The Exorcist: childhood
trauma and loss
Jon Frederickson, MSW
Multiple Sclerosis and
Stress
 Extensive research shows that stress triggers relapses in multiple
sclerosis.
 Psychosomatic Medicine Nov-Dec 2002
 Mohr DC, Goodkin DE, Bacchetti P, et al. Psychological stress and
the subsequent appearance of new brain MRI lesions in MS.
Neurology 2000; 55:55-61
 Mohr DC, Goodkin DE, Nelson S, et al. Moderating effects of
coping on the relationship between stress and the development of
new brain lesions in multiple sclerosis. Psychosom Med 2002;
64:803-809

Buljevac D, Hop WC, Reedeker W, et al. Self reported stressful
life events and exacerbations in multiple sclerosis: prospective
study. Bmj 2003; 327:646.
Why?
 Feelings trigger anxiety.
 Anxiety is discharged in the somatic, sympathetic,
and parasympathetic nervous systems.
 These systems prepare the body internally to
response externally to a threat.
 Muscles: to fight or flee.
 Sympathetic nervous system: to support actions.
Somatic Nervous System:
Striated Muscles
 Sighing
 Clenching of the hands
 Arms, neck and chest tense. Tension headaches.
 Chest pains
 Back pain and pain in the joints.
 Tight stomach muscles
Sympathetic Nervous
System

Dry mouth and eyes

Dilated pupils

Increased sweating, Cold hands and feet

Blushing

Increased heart rate, blood pressure, and respiration

Shivering

Gastrointestinal tract (decreased motility)

Piloerection muscles contract (hair stands on end)

Bladder (constrict sphincter---urinary retention)
Parasympathetic Nervous
System: Smooth Muscles and
c/p disruption

Salivation, teary eyes

Constricted pupils

Warm hands

Migraine headaches

Decreased heart rate, blood pressure, and respiration

Gastrointestinal tract (increased motility)

Bladder (relaxed sphincter)---urge to urinate

Dizziness, foggy thinking

Bodily anaesthesia, limpness
Parasympathetic Nervous
System II
 Localized weakness.. “Jelly legs”. Trouble walking.
 Deafness, ringing in the ears, and roaring in the ears .
 Blindness, blurry vision, and tunnel vision.
 Fainting, loss of consciousness, or dizziness. Hypoperfusion in the brain.
 Amnesia and memory loss. Hippocampus shuts down.
 Hallucinations.
 No tension, but cognitively confused.
Balance
 Sympathetic and parasympathetic nervous systems
ideally are in balance.
 When the parasympathetic nervous system cannot
function properly, the immune system malfunctions
resulting in an increase in Th1 cytokines
(inflammation) and TNF production.
 This imbalance is a factor in heart disease, autoimmune disorders, diabetes, and other chronic
diseases. See Schulkin’s, Allostasis, Homeostasis, and
the Costs of Physiological Adaptation.
What to Do?
 Regulate the patient’s anxiety by improving the
functioning of the parasympathetic nervous system.
 This will reduce TNF production. Shock, April 2010 Volume 33 (4): 363-368 Relationship of basal heart rate
variability to in vivo responses after endotoxin exposure
 And inhibit production of pro inflammatory cytokines.
Psychosomatic Medicine October 2007. Stimulated
Production of Proinflammatory Cytokines Covaries
Inversely With Heart Rate Variability. Also see, Nature
420:853-9, 2002 .
How?
 Psychotherapy. Neurology July 2012. Patients who attended six
months of stress-management sessions had fewer brain lesions
and a slower disease progression compared to people who
didn't attend the sessions.
 Their lesions were measured by magnetic resonance imaging.
Two types of brain lesions in the study participants were
observed — gadolinium-enhancing and T2. Patients with
stress management therapy had fewer of each. "This is the first
time counseling or psychotherapy has been shown to affect the
development of new lesions."

Today
 Purpose today is to show how to help regulate
anxiety in a patient with MS to improve anxiety
regulation, immune function, and reduce the risk of
MS relapses.
 Stress, emotion activation, and anxiety occurs in all
of us. Life.
 Causation.
Inquiry
 Find out the internal emotional problem for which
the patient seeks our help.
 Assess responses to intervention moment-tomoment to discern the triangle of conflict.
 Assess anxiety discharge pattern and defenses to
understand what causes the patient’s problems and
symptoms.
Anxiety Assessment
 Discern where anxiety is discharged in the body.
 Striated muscles
 Smooth muscles
 Cognitive/perceptual disruption.
Graded Format
 Explore feeling.
 When anxiety goes out of striated muscles or the
patient uses regressive defenses, pause.
 Restructure the pathway of anxiety discharge or the
regressive defenses.
 Then explore feeling again.
 Step by step build the patient’s capacity to bear
feelings while anxiety is regulated.
Cognitive Recapitulation
 To regulate anxiety, help the patient see the anxiety
symptom and identify it as anxiety.
 Point out causality.
 Offer repressive defenses.
 When anxiety returns to the striated muscles,
explore feeling again.
Conscious Therapeutic
Alliance: Consensus on the
Triangle
 To know what to do, the patient must know the
task.
 To know the therapeutic task, the patient must
understand what the triangle of conflict is.
 To learn the triangle of conflict, the patient must be
shown moment-to-moment how it is active in
session.
Conscious Therapeutic
Alliance: Mobilizing Will to a
Positive Goal
 Positive vs. negative goals.
 Aversion vs. approach
 Clarifying the therapeutic task: why we do this.
 Patient’s vs. therapist’s goals.
Conscious Therapeutic
Alliance: Consensus on the
Task
 To let go of defenses which hurt the patient.
 To face rather than avoid what makes the patient
anxious.
 To feel feelings as deeply as possible.
 To overcome the patient’s difficulties and to achieve
the patient’s positive goals.
 Without consensus on task: no conscious
therapeutic alliance.
Pressure to Feeling in the
Graded Format: Building
Capacity
 Invite feeling.
 Restructure the pathway of anxiety discharge.
 Restructure regressive defenses which create the
patient’s presenting problems.
 Excessive anxiety and regressive defenses are not
“problems”: they indicate the next thing you need
to heal. They are good information.
Going Over the Threshold of
Anxiety Tolerance
 When anxiety goes out of striated muscles into the
smooth muscles or cognitive/perceptual disruption.
 Pause.
 Immediate anxiety regulation.
 Failures: regression.
Repressive Defenses
 Intellectualization
 Rationalization
 Rumination
 Denial
 Forgetting
 Negation
 Slowing down
 Isolation of affect
Character Defenses
 Based on identification.
 I do to myself what others did to me.
 I ignore my anxiety. “I’m always like this.”
 I dismiss my anxiety. “It’s no big deal.”
 I ridicule my anxiety. “It’s stupid.”
Projection of the Superego
 Triangle of conflict: Anger, anxiety, self-judgment.
 I project: “You judge me.”
 Spectrum of projection: anxiety, defenses, reality
testing.
Misuse of Reality
 In the service of self punishment.
 Do not dispute the reality or fact.
 Point out the function it is being asked to serve: to
punish.
 Any fact can be misused in the service of selfpunishment.
Mobilizing Self-Observing
Capacity
 Not, “Do you see how you punish yourself?”
 Instead, “You are able to observe a reaction inside
you.”
 “There’s an awareness of something inside you that
wants to criticize.”
 “As we take a look, we can observe some urge
inside you that seems to have a life of its own.”
Undoing Identification
 “I punish myself” = identification = a failure in selfobservation.
 “I dreamt.” Dreaming occurred without you doing
it.
 In fact, urges occur, thoughts happen, and
automatisms are activated in the patient without his
will or intent.
 We simply help him see that as a first step.
Portrayal
 When a physical impulse occurs, that often signals
that feeling has risen enough and defense has
dropped enough that the unconscious is available.
 “In thoughts, words, and ideas, how do you picture
this impulse going out onto him.”
 As in every other form of pressure, we will observe
the response to intervention.
Defense of Identification
 Rage, anxiety, identification with the object of one’s
rage.
 “I’m not me. I’m him.”
 “I’m not terrified of him. I’m terrified of me.”
 Manic defense against the experience of terror.
 Unconscious form of self-punishment for
murderour rage toward a predator.
Adaptive Function of the
Defense
 Relocate the danger within himself.
 Control over the danger.
 Retain hope that the father is all-good.
Denial Through Fantasy
 Rather than relate to reality, relate to a fantasy of
how you wished reality would be.
 “You should know what you don’t know.”
 “You should be able to do what you cannot do.”
 “You should see what you don’t see.”
 “You should be like someone else instead of like
you.”
Regressive Defenses to
Avoid Complex Feelings
 Splitting: I will keep dad’s good qualities separate
from his bad qualities.
 Identification: I will identify with dad’s bad
qualities, so he remains good.
 Idealization: Dad is all-good.
 Devaluation: I am all bad.
Pressure to SelfAcceptance
 Superego pathology = rejecting reality, especially of
you.
 Success in therapy: successful self-acceptance of
your inner life.
 Deactivating self-rejection by inviting selfacceptance.
 Weakening of defense = rise in feelings, and anxiety
related to self-punishment.
Undoing Splitting
 Splitting: keeping opposing feelings or facts
separate.
 Undoing splitting: remind the patient of opposing
feelings and contradictory facts.
 “Pressure to consciousness.”
 Father who saved your life, nearly took a life.
 Father who loved, also hated.
 Range of responses in spectrum.
Process I
 Invited portrayal.
 Response: identification with father, splitting of
mixed feelings, projection and introjection.
 Intervention: undo all defenses until the patient can
bear mixed feelings. Then portrayal will be
possible.
 Undo defenses.
 Response: rise of grief.
Process II
 Intervention: invite acceptance of his ‘inner
panther.’ Invited him to face rage toward father.
 Response: identification with father, splitting, and
introjection.
 Intervention: undo splitting.
 Response: ability to bear complex feelings without
splitting. Understanding clear.
Pathological Mourning
 Freud: Rage toward lost figure; anxiety;
identification with the figure.
 “I did not want to kill you; I want to be you.”
 “I have not lost you; I am you.”
 Defense against rage and grief; simultaneously
allows self-punishment by turning rage onto
oneself.
 Pathological mourning must be addressed first for
rage to become accessible.
Smile as a Character
Defense
 By smiling, I reject my feelings.
 By smiling, I am cruel and dismissive to myself.
 By smiling and cynicism, I hide my love.
 By hiding my love, I hide my grief.
Identification as a Defense
 Murderous rage toward father triggers guilt toward
a loved one.
 Rather than bear the guilt, he punished himself.
 “I must eat his sins forever to atone for my own sin
of wanting to kill him. And through my sin eating,
I will prove my love.”
Compassion
 To undo splitting, important that he can feel
compassion for his father and for himself.
 Otherwise, “I feel compassion for me but not for
him, is another form of splitting.”
 Likewise, “I feel compassion for him, but not for
me,” is also splitting.
Compassion for
the Origin of the Defenses
 Self-judgment of his defenses merely perpetuates
the self-rejection of superego pathology.
 Point out the adaptive function of his defenses to
undo his self-rejection and increase his selfacceptance.
 Patients can easily misuse defenses for the purpose
of self-hatred as if that is therapy.
Compassion for Self =
Acceptance of Reality
 “You did what you could do and that was all you
could do.”
 “Yes. You managed it terribly. And it sounds like
that was the best you could do at the time: terribly.”
 “You didn’t know what you didn’t know.”
 “You didn’t see then what you see now.”
Portrayal and Pathological
Mourning
 Defenses can arise which prevent the mourning
process from unfolding.
 Note all resistances to saying goodbye.
 Note all attempts to bury his internal life, to remain
dead with the lost figure and thus avoid loss and
punish himself.
Undoing Splitting and
Denial
 Undoing splitting allows the patient to experience
complex, mixed feelings toward his father.
 Undoing denial allows the patient’s repressed
feelings to finally rise to the surface.
Consolidation
 Offers a coherent narrative of the patient’s inner and
outer lives.
 Describe the process of the session in terms of the
triangle of conflict.
 Show causality: feelings, anxiety, and the defenses
which caused his presenting problems.
 Make sure patient understands what the two of you
have learned together.
One Year Follow-up
 “My legs are perfectly responsive to sensation in
every place. Nobody understood why this is the
case.”
 “The staff at [rehabilitation center] had me dance on
a cushioned pad for one half hour…They were
dumbfounded that my balance was so good.”
 “That was a watershed day for me. The result was
truly miraculous for me in my opinion.”
Resources
 Go to www.istdpinstitute.com for articles, blogs,
dvds, skill building audio studies, and webinars on
ISTDP.
 Co-Creating Change: Effective Dynamic Therapy
Techniques, May 2013. Seven Leaves Press.
 Go to
www.facebook.com/DynamicPsychotherapy/ for
answers to your clinical questions.