Unlocked SELF ASSESSMENT KEY PRINCIPLES REVIEWED. Resistance P R. What is the one thing that stood out to you from your last class?

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1 SELF ASSESSMENT What is the one thing that stood out to you from your last class? Your professional take away? How confident are you to be able to identify a client s somatic pathway of emotion? How comfortable are you identifying a client s anxiety pathway? What is the purpose of identifying the pathway of anxiety discharge? What concerns do you have so far? KEY PRINCIPLES REVIEWED This is about validation and acceptance. It should never be construed as critical of the patient The main guide to all of your interventions is this: how can I reach through and connect with the healthy part of the person who is stuck underneath defense and anxiety. Relentless efforts to attach (pressure) mobilize all the attachment related feelings (Complex Transference Feelings) and mobilizes the Unconscious Therapeutic Alliance (UTA). Make it Simple: Reach to the person stuck underneath (pressure) If they defend, help them to see it and to stop If they go flat, help lift them up. Resistance Complex T Feelings Unconscious Therapeutic Alliance PR P R Unlocked P Th R

2 COMPLEX TRANSFERENCE FEELINGS (CTF) Complex feelings mobilized in therapy which are linked to the past bond, trauma, pain, rage and guilt about rage. Includes deep appreciation for the therapist persisting with them for the best outcome. As well includes irritation toward the therapist (T) because of the challenge to resistance. OVERVIEW OF DEFENSES

3 DEFENSES Everyone defends Ways we learned to regulate affect and relationships Ends ups causing and perpetrating pathology Defenses block feelings, wishes, impulse, goals Defenses take energy Defenses block closeness with others Defenses are habitual and unconscious

4 SYNTONIC VS DYSTONIC Syntonic defenses: Client does not see as a problem or how it hurts them and relationship. that is just how I am Dystonic defenses: Client sees as a problem and wants to change. Not use the defense anymore. Has turned against the defense We need to help the client turn their defenses from Syntonic to Dystonic. Otherwise, they will feel attacked and misunderstood. DEFENSES We will divide the defenses into 2 Categories: Tactical and The Major Resistances 1. Tactical 2. Major Resistance: 1. Isolation of Affect 2. Repression 3. Projection/Splitting 4. Superego Pathology 1. TACTICAL DEFENSES Small tactics the client uses to throw off the therapist They are loosely held and fade with either blocking them, ignoring them, or pressing against them These are the most common ones:

5 Common Tactical Defenses Defense Example Cover words It bugged me, I feel embarrassed (avoiding closeness), I feel angst, I Feel upset Lack of focus, vagueness, evasive There is lots going on, It s a relationship problem of sorts, I seem to have some emotional issues Indirect Speech I was probably mad, I guess I feel angry, It could be that Diversification Jumping around from topic to topic, example to example, etc Passive I am not sure where to start. What do you think? Externalization My mother just needs to get in therapy If I could only find a job, life would be better Body movements Smiling, laughing, closing up, turning away, posture, eye contact, etc. MAJOR RESISTANCES 1. ISOLATION OF AFFECT Part of major resistance (tightly held, will not go away by ignoring, etc) Person will intellectualize and isolate affect from experience Associated with striated anxiety

6 ISOLATION OF AFFECT CUT OFF FROM EXPERIENCE OF FEELINGS Defense Example Rummination Overly thinking and speculating Intellectualization, rationalization Using thoughts or ideas instead of feelings Detached Aloof, uninvolved, blank, Passive Waiting on you to take the lead, not invested Slowing down Longer pauses between speech, less output Arguing Keeping things emotionally detached why should I look at my feelings. I need tools I am not angry, I didn t want to punch him, I don t know what I am feeling, etc. Negation Body movements Turning away, eye avoidance, closed posture 2. REPRESSION Helpless, hopeless Self-attack, beating up self Getting angry at self Shutting down Weak, depressed Associated with Smooth Muscle REPRESSIVE DEFENSES Repressive Barrier Feelings RAGE IS TURNED AGAINST THE SELF. RESULTS IN SHUTTING DOWN FEELINGS CLIENT WILL POWERING DOWN, CRUMBLING, GET WEAK, ETC Self

7 REPRESSION Defense Example Shut downs feelings, denial I feel empty, I don t have feelings Smooth muscle symptoms Sick at stomach, weakness Helpless I don t know what to do or how I feel. I can t do this Hopeless It will never get better I am incurable Self-attack, anger at self I m stupid, I deserve this Who would like someone like me Weepy Tears that really cover anger, helpless Body movements Looking flat, depleted, lack of tone and energy, depressed 3. PROJECTION AND SPLITTING Projection: Putting out there one s feelings and impulses. Splitting: Splitting off contradictory views/feelings. Holding onedimensional view of self or people Precludes complex feelings and contradictory feeling states Associated with Cognitive Perceptual disruption Found with more severe and traumatized cases PROJECTION AND SPLITTING Defense Projection Example I don t trust you I think you are angry with me Projection My mother and everyone just hates me Projection The last session I felt like you were implying I just needed to get over it and quit being a baby about this Splitting You are the worst therapist I have ever had. My last therapist was so wonderful Splitting My mother is a witch. I have no love at all for her Splitting I hit the jackpot with my boyfriend. He is absolutely perfect in every way! Associated behavioral manifestations Temper tantrums, impulsive discharge of affect, impulsive behaviors, selfdestructive behaviors

8 4. SUPEREGO PATHOLOGY Resistance of guilt Davanloo calls this the Perpetrator of the unconscious Represents a built-in need to defeat and sabotage treatment to avoid unconscious feelings and impulses. Driven by intense guilt over rage towards loved ones. Unconscious guilt punishes the client for his feelings: The client harms himself to avoid the guilt over wanting to harm attachment figures Results in damaged relationships, self-harm, depression, suicidality, lack of enjoyment in life, reduced insight into oneself, etc. Found mainly in High Resistant, Fragile, and Severe Fragile Clients Examples of Supergo Patholgy: Defense Example Self-harm Cutting, addictions, risky behaviors, impulsive, missing sessions Anger at self, Selfhatred I can t do anything right, I am so stupid I am worthless and unlovable Victim stance What is the point of trying, I can t do anything to change it Need to punish self Self-sabotage Ignoring oneself, neglecting oneself Devaluing self and others, defiant WORKING WITH DEFENSES GENERAL GUIDELINES In general, most defenses are at first treated as tactical, so stance is to ignore or block them, and continue with pressure. tactical defenses are not worth your time If they continue, then brief clarification, and continue with pressure: feeling like he does not understand you is a thought, but how do you feel towards him? If they continue to return, then more direct clarification and challenge is needed. Flick vs Hammer If you can remove a defense by flicking it, then no need to use a hammer. For example, if a fly lands your arm and you hit it with a hammer, then you hurt yourself. Match the degree of challenge with the persistence of defense.

9 CLOSED SYSTEM Closed system is when one or more defenses are in operation in the room and heavily blocking the work. You will not see a lot of signals when this happens Pressure to feeling in a closed system will Puff up defenses Defenses that tend to close the system: Externalization Passivity Defiance and compliance One down Helpless Detachment Superego pathology Identify the client response I notice you are tense and anxious right now. What feelings generate this tension here with me? Client response (sighs) Well, I guess it s that some of the topics I have to raise today are worrysome, that is how I feel. (sighs) Well, I guess I feels overwhelmed by this therapy already umm, I am not sure what I feel, I don t think I can feel my feelings. I am always like that (sighs) Well, I feel like you just sit there and don t offer much. (sighs) Well, I feel like I just want to run away when you keep askingthat (sitting calmly but looking afraid) Well, I just keep wondering about your intentions and what you want from me (looking suspiciously) I don t know, I keep analyzing this therapy approach and think you are disappointed with me for some reason Defense type or feeling?

10 Continued Client response Defense type or feeling? Believe it or not, I just don t know.maybe I can t feel anything I feel so stupid and angry at myself for not knowing what I feel (getting weepy and choked up) I never can do this right, I am such a failure. This is hopeless (Sigh) I am probably getting a little frustrated. I feel an anger rising up from my stomach and would like to shake you right now! (Smiles) Yes, I thought you might ask what I feel. SPECTRUM OF PSYCHONEUROTIC DISORDERS PATTERNS OF PROBLEMS FROM ATTACHMENT TRAUMA Spectrum of Psychoneurotic Disorders 1. Low Resistance 2. Moderate Resistance 3. High Resistance Fragile Spectrum 4. High Resistance with Repression 5. Mild- Moderate or Severe Fragile Character Structure: repression, splitting, and projection dominant

11 THE LOW RESISTANT PATIENT: OPEN ACCESS IS ALREADY THERE Low Resistant patients come with an alliance in place -there is no Rage, thus no Major Resistance Only have tactical defenses They go to the issue then dance around it until you encourage them to feel the grief about the loss in the past. 5 percent of office referrals 1-3 sessions Davanloo, H Abbass 2002 LOW RESISTANT PATIENT Eg. Maybe, perhaps Eg. Kind of, a little Tactical Defenses Eg. vagueness Eg Smile Grief No Rage= No Major Resistance Only Tacticals MODERATE RESISTANT With more resistance, the patient brings more defenses that obstruct the process Pressure is needed to mobilize Complex Transference Feelings (CTF) Resistances mount and need to be clarified, blocked or challenged Presence of Violent and/or Murderous Rage, Guilt, Grief 5-10 sessions Davanloo, H Abbass 2002

12 MODERATE RESISTANT CLIENT Detaching Eye avoidance Rationalizing Eg Smile Major Resistances: Isolation of affect Violent Rage, Guilt, Grief, Craving HIGHLY RESISTANT PATIENT They have major resistances and go to resistance in the Transference Heavy focus in the Transference is needed Standard intervention is Pressure, clarification, challenge, Head-on-collisions Small breakthroughs first to weaken the resistance Later in process typical breakthroughs of MR or PMR in the T which transfer the image to the past figure Primitive Murderous Rage, Guilt, and Grief/pain, love 1/3 of office referrals sessions THE HIGHLY RESISTANT PATIENT: THE LOCKED UNCONSCIOUS Slowing down Helpless Arguing Defiance Devaluing Major Resistances Murderous Rage and Guilt Grief Externalizing

13 HIGH RESISTANCE WITH REPRESSION Instead of feeling rage, it is repressed into the body In face of feelings, client goes flat, loses tone and energy, instant repression takes place. Often weepy Will often have physical symptoms: IBS, Stomach upset, migraines Anger is turned inward to protect attachment figures from the anger Common among depressed clients HIGHLY RESISTANT PATIENT WITH REPRESSION DONEC QUIS NUNC Repression Hopeless Going flat Major Resistance: Repression Primitive Rage, Guilt, Grief, Craving FRAGILE CHARACTER STRUCTURE Severe trauma plus weak attachment Cognitive disruption when anxious Primitive defences: projection, splitting, dissociation, regressive defences Lack clear sense of self Self-harm common (cutting, drugs/alcohol, acting out) 25% of office referrals sessions to treat Davanloo, H Abbass 2002

14 BREAKTHROUGH OF GRIEF ABOUT LOSS Inquiry LOW RESISTANCE Resistance Rises Pressure STRIATED MUSCLE ANXIETY PLUS FEEL COMPLEX TRANSFERENCE FEELINGS MODERATE RESISTANCE Resistance crystallizes in the transference Clarify, Challenge, Head on Collision STRIATED MUSCLE ANXIETY PLUS FEEL COMPLEX TRANSFERENCE FEELINGS Depression, smooth muscle anxiety or motor conversion GO FLAT: No striated muscle anxiety Dr Allan Abbass 2017 COGNITIVE-PERCEPTUAL DISRUPTION OR PRIMITIVE DEFENSES HIGH RESISTANCE Complete treatment In a few sessions Repeated unlocking, working through, termination HIGH RESISTANCE WITH REPRESSION FRAGILE CHARACTER STRUCTURE Capacity Building Formats