Experiencing Love and Guilt about
Rage: the central change agent in
Davanloo's ISTDP
Allan Abbass MD, FRCPC
Professor and Director of Education,
Director, Centre for Emotions and Health
Dalhousie University, Halifax, Canada
[email protected] www.istdp.ca
(c) Dr Allan Abbass
Overview
• Davanloo’s “new metapsychology of the
unconscious”
• Clarifications of major technical interventions
• Case example: The Angry Scientist
(c) Dr Allan Abbass
“The ISTDP therapist must have the utmost
respect for the patient while at the same time no
respect for the resistances that have paralyzed his
or her functioning”
(c) Dr Allan Abbass
“The ISTDP therapist must have the utmost
respect for the patient while at the same time no
respect for the resistances that have paralyzed his
or her functioning”
These 2 processes should happen
simultaneously: otherwise the process is
splitting and can have negative effects
(c) Dr Allan Abbass
ISTDP Papers Since 1995
– Specific diagnosable patient categories
– Central focus on the T
– Specific interventions and timing
– Specific responses relates to specific therapy events
– How to identify and use specific unconscious signals
– Specific techniques for fragile, somatizing and other
patients
– The somatic pathways of rage, guilt and grief
– The need for continuous positive regard
– Central role of love and forgiveness
(c) Dr Allan Abbass
The evolving Davanloo: 2012 +
•
•
•
•
He still teaches
Others teach for him
He cites published research
Acknowledges, including by letter, contributions
of others
• Is much clearer about technique, how it works
and how to teach it.
• Is clearer about the central role of love,
attachment and forgiveness
(c) Dr Allan Abbass
Metapsychology of ISTDP
Genesis of Psychoneurotic Disorders
BOND
PAIN
RAGE, GUILT
about the Rage
Character problems
Symptoms
(c) Dr Allan Abbass
Spectrum of Patients with
Fragile Character Structure
Spectrum of
Psychoneurotic Disorders
Low R
Moderate R
High R
Mild
Moderate
Severe/
Borderline
These are diagnosable and have different treatment pathways
(c) Dr Allan Abbass
Davanloo, 1995, Abbass 2002
Metapsychology of ISTDP
Triangle of Conflict
Unconscious
Defence
Unconscious Anxiety
Striated Muscle
Smooth Muscle
Cognitive-perceptual
Isolation
Repression
Projection
Superego
Unconscious Feelings
Pain, Rage, Guilt, Grief
(c) Dr Allan Abbass
Psychodiagnosis  Roadmap
Clamp Resistance
Unconscious
Defenses
Unconscious
Anxiety
Monitor
Response
Pressure
Unconscious
Feelings
(c) Dr Allan Abbass
3 Categories of major resistance
• Isolation of Affect
– Talk about it without somatic experience
• Repression
– Shut down emotions unconsciously into the body
or depression etc
• Projection and Projective Identification
(c) Dr Allan Abbass
Resistance of the Punitive Superego
Davanloo 1988 a and b
• Manifestations: Repeated/chronic self defeat and self
sabotage.
• Origins: Violent and murderous rage toward loved ones and
guilt about this rage.
• Countless modes of presenting to psychology, medical,
social and legal systems
• IT is protective of others AND self-constrictive and selfpunitive
(c) Dr Allan Abbass
Complex Transference Feelings (CTF) I
• Includes positive feelings and irritation toward the therapist
which link to past feelings about the bond, trauma, pain,
rage and guilt
• Mobilizing CTF is the engine to the Unconscious
Therapeutic Alliance.
• The essential element of ISTDP is rise in CTF  UTA
• Mobilized by having an increasing lack of respect for the
resistance in the service of assisting the patient to
overcome these behaviors.
(c) Dr Allan Abbass
The central task of the ISTDP Therapist is to
reach through the Resistance to the person
stuck underneath (Pressure)
If the patient is too weak to reach
back then build capacity (Graded
work and other elements)
If they involuntarily resist in the
transference help them see and
overcome that barrier (Clarify,
challenge and Head on collide)
(c) Dr Allan Abbass
This can only happen with continuous
positive regard for the patient
Coupled with this is a continuous
negative regard for the resistances that
are destroying the patient and his
relationships
(c) Dr Allan Abbass
Interventions in 30 ISTDP Trial Therapies
(Abbass, Joffres & Ogrodniczuk, 2009)
Intervention
Rate per hour
Percent of all
Pressure
97
59%
Recapitulation
29
19%
Clarification/challen 23
ge
Inquiry
9
14%
Dynamic Exploration 6
3%
5%
(c) Dr Allan Abbass
Pressure
Davanloo 1999
• The mainstay intervention of ISTDP
• Encouraging the patient to connect to his true feelings and
be open with the therapist about these feelings.
• = Reaching through resistance to the person underneath
• Psychodiagnosis and Road map
• Pressure increases CTF, UTA and Resistance
(c) Dr Allan Abbass
Technique of Unlocking the Unconscious
Davanloo 1988-2001
UTA
R
CTF
R
UTA
Pressure
(c) Dr Allan Abbass
“Unlocked”
Challenge Davanloo 1999
– This is done only when the resistances are crystallizing in
the therapeutic relationship (transference), when they
are an obstruction to the therapeutic bond and task
– First, clarify the defences with the Patient
– Then pressure: encourage the patient to overcome the
resistances with you
– Finally, challenge the defences in concert with the
patient.
(c) Dr Allan Abbass
Technique of Unlocking the Unconscious
Davanloo 1988-2001
UTA
R
Resistance is in T
Clarify
CTF
and Challenge
Keep up Pressure
UTA
(c) Dr Allan Abbass
R
“Unlocked”
Head on Collision Davanloo 1999
• With the resistances crystallized in the
transference this most powerful intervention
highlights the reality of
– the limits of the therapist,
– effects of resistance
– potential of the alliance
– And encourages the patient to do his or her best
• Again, seldom used with low capacity patients.
(c) Dr Allan Abbass
Technique of Unlocking the Unconscious
Davanloo 1988-2001
UTA
R
CTF
Resistance in T
Head on Collision
Pressure
Challenge
R
UTA
(c) Dr Allan Abbass
“Unlocked”
Unlocking of the Unconscious
– CTF are experienced: anxiety and defence are
removed or reduced
– UTA is greater than resistance
– Partial versus major versus extended unlocking
• Partial: Link to past
• Major: Image changes to the past person
• Extended: During breakthrough of rage the
image is the past person
(c) Dr Allan Abbass
Central Dynamic Sequence
• Systematic Analysis of the Transference
–Extensive Cognitive Recap of findings
–Collaborative and repetitive
–Extremely important in patients with panic,
somatization, depressive disorders and
fragile character structure
(c) Dr Allan Abbass
Inquiry
Experience
Feelings
Low
Resistance
Resistance goes up
Experience
Feelings
Pressure
Moderate
Resistance
Resistance goes into the T
Clarify and Challenge
Go flat at any point
Experience
Feelings
Depression,
Somatization,
Fragile
(c) Dr Allan Abbass
High
Resistance
Graded
Format
to build
Capacity
Graded Format:
1. Pressure to feelings or to defences
2. Rise in complex feelings and anxiety
3. Intellectual recap to bring down anxiety
1
Anxiety
2
(c) Dr Allan Abbass
Summary
• ISTDP takes place via continuous positive regard for the
patient
• Out of that positive regard there is a continuous pressure
on or disrespect for the resistances that paralyze his or her
functioning.
• This complex stance brings the UTA
• Specific diagnostic system and treatment system
• Specific interventions, timed and dictated by the format of
unc anxiety, resistance, state of complex feelings and UTA
– Pressure vs Challenge vs Head on Collision
(c) Dr Allan Abbass
Immersion Training
• Halifax Canada September 24-27: Focus on
detecting mobilzation of the Unconscious.
Plus 6 quest speakers
• Stockholm: October 18-21, 2012: Overview
and psychodiagnosis across spectrum
• Norway June 10-13, 2013: The Highly
Resistant Patient
• Contact Jennifer at [email protected]
(c) Dr Allan Abbass
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Experiencing Love and Guilt about Rage - istdp-uk