying. Some may say this is an overstatement, but I am speaking for myself. A misstep or misalliance could have real consequences such as wounding or alienating a valued client. A failure to intervene could also have consequences, an ineffective treatment. All therapies carry some of these risks, but ISTDP seemed to heighten them…while also holding out the possibility of greater reward.
Once in my youth, I was on an island in the Sacramento River delta that had some canoes along the shore. A friend and myself foolishly thought we could drift a little way along the edge of the island even though we had no paddles!!! We were holding on to branches and thought we could just jump out at any time. We hadn’t foreseen that we would in minutes be in the midst of swirling, fierce currents beneath the calm river, and our little canoe was rapidly swept far from the shore beyond our control. Had there not been others who were able to rescue us, I might not be writing this blog.
If you look at my website, you will see the words “Journey to the Core.” Our core emotions, especially when linked to excruciating traumatic experiences, can be very akin to those powerful, wild river currents. Human emotions can howl and rip apart and also fiercely embrace. They can be so BIG that grown-ups as well as children shrink from them. And if we’re going to enter that territory beyond the defenses, we had better have our paddles and know how to use them!
The ISTDP therapist deals with emotional hurricanes, including amazingly touching moments, every day, even every hour. A colleague called the training “labor intensive.” A trainee told me she couldn’t imagine dealing with this level of intensity on a regular basis. Patients/clients routinely say, “How do you do this?” Understandable… we are the trauma team rushing into a building that everyone else is trying to escape.
So, what can I say to my challenged colleague? Obviously, you are not alone in what you are experiencing! All of us pass through the period where we are “drained, exhausted, stressed and more porous to all my patients’ distress,” if we are dedicated ISTDP therapists. And yes, the waters get very rocky until we learn how to maneuver our paddles, i.e. recognize the patient’s fragile structures and know when there is enough ego strength (“restructured defense and anxiety”) before venturing into the open sea of feeling.
Just be kind to yourself, dear therapist, and go slowly with yourself as well as your patient. Practice due diligence as you build your skills. Get lots of support, breathe, watch your own anxiety levels and heed them (i.e. track your own physiological events) and slow down when you need to. Restore yourself in the many ways that can work for you. And APPRECIATE your courage and dedication as a member of a specialized trauma team.
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December 1st, 2010 admin
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.
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October 13th, 2010 admin
Have you marked November 13 on your calendars yet? If you want to introduce yourself to ISTDP or strengthen your existing skills, please join Thomas Brod, M.D. and me as we present cases (video) at a special joint event co-sponsored by Southern California Society for ISTDP and the New Center for Psychoanalysis (Los Angeles) on Saturday afternoon November 13 1-4 pm. Each theoretical element of this amazing therapy can deepen your work!
For details go to: <http://www.n-c-p.org/edu-event.asp?id=160&the_type=Course>. CEUs included.
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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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