Approaches to Complex Pa1ents Intensive Short-term Dynamic ...
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Approaches to Complex Pa1ents Intensive Short-term Dynamic Psychotherapy Austen Riggs Grand Rounds, October 2017 Allan Abbass MD, FRCPC Dalhousie University, Halifax, Canada. www.allanabbass.com Dr Allan Abbass
Transcript of Approaches to Complex Pa1ents Intensive Short-term Dynamic ...
ApproachestoComplexPa1ents
IntensiveShort-termDynamicPsychotherapyAustenRiggsGrandRounds,October2017
AllanAbbassMD,FRCPCDalhousieUniversity,Halifax,Canada.
www.allanabbass.com
Dr Allan Abbass
ReferenceMaterialsn ReachingthroughResistancen DetailedmanualonISTDPpsychodiagnosisand
treatmentwithcaseexamplesn www.allanabbass.comn AvailableonAmazon:hHp://a.co/3UGMWx0OtherarOclesunderpublicaOonsatwww.allanabbass.com
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Plan
n Evidencebasen Metapsychologyn PaHernsofResistancen ISTDPforFragilepaOents
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ISTDP
n DevelopedbyDavanlooandMalanwithvideotapelargecaseseriesresearch
n BroadapplicaOon:madeforresistantpopulaOons
n EmphasisonbuildingcapaciOesenablingtheexperienceandworkingthroughofaHachmenttrauma
n 11studiesofcomplexpopulaOons:meanEffectSized=1.59
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Cornelissen KLM, Smeets D, Willemsen SP, Busschbach JJV, Verheul R.
ResidenOalISTDPMax6monthadmissionsfortreatmentresistantpersonalitydisorders.N=155
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8weekISTDPInpa1entTreatmentRefractoryServiceNorway:Allhadfailed3ormoretreatments
SolbakkenandAbbass2016
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RCTofISTDPinTreatmentResistantDepression
ISTDP 36% Remission
Community Mental Health 3.7% Remission
Town et al, 2017
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Adjunc1veISTDPinpsychosis
Abbass et al, 2015
For residual anxiety, depression and interpersonal problems and some psychotogenic cycles N=38, Mean 13 sessions Large Significant Health care Cost reductions
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SelfreportOutcomes
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Metapsychology
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BOND With
Parents
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BOND With
Parents PAIN FEAR
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BOND With
Parents PAIN FEAR
Rage, Guilt about the Rage
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BOND With
Parents PAIN FEAR
Rage, Guilt about the Rage
Self-destruct Symptoms
Somatization Dr Allan Abbass
Currentperson
Transference(Therapist/Doctor)
Pastperson
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UnconsciousAnxiety
UnconsciousDefense
UnconsciousImpulses&Feelings
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UnconsciousAnxiety
UnconsciousDefense
UnconsciousImpulses&Feelings
1.PressureonFeelingsorDefenses
2.MonitorAnxiety&Defenseresponses
Psychodiagnosis
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UnconsciousAnxiety
n StriatedMuscle:Voluntarymuscletensionn SeewithisolaOonofaffect/selfreflecOononbodyandaffect
n SmoothMuscle:Bodyorgansn Seewithrepression
n CogniOve–perceptualDisrupOonn SeewithprimiOvedefenses
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SpectrumofPsychoneuro1cDisorders
(NONFRAGILE)Low Resistant
Highly Resistant
Moderate Resistant Mild Severe/
Borderline Moderate
SmoothMuscle/Conversion+Repression
CogniOve-PerceptualDisrupOon+PrimiOveDefenses
SpectrumofPaOentswithFragileCharacterStructure
StriatedMuscle+IsolaOonofaffect
All these are specifically diagnosable and each have a different treatment pathway Dr Allan Abbass
ComplexTransferenceFeelings(CTF)andUnconsciousTherapeu1cAlliance
n MixedFeelingsmobilizedbytryingtotherapeuOcallyaHachtopaOent
n Linkedtothepastbond,trauma,pain,rageandguiltaboutrage
n AcOvatesthe“unconscioustherapeuOcalliance”:deepdesiretohealbyseeingandworkingthroughfeelingsaboutthetrauma:producesimagesandlinkagestopasttrauma
n
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FragileCharacterStructurePa1ents
n Earlyneglect,abuse,invalidaOonn Absenceofparentalfigurewithanxietytolerance:usuallyfragileparentswhoprojectonchild
n CogniOve-perceptualdisrupOonatsomelevelofriseinanxiety
n ProjecOon,spligng,projecOveidenOficaOonn Needcapacitybuilding
n Anxietytostriated/voluntarymusclen DefensetoselfreflecOononfeelings/isolaOonofaffect
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WEAK BOND
PAIN
Rage, Guilt about the Rage
Self-destruct Symptoms
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UnconsciousAnxiety
StriatedMuscleAnxietyIsolaOonofAffect
ConsciousFeelings
Mildfragile
Moderatefragile
Severefragile
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TreatmentPhasesinFragileCharacterStructure
n CapacityBuildingn RepeatedUnlockingn WorkingThroughn TerminaOon
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Accelera1oninISTDPn Psychodiagnosistofindmaximumanxietytolerancethreshold(Findthecurve)
n UsenonverbalcuestoopOmizedosageofemoOonacOvaOon(Hugthecurve)
n AcOveinterrupOonofprojecOon(Stayontrackofinternalprocess)
n PressureonGuiltaboutragetobuildanxietytolerance:psychicintegraOonathigherlevelsofanxiety
n Repeatedunlockingoflovingfeelings,rage,guiltandgriefusingtheaHachmentrelaOonshipintheTransference(Lethimrun)
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UnconsciousAnxiety
StriatedMuscleAnxietyIsolaOonofAffect
ConsciousFeelings
1.Pressuretofeelingsortodefenses2.Riseincomplextransferencefeelingsandanxiety3.IntellectualrecaptobringisolaOonofaffect
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3 2
3 2
1
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UnconsciousAnxiety
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2
1
ConsciousFeelings
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IsolaOonofaffectStriatedmuscle
Mildfragile
Moderatefragile
Severefragile,borderline
Threshold
toCPDorp
rimiOvede
fenses
TherapeuO
cwindow
1
3
2 12
3
1. Pressure 2. Rise in CTF 3. Recap
Unconsciousanxietyanddefense
Consciousfeelings
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CaseofModerateFragility/Psychosisn 60yearoldmanlivesinSalvaOonArmyapt.n 5years+ofschizophrenia:5admissionsover200days
n JailedfewOmes:terrified.FearinHospital.n Beganwhenfather‘becamedementedandstartedaHackinghim,hadhimjailed’
n MovedtoHalifaxunderdelusionsandthenlivingonstreet
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CogniOve
Perceptual
DisrupOon
Repression
SmoothMuscle
IsolaOonofaffectStriatedMuscle
MildFragileModerateFragileSevereFragileBorderline
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HowtoReduceAnxiety
n Talkandlettheclient/paOenttalkn ChangeStaOonsCàTorTàCorCàCn Focusonbodilycuesn RecapitulateonwhathappenedP-C-TandI/F-Anxiety-Defence
n Stayofffeelingsforamoment
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MildFragility:Can“see”Psychosis
IsolaOonofaffectStriatedmuscle
Mildfragile
Moderatefragile
Severefragile,borderline
Threshold
toCPDorp
rimiOvede
fenses
TherapeuO
cwindow
1
3
2 12
3
1. Pressure 2. Rise in CTF 3. Recap
Unconsciousanxietyanddefense
Consciousfeelings
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Projection of rage or punishment
Fear attack or punishment
Guilt about rage is repressed
Rage about the attack or punishment
Self Escalation in severe fragile and psychosis
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UnconsciousAnxiety
StriatedMuscleAnxietyIsolaOonofAffect
ConsciousFeelings
1.Pressuretorage2.Risetoabovethreshold3.PresstoGuiltandregulatedownanxietyasneeded4.ExtensiveRecapping
1
3
2
3
2
1
Immersive Approach to Building Capacity
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3laterphaseswithFragilePa1entn Manwithchronicdepression,paranoia,dysfuncOon.OnWelfareformanyyears
n Moderatetoseverefragility:prominentprojecOon
n Historyalcoholismn HadpsychoOcepisodeondexedrineforADHDthatpersisted
n Paranoidfamily,sisterborderlinedisordern Firstyearnovideoasfelthewastooparanoideventoask
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ResultsofCapacityBuildingPhase
n Anxietyinstriatedmusclen Abilitytoselfreflectn Abilitytoreduceownanxietyn Understandingofthetrauman ReducOonofparanoia/projecOonandgriefaboutit
n Emergingempathyforfamily
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RepeatedUnlockingPhase
n Inlongercases,phaseisayearormorelongn RepeatedparOalthenmajorunlockingoftheunconscious
n Drainingthepathogenicreservoirofrageandguilt
n MobilizingposiOvefeelingswhichmobilizesmorerageandguilt
n Inlongertermcasemaybe2-300unlockings
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UTAinRepeatedUnlocking
n Spontaneousunlockingsinweekn Imagerypopsinheadn Deadbodiesn SensaOonsinbodyn Dreamsthatarebreakthroughsn Vividcontentallowstrongguilttobefeltn SenseofPresence:UTA
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Resultsofrepeatedunlockingphase
n Nexttonosignsoffragilityn EmoOonsareseparated:de-fusedn Compassionforselfn Empathyandloveforothers:survivorguiltn Griefaboutpsychopathologyn FuncOonalgainsn Growingmasteryofpsychodynamicsn Altruism:wishtogivetoothers
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WorkingThroughPhase
n MobilizaOonofgriefandselfcompassionasguiltisremoved
n DefusionofpuniOvesuperegofromselfn DrivesforaHachmentn HealthyacOvityinlifen ReturntofuncOonn PocketsofrageandguiltsOllemergen Griefisdominantn Empathy/loveforfamilymembers
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CourseofIntensive“Long-term”DP
Start End
Capacity Building
Repeated Unlocking
Working Through Termination
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Pressure ModerateResistance
Striatedmuscleanxietyplusfeelcomplex
transferencefeelings
HighResistance
Depression,smoothmuscleanxietyormotorconversion
HighResistancewithRepression
CogniOve-perceptualdisrupOonorprimiOvedefenses
FragileCharacterStructure
GOFLAT:Nostriatedmuscleanxietyandcantselfreflect
CapacityBuildingFormats
Repeatedunlocking,workingthrough,terminaOon
Striatedmuscleanxietyplusfeelcomplex
transferencefeelings
Breakthroughofgriefaboutloss
LowResistance
Completetreatmentin1or2sessions
Inquiry
ResistanceRises
Resistancecrystallizesinthetransference
Clarify,Challenge,
HeadonCollision
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