davanloo.pdf

(1)

American Psychiatric

Association



_{New York, NY, May 3 - 7, 2014}



₁₆₇

th

_Annual

_Meeting

Seminar 9

Directors:

Alan

Beeber

,

M.D.

Gary

Gala,

M.D.

Date:

Monday

,

May

5,

2014

Tim

e:

8

8 AM

AM

-

12

12 noon

noon

Location

:

New

Y

ork

Hilton

Midtown

Bryant Suite

Introduction to Davanloo’s Intensive

Short-Term Dynamic Psychotherapy

With Highly Resistant Patients

(2)

(3)

Seminar

Seminar 9

9 Educational

Educational Objectives:

Objectives:

At

At the

the conclusion

conclusion of

of this

this session,

session, the

the participant

participant should

should be

be able

able to:

to: 1)

1) Identify

Identify the

the

psychodynamic

psychodynamic forces

forces underlying

underlying human

human psychopathology

psychopathology in

in a

a broad

broad range

range of

of

patients;

patients; 2)

2) Identify

Identify and

and diagnose

diagnose the

the manifestations

manifestations of

of Major

Major Resistance

Resistance in

in the

the

psychotherapeutic

psychotherapeutic process;

process; 3)

3) Identify

Identify and

and describe

describe the

the main

main elements

elements of

of

Davanloo's

Davanloo's technique;

technique; and

and 4)

4) Acquire

Acquire an

an understanding

understanding of

of the

the crucial

crucial elements

elements of

of

Seminar

Seminar Information

Information

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Seminars will

will be

be held

held at

at the

the Hilton

Hilton Midtown

Midtown from

from Saturday

Saturday to

to Tuesday.

Tuesday.

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Please vacate

vacate the

the classroom

classroom promptly

promptly at

at the

the conclusion

conclusion of

of the

the course.

course. If

If

you

you must

must speak

speak to

to the

the Seminar

Seminar Director

Director or

or Faculty,

Faculty, please

please do

do so

so outside

outside

of

of the

the room.

room. Audio

Audio

_‐‐

visual and

visual

and hotel

hotel personnel

personnel must

must have

have time

time to

to set

set the

the

room

room before

before the

the next

next function.

function.

3. 3. Instructions

Instructions on

on how

how to

to complete

complete your

your conference

conference evaluation

evaluation and

and receive

receive

your

attendance

certificate

can

be

found

at

www.psych.org/annualmeetingcme

.. Please

Please retain

retain your

your Badge

Badge No.

No. to

to

access

access the

the evaluation

evaluation on

on line.

line. For

For questions,

questions, please

please contact

contact APA’s

APA’s

Department

Department of

of CME

CME at

Thank

(4)

Seminar

Seminar 9

9 COURSE

COURSE FACULTY

FACULTY

Director:

Alan

Alan Beeber,

Beeber, M.D.

M.D.

Faculty:

(5)

Te materials contained in this packet were submitted

and reviewed by the course

/seminar director(s) and

were correct at the time o print. Any changes to the

material that wer

e made afer the review

deadline

are the responsibility o the course/seminar

directo

r(s).

Agen

(6)

Introduction to Davanloo’s Intensive Short

_‐

Term

Dynamic Psychotherapy in Highly Resistant Patients

Schedule of Presentations

1:00 Introduction and Announcements 10 min. Dr. Beeber 1:10 Overview, and History 20 min. Dr. Gala 1:30 Davanloo’s Metapsychology 1 hr. Dr. Beeber 2:30 Break

2:45 Audiovisual presentation I 45 min. Dr. Beeber

This presentation will focus on the early phase of an initial interview with a highly resistant patient with mixed symptom disturbance and syntonic character pathology. The emphasis will be on the psychodiagnostic process. The technique of application of the phases of inquiry, pressure and crystallization of the character defenses in the dimension of the transference will be demonstrated.

Time will be divided as follows:

10 min. introduction of the case and central concepts 25 min. video vignette

10 min. discussion by Dr. Gala and questions from participants

3:30 Audiovisual presentation II 1 hr. Dr. Beeber

This presentation will focus on the later phases of the initial interview with the same patient. The emphasis will be on the technique of mobilization of the transference component of the resistance, “head on collision with the resistance” and removal of the major resistance. Mobilization of the direct experience of the transference feeling will be demonstrated which leads to direct access to the unconscious pychopathological nuclear structure.

Time will be divided as follows:

10 min. introduction of the case and central concepts 30 min. video vignette

20 min. discussion by Dr. Gala and questions from participants 4:30 Group discussion by Faculty and Participants 25 min. 4:55 Feedback and Adjourn

(7)

Te materials contained in this packet were submitted

and reviewed by the course /seminar director(s) and

were correct at the time o print. Any changes to the

material that were made afer the review deadline

are the responsibility o the course/seminar director(s).

(8)

Introduction to Davanloo’s Intensive Short

_‐

Term

Dynamic Psychotherapy in Highly Resistant Patients

Outline of presentations

Introduction and Announcements Dr. Beeber Overview, and History Dr. Gala

 History of the development of short‐term dynamic psychotherapies  Development of Davanloo’s technique based on clinical research

 Development of Davanloo’s metapsychology, the problem of resistance

Davanloo’s Metapsychology Dr. Beeber

 Spectrum of psychopathology treatable with Davanloo’s Intensive Short‐Term

Dynamic Psychotherapy (DISTDP)

 Psychopathological dynamic forces. The role of Fusion.  Central Dynamic Sequence

 Adverse phenomena avoided by DISTDP  Contraindications to DISTDP

Audiovisual presentation I Dr. Beeber

 Video vignettes of the early phase of an initial interview with a highly resistant

patient with mixed symptom disturbance and syntonic character pathology. Focus will be on the psychodiagnostic process.

 Technique of application of the Central Dynamic Sequence, phases of Inquiry and

Pressure will be demonstrated. Rapidly identification of the discharge pattern of unconscious anxiety and the patient’s capacity to tolerate anxiety.

 Nature of the defensive structure including tactical and characterological defenses

will be illustrated.

 Pathway to direct access to the Unconscious will be elucidated. Further application

of the phase of Pressure to crystallize the patient’s characterological defenses in the dimension of the Transference. Preparation for turning the patient against his destructive defenses (making syntonic defenses dystonic).

Audiovisual presentation II Dr. Beeber

 Video vignettes of the later phases of the initial interview with the same patient.  Technique of mobilization of the Complex Transference Feeling (CTF), the

Transference Component of the Resistance (TCR), “Head on Collision with the destructiveness of the resistance” and removal of the Major Resistance.

 Mobilization of the direct experience of the CTF, which leads to dominance of the

Unconscious Therapeutic Alliance over the forces of the Major Resistance

 Mobilization of the Neurobiological Pathways (NBP) of Murderous Rage, the NBP of

Guilt‐laden and Grief‐laden unconscious feeling.

 Direct access to the unconscious with the first view of the unconscious

(9)

(10)

Te materials contained in this packet were submitted

and reviewed by the course /seminar director(s) and

were correct at the time o print. Any changes to the

material that were made afer the review deadline

are the responsibility o the course/seminar director(s).

(11)

INTRODUCTION TO DAVANLOO

’

S

INTENSIVE SHORT-TERM DYNAMIC

PSYCHOTHERAPY WITH HIGHLY

RESISTANT PATIENTS

Course Director: Alan R. Beeber, MD.

Professor Emeritus of Psychiatry

Faculty:

Gary J. Gala, MD.

Associate Professor of Psychiatry

UNC School of Medicine

Chapel Hill, NC

(12)

Disclos

ure:

Alan

Beeber

,

MD

•

• No significant financial or affiliation interest with

No significant financial or affiliation interest with

goods/organizations regulated by Food and Drug

Administration that may h

ave a direct or indire

ct interest in

the

(13)

Disclosure: Gary Gala, MD

•

• No significant financial or affiliation interest with

No significant financial or affiliation interest with

goods/organizations regulated by Food and Drug

Administration that may h

ave a direct or indire

ct interest in

the

(14)

A

c

k

n

o

w

l

e

d

g

m

e

n

t

s

•

• Habib Davanloo, MD

Habib Davanloo, MD

•

(15)

(16)

DAVANLOO

’

S INTENSIVE SHORT-TERM

DYNAMIC PSYCHOTHERAPY :

OVERVIEW AND HISTORY

Gary J. Gala, MD.

Associate Professor of Psychiatry

Associate Chair for Education

UNC School of Medicine

Chapel Hill, NC

(17)

Disclosure: Gary Gala, MD

• No significant financial or affiliation interest with

goods/organizations regulated by Food and Drug

Administration that may have a direct or indirect interest in

the subject matter of this program.

(18)

Overview

• History of the development of short-term dynamic

psychotherapies

• Development of Davanloo’s technique based on clinical

research

• Development of Davanloo’s Metapsychology, the problem

(19)

History of STDP: Contributions of Habib

Davanloo

• Psychoanalytic background

• Influenced by Zetzel, Deutsch, Alexander

• Disillusioned with the increasing length of analysis

• Disillusioned with intractable Transference Neurosis/analysis

interminable

• Developed Short –Term Dynamic Psychotherapy

• Initial focus on highly responsive patients

• Emphasis in early work was on interpretation of T-C-P link

• Expanded the spectrum of patients who could be treated

with Intensive STDP

(20)

The Problem of Resistance

• Resistance was central to Freud’s theory of

Psychoanalysis and of the Unconscious

• Secondary and primary gains from neurotic disturbances

(21)

The Problem of Resistance II

• "It may thus be said that the theory of psycho-analysis is

an attempt to account for two observed facts that strike

one conspicuously and unexpectedly whenever an

attempt is made to trace the symptoms of a neurotic back

to their source in his past life: the facts of transference

and resistance. Any line of investigation, no matter what

its direction, which recognizes these two facts and takes

them as the starting-point of its work may call itself

psychoanalysis, though it arrives at results other than my

own”

• Freud, S. (1959). "Inhibitions, symptoms, and anxiety". In J. Strachey (Ed. & Trans.) The standard edition of the complete psychological works of Sigmund Freud (Vol. 20, pp. 75–175). London: Hogarth Press.

(22)

Resistance of Repression

Freud wrote optimistically in 1914,

“

…the doctor uncovers the resistances which

are unknown to the patient; when these have

been got the better of, the patient often relates

the forgotten situations and connections without

any difficulty.

”

Freud S. Remembering, Repeating and Working-through. In: Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 12. London: Hogarth Press; 1996:145–156.

(23)

Resistance of the Superego I

In 1926 Freud wrote pessimistically,

“

The

‘

unconscious sense of guilt

’

represents

the superego's resistance. It is the most

powerful factor, and the one most dreaded by

us.

”

Freud S. The Question of Lay Analysis. In: Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 20. London: Hogarth Press; 1996:177–250.

(24)

Resistance of the Superego II

In Analysis Terminable and Interminable, 1937 Freud wrote much more

pessimistically,

“

For the moment we must bow to the

superiority of the forces against which we see

our effort come to nothing

”

Freud S: Analysis Terminable and Interminable. In: Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 23. London: Hogarth Press; 1996:209–254.

(25)

Davanloo

’s contributions:

• Developed technique of Mobilization of the Unconscious

• Developed technique of Total Removal of the Resistance

• Developed the techniques of ISTDP and Block Therapy,

as well as a method of psychoanalytic investigation and

Multidimensional Unconscious Structural Change

(26)

DAVANLOO’S METAPSYCHOLOGY

Alan R. Beeber, MD.

Professor Emeritus of Psychiatry

UNC School of Medicine

(27)

Davanloo

’s contribution III:

• Developed technique of Mobilization of the Unconscious

• Rapid mobilization of tactical and characterological defenses

• Rapid activation of transference feeling

• Crystallization of the Resistance in the Transference

• De- fusion of primitive murderous rage, sexualized feeling and guilt

• Direct access to the psychopathological dynamic forces (Davanloo,

1988)

(28)

Mobilization of the Unconscious

• Depends heavily on the development of the Twin

Factors of:

• Transference Component of the Resistance

• Complex Transference Feelings

Davanloo, H. (2010). Annual Audiovisual Immersion Course: the technique of the Removal of Resistance. Montreal, Que. , October 2010.

(29)

Mobilization of the Unconscious

• Affective responses predominate over Cognitive

responses

• Unconscious Therapeutic Alliance predominates over

the forces of the Resistance

Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155

(30)

Mobilization of the Unconscious

• Major mobilization of the Transference Component of

the Resistance

• Major mobilization of the Neurobiological Pathway of

Primitive Murderous Rage in the Transference

• Major mobilization of the Neurobiological Pathway of

Guilt

(31)

Mobilization of the Unconscious

• Creates fluidity in the Unconscious

• Provides a vivid portrait of the Pathogenic

Organization of the Unconscious

• Brings about intrapsychic reorganization of the

defensive system; and increases capacity to tolerate

anxiety and painful affects.

(32)

Highly responsive; single

focus; low resistance

High resistance; complex

symptom and character

pathology

Spectrum of Psychopathology

(33)

Low Resistance

• Highly Responsive

• Circumscribed Problem

• Single Psychotherapeutic Focus

(34)

Moderate Resistance

• Diffuse Psychoneurotic Disturbances

• Presence of Character Pathology

• Multi-foci Core Neurotic Structure

(35)

High Resistance

• Character Neurosis

• Diffuse Symptoms and Character Disturbances

• Highly complicated Core Pathology

(36)

Extreme Resistance

• Diffuse Symptoms and Major Character Disturbances

• Extremely Complex Core Pathology

(37)

Psychopathologic Dynamic Forces 1

Bond, Attachment

Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the

Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy,10(3,4), 183-240

(38)

Psychopathologic Dynamic Forces 2

Bond, Attachment

Pain of Trauma to Bond

(39)

Psychopathologic Dynamic Forces 3

Bond, Attachment

Primitive Murderous Rage

Pain of Trauma to Bond

(40)

Psychopathologic Dynamic Forces 4

Sexual

Bond, Attachment

Primitive Murderous

Rage

Pain of Trauma to Bond

(41)

Psychopathologic Dynamic Forces 5

Guilt

Sexual

Bond, Attachment

Primitive Murderous Rage

Pain of Trauma to Bond

(42)

Psychopathologic Dynamic Forces 6

Grief

Guilt

Sexual

Bond, Attachment

Primitive Murderous Rage

Pain of Trauma to Bond

(43)

Psychopathologic Dynamic Forces 7

Character Resistance

Grief

Guilt

Sexual

Bond, Attachment

Primitive Murderous Rage

Pain of Trauma to Bond

(44)

Psychopathologic Dynamic Forces 8

Resistance Against

Emotional Closeness

Character Resistance

Grief

Guilt

Sexual

Bond, Attachment

Primitive Murderous Rage

Pain of Trauma to Bond

(45)

Triangle of Persons

Past

(46)

Defense

Triangle of Conflict

Anxiety

(47)

Unconscious Discharge Patterns of

Anxiety

• Striated muscle tension

• Smooth muscle e.g. irritable bowel or migraine

headaches

• Cognitive and Perceptual system e.g. drifting of

(48)

Anxiety

Benefit

(49)

Physiological Concomitants of Feelings

• Rage

• Fireball in abdomen, moves upward to chest, arms, hands; jaw,

biting.

• Guilt

• Deeply painful, high amplitude waves, chest, upper

bronchi/pharynx, gasping, +/- nausea

• Grief

(50)

Mobilization of the Unconscious

• Major mobilization of the Transference Component of

the Resistance

• Major mobilization of the Neurobiological Pathway of

Primitive Murderous Rage in the Transference

• Major mobilization of the Neurobiological Pathway of

Guilt

(51)

Resistance and the Unconscious

Therapeutic Alliance

R

UTA

R - Resistance

UTA - Unconscious

Therapeutic Alliance

(52)

H. Davanloo unpublished used with permission

Resistance, Transference and

Unconscious Therapeutic Alliance

Time

I n t e n s i t y

Resistance

Complex

Transference

Feelings

Unconscious

Therapeutic

Alliance

(53)

Highly responsive; single

focus; low resistance

High resistance; complex

symptom and character

pathology

Spectrum of Psychopathology

(54)

DISCHARGE PATHWAY :

Spectrum of Capacity to

Tolerate Anxiety

Adapted fromDavanloo, H. (1995). Intensive Short-Term D Journal of Short-Term Psychotherapy,

10

_(3,4),

121-155 ynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International

striated muscle

tension

CAPACITY:

high

moderate

low

cognitive and

perceptual

autonomic

(55)

PROBLEMS:

RESISTANCE:

Spectrum of Psychopathology II

Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders.

International Journal of Short-Term Psychotherapy, 10

_{(3,4), 121-155}

focal

diffuse

symptoms

low

mild

moderate

high

CHARACTER PATHOLOGY:

absent

or mild

dystonic

syntonic

diffuse and

(56)

TRAUMA:

RAGE:

Spectrum of Psychopathology III

Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders.

International Journal of Short-Term Psychotherapy,10_{(3,4), 121-155}

mild

moderate

severe

very serve - early

and/or repetitive

absent

murderous

primitive

murderous

primitive

torturous mr

GUILT:

absent

or mild

moderate

heavy

extremely heavy guilt

(57)

Fusion

• Fusion of Guilt and Primitive Murderous Rage :

• “ a pathogenic destructive dynamic system in the unconscious.”

• A major task of the therapist is the rapid removal of this destructive

system

• Age at the time of Trauma:

• The earlier and more intense the trauma:

• The more tenacious the fusion and the more resistant the feelings are

to mobilization

• The more intense and primitive the unconscious rage

• The more complexity in and hence the longer the duration of therapy

(58)

Psychopathologic Dynamic Forces 8

Resistance Against

Emotional Closeness

Character Resistance

Grief

Guilt

Sexual

Bond, Attachment

Primitive Murderous Rage

Pain of Trauma to Bond

(59)

Fusion

Bond, Attachment

Trauma

to Bond

Fusion of

Murderous Rage,

Sexual Feeling and

Guilt

(60)

Central Dynamic Sequence

(overview)

• Phase 1 Inquiry

• Phase 2 Pressure

• Phase 3 Challenge

• Phase 4 Transference Resistance

• Phase 5 Direct Access to the Unconscious

Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient---Part I. Partial Unlocking of the Unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181

(61)

Central Dynamic Sequence

(overview cont

’

d)

• Phase 6 Systematic analysis of the

transference

• Phase 7 Dynamic exploration of the

unconscious

• Phase 8 Consolidation/psychotherapeutic

planning

(62)

Pathogenic

Organization

Character

Defenses

Preconscious

Conscious

Unconscious

Discharge

Pathway of

UCS Anxiety

(63)

Pathogenic

Organization

( fused rage/guilt)

Character

Defenses

Preconscious

Conscious

Unconscious

Discharge

Pathway of

UCS Anxiety

(64)

Resistance and the Unconscious

Therapeutic Alliance

R

UTA

R - Resistance

UTA - Unconscious

Therapeutic Alliance

Partial Mobilization

(65)

Resistance and the Unconscious

Therapeutic Alliance

R

UTA

R - Resistance

UTA - Unconscious

Therapeutic Alliance

Major Mobilization

(66)

AUDIOVISUAL PRESENTATION I

THE DIAGNOSTIC PROCESS

Alan R. Beeber, MD.

Professor Emeritus of Psychiatry

UNC School of Medicine

(67)

Central Dynamic Sequence

• Phase 1 Inquiry.

• Phase 2 Pressure

(68)

Central Dynamic Sequence 1

• Exploring the patient

’

s difficulties: initial ability to

respond.

• Psychodiagnostic in function

Phase 1,

Inquiry:

Davanloo, H: "Intensive Short-Term Dynamic Psychotherapy", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot

(69)

Central Dynamic Sequence 2

• The aim of the pressure phase is to mobilize

resistance until resistance is tangibly crystallized

between the therapist and the patient.

Phase 2,

Pressure:

(70)

Resistance, Transference and

Unconscious Therapeutic Alliance

Time

I n t e n s i t y

Resistance

Complex

Transference

Feelings

Unconscious

Therapeutic

Alliance

(71)

Pathogenic

Organization

Character

Defenses

Preconscious

Conscious

Unconscious

Discharge

Pathway of

UCS Anxiety

(72)

Pathogenic

Organization

( fused rage/guilt)

Character

Defenses

Preconscious

Conscious

Unconscious

Discharge

Pathway of

UCS Anxiety

(73)

Case Presentation

• 23 year old man referred for ISTDP by a resident

• Past history of polysubstance abuse (amphetamines,

cocaine, hallucinogens) with mood symptoms and

paranoid ideation. Abstinent for 11 mos.

• Depression, paranoid ideation, generalized and social

(74)

Case Presentation II

• Difficulties in IPR

’

s. Few friends, anxiety in intimate

relationships, strained relationship with Grandfather



Difficulties with anger. Temper tantrums, revenge

fantasies.



Treatment: Sertraline, quetiapine, atomoxitene. Referred

(75)

Case Presentation III

• Past personal history

• Born/raised in NC

• One brother 6 yrs. His junior.

• Father was

“

closest friend.

”

Suicided when patient 8 years old.

Distinct memories of events. Mother

“

looked like a corpse.

”

• Strained relationship with Grandfather.

• Graduated #2 in high school class, accepted to an Ivy but couldn

’

t

(76)

Video Vignette

(77)

Highly responsive; single

focus;

low

resistance

High resistance; complex

symptom and character

pathology

Spectrum of

Psychopathology

Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic

Disorders.

(78)

DISCHARGE PATHWAY

:

Spectrum of Capacity to

T

ole

rate

Anxi

ety

Adapted fromDavanloo, H. (1995). Intensive

Short-T

erm D

Journal o

f Short-T

erm

Psychothera

py

,

1010

_(3,4),

121-155 ynamic Psychotherapy: Spectrum of Psychoneurotic Disorders.

Internationa

l

striated muscle

tension

CAPACITY:

high

moderate

low

cognitive and

perceptual

autonomic

(79)

PROBLEMS:

RESISTANCE

:

Spectrum of Psychopathology II

Adapted from: Davanloo, H.

(1995). Intensive Short-T

erm Dynamic Psychotherapy: Spectrum

of Psychoneurotic Disorders.

International Journ

International Journal of Short-Tal of Short-Term erm PsychotherapyPsychotherapy,, 1010

_{(3,4), 121-155}

f

o

c

a

l

d

i

f

u

s

e

s

y

m

p

t

o

m

s

l

o

w

m

i

l

d

m

o

d

e

r

a

t

e

h

i

g

h

CHA

RA

CTER

P

ATHOLOGY

:

absent

or mild

d

y

s

t

o

n

i

c

s

y

n

t

o

n

i

c

d

i

f

u

s

e

a

n

d

primitive

(80)

TRAUMA:

RAGE:

Spectrum of Psychopathology III

mild

moderate

severe

very serve - early

and/or repetitive

absent

murderous

primitive

murderous

primitive

torturous mr

GUILT:

absent

or mild

moderate

heavy

extremely heavy guilt

(81)

AUDIOVISUAL PRESENTATION II

MOBILIZATION, REMOVAL OF

RESISTANCE , DIRECT ACCESS TO UCS

Alan R. Beeber, MD.

Professor Emeritus of Psychiatry

UNC School of Medicine

(82)

Central Dynamic Sequence

(overview)

• Phase 1 Inquiry

• Phase 2 Pressure

• Phase 3 Challenge

• Phase 4 Transference Resistance

• Phase 5 Direct Access to the Unconscious

(83)

Central Dynamic Sequence

(overview cont

’

d)

• Phase 6 Systematic analysis of the

transference

• Phase 7 Dynamic exploration of the

unconscious

• Phase 8 Consolidation/psychotherapeutic

planning

(84)

Central Dynamic Sequence 3

• Resistance needs to be crystallized to the point at

which it can be systematically challenged meaningfully

and effectively.

Phase 3, Challenge:

(85)

Central Dynamic Sequence 4

• Intensification of the resistance and its transference

component, transference resistance

• Mounting the challenge to the transference resistance

Phase 4, Transference

Resistance:

(86)

Central Dynamic Sequence 5

• Head-on collision with the transference resistance to

bring the patient face to face with the

self-destructiveness of his or her resistance

Phase 4, Transference Resistance

(cont.):

(87)

Central Dynamic Sequence 6

• Mobilization of the unconscious therapeutic alliance

against the resistance, which leads to the state of

intrapsychic crisis, or tension between the resistance

and unconscious therapeutic alliance

Phase 4, Transference Resistance

(cont.):

(88)

Resistance, Transference and

Unconscious Therapeutic Alliance

Time

I n t e n s i t y

Resistance

Complex

Transference

Feelings

Unconscious

Thrapeutic Alliance

(89)

Central Dynamic Sequence 7

• Mobilization of the neurobiological pathway of the

primitive murderous rage and its passage in the

transference. This is immediately followed by

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(90)

Central Dynamic Sequence 8

• The emergence of sadness, a further affective

response indicating that the intense guilt feelings are

mobilized but have not yet been experienced

consciously.

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(91)

Central Dynamic Sequence 9

• The patient attentively looks at the visual imagery of

the murdered damaged body of the therapist, and then

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(92)

Central Dynamic Sequence 10

• The visual imagery of the murdered body of the

therapist is transferred to the visual imagery of the

murdered body of the biological figure of the early life

orbit of the patient—mother, father, sibling,

grandparent, and so on.

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(93)

Central Dynamic Sequence 11

• It is important to note that, in this mental imagery, the

visual imagery of the murdered body of the therapist

appears exactly as does the visual imagery of the

murdered body of the mother, father, or sibling—in

terms of the color of the hair, eyes, and so forth.

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(94)

Central Dynamic Sequence 12

• This visual imagery is extremely intense—for example,

the patient sees the visual imagery of the dead body of

the mother with blond hair and blue eyes, and the

visual imagery of the dead body of the therapist is no

longer present.

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(95)

Central Dynamic Sequence 13

• The actual experience of intense guilt-laden

unconscious feeling, which is an intense affective

response—a very painful experience that involves the

neck and the upper part of the chest.

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(96)

Central Dynamic Sequence 14

• The duration of the passage of the guilt averages 8 to

12 minutes in the first major unlocking. This is followed

by

• The emergence of intense positive feeling toward the

people of the past and the actual experience of the

grief-laden unconscious feeling

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(97)

Central Dynamic Sequence 15

• Now, both the patient and the therapist have a first

direct view of the psychopathological dynamic forces

responsible for the patient's symptom and character

disturbances.

Phase 5, Direct Access to the

Unconscious, Major Direct Access to

the Unconscious:

(98)

Central Dynamic Sequence 16

• This is extremely important, particularly in patients with

panic, somatization, functional, and depressive

disorders.

Phase 6, Systematic Analysis of the

Transference:

(99)

Central Dynamic Sequence 17

• With the breakdown of the major resistance and major

mobilization of the unconscious therapeutic alliance,

the unconscious introduces the pain of trauma and

vivid incidences of traumatic events of the past, with

repeated breakthrough of the guilt and painful feelings.

Phase 7, Dynamic exploration into the

unconscious:

(100)

Central Dynamic Sequence 18

•

• Extensive recapitulation and analysis of the

Extensive recapitulation and analysis of the

whole

process

•

• Exploring the patient's response and setting up

Exploring the patient's response and setting up

psychothera

peutic

planning

P

hase

7

7 ,

,

P

hase

of

C

on

so

li

dati

on

:

Davanloo, H: "

Davanloo, H: "Intensive Short-TIntensive Short-Term Dynamic Psycherm Dynamic Psychotherapyotherapy", in: Kaplan H., and Sadock B. (eds),", in: Kaplan H., and Sadock B. (eds),

Comprehensive T

Comprehensive Textbook of extbook of PsychiatryPsychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot

Williams & Wilkins, Philadelphia, 2005

(101)

Video Vignette II

(102)

A

U

D

I

O

V

I

S

U

A

L

P

R

E

S

E

N

T

A

T

I

O

N

I

GRADED TECHNIQUE: PATIENT WITH

LOW

CAP

ACIT

Y TO TOLERA

TE ANXIE

TY

Alan R. Beeber

, MD.

Professor Emeritus of Psychiatry

UNC School of Medicine

Chapel Hill, NC

(103)

Highly responsive; single

focus;

low

resistance

High resistance; complex

symptom and character

pathology

Spectrum of

Psychopathology

Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic

Disorders.

(104)

DISCHARGE PATHWAY :

Spectrum of Capacity to

Tolerate Anxiety

Adapted fromDavanloo, H. (1995). Intensive Short-Term D Journal of Short-Term Psychotherapy,

10

_(3,4),

121-155 ynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International

striated muscle

tension

CAPACITY:

high

moderate

low

cognitive and

perceptual

autonomic

(105)

PROBLEMS:

RESISTANCE:

Spectrum of Psychopathology II

Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders.

International Journal of Short-Term Psychotherapy, 10

_{(3,4), 121-155}

focal

diffuse

symptoms

low

mild

moderate

high

CHARACTER PATHOLOGY:

absent

or mild

dystonic

syntonic

diffuse and

(106)

TRAUMA:

RAGE:

Spectrum of Psychopathology III

mild

moderate

severe

very serve - early

and/or repetitive

absent

murderous

primitive

murderous

primitive

torturous mr

GUILT:

absent

or mild

moderate

heavy

extremely heavy guilt

(107)

AUDIOVISUAL PRESENTATION IV

PROCESS OF WORKING THROUGH

Alan R. Beeber, MD.

Professor Emeritus of Psychiatry

UNC School of Medicine

(108)

Psychopathologic Dynamic Forces 8

R

esist

ance

Agains

t

Emotional Closeness

C

haracter Re

sis

tance

Grief

Guilt

Sexual

Bond

,

Attachment

P

rim

itiv

e M

urd

e

rou

s

R

a

ge

P

ain of

T

rauma to B

on

d

Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking.

Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International JournalInternational Journal

of

(109)

Fusion

Bon

d,

Att

achment

Trauma

to Bond

F

usion of

Murd

erous

Ra

ge,

Se

xual

Fe

eling

and

Guilt

(110)

Pathogenic

Organization

( fused rage/guilt)

Character

Defenses

Preconscious

Conscious

Unconscious

Discharge

Pathway of

UCS Anxiety

(111)

H. Davanloo unpublished used with

permission

Resistance, Transference and

Unconscious

Therapeutic Allianc

e

Time

I I n n t t e e n n s s i i t t y y

Resistance

Complex

Transference

Feelings

Unconscious

Therapeutic

Alliance

(112)

DAVANLOO

’

S METAPSYCHOLOGY:

PERSPECTIVES FROM A NON

‐

ISTDP

THERAPIST

Gary J. Gala, MD.

Associate Professor of Psychiatry

Associate Chair for Education

UNC School of Medicine

Chapel Hill, NC

(113)

Perspectives

•

Settings in which to apply ISTDP—other than outpatient:

strategies and rationale

•

Durability of the effect: What is the evidence?

•

How far away is the unconscious anyway? ISTDP as a more

direct approach.

•

What do we mean when we talk about parts of the self? Is

(114)

Cochrane Review of STPP

•

Abbas et al: Short

‐

term psychodynamic

psychotherapies for common mental

disorders: Cochrane Database:2006 Issue 4,

Art. No. CD004687

–

Efficacy of STPP vs. minimal or non

‐

treatment

–

23 studies/1431 pts. In RCT

’

s

–

Measured general sx, anxiety, depression and

(115)

Cochrane Review of STPP II

•

Results

–

Significantly greater improvement in treatment group vs.

controls

–

Maintained in medium/long

‐

term follow

‐

up

–

Modest to moderate often sustained gains for a variety of

patients

–

Limited data and heterogeneity between studies.

Abbass AA, Hancock JT, Henderson J, Kisely SR. Short‐term psychodynamic psychotherapies for common mental disorders. Cochrane Database of

(116)

•

Targets unconscious emotional processes

•

>60 CT

’

s. >40 RCT

’

s

•

Efficacious with anxiety, depression, personality

disorder, and somatic symptom disorders. Gains are

held in long

‐

term follow

‐

up

(Anderson and Lambert, 1995, Leischering 2004, Abbass, Kisely, Henderson

and Hancock, Cochrane review, 2006)

•

Equal other therapies for symptom reduction

–

Superior to wait list and minimal treatments

–

Superior to medication alone

•

Evidence for persistent Cost Effectiveness

(Abbass,

2002, 2003)

(117)

Systematic Review STDP for Symptom

Disorders

•

23 studies: 13 RCT, 10 Case Series

•

Conditions: IBS, Chronic Pain, Urethral Syndrome, Chronic dyspepsia,

Ulcer, Ischemic Heart Disease, COPD, Crohn

’

s D., Rheumatoid D.,

Dermatitis, Functional Movement Disorders

•

91.3% had sig symptom reduction

•

91.6% had sig social

‐

occupational gains

•

76.2% had sig psychological improvement

•

77.8% had reduced Healthcare Utilization: less surgery in Crohn

’

s

(118)

Systematic Review II

Metaanalysis:

•

Sig effects for Somatic Symptoms, anxiety, depression

in ST and LT

•

Significantly fewer dropouts in STDP patients.

•

Heterogeneity means interpret results with caution.

Short_‐Term Psychodynamic Psychotherapy for Somatic DisordersAbbass A. ∙Kisely S. ∙Kroenke K.

(119)

Overview of ISTDP Outcome Studies

•

N=7 RCT

’

s

–

N=109 patients, mostly with PD

’

s

–

All but 1 main measure statistically sig gains

–

Robust effect sizes

–

Superior to wait

‐

list/minimal contact controls

–

Equal to other similar models

–

Effects maintained in Mean 1.5 year follow

‐

up

•

N= 1 CT

–

N = 166, Robust effects versus wait list control

•

N=9 Case Series

–

N = 578

–

Robust effect sizes.

–

Broadly effective in the real world

–

Evidence of persistent cost effectiveness

–

Mean 2.5 year follow

‐

up shows gains maintained

davanloo.pdf

American Psychiatric

American Psychiatric

Association

Association





New York, NY, May 3 - 7, 2014

New York, NY, May 3 - 7, 2014





167

167

th

th

Annual

Annual

Meeting

Meeting

Seminar 9

Seminar 9

Directors:

Directors:

Alan

Alan

Beeber

Beeber

,

,

M.D.

M.D.

Gary

Gary

Gala,

Gala,

M.D.

M.D.

Date:

Date:

Monday

Monday

,

,

May

May

5,

5,

2014

2014

Tim

Tim

e:

e:

8

8

AM

AM

-

-

12

12

noon

noon

Location

Location

:

:

New

New

Y

Y

ork

ork

Hilton

Hilton

Midtown

Midtown

Bryant Suite

Bryant Suite

Introduction to Davanloo’s Intensive

_{New York, NY, May 3 - 7, 2014}

_{New York, NY, May 3 - 7, 2014}

₁₆₇

₁₆₇

_Annual

_Annual

_Meeting

_Meeting