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LIVES TRANSFORMED

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LIVES TRANSFORMED The Art and Science of Experiential Dynamic Psychotherapy Stockholm August 2010 Patricia Coughlin, Ph.D. Take home message It is possible to become ... – PowerPoint PPT presentation

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Title: LIVES TRANSFORMED


1
LIVES TRANSFORMED
  • The Art and Science of Experiential
  • Dynamic Psychotherapy
  • Stockholm
  • August 2010
  • Patricia Coughlin, Ph.D.

2
Sullivan
  • If you do not feel equal to the headaches that
    Psychiatry induces, you are in the wrong
    business.
  • Skill in psychotherapy consists of doing as much
    with as little as possible.

3
Scientific Approach
  • 1 Must have a theoretical basis of
    understanding human functioning and unconscious
    processes
  • 2 develop skills/techniques that clinically
    effective and
  • 3 - are consonant with theory and supported by
    empirical research

4
Todays Program
  • Introduce you to Davanloos method of Intensive
    Short Term Dynamic Psychotherapy
  • By laying a theoretical foundation
  • Describing the method in detail
  • Acquainting you with the research support
  • Illustrating the method with videotape

5
DAVANLOOS ISTDP
  • Based on his understanding of psychoanalytic
    theory of neurosis
  • Developed new techniques designed to accelerate
    and condense the process by precipitating an
    intrapsychic crisis, creating an opening into the
    unconscious
  • Taped sessions and conducted follow to study
    outcome and bring scientific method to bear

6
PSYCHODYNAMIC PRINCIPLES
  • Based on Freuds Second Theory of
    Anxiety Anxiety is a signal that some
    threatening feeling or impulse is on the rise.
  • Defenses reduce anxiety and keep threatening
    feelings out of consciousness BUT
  • Excessive reliance on these defenses causes
    the symptoms and difficulties the patient wants
    help with
  • This creates conflict patient wants help for
    relief of symptoms but doesnt want to face
    feelings they have been avoiding

7
Attachment/Emotion Theory
  • This is an attachment theory
  • Feelings that are thwarted or punished become
    associated with anxiety and are avoided
  • If there is significant or repeated rupture to
    the attachment, the child is overwhelmed with
    pain and reactive rage
  • Rage toward loved one stimulates guilt
  • Guilt drives self punishment and protects loved
    one

8
BOND With Parents
9
BOND With Parents
Trauma
10
BOND With Parents
Trauma
PAIN
Rage, Guilt about the Rage
11
BOND With Parents
Trauma
PAIN
Rage, Guilt about the Rage
Feelings avoided Self-destruct Symptoms
12
THE TWO TRIANGLES
A
D
C
T
  • Triangle of the Person
  • T Transference
  • C Current Figures
  • P Past Genetic Figures
  • Triangle of Conflict
  • A Anxiety
  • D Defense
  • I/F Impulse/Feeling

P
I/F
13
Same theory, new technique
  • Only 20 respond to interpretation
  • Developed techniques designed to create/intensify
    internal conflict
  • Shift from defense and resistance to activation
    and alliance
  • Experience of avoided feelings is key to
    unlocking the unconscious
  • De-repressed material makes sense of patients
    suffering
  • Awareness create choice

14
Central Dynamic Sequence
  • Phase I INQUIRY
  • Phenomenological approach
  • Survey of difficulties/symptoms
  • Get example, usually regarding
    precipitant
  • Focus on feelings
  • Phase II DEFENSE WORK
  • Identify and clarify defenses
  • Focus on negative consequences
  • Pressure and challenge
  • Turn the ego against defenses

15
Central Dynamic Sequence
  • Phase III BREAKTHROUGH OF FEELINGS
  • Rise in complex feelings in C or T
  • Signal from the unconscious that
    impulse is pre-cs
  • Passing of the impulse with portrait
  • De-repression of memories
  • Obtain relevant history
  • Phase IV INTERPRETIVE PHASE
  • Cognitive re-analysis of process
  • Make T-C-P links
  • Get consensus and form contract

16
Psychodianostic Procedure
  • 1- Pressure to feelings toward significant other
  • 2 - Monitor anxiety
  • 3 - Block defense
  • Only 3 responses possible
  • Patients response to intervention is diagnostic
    and guides next step
  • Each treatment tailor made

17
Two Forces within Psyche
  • As Davanloo developed techniques to block defense
    and resistance and got to buried feelings he
    discovered
  • There is a healing force within the unconscious
  • This is our ally unconscious therapeutic
    alliance
  • Work to activate and strengthen healing capacity
    while blocking defenses that prevent growth and
    perpetuate suffering

18
Basic Human Feelings
  • Love, fear, anger, sadness/grief, sexual desire
  • Components of Affect
  • 1 - cognitive label
  • 2 - physiological activation
  • 3 - impulse/action tendency

19
CHANNELS OF ANXIETY
  • STRIATED MUSCLE
  • SMOOTH MUSCLE
  • COGNITIVE DISRUPTION

20
FORMAL DEFENSES
  • REGRESSIVE
  • Projection
  • Denial
  • Dissociation
  • Acting out
  • Somatization
  • REPRESSIVE
  • Intellectualization
  • Rationalization
  • Minimization
  • Displacement
  • Reaction formation

21
TACTICAL DEFENSES
  • VERBAL
  • Vague and general
  • Diversification
  • Sarcasm
  • Argumentative
  • Contradictory
  • Rate of speech
  • NON-VERBAL
  • Avoiding eye contact
  • Arms and legs crossed
  • Smiling
  • Laughing
  • Weepiness
  • Temper tantrums

22
RESULTS OF WORKING THROUGH
  • Reduction in anxiety/increased tolerance for
    conscious experience of anxiety
  • Decreased reliance on defenses
  • Increased emotional activation and expression
  • Enhanced understanding of inner self with
    coherent life narrative
  • Increasing tolerance for ambivalence and
    complexity

23
Early Research Efforts
  • Alexander and French
  • David Malan
  • Davanloo
  • Winston and Beth Israel Group
  • Allan Abbass
  • Leigh Mc Cullough the Norwegians

24
Davanloo
  • Amassed N1 studies, all recorded on video tape
  • Demonstrated that it is possible to expose core
    conflicts within first contact
  • The emotional and visceral experience of feelings
    is key to cure
  • Developed techniques to create an intrapsychic
    crisis, creating a therapeutic emergency,
    allowing for rapid re-organization of personality
  • Long term follow-up revealing the sustained
    nature of changes achieved in therapy

25
Empirical Basis of ISTDP
  • 1960-Present Davanloos case studies
  • Controlled Clinical Trials 60 published studies
    finding strong evidence for efficacy in broad
    range of conditions
  • Effective with treatment resistant depressives
  • Effective with personality disorders
  • Effective with somatic patients, movement
    disorders and fragile patients
  • Huge cost savings to the health care system

26
Empirical Basis of ISTDP II
  • Superior to wait list
  • Superior to medication in long run
  • Clinically effective in real world
  • Cost effective
  • One ISTDP session outperforms standard intake
    interview

27
ABBASS, 2002
  • 89 consecutively referred patients treated on an
    average of 15 sessions
  • Average age of 40
  • 25 unemployed and on disability
  • 46 on multiple meds
  • 83 treatment resistant

28
Abbass Results
  • 71 stopped all meds
  • 18 of 22 back to work
  • 17 of 18 off disability insurance
  • Combined savings from prescriptions, disability,
    hospital and physician costs of 402,523 per year
    for three years following treatment

29
Process Research
  • Weinbergers Meta-analysis revealed
  • 1 development of strong therapeutic alliance
  • 2 helping patient confront what they tend to
    avoid
  • 3 revival of hope
  • 4 increased sense of mastery competence
  • 5 attribution of success to patient

30
Case Studies
  • Possible for patients to serve as their own
    controls
  • Lay down criteria for cure following the trial
    therapy
  • Make predictions about issues to be dealt with
    and compare those to actual results at end of
    treatment
  • Follow-up to assess whether changes hold over time

31
Neuroscientific evidence
  • Our brains are wired interpersonally
  • Neurons that fire together, wire together
  • The brain is plastic and changes as the result of
    experience
  • Psychotherapy changes the brain

32
How to change the brain
  • Establish trust and collaborative alliance
  • Focus, intensity and repetition
  • Induce moderate levels of anxiety, alternate with
    periods of calm
  • Activate multiple levels of experiencecogntive,
    emotional, somatic and interpersonal
  • Facilitate profound moments of meeting
  • Create meaning and coherence

33
The most vital elementYOU
  • The person of the therapist is the most potent
    but understudied variable
  • Top 15 do better than all the rest combined
  • Passionate and enthusiastic
  • Open and flexible/adaptable/approachable
  • Masters at handling relationship
  • Humble, life long learners
  • Pressure themselves and patients to get
    extraordinary results
  • Reflective - they ARE the change they want to
    promote

34
Take home message
  • It is possible to become far more effective and
    efficient
  • Self development
  • Study
  • Practice, Practice, Practice
  • 10,000 hours to become a master
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