II. History of Experiential Dynamic Therapy (EDT)

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1 Transforming Resistance Effectively and Efficiently in Difficult to Reach Clients: A Video Demonstration Steven S. Shapiro, Ph.D. PPA Fall Conference; Fraser, PA; October 30, Mystic Lane; Malvern, PA ; stevesshapiro12@gmail,com Accelerated Experiential Dynamic Psychotherapy Institute; New York City, New York; Senior Faculty For more information: ; Steven S. Shapiro, Ph.D. II. History of Experiential Dynamic Therapy (EDT) History of Major Contributors* 1. Freud 2. Ferenczi 3. Ferenczi and Rank 4. Alexander and French 5. Malan (Brief Therapy) 6. Davanloo (Intensive Short-Term Dynamic Psychotherapy) 7. Alpert (Accelerated Empathic Therapy) 8. Fosha (Accelerated Experiential-Dynamic Psychotherapy) *List is not inclusive 1

2 History of Psychoanalysis and Psychodynamic Psychotherapy 1. Different than ordinary polite conversation. 2. Fear of exerting undo influence. 3. Neutrality, non-directiveness, abstinence as technical aspects. 4. Not face-to-face. 5. Focus on insight. 6. Therapist interprets material. 7. Focus on origins of conflicts. 8. Allow or encourage distortions. 9. Focus on patient. History of Psychoanalysis and Psychodynamic Psychotherapy 10. Resistance contributed to increased length. 11. Interpretive techniques created intellectual insight. 12. Insight did not reliably lead to symptom reduction or improvement in functioning. 13. Character disorders and others with high resistance did not respond to interpretation. Experiential Dynamic Therapy (EDT): General Treatment Principles 1. Based on psychoanalytic principles. 2. Goal is visceral experience not insight. 3. Non-interpretive techniques. 4. High level of therapist activity, engagement and focus. 5. Active work with defenses. 2

3 Experiential Dynamic Therapy (EDT): General Treatment Principles 6. Systematic moment-to-moment conceptualization of clinical material. 7. Collaborative approach; relational techniques. 8. Trial therapy to determine response. 9. Change can occur in abrupt steps. -quantum transformation vs incremental change An Experiential Approach The single most important and defining aspect of the therapy is that it is experiential: the clinical phenomenon are not inferred, referred to, interpreted or only talked about: they are experienced by the patient. The experience of vital affects in the context of an attached relationship is the primary agent of emotional transformation (Fosha, p. 5) From: Fosha, D., Ph.D The Transforming Power of Affect: A Model for Accelerated Change. New York: Basic Books (ISBN: ) All knowledge is experience; everything else is just information Albert Einstein 3

4 the patient needs an experience, not an explanation. -Frieda Fromm-Reichmann Healing does not occur through insight, but insight occurs through healing. Corrective Emotional Experience the basic therapeutic principle is the same: to reexpose the patient, under more favorable circumstances, to emotional situations he could not handle in the past. (p. 66) Because the therapist s attitude is different from that of the authoritative person of the past, he gives the patient an opportunity to face again and again, under more favorable circumstances, those emotional situations which were formerly unbearable and to deal with them in a manner different from the old (p.67) Alexander, F. & French, T Psychoanalytic Therapy: Principles and Application. Lincoln and London: University of Nebraska Press 4

5 An Active & Focused Approach Patients and psychic phenomenon prove quite robust; for the well trained clinician, the danger of ineffectiveness and avoided action looms much larger than the danger of damage from direct intervention. (Fosha, p. 2) From: Fosha, D. Ph.D The Transforming Power of Affect: A Mode for Accelerated Change. New York: Basic Books (ISBN: ) An Active & Focused Approach It needs to be stated categorically that in the early part of the century, Freud unwittingly took a wrong turning, which lead to disastrous consequences for the future of psychotherapy. This was to react to increasing resistance with increasing passivity eventually adopting a technique of free-association on the part of the patient, and the role of passive sounding board, free floating attention and infinite patience on the part of the therapist. (Malan, 1980, p. 13) Note: Bold type added A completely neutral psychoanalyst does not exist in reality, nor would he be desirable. (p.67) Alexander, F. & French, T Psychoanalytic Therapy: Principles and Application. Lincoln and London: University of Nebraska Press 5

6 EDT Approaches: Anxiety Provoking Anxiety Regulating Intensive- Short Term Dynamic Psychotherapy I-STDP Anxiety Provoking Expressive- Short Term Dynamic Psychotherapy E-STDP Accelerated Experiential Dynamic Psychotherapy AEDP Anxiety Regulating Why do we ask patients how they feel? To clearly view: Characteristic defenses Anxiety patterns Tolerance for anxiety and affect Attachment style Psychodiagnostic Assessment: Intrapsychic Formulation 6

7 Pt s Response to Th s Invitation to Experience and Connect EXPRESSIVE DEFENSIVE Self-at-Best Self-at-Worst Who Needs Defense Restructuring? (before exposure to core affective phenomena) 1. Limited affect/ anxiety tolerance 2. Fewer internal resources 3. Syntonic defensive structure 4. And everyone else Benefits of Comprehensive Moment to Moment Tracking 1. Determines therapists interventions, style, pace 2. Rapport 3. Avoid ruptures 4. Counter-transference 7

8 METAPSYCHOLOGY: Accessing Right Brain Phenomena and the Unconscious Resistance: The Tip of the Iceberg DEFENSES INHIBITORY AFFECTS Defense dominated functioning 8

9 DEFENSES INHIBITORY AFFECTS acting out behavior interpersonal conflict... defenses against intimacy intense suffering life-long psychiatric symptoms self-destructive patterns... compromised sense of self limited affect & anxiety tolerance DEFENSES Defensive Exclusion self-at-worst INHIBITORY AFFECTS self-at-best Internal Resources 9

10 Defense Restructuring How do we discourage use of characteristic defenses? DEFENSES INHIBITORY AFFECTS Self-at-Best" How do we access core affective experiences which are adaptive and healing? a means to an end DEFENSES INHIBITORY AFFECTS ADAPTIVE CORE AFFECTIVE PHENOMENA CORE STATE self-at-best Blocked Internal Resources 10

11 Eliciting Unconscious Phenomena and Self-at-Best CONSCIOUS EXPERIENCE ATTACHMENT TRAUMA IMMOBILIZATION UNCONSCIOUS INTRAPSYCHIC CONFLICTS FORBIDDEN FEELINGS, IMPULSES ADAPTIVE ACTION TENDENCIES SOMATIC MEMORIES Therapeutic Approach: EXPERIENTIAL RIGHT BRAIN ENGAGED FOCUSED ACTIVE SAFE Therapeutic Choice Points: Facilitating a Different Experience Self-at-Worst Defense, Inhibitory Affects Embodied or Enacted Familiar, Comfortable Self-at-best Adaptive, Expressive Affect Experienced and Metabolized Unfamiliar, Uncomfortable 11

12 Redoing, not Reliving (Trauma) Reliving (Experience) Symptomatic relief Venting Catharsis Redoing (Experience) Psychological transformation Deep healing Emotional change MOMENT TO MOMENT TRACKING: CLINICAL MAPS Pt s Response to Th s Invitation to Experience and Connect 1. Access to affective and relational experiences, (Core Affective Experiences) 2. Resistance to affective experience or connection (Defense) 3. Inhibitory responses, discomfort, anxiety, difficulty exploring (Red-Signal Affects). 4. Shut down, disorganization, flooded with anxiety & distress, fear & shame (pathogenic affects) 12

13 Triangle of Experience Triangle of Relationship D A T C Core Affective Phenom. P A = Anxiety, Red Signal Affects, inhibitory affects D = Defenses Against emotional experience Against relational experience T = Therapist C = Current figures P = Past figures Triangle of Experience: What Feeling is Feared, How is it Avoided & Why? HOW is the adaptive, core affective experience avoided? (what response?) WHY is the adaptive feeling avoided (cause)? What anxiety would emerge if the defense was not used? Defenses Explains the reason for the defensive response. Red Signal Affects/ Inhibitory Anxieties Core Affective Experiences WHAT feelings are being avoided? What would be an adaptive response? What response would be self-caring? Adapted from: McCullough et al Treating Affect Phobia: A Manual for Short-Term Dynamic Psychotherapy. The Guildford Press, New York. p. 84 Triangle of Experience Brakes D Warning Light A F Engine; Gas Pedal 13

14 Triangle of Experience Triangle of Relationship Defense Red Signal Green Signal Therapist Current Affects Affects Core Affective Phenomena Core State Affect 1. Cognitive 2. Physiological 3. Action Tend. Portrayal Facilitating Affect Defense Restructuring Anxiety Regulation Relational Intervention Transitional affects/ Intrapsychic crisis Corr. Emot. Exper. Pathogenic affects Past Therapist Patient + _ Patient + _ A N X I E T Y TOO HIGH OPTIMAL TOO LOW Copyright: 2006; Steven S. Shapiro 3. COG./ PERCEP. 2. SMOOTH MUSC 1. MUSC. TENSION Triangle of Experience Self at best Self at worst D A D A Core Affect Core Affect 14

15 Feeling, Anxiety or Defense? Defense Red-Signal Affects (Anxiety) Core Affective Phenomena (Feeling) Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Getting the Raw Data (Somatic): Feeling, Anxiety or Defense? Defense Red-Signal Affects (Anxiety) Core Affective Phenomena (Feeling) 15

16 Therapist: How do you experience this anger right now in your body? Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Therapist: How do you experience this anger right now? Patient: Well, I m sure he had his reasons. I have been really messing things up lately at work. I ve always been lazy Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Therapist: How do you experience this anger right now? Patient: Well, I m sure he had his reasons. I have been really messing things up lately at work. I ve always been lazy 16

17 Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Therapist: How do you experience this anger right now? Patient: I feel kinda queasy and light headed. Every time I think about it I feel a giant knot in my stomach. I hate being angry! Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Therapist: How do you experience this anger right now? Patient: I feel kinda queasy and light headed. Every time I think about it I feel a giant knot in my stomach. I hate being angry! Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Therapist: How do you experience this anger right now? Patient: I feel tense in my back, chest and shoulders, like there is an energy rising up in me. I would love to have let him know what it feels like to be humiliated in front of all your coworkers! 17

18 Patient: I feel so angry at my boss for undermining and scolding me in front of the entire team Therapist: How do you experience this anger right now? Patient: I feel tense in my back, chest and shoulders, like there is an energy rising up in me. I would love to have let him know what it feels like to be humiliated in front of all your coworkers! Components of Affect Activation 1. Cognitive 2. Physiological 3. Motoric/ Action Tendency P O R T R A Y A L The Immobility Response A traumatized person s nervous system is not damaged; it is frozen in a kind of suspended animation. Rediscovering the felt sense will bring warmth and vitality to our experiences. (p. 86) Quotes from: Peter Levine; Waking the Tiger,

19 Incomplete Responses & Portrayals: A Different Ending 1. Reliving the memory is re-traumatizing 2. Portraying an alternate version is therapeutic. 3. Releasing adaptive action tendencies. 4. Moving beyond trauma by engaging bodily processes that SHOULD *have happened, not merely reliving what DID happen. * SHOULD = fight or flight; action tendency Recommended Readings & Resources Osimo, F.(2003). Experiential short-term dynamic therapy: a manual. Bloomington, IN. 1st Books. Practical focus on technique, especially about the triangles of person and relationship. Reflects an STDP orientation. Fosha, D. The transforming power of affect. New York, Basic Books. Primary text reviewing theoretical and technical aspects of AEDP, written by the developer of this approach. Reviews the 3 states and 2 state transformations, development of psychopathology from an attachment perspective AEDP website to access various articles about AEDP by Dianna Fosha, PHD and others, educational opportunities, etc. Intensive short-term dynamic psychotherapy; theory and technique. Della Selva, P. C. (1996). New York: John Wiley & Sons Inc. Treating affect phobia: a manual for short-term dynamic psychotherapy. McCullough, Kuhn, Andrews, Kaplan, Wolf, Hurley. (2003). The Guilford Press. Changing character: short-term anxiety-regulating psychotherapy for restructuring defenses, affects, & attachment. Leigh McCullough Vailliant. (1997). Basic Books. 19