Separating the Ego and
Superego: Working with a
Fragile Recovering Drug
Addict
Jon Frederickson, MSW
November 2011
Copenhagen, Denmark
www.ISTDPInstitute.com
Psychodiagnosis
3) Identify Defences
2) Monitor Anxiety
Unconscious
Defences
Unconscious
Anxiety
Unconscious
Feelings
1) Invite
feeling
Levels of SE Pathology
• Fragile patients
• High Resistance
• Moderate Resistance
• Low Resistance
ISTDP and the Superego
• Pressure to Feeling
• Defense identification
• Challenge Defenses
• Resistance in the T
• Confront the Transference Resistance
• Breakthrough
Modifications of ISTDP Technique I
• Ten Have de Labije: mobilization of ego
adaptive capacity and separation of ego
and superego prior to the phase of
pressure. Immediately point out the
superego basis of defenses and the
superego basis of the non-therapeutic
relationship the patient tries to establish.
Ideal Ego Adaptive Capacity
• Observing ego: anxiety, feeling and defense
• Attentive ego: anxiety, feeling and defense.
• Ability to differentiate feeling from anxiety,
•
•
feeling from defense, and anxiety from defense.
Able to see causality: feeling evokes anxiety
which evokes defenses.
Dystonic: able to distinguish healthy ego from
unhealthy part of the superego; able to feel guilt
and grief over the cost of the defenses; able to
turn against destructive defenses.
Do we see ego or identification
with the superego?
• I don’t observe my feelings or anxiety.
• I don’t pay attention to my F, A, or D.
• I don’t differentiate feeling from anxiety: I
strangle and punish myself with anxiety.
• I don’t differentiate myself from defense: I
identify with my destructive defenses.
• Causality? My defenses don’t cause my
presenting problems; other people do.
Do we see ego or identification
with the Superego?
• I can’t help it = I’m identified with my
superego, my healthy ego is in you, so get
to work and see if you can overcome the
team of me and my superego against you.
• My defenses aren’t destructive; they’re
what make me feel safe.
Separation of Ego and Superego
• Confront patient with her identification with the
•
•
•
•
superego
Differentiate the healthy part of the ego from
the unhealthy part of the superego
Restructure ego capacity; differentiate the
triangle and see causality
Challenge patient to stand up to the SE
Help patient bear increasing levels of feeling
with manageable anxiety.
Modifications of ISTDP
Technique II
• Robert Neborsky: distinguish between the
superego based insecure attachment and
the secure attachment offered by the
therapist; point out the function of
superego affects; point out the superego
based relationship each defense invites;
point out the superego basis of projected
transference images; metaphors to help
patients with problems of symbolization.
Modifications of ISTDP
Technique III
• Allen Kalpin: attention as the basis of a
secure attachment, inattention as
evidence of superego activity; use of
cognitive therapy techniques to help
patients differentiate feeling from
defenses (pathological beliefs), see correct
causality, differentiate ego from superego
habit. In other words, develop all ego
capacities necessary prior to the phase of
challenge.
Modifications of ISTDP
Technique IV
• Each of these innovators understands the
difference between a principle and a
technique.
• Principle: separate ego and superego.
• Technique: any technique from any school
of thought may used as long as it serves
the fundamental principle.
Viewing Defenses and the Alliance
through the Prism of the Superego
Defense: patient talks over and ignores her
anxiety. [identifies with superego]
Relationship: I invite you to join me in
ignoring my anxiety. [be a superego to
me]
Object relation: dismissive parent and
suffering, ignored child.
Attachment pattern: insecure, avoidant
Superego based Interventions
• Defense: Do you notice you ignore your
anxiety right now?
• Relationship: Do you notice that you are
inviting me to pay attention to your friend
instead of to you right now? That you
invite me to ignore you?
• Object relation: What kind of therapist
would I be if I joined you in ignoring you?
Superego based Interventions II
• “I don’t know.” “Is that really true, or is
that a way you have of ignoring yourself?”
• “Do you notice that you say that before
you even give yourself a chance to pay
attention to yourself, before you even let
yourself think? Is that a way you have of
not paying closer attention to yourself?”
Task versus Superego Activity
• You will need to take a stand against that
self dismissal of your emotions.
Otherwise, we will not be successful.
• So who is going to be in charge here--you, or these destructive habits?
• Ego or superego?
• Secure attachment or insecure?
• New relationship or repetition of trauma
bond.
Why the patient does not see the
superego: Externalization!
• She obviously doesn’t care about me,
because if she did she wouldn’t wear
perfume when I come to visit.
• You obviously don’t care about you,
because if you did you wouldn’t wear her
perfume by staying there for hours while
having that allergic reaction.
Externalization:
the superego’s best friend
• Mistaken causality: she ignores me.
• True causality: When angry, I punish myself by
•
staying by her perfume and inflicting an allergy
upon myself. Then I blame her for my choice to
stay and have an allergic reaction.
As long as the patient projects his superego
onto others, he does not see how he creates his
suffering. His suffering is “caused” by people in
the external world. The patient remains blind to
the ways the superego inside him causes his
suffering. Thus, the patient chronically
misunderstands causality.
Externalization:
the superego’s best friend II
• Problem of causality:
• Mistaken causality: she made me put $100,000 into her
•
•
•
bank account.
True causality: I was angry with her, punished myself by
putting $100,000 into her account, then blamed her for
my decision.
Anger; A; self punishment; projection of superego.
If I accuse her of punishing me, I can ignore how I
punish myself, thus allowing my suffering to continue.
This is why blame and complaining are considered
defenses in ISTDP.
Externalization:
The superego’s best friend III
• Mistaken causality: He hit me twice!
• True causality: enraged with his brother,
he punished himself by accepting the
second blow, then blamed his brother.
• Anger; A; self punishment; blame.
• He hit you once. The second time you hit
yourself, using his arm.
Impact of Superego Pathology on
Ego Adaptive Capacity I
• High anxiety prevents the mobilization of
an observing or attentive ego. Since she
can’t see her defenses, she can’t turn
against them.
• Identification with a neglectful parent
leads patient not to pay attention to her
anxiety or feelings. Since she does not
pay attention to her anxiety, she can’t
regulate it. Thus, she remains tortured by
anxiety.
Impact of Superego Pathology on
Ego Adaptive Capacity II
• Since the defenses are so chronic and
•
automatic, the patient believes that is who she
is. Fusion of ego and superego.
The patient cannot see causality: feeling triggers
anxiety which triggers defenses which cause her
presenting problems. As a result, the patient
has a mistaken theory of causality: defenses are
the solution to my problem, not its cause.
Separating Ego and Superego
• Identification with the superego: “that’s the way
•
I am.” “No, that’s the way you deal with your
feelings.”
“Do you remember when you saw your babies?
Did they hate themselves? Did they hurt
themselves? Right. See, you have to learn to
do crazy stuff like that. So those babies? That’s
you. This self hate and all that, those are just
habits you picked up along the way. They have
as little to do with you as a cancer tumor does.”
Separating Ego and Superego II
• Inability to differentiate observing ego
from superego affects. “I am anxious.”
“Do you notice how it’s as if a policeman
comes in the room right now to paralyze
you with this anxiety? How this anxiety
comes in to attack you right now? This
must be upsetting how this anxiety does
such a number to you.”
Superego Affects
• Anxiety, guilt, and shame.
• The key is not the historical origin, but the
function of these affects in the here and
now: to paralyze and cripple the patient.
• The superego attacks the ego through
these affects to prevent the patient from
using adaptive feelings in an adaptive
way.
Separating Ego and Superego III
• Inability to differentiate conscious choice
of the ego from automaticity of the
superego. “It’s not a choice.” Analogy of
driving a car.
• Inability to distinguish the healthy ego
from the unhealthy part of the superego.
“Is that the healthy or the unhealthy part
of you?”
Separating Ego and Superego IV
• Problem in representation: “But that
anxiety is not you. You are like this tree,
but it’s so covered up with this vine of
anxiety and shame that after awhile you
forgot there was a tree, you, underneath
all those vines. So we are having to peel
those vines of anxiety and shame off of
you so we can see who you really are
underneath all of that.”
Superego Theory Advances within
ISTDP
• Davanloo: pathological superego based on
unconscious guilt due to murderous rage
in the context of a trauma to the bond.
• Kernberg: superego comprised of
internalized object relations.
• Neborsky: each defense is an invitation to
act out an internalized object relation in
the superego which would lead to an
insecure attachment.
The Guises of the Superego
• These pathological superego internalized object
•
•
•
relations take three forms:
1) I will be a superego to myself. [Patient
ignores her anxiety.]
2) Let’s both be a superego to me. [I invite you
to ignore my anxiety too.]
3) I will be the superego to you. [I (as SE) will
ignore and dismiss your efforts and invite you to
be my healthy part. Therapist masochistically
submits to the patient’s superego.]
Patient
• African-American woman in her forties
who is in a drug rehabilitation facility to
overcome her twenty year addiction to
cocaine. She suffers from chronic
depression, panic attacks, frequent
migraine headaches, vomits as soon as
she has a feeling, and hears a voice that
tells her to use drugs.
Smooth Muscle Pathway of Unc.
Anxiety Discharge
• Exceeds threshold of anxiety tolerance.
• Regulate anxiety immediately.
• Identify anxiety.
• Differentiate observing ego from
experiencing self.
• Recap the triangle of conflict.
Structure the Treatment: Task I
• Patients with low ego adaptive capacity
can not maintain focused attention on
therapeutic goals. Instead, their defenses
create unfocused sessions which yield little
benefit. And their defenses keep them in
a physically dysregulated state! A
disorganized, inattentive, and noncollaborative relationship results because
they are unaware of the TASK.
Structure the Treatment: Task
• The therapeutic task is for both patient and
•
therapist together to:
Pay continual, kind, and loving attention to the
bodily experience of feelings, the bodily
experience of anxiety, the shifts in feeling and
anxiety, and shifts in the degree of collaboration
and relationship. That is a secure attachment. It
also means a partnership where both therapist
and patient take a stand against the superego.
The Task as Proposed by the
Superego
• We are here to ignore and dismiss my feelings,
anxiety, and defenses (and the therapist). We
are also supposed to ignore how these defenses
create my presenting problems, how they
prevent any anxiety regulation, and how they
are destroying any possibility of a collaborative
relationship. You see, I am busy trying to
recreate the insecure attachment I grew up
with.
Projection
• This wish frightens me. Therefore,
• I attribute this wish to you. It is not that I
want to reveal myself to you; it is that you
want to ask questions and find out about
me.”
• I don’t have a wish to reveal; you have a
wish to invade.
• “I want to reveal myself to you.”
Superego Affects
• Anxiety, guilt, and shame.
• As soon as the patient wants to reveal
herself, the superego uses these affects to
paralyze the patient.
• Superego affects are the bars of the cage
which imprisons the patient.
• We help the patient see the FUNCTION of
these affects: to inhibit, paralyze, and
sabotage.
Differentiate Ego and Superego
• Differentiate observing ego and superego
affects.
• Differentiate observing ego and self
attacking defenses (dis-identification):
“this attacking anxiety must be upsetting
to you.”
• Differentiate who she is from how she
treats herself.
Deactivating Projections
• Splitting: I want this; I don’t want this.
• Projection: You want this.
• Redirect her attention inward.
• Remind patient of facts which she forgets
under the impact of projection: her will,
her goal, her desire, her agency.
• Indication projection is deactivated: drop
in projective anxiety. Patient will relax,
become present, thinking will clear.
Assessing Projection
• Tactical defense: patient has access to
striated, can mentate, and projection is
merely a device to distract you from
pressure to feeling. Press for feeling.
• Cognitive/perceptual disruption: little or
no striated, drifting, can not mentate,
patient fears you as the projected figure.
Recap, regulate anxiety, restructure
projection.
Anxiety vs. Projective Anxiety I
• CTF rising in the patient cause anxiety.
• When the patient projects her anger on
you (her will to reveal herself, her wish to
know herself), she will fear you as the
“angry” one, the one who “wants to ask
questions”, the one who wants to get “in
her mind.”
• Anxiety in response to her projection onto
you is projective anxiety.
Anxiety and Projective Anxiety
• If a patient is projecting and fearing you
as the projection, you must clear up the
projection and the projective anxiety first.
• If a patient projects her anger onto you,
then is angry at you, do NOT pressure to
this anger. It is not anger at you, but
anger at a projection. This will lead to a
misalliance.
Intervene before the Defense
• Feeling
anxiety
defense.
• One second
concurrent
two seconds
• Mobilize attention to what is new and
emergent before defenses derail the
observing ego.
• Mobilizes capacity to bear her wish and
anxiety without having to resort to
defense. Thus, building ego capacity.
Anxiety Regulation
• Pause as soon as patient exceeds her
threshold of anxiety tolerance.
• Cognitive recap.
• Differentiate observing ego from
experiencing self.
• Rebalance parasympathetic and
sympathetic systems.
• Defenses increase anxiety in the body!
Mobilize Will to the Task
• When I talk about me. “Do you want to talk
•
•
•
•
about you?”
I’ll be vulnerable. “Are you willing to be
vulnerable and open?”
I’m scared of my feelings. “Do you want to face
your feelings or run from them?”
Mobilizing conscious will decreases projection
and projective anxiety, and defiance, and
reminds patient of her therapeutic goal.
Mobilizing the ego to take a stand against the
superego.
Managing Defiance
• Fragile patients project onto you their will
to do therapy. Then they experience you
as if you want to control or dominate the
patient. As a result, the patient will defy
you (as the projected will). The antidote
to these projections and the resulting
defiance is mobilization of the patient’s
will.
Mobilizing Will to Undo Defiance
• Did you come here of your free will?
• Is it your will to be here today?
• Is this a problem in your opinion?
• Is this a problem you want help with?
• Do you want me to help you with this?
• Is this a problem you want to overcome?
• Are you sure?
Mini-mobilizations of Will
• Would you like to take a look at this?
• Would you be willing not to put yourself
down so we can look at this feeling?
• Would you like to overcome this critical
system in your mind?
• Would you like to find out what’s going on
underneath this anxiety?
• What would you like to do about this
distancing?
Differentiate Ego and Superego
• F, A, and D are all invisible.
• Use visible physical gestures and visual
metaphors to help the patient visualize an
internal process, externalize, and disidentify with the self attack.
• Mistaken causality. “I fear feeling.” “No,
you fear how you attack yourself for
having a feeling.” Feeling is not the
problem, the defense of self attack is.
Differentiate Ego and Superego
• Not: “Do you see how you attack
yourself.” Premature Challenge will lead
to self attack.
• Instead: “Do you see how that anxiety
attacks you?” “Is there a critical system in
your brain that’s coming in now?” “Could
that be a self critical thought?” “Do you
think it might be hurting you?” “Would
you be willing to turn against that
mechanism?”
Differentiate Ego and Superego
• “Cruel” highlights the superego function.
• Differentiates her from how the voice
treats her.
• Separation of observing ego from
superego causes a rise in self compassion,
pain, and anxiety. Help patient integrate
this new experience. Grief over cruelty to
herself will help her turn against the
defense of self attack.
Differentiate Ego from Superego
Feelings evoke anxiety which evokes
defenses. Defenses create the presenting
problems. If you can show the patient
how her defenses are creating her
problems, she will be motivated to turn
against those defenses and face what she
has avoided. “These defenses which
originally were your friends are now your
enemies.”
Steps in Differentiating Ego and
Superego at 23:50
• I am anxiety vs. anxiety attacks me.
• I am stupid vs. voice tells me.
• Voice has a name: Nadine.
• “I want to break that voice.”
Migraine
• Rise of feeling past capacity. Anxiety no
longer contained in striated muscles, goes
into smooth muscles, leading to migraine.
• Regulate: pause, mobilize attention to
physical signs of anxiety, note triangle of
conflict, introduce higher level defenses if
necessary.
Differentiate Ego from Superego
• Distinguish healthy existential guilt from
unhealthy pathological guilt.
• Pathological guilt based on unc. primitive
murderous rage, the defense of identifying with
the perpetrating criminal, and punishing oneself.
Healthy guilt mobilizes a reparative response.
Pathological guilt mobilizes self punishment and
self torture.
Differentiate External Reality from
Internal Reality
We can not change what happened in the past.
We can change the way she handles her
emotions internally in the present and future.
[SE: since we can’t change the past, let’s not
change anything now.]
Establish an intrapsychic focus.
Remind patient of the psychotherapeutic task and
her goal: to face emotions so she doesn’t have
to be sick.
Origin of the Superego
• Trauma to bond: pmr and mixed
emotions.
• Defense of identification with her mother’s
cruelty to her.
• Defense as gift of love (Benjamin).
• Ignoring feelings and cruelty to self as the
pathways to connection.
Building Ego Capacity 33-50”
• 33: sees that she ignores her feeling like her mother did.
•
•
•
•
Understands origin of defense of ignoring. With increase
in observing ego and differentiation of defense from
feeling, feeling arises.
41: anger toward mother---smooth muscle.
45: Now differentiate feeling from anxiety. Sees conflict
of feeling, anxiety and sick, and causality.
49: With feeling differentiated from anxiety, feeling
becomes accessible again. She makes a spontaneous
link to the children’s father.
50: “I tried to kill him once.”
Portrayal for the Fragile Patient
• Let patient imagine the urge he wants to do.
• Helps patient be aware of and isolate the affect:
•
•
•
desensitizes him.
Can be used with little or no experience of the
rage.
Increases isolation of affect and brings anxiety
over time into the striated muscles.
Raises the threshold of anxiety tolerance so that
he can use these defenses (isolation of affect
and intellectualization) and tolerate anxiety.
Graded Portrayal:
The Projective Technique
• Introduce the defense of displacement to
grade the patient’s experience of guilt.
• If a wild animal attacked what would it
do? If the beast in you came out….
• If someone else felt this rage, how would
it come out on me?
• If someone else felt this rage, how would
it come out on another person?
Graded Breakthrough for the
Fragile Patient
• When strong rage and guilt arrive, fragile
patients may immediately somatize,
repress, project, or have conversion.
• Grade the affective experience to bring in
isolation of affect, use a recap, and go
slowly to allow the breakthrough without
going over the patient’s threshold of
anxiety tolerance.
Differentiation of Ego and Superego
• Sadistic, murderous rage toward the molester.
• “What he did was his fault. My fault I was on the
•
streets.” Differentiation of her existential guilt
from guilt over murderous rage.
“Feel fine, gut is fine.” Drop in anxiety. No
longer somatically identified with the murdered
figure who is strangled by his own guts.
Integration of Experiential Insights
• Unconscious guilt over murderous rage led
her to identify with molester’s projections.
• Dis-identifying with projections.
• Link of rage to breakdown and
hospitalization: ego regression as a
defense against experiencing her rage.
• “Not my fault.” Further differentiation.
Differentation of Ego and Superego
at this Point
• Guilt over daughter being molested.
• Fusion of existential guilt and pathological
guilt.
• “Lived in fantasy world.”
• Anger re: mother, then to molester.
• What he did was his fault, not my fault.
• “Want to stop punishing myself.”
Follow-up Session
• Anxiety was 8, now 4.
• Depression was 9, now 6.
• Had 12 migraines a month, now 2.
• Week before first session tried to leave
program to go back to use drugs.
Compliant with drug rehab ever since
session.
Emergence of Coherent Narrative
• Trauma at age 8, experiencing mother’s
murderous rage and hatred.
• Identification with mother as defense
against loss of mother.
• Validation of grief, loss, terror, rage,
genuine helplessness, longing for mother
leads to increased capacity.
• Her emotional life makes sense to her.
Final Differentiation of
Ego and Superego
• Use of play with superego role.
• Dis-identification with mother’s defenses.
Change Processes
• Build capacity: mobilize will, deactivate
projections; observing and attentive ego;
differentiate observing ego and
experiencing self; differentiate feeling,
anxiety and defense; differentiate ego and
superego; differentiate healthy guilt from
neurotic self attack; build capacity to bear
feeling; restructure unconscious pathway
of anxiety discharge; relational capacity.
Outcome
• At nine month follow up, depression,
anxiety remain lowered. Drop in
migraines was maintained. Successful
completion of rehab. Clean from drugs for
first time in 20 years. Attends narcotics
anonymous faithfully. Moved in with
daughter and cares for grand daughter.
Now employed full time. Manages a day
care center.
Literature
• Intensive Short Term Dynamic
Psychotherapy by Patricia Della Selva
• Intensive Short Term Dynamic
Psychotherapy by Habib Davanloo
• Articles from www.ISTDP.no
• Google Allan Abbass or Centre for
Emotions and Health
References
• Davanloo, H. (1987) ISTDP with highly
resistant depressed patients. Part I--restructuring Ego’s regressive defenses.
Int. J. Short term psychotherapy 2:99132. Reprinted in Davanloo (1990).
References
• Davanloo, H. (1989) The technique of
unlocking the unconscious in patients
suffering from functional disorders. Part
I: Restructuring Ego’s defenses. Int. J.
Short term psychotherapy 4:93-116.
Reprinted in Davanloo (1990).
References
• Davanloo, H. Clinical Manifestations of Superego
•
Pathology. In Unlocking the Unconscious
(1990).
Havelaby, J. (2003) Red Lights and Green Lights
on Davanloo’s Road to the Unconscious. In: The
Working Alliance in ISTDP: Whose Intrapsychic
Crisis?
References
• Korff, P. von (1998) Early management of
unconscious defiance in Davanloo’s ISTDP.
Part I. Int. J. Intensive short term
dynamic psychotherapy 12:183-208.
• Neborsky, R. and Peluso, M. Identifying
and Overcoming the Punitive Superego in
Short-Term Dynamic Psychotherapy. In
Ad Hoc J. of STDP, August, 2007.
References
• Whittemore, J. (1996) Paving the royal
road: an overview of conceptual and
technical features in the Graded Format of
Davanloo’s ISTDP. Int. J. Short term
dynamic psychotherapy 11:21-39.
References
• Whittemore, J. (1998) The application of
Davanloo’s ISTDP to a complex
masochistic patient with panic, functional
and somatization disorders: From the
‘Frying Pan’ into freedom. Part I. Int. J.
Short term dynamic psychotherapy
12:151-181.
References
• Whittemore, J. (1999) The application of
Davanloo’s ISTDP to a complex
masochistic patient with panic, functional
and somatization disorders: From the
‘Frying Pan’ into freedom. Part II. Int. J.
Short term dynamic psychotherapy 13:1748.
References
• Whittemore, J. (1999) The application of
Davanloo’s ISTDP to a complex
masochistic patient with panic, functional
and somatization disorders: From the
‘Frying Pan’ into freedom. Part I. Int. J.
Short term dynamic psychotherapy 13:4979.
References
• Troendle, P. (2003) Psychotherapie:
dynamisch-intensiv-direkt. Psychosozialverlag. Most comprehensive textbook in
ISTDP. Currently available only in
German.