January 25th, 2011 admin
I wish to express much gratitude to Bridget Quebodeaux for her penetrating questions/comments that inspired my last posting, “Dalai Lama or Davanloo.” I alerted the STDP listserve of this vibrant topic and counted 39 thought provoking exchanges that resulted.
Before sharing further reflections on this topic, I’m happy to say that my excitement over both practicing and teaching ISTDP continues to grow. Dr. Tom Brod and I are currently conducting an extended workshop in ISTDP to a terrific group of therapists in L.A. We are including an experiential portion that invites therapists to share their feelings as they are exposed to our teaching, as they participate in our group, and towards us as well. It brings us to a deepening level of connection, compassion and respect for one another and lessens barriers to learning. Now, to continue on the topic…
Bruce Ammons, Ph.D.. Clinical Psychologist, quoted Jack Kornfield, a teacher of the Buddhist mindfulness practice known as Vipassana, who tells us that while “some people have come to meditation after working with traditional psychotherapy…[and have] found therapy to be of value, its limitations led them to seek a spiritual practice. For me it was the opposite. While I benefited enormously from the training offered in the Thai and Burmese monasteries…I noticed two striking things… first, there were major areas of difficulty in my life, such as loneliness, intimate relationships, work, childhood wounds, and patterns of fear, that even very deep meditation didn¹t touch; second, among the several dozen Western monks (and lots of Asian meditators) whom I met during my time in Asia, with a few notable exceptions, most were not helped by meditation in big areas of their lives. Many were deeply wounded, neurotic, frightened, grieving, and they often used spiritual practice to hide and avoid problematic parts of themselves.”
I see inevitable limitations and also breathtaking strengths in many of our therapeutic and spiritual practices simply because we are, after all, humankind. It is our nature to evolve and yet never to arrive. I believe it is a fearful thing to be human in a grand universe over which we have little control and both the Dalai Lama and Davanloo advocate the wisdom of surrender, utilizing our capacities for discipline and awareness, as have many other great teachers. Each teach us different aspects of surrender. Davanloo would have us flow with, rather than against, the feeling forces within us and also to engage in the daily practice of self/other compassion.
The grand debate seems to whether anger is a less evolved state, an emotion to rid ourselves of, or whether it is a feeling to be trusted and fully experienced. I subscribe to the latter and have found invaluable direction, protection and also satisfaction through respect for this emotion. Anger is not pleasant but both physical and psychological pain is always made worse by resistance and fear, which also serve to suppress our joyful, loving feelings. Anger is also a part of ourselves, like it or not, so to reject it is to turn away from a vital part of who we are. There are 2 relationships we cannot live without…to self and other. I happen to be among those who believe that a spiritual relationship is also vital to our fulfillment.
James Phillips, MBACP UKCP reg., tells us “the Buddhist writer Pema Chodron’s motto for meditating on difficult emotions is ‘neither repress nor indulge’ which I think is exactly what we train our patients to do, to experience their full range of emotions and impulses as they arise within, without either repressing them or acting out. I do struggle to get some patients, who are very identified with ‘transcending’ anger, to see that this amounts to repression and is the surest way to guarantee that the anger will in fact hang around and leak out in all kinds of undesirable and unconscious ways.”
Thanks for this contribution, James. I do have one suggestion…When you say “to get some patients to,” you may be placing more of a burden on yourself than is necessary. I might say to such a patient, “We see how your attempts to transcend anger has not prevented it from coming out in ways that you do not want. It is futile to try to convince you that there is a link between your disdain for your anger and your (explosive outbursts) or (cutting comments to your wife). However, we could experiment with a new way of approaching and fully exploring your anger and you will then see for yourself if you get a better result. On the the hand, you could continue to pursue transcending rather than experiencing your anger. It is up to you.
My hope is to help people to SEE their dilemma..to risk cooperating with the ISTDP therapist’s approach or to guarantee that the treatment will fail. It helps a great deal that I have grown so confident in its efficacy. I really can’t think of a patient who has CHOSEN to try the ISTDP approach and engage in a practice of tracking emotions, anxiety and defense…working through rage, guilt, grief and almost inevitably arriving at longing/love…and practicing caring treatment towards the self…who has not seen real change, often character change, in themselves. Success over the resistance to deep exploration of feelings will depend both on the client’s choice and the therapist’s skill, but once this path is embraced, the outcomes are rich.
James goes on to say, “I would agree that many writings about Davanloo’s work lead one to believe that it’s about “anger, rage, murderous rage, etc.” but my experience of his tapes has been different (and I’ve been to quite a few of his metapsychology workshops in Montreal). He does work in very penetrating ways, and the work he shows illustrates a high rise in complex transference feelings. The tapes almost always include anger, and they often stir up a lot for the therapists watching them, but ultimately his work is about freeing the person from the repressive forces which haunt them. This, in turn, gives room for re-connection and forgiveness to arise – and for a more caring and compassionate life. Whether we talk about it from a ‘spiritual’ perspective or a ‘psychotherapeutic’ perspective, isn’t that what it’s all about?
One listserve participant shared this quote from Einstein: ‘A human being is part of a whole, called by us the ‘Universe,’ a part limited in time and space. He experiences himself, his thoughts and feelings, as something separated from the rest – a kind of optical delusion of his consciousness. This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest us. Our task must be to free ourselves from this prison by widening our circles of compassion to embrace all living creatures and the whole of nature in its beauty.’ ”
One of my supervisees had a patient who declared, “I do not WANT” to care about others.’ My question to her would have been, ‘And do you WANT to care about yourself?” To “widen our circles of compassion,” must we not start within?
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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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