ISTDP Techniques by Dr. Allan Abbass
Allan Abbass MD, FRCPC
Professor & Director
Centre for Emotions and Health,
Dalhousie University, Canada.www.allanabbass.com
ISTDP Supervision
Dr Allan Abbass
BOND
With
Parents
Trauma
PAIN
Rage, Guilt
about the Rage
Feelings
Avoided
Self-destruct
Symptoms
Dr Allan Abbass
Current
person
Transference
(Therapist)
Past
person
Dr Allan Abbass
Unconscious
Anxiety
Unconscious
Defense
Unconscious
Impulses & Feelings
Dr Allan Abbass
SPECTRUM OF
PSYCHONEUROTIC
DISORDERS
Low
Resistant
Highly
Resistant
Moderate
Resistant
Mild
Severe/
Borderline
Moderate
Trauma age 5-
7, some rage
+ guilt.
Muscle
tension,
detachment
and defensive
Spectrum of Patients with
Fragile Character Structure
Grief about
loss
Muscle
tension,
detachment +
Minor
defenses
SPECTRUM OF
FRAGILE CHARACTER
STRUCTURE
Trauma age 2-
5, massive
rage + guilt.
Muscle
tension.
Major
detachment
and character
defenses
Trauma age 0-2, massive
rage + guilt and craving
attachment.
Anxiety interrupts cognitive-
perceptual function,
primitive defenses.
Resistant
with
Repression
Trauma age 2-
5, massive
rage + guilt.
Smooth
Muscle,
Conversion,
and
depression
Feel the Grief
Help block
detachment and
feel complex
feelings
Handle defense,
feel complex
feelings
Build anxiety tolerance
first, then feel complex
feelings
Tactical Defense
•
Minor defenses
•
Aim to divert the therapist
•
Can be peripheral to major resistance or work
on their own
•
Are not tightly held
•
Can usually either ignore them to block them
easily
Dr Allan Abbass
Major Resistance: 4 Types
•
Isolation of affect: see with voluntary muscle
anxiety
•
Repression: see with smooth muscle anxiety
and conversion
•
Primitive Defense: See with cognitive-
perceptual disruption
•
Resistance of Guilt: Punitive Superego: need
to defeat and sabotage
Dr Allan Abbass
Complex Transference Feelings (CTF)
•
Complex feelings mobilized in
therapy linked to the past bond,
trauma, pain, rage and guilt about
rage.
•
Includes appreciation and irritation
toward the therapist (T) because of
the challenge to resistance
Dr Allan Abbass
Unconscious Therapeutic Alliance (UTA)
•
This is the unconscious healing force in
the patient
•
UTA is mobilized in proportion to the
degree of mobilization of the complex
transference feelings
•
Elevates mood over minutes
•
Brings mental images and clear linkages
to trauma
Dr Allan Abbass
Dr Allan Abbass
Initiating ISTDP: Steps
•
1. Handle barriers to engagement
•
2. Find the Front of the System
•
3. Psychodiagnosis
•
4. Monitor and work with 5 parameters
•
These will determine next interventions, pace
and expected processes
Dr Allan Abbass
STEP 1: Barriers to engagement
•
Barriers to collaborative engagement
must be undone to see anxiety and
defense manifestations
•
Conscious resistances must be addressed
by a conversation and conscious decision
making by the patient
Dr Allan Abbass
Examples of Barriers to engagement
•
No internal problem
•
Procrastination
•
Defiance: Don
’
t want to deal with it
•
Suicidal
Dr Allan Abbass
STEP 2: Find the Front of the System
1. Activated and avoided complex feelings
: focus
on the cognitive and somatic experiences of the
underlying complex feelings.
2. Active defenses at the front
: turn him against
the defences in the room and focus on
underlying feelings.
Dr Allan Abbass
4 Fronts
3. Active Unconscious Anxiety
: focus on the
underlying feelings. If anxiety is too high, reduce
it by recapping or reviewing bodily symptoms.
4. No activation
: Take history. Explore problem
areas searching for signs of anxiety and
resistance.
Dr Allan Abbass
Unconscious
Anxiety
Unconscious
Defense
Unconscious
Impulses & Feelings
1. Pressure on
Feelings
or Defenses
2. Monitor Anxiety &
Defense responses
Dr Allan Abbass
Striated Muscle Unconscious Anxiety
•
Thumbs clench
•
Hands Clench
•
Arms
•
Shoulders, Neck, Jaw
•
Intercostal:
Sighs
•
Abdomen, back
•
Legs and Feet
•
Hyperventilation,
Fibromyalgia, headache,
chest pain, abdominal wall pain
•
SEE WITH ISOLATION OF AFFECT
Dr Allan Abbass
Smooth Muscle Anxiety
•
Gastrointestinal
•
Vascular, Coronary Arteries
•
Bronchi
•
Bladder
•
hypertension, IBS, migraine, reactive
airways, bladder spasm, abdominal pain
•
SEE WITH REPRESSION OF AFFECT
Dr Allan Abbass
Cognitive-perceptual Disruption
•
Drifting
, dissociation, losing track of thoughts, poor
memory,
fainting
•
Visual blurring
,
tunnel vision, blindness
•
Dysfunction/loss of other senses
•
Hallucinations in all 5 senses
•
Neurological complaints, dizziness, fainting,
conversion
•
SEE WITH REPRESSION AND PROJECTION/PRIMITIVE
DEFENSES
Dr Allan Abbass
Motor Conversion
•
With a rise in feelings, instead of feeling
emotions, the person becomes weak in the
body in one or more areas.
•
When conversion is active, there is no
unconscious anxiety in the striated muscles
•
When we treat this, the anxiety shifts to
striated muscle
•
SEE WITH REPRESSION
Dr Allan Abbass
STEP 3: Psychodiagnosis: 6 responses
•
Feel Feelings with inquiry: Low Resistant
•
Feel feelings after pressure: Moderate R
•
Defend: High Resistance
•
Go Flat: Repression: High r with repression
•
Go Flat: Projection or CPD: Fragile
•
No Response: Search for the anxiety and
resistance
Dr Allan Abbass
Pressure
Moderate
Resistance
Striated muscle anxiety
plus feel complex
transference feelings
High
Resistance
Depression, smooth
muscle anxiety or
motor conversion
High Resistance
with Repression
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure
GO FLAT: No striated
muscle anxiety
Capacity
Building
Formats
Repeated
unlocking,
working
through,
termination
Striated muscle anxiety
plus feel complex
transference Feelings
Breakthrough
of grief about loss
Low
Resistance
Complete
treatment
in 1 or 2
sessions
Inquiry
Resistance Rises
Resistance crystallizes
in the transference
Clarify,
Challenge,
Head on Collision
Dr Allan Abbass
Search for Resistance
If there are no signals of unconscious anxiety
and defence, then we must search for the
resistance and press in that direction to
mobilize the unconscious
Dr Allan Abbass
Why no signals?
1.
Blockers of Primary Engagement in the Process
2.
Anxiety goes other places
3.
Hiding the anxiety
4.
Character defenses
5.
Organic factors
6.
Psychotic/Projective processes
7.
Repression
8.
Suicidal or homicidal intention
9.
Absence of unconscious Problem
10.
Technical Problems
Dr Allan Abbass
STEP 4: Monitor 5 Parameters
1.
Active unconscious anxiety pathways
:
striated muscle, smooth muscle, cognitive-
perceptual disruption.
2.
Active major defense patterns
: isolation of
affect, repression, projection, and resistance
of guilt (superego).
3.
Degree to which resistances are syntonic
versus dyst
onic: how much the patient
identifies with his defenses.
Dr Allan Abbass
5 Parameters
4.
Degree of rise in the transference
: low-, mid-,
high-rise in CTF, or an already mobilized UTA.
5.
Presence of thresholds and how high
thresholds are
: low moderate or high
threshold to smooth muscle anxiety, CPD,
repression or projection.
Dr Allan Abbass
•
Low Rise: Flat process: Little to no unc
anxiety/defense present
•
Mid rise:
–
Resistance starts to
crystallize
between patient and therapist
•
Breaking eye contact
•
Slowing
•
Ruminating
–
Tense Muscles
•
UTA: May see “negation” or “Whisper from UTA”
•
Intervention: Clarify Defenses and Maintain Pressure
Spectrum of Mobilization
Dr Allan Abbass
•
High Rise
–
High degree of crystallization of defenses in the
transference.
–
Battle between Resistance and the Unconscious
Therapeutic Alliance. Whispers and Negation.
–
High tension in muscle
•
Intervention: Challenge with the patient
•
Maintain pressure
High Rise
Dr Allan Abbass
Therapist
Patient
Therapist
Patient
Therapist
Patient
Low
rise
High
rise
Mid
rise
= Defense
Dr Allan Abbass
Low Rise
•
Low activation of feelings, anxiety and defense
•
Need Pressure applied to front of the system
Dr Allan Abbass
Unconscious
therapeutic
alliance
Complex
Transference
feelings
“
Unlocked”
Resistance
UTA, CTF AND RESISTANCE RISE
Dr Allan Abbass
Pressure: Encourage good actions
•
All efforts encouraging the patient to do
something healthy
•
Cementing the Bond
•
Reaching to the person stuck under the
resistances
•
Several foci of pressure
–
Identify Feelings
–
Feel feelings
–
Specifics
–
Be present
–
Be active
–
Care for self
Dr Allan Abbass
Unconscious
therapeutic
alliance
Complex
Transference
feelings
“
Unlocked”
Resistance
Mid rise:
Resistance
crystallizing in
transference.
Clarify and
Challenge,
Maintain pressure
UTA, CTF AND RESISTANCE RISE
Dr Allan Abbass
Clarification: Question unhealthy
behaviors
•
Pointing out
–
Do you notice you go detached now?
•
Questioning
–
Are you slowing down?
•
Exploring impact of defense
–
What will it do to our work if you go detached?
Always keep up pressure
- So let’s see what you are going to do about it.
Dr Allan Abbass
Challenge
•
Interrupting and Blocking Defenses
–
If you don
’
t detach, if you dont shut down
–
AGAIN
you slow down and go passive
–
AGAIN
you go vague
•
Pointing out non verbal resistance
–
Do you see the way you hold your hands … and
now you now you smile
Challenge is always done in concert with the patient
and the growing UTA
Challenge is always done while maintaining Pressure
Dr Allan Abbass
Head on Collision
•
Therapist
s most powerful intervention
•
Confronts patient with reality
•
Puts responsibility for change where it belongs – with the
patient
•
Mobilizes patient to become involved in therapeutic task
and increases CTF
•
Addressed to UTA to go into battle against the R
•
Inter-locking chain of Clarification and Challenge to
major
defense
•
Followed by Pressure to do something about the Defense
Dr Allan Abbass
Head on Collision II
•
Head on Collide with the Resistance in the Transference
–
Point out the destructiveness of the R
–
Point out the benefits of giving up the R
–
Verify the patient’s will to overcome the R
–
Underline the partnership
–
Deactivate any defiance
–
Get out of “the shoes of parent”: deactivate the transference
–
Undo notion of therapist omnipotence
–
Pressure: encourage them to give it their best effort
–
Result:
•
Complex feelings are experienced:
–
the triggering mechanism for direct access to unconscious
feelings
Dr Allan Abbass
Head on Collision III
•
Short Range HOC: for low to Mid Rise
•
Interlocking Chain: For Syntonic High Resistant
cases
•
Comprehensive: For unlocking at High Rise
Dr Allan Abbass
Unconscious
therapeutic
alliance
Complex
Transference
feelings
“
Unlocked”
Resistance
High rise:
Resistance in
transference.
Challenge,
Maintain pressure,
Head on collide
Dr Allan Abbass
Striated Muscle
Anxiety
Goes Down Body
Neurobiological
Pathway of
Rage: goes up same
system displacing
somatization
AMA Atlas online
Dr Allan Abbass
First breakthrough: some passage of grief with
linkage to past or recent person
Partial Unlocking: somatic pathway of love, rage,
guilt and grief are experienced to small degree:
vivid link to past person.
Breakthrough
Dr Allan Abbass
Dynamic Exploration
•
UTA leads process to key areas
•
Feelings are experienced
•
Recapping in between
•
Deepening insight and planning the work that
needs to be done
•
Case example
Dr Allan Abbass
First breakthrough: some passage of grief with
linkage to past or recent person
Partial Unlocking: somatic pathway of love, rage,
guilt and grief are experienced to small degree:
vivid link to past person.
Unlocking
Dr Allan Abbass
Unconscious
therapeutic
alliance
Complex
Transference
feelings
“
Unlocked”
Resistance
Partial Unlocking
Partial passage of
rage guilt and grief
UTA: Links
RESISTANCE DROPS: UTA DOMINATES
Dr Allan Abbass
Unconscious
therapeutic
alliance
Complex
Transference
feelings
First breakthrough
Resistance
Low rise:
inquiry and
pressure
Mid rise:
Resistance
crystallizing in
transference.
Clarify and
challenge
High rise:
Resistance
crystallized in
transference.
Head on
collision
Violent rage
Murderous Rage
Guilt
Grief
Locked Zone
Partial Unlocking of the Unconscious
•
CTF are mobilized and all aspects are partly
experienced
•
Rage and guilt partly experienced
•
Anxiety and defences drop in proportion
•
UTA give clear link or image of person from
the past
Violent rage
Murderous Rage
Guilt
Grief
Locked Zone
Unconscious
therapeutic
alliance
Complex
Transference
feelings
Partial
Unlocking
Resistance
Low rise:
inquiry and
pressure
Mid rise:
Resistance
crystallizing in
transference.
Clarify and
challenge
High rise:
Resistance
crystallized in
transference.
Head on
collision
Major Unlocking: Major Dominance of
UTA over R
•
Murderous rage passes in the transference
•
Images transfers to past person
•
Guilt passes for several minutes
•
UTA is dominant
•
Powerful effects: resistance is put down
markedly
Violent rage
Murderous Rage
Guilt
Grief
Locked Zone
Unconscious
therapeutic
alliance
Complex
Transference
feelings
Major
Unlocking
Resistance
Low rise:
inquiry and
pressure
Mid rise:
Resistance
crystallizing in
transference.
Clarify and
challenge
High rise:
Resistance
crystallized in
transference.
Head on
collision
Unconscious
Anxiety
Striated Muscle Anxiety
Isolation of Affect
Threshold to Repression
Severe
Repression
Moderate
Repression
Mild
Repression
Conscious
Feelings
Threshold to experiencing impulse/feelings
Dr Allan Abbass
Unconscious
Anxiety
Striated Muscle Anxiety
Isolation of Affect
Threshold to Repression
Conscious
Feelings
1
3
2
3
2
1
1.
Pressure
2.
Rise in CTF
3.
Recap
Severe
Repression
Moderate
Repression
Mild
Repression
Dr Allan Abbass
Unconscious
Anxiety
3
2
1
Conscious
Feelings
Threshold
Dr Allan Abbass
Isolation of affect
Striated muscle
Threshold
Therapeutic window
1
3
2
1
2
3
1.
Pressure
2.
Rise in CTF
3.
Recap
Unconscious
anxiety and
defense
Conscious
feelings
Dr Allan Abbass
Threshold
Unconscious
anxiety and
defense
Conscious
feelings
Rage
Grief
R >> UTA
Mid Rise.
Whispers from
the alliance:
concise
understanding
of dynamics
R << UTA
Major
Unlocking
Rage and
Guilt: image
transfer
R < UTA
Partial
Unlocking.
Rage, grief:
clear
linkages
R > UTA
High rise.
Negation,
slips of the
tongue
Guilt
No UTA:
No rise.
Rotating
resistance
dominates
Positive
Over treatment course, the patient can tolerate more feelings in a typical sequence
from positive feeling/grief to rage and finally guilt. We can accelerate these steps.
Striated Muscle Anxiety
Isolation of Affect
Isolation of affect
Striated Muscle
Mild
Fragile
Moderate
Fragile
Severe Fragile
Borderline
Resistance with
Repression
Rage
Grief
Guilt
Positive
Repression, Depression,
Smooth Muscle, motor conversion
Cognitive Perceptual
Disruption
Projection,
Projective Identification
Splitting
Use when below
thresholds
Evoke feelings
Activate somatic
pathway of rage
Develop images
Fire limbic areas
including amygdala
Use when above
thresholds
Self-reflect
Link phenomena
Observe the body
Observe thoughts
Fire brain self-
reflective centers
Reflection:
Recap
Pressure
Use to optimize
rise without being
over threshold
Combine both
self-reflection and
pressure
Train brain to fire
both functional
regions together
BRACING
Abbass, Reaching Through
Resistance, 2015
Splitting, Projective Identification
Projection
Cognitive Perceptual
Disruption
Repression
Smooth Muscle
Isolation of affect
Striated Muscle
Mild Fragile
Moderate Fragile
Severe Fragile
Borderline
Dr Allan Abbass
Isolation of affect
Striated muscle
Mild
fragile
Moderate
fragile
Severe fragile,
borderline
Threshold to CPD or primitive defenses
Therapeutic window
1
3
2
1
2
3
1.
Pressure
2.
Rise in CTF
3.
Recap
Unconscious
anxiety and
defense
Conscious
feelings
Dr Allan Abbass
Unconscious
Anxiety
Conscious
Feelings
UTA RISES WITH CTF
Threshold
CTF
UTA
Dr Allan Abbass
Paranoia
Depression
Anxiety
Sadism:
abuse power
Economy of Suffering: Fragile Patients
No work or $$$
Dependence/
Addiction
Somatization/
Paralysis
Social Isolation
Dissociation
Masochism
Deception
Dr Allan Abbass
Projection:
Afraid
Repression:
Flat, weak,
depressed
Cognitive
Perceptual
Disruption
Self attack or
seek
punishment
Rapidly Rotating Fronts
Projection
of rage or
punishment
Fear attack or
punishment
Guilt about rage
is repressed
Feel rage
about the
attack or
punishment
Unconscious
Anxiety
Striated Muscle Anxiety
Isolation of Affect
Threshold
Conscious
Feelings
1. Pressure to rage
2. Rise to above threshold
3. Press to Guilt and regulate down anxiety as needed
4. Extensive Recapping
1
3
2
3
2
1
Immersive Approach to Building Capacity
Dr Allan Abbass
Barriers to Engagement
Yes
CPD or
Smooth
Striated
No Signals
Anxiety
Defense
Active
Feelings
Assess Front of System
Resolve by conversation
No
Psychodiagnostic
Assessment
Reduce Anxiety
Take History
Press on
Feelings
Press on and
Clarify Defense
Low
Resistance
Go Flat: thresholds to CPD, Primitive
defense, Repression
Defend
Feel
Feelings
Handle Tactical
Defense
Focus on Grief
Moderate
Resistance
Clarify challenge
defense
Press to feelings.
Follow UTA
High
Resistance
Clarify challenge Defense
Head on Collision
Syntonic
dystonic
Small then bigger
breakthroughs of CTF
Strengthen and Follow UTA
High Resistance
with Repression
Mild to Moderate
Fragility
Severe Fragility
Psychic Integration: overcome splits,
Projection to make integrated
but anxious person
Graded Format:
Cycles of Pressure or Bracing
And Recapitulation
Monitor thresholds
Focus on Guilt about rage
to build capacity
1-5 Sessions
Process grief
Repeated unlocking
Working through to
termination in
5-20 Sessions
Repeated unlocking
Working through to
Phase of termination in
20-40 Sessions
Repeated partial then major unlocking
Working through to Phase of termination in
50-150 Sessions
Monitor Parameters: Degree of Rise, Discharge pathways, defense patterns, syntonic vs dystonic, height of thresholds
Initiate Process
ISTDP
Treatment
No Signals
Search for Cause
of no signals
Signals
CHAPTER 6
CHAPTER 7
CHAPTERS 8-16
A Abbass 2018
Barriers to Engagement
Yes
CPD or
Smooth
Striated
No Signals
Anxiety
Defense
Active
Feelings
Assess Front of System
Resolve by conversation
No
Take History
Initiate Process
No Signals
Search for Cause
of no signals
Signals
A Abbass 2018
Dr Allan Abbass
Psychodiagnostic
Assessment
Reduce Anxiety
Press on
Feelings
Press on and
Clarify Defense
Low
Resistance
Go Flat: thresholds to CPD, Primitive
defense, Repression
Defend
Feel
Feelings
Moderate
Resistance
High
Resistance
High Resistance
with Repression
Mild to Moderate
Fragility
Severe Fragility
Monitor Parameters: Degree of Rise, Discharge pathways, defense patterns, syntonic vs dystonic, height of thresholds
A Abbass 2018
Dr Allan Abbass
Handle Tactical
Defense
Focus on Grief
Clarify challenge
defense
Press to feelings.
Follow UTA
Clarify challenge Defense
Head on Collision
Syntonic
dystonic
Small then bigger
breakthroughs of CTF
Strengthen and Follow UTA
Psychic Integration: overcome splits,
Projection to make integrated
but anxious person
Graded Format:
Cycles of Pressure or Bracing
And Recapitulation
Monitor thresholds
Focus on Guilt about rage
to build capacity
1-5 Sessions
Process grief
Repeated unlocking
Working through to
termination in
5-20 Sessions
Repeated unlocking
Working through to
Phase of termination in
20-40 Sessions
Repeated partial then major unlocking
Working through to Phase of termination in
50-150 Sessions
ISTDP
Treatment
Low
Resistance
Moderate
Resistance
High
Resistance
High Resistance
with Repression
Mild to Moderate
Fragility
Severe Fragility
A Abbass 2018
Dr Allan Abbass
Dr. Allan Abbass, a renowned professor at Dalhousie University, Canada, specializes in Intensive Short-Term Dynamic Psychotherapy (ISTDP). His work focuses on exploring transference, unconscious defense mechanisms, major resistance types, and complex transference feelings in therapy sessions. By delving into the spectrum of psychoneurotic disorders and tactical defenses, Dr. Abbass provides valuable insights into working through emotional challenges and fostering healthy relationships with parents and therapists.
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ISTDP Supervision Allan Abbass MD, FRCPC Professor & Director Centre for Emotions and Health, Dalhousie University, Canada. www.allanabbass.com Dr Allan Abbass
0061-0502-2507-4936_TN DeppressedChild BOND With Parents draft_lens2306692module12770636photo_1227683423small_out_of_control PAIN Rage, Guilt about the Rage Feelings Avoided Self-destruct Symptoms Dr Allan Abbass
Transference (Therapist) Current person Past person Dr Allan Abbass
Unconscious Defense Unconscious Anxiety Unconscious Impulses & Feelings Dr Allan Abbass
SPECTRUM OF PSYCHONEUROTIC DISORDERS SPECTRUM OF FRAGILE CHARACTER Spectrum of Patients with Fragile Character Structure STRUCTURE Severe/ Borderline Low Resistant Moderate Resistant Highly Resistant Resistant with Repression Mild Moderate Trauma age 2- 5, massive rage + guilt. Smooth Muscle, Conversion, and depression Trauma age 2- 5, massive rage + guilt. Muscle tension. Major detachment and character defenses Trauma age 5- 7, some rage + guilt. Muscle tension, detachment and defensive Grief about loss Muscle tension, detachment + Minor defenses Trauma age 0-2, massive rage + guilt and craving attachment. Anxiety interrupts cognitive- perceptual function, primitive defenses. Help block detachment and feel complex feelings Feel the Grief Build anxiety tolerance first, then feel complex feelings Handle defense, feel complex feelings
Tactical Defense Minor defenses Aim to divert the therapist Can be peripheral to major resistance or work on their own Are not tightly held Can usually either ignore them to block them easily Dr Allan Abbass
Major Resistance: 4 Types Isolation of affect: see with voluntary muscle anxiety Repression: see with smooth muscle anxiety and conversion Primitive Defense: See with cognitive- perceptual disruption Resistance of Guilt: Punitive Superego: need to defeat and sabotage Dr Allan Abbass
Complex Transference Feelings (CTF) Complex feelings mobilized in therapy linked to the past bond, trauma, pain, rage and guilt about rage. Includes appreciation and irritation toward the therapist (T) because of the challenge to resistance Dr Allan Abbass
Unconscious Therapeutic Alliance (UTA) This is the unconscious healing force in the patient UTA is mobilized in proportion to the degree of mobilization of the complex transference feelings Elevates mood over minutes Brings mental images and clear linkages to trauma Dr Allan Abbass
Initiating ISTDP: Steps 1. Handle barriers to engagement 2. Find the Front of the System 3. Psychodiagnosis 4. Monitor and work with 5 parameters These will determine next interventions, pace and expected processes Dr Allan Abbass
STEP 1: Barriers to engagement Barriers to collaborative engagement must be undone to see anxiety and defense manifestations Conscious resistances must be addressed by a conversation and conscious decision making by the patient Dr Allan Abbass
Examples of Barriers to engagement No internal problem Procrastination Defiance: Don t want to deal with it Suicidal Dr Allan Abbass
STEP 2: Find the Front of the System 1. Activated and avoided complex feelings: focus on the cognitive and somatic experiences of the underlying complex feelings. 2. Active defenses at the front: turn him against the defences in the room and focus on underlying feelings. Dr Allan Abbass
4 Fronts 3. Active Unconscious Anxiety: focus on the underlying feelings. If anxiety is too high, reduce it by recapping or reviewing bodily symptoms. 4. No activation: Take history. Explore problem areas searching for signs of anxiety and resistance. Dr Allan Abbass
2. Monitor Anxiety & Defense responses Unconscious Defense Unconscious Anxiety 1. Pressure on Feelings or Defenses Unconscious Impulses & Feelings Dr Allan Abbass
Striated Muscle Unconscious Anxiety Thumbs clench Hands Clench Arms Shoulders, Neck, Jaw Intercostal: Sighs Abdomen, back Legs and Feet Hyperventilation, Fibromyalgia, headache, chest pain, abdominal wall pain SEE WITH ISOLATION OF AFFECT Dr Allan Abbass
Smooth Muscle Anxiety Gastrointestinal Vascular, Coronary Arteries Bronchi Bladder hypertension, IBS, migraine, reactive airways, bladder spasm, abdominal pain SEE WITH REPRESSION OF AFFECT Dr Allan Abbass
Cognitive-perceptual Disruption Drifting, dissociation, losing track of thoughts, poor memory, fainting Visual blurring, tunnel vision, blindness Dysfunction/loss of other senses Hallucinations in all 5 senses Neurological complaints, dizziness, fainting, conversion SEE WITH REPRESSION AND PROJECTION/PRIMITIVE DEFENSES Dr Allan Abbass
Motor Conversion With a rise in feelings, instead of feeling emotions, the person becomes weak in the body in one or more areas. When conversion is active, there is no unconscious anxiety in the striated muscles When we treat this, the anxiety shifts to striated muscle SEE WITH REPRESSION Dr Allan Abbass
STEP 3: Psychodiagnosis: 6 responses Feel Feelings with inquiry: Low Resistant Feel feelings after pressure: Moderate R Defend: High Resistance Go Flat: Repression: High r with repression Go Flat: Projection or CPD: Fragile No Response: Search for the anxiety and resistance Dr Allan Abbass
Complete treatment in 1 or 2 sessions Breakthrough of grief about loss Low Inquiry Resistance Resistance Rises Striated muscle anxiety plus feel complex transference Feelings Moderate Resistance Pressure Repeated unlocking, working through, termination Resistance crystallizes in the transference Striated muscle anxiety plus feel complex transference feelings High Clarify, Challenge, Head on Collision Resistance Depression, smooth muscle anxiety or motor conversion High Resistance with Repression Capacity Building Formats GO FLAT: No striated muscle anxiety Cognitive-perceptual disruption or primitive defenses Fragile Character Structure Dr Allan Abbass
Search for Resistance If there are no signals of unconscious anxiety and defence, then we must search for the resistance and press in that direction to mobilize the unconscious Dr Allan Abbass
Why no signals? 1. Blockers of Primary Engagement in the Process 2. Anxiety goes other places 3. Hiding the anxiety 4. Character defenses 5. Organic factors 6. Psychotic/Projective processes 7. Repression 8. Suicidal or homicidal intention 9. Absence of unconscious Problem 10. Technical Problems Dr Allan Abbass
STEP 4: Monitor 5 Parameters 1. Active unconscious anxiety pathways: striated muscle, smooth muscle, cognitive- perceptual disruption. 2. Active major defense patterns: isolation of affect, repression, projection, and resistance of guilt (superego). 3. Degree to which resistances are syntonic versus dystonic: how much the patient identifies with his defenses. Dr Allan Abbass
5 Parameters 4. Degree of rise in the transference: low-, mid-, high-rise in CTF, or an already mobilized UTA. 5. Presence of thresholds and how high thresholds are: low moderate or high threshold to smooth muscle anxiety, CPD, repression or projection. Dr Allan Abbass
Spectrum of Mobilization Low Rise: Flat process: Little to no unc anxiety/defense present Mid rise: Resistance starts to crystallize between patient and therapist Breaking eye contact Slowing Ruminating Tense Muscles UTA: May see negation or Whisper from UTA Intervention: Clarify Defenses and Maintain Pressure Dr Allan Abbass
High Rise High Rise High degree of crystallization of defenses in the transference. Battle between Resistance and the Unconscious Therapeutic Alliance. Whispers and Negation. High tension in muscle Intervention: Challenge with the patient Maintain pressure Dr Allan Abbass
Low rise Therapist Patient Mid rise Patient Therapist High rise Therapist Patient = Defense Dr Allan Abbass
Low Rise Low activation of feelings, anxiety and defense Need Pressure applied to front of the system Dr Allan Abbass
UTA, CTF AND RESISTANCE RISE Resistance Unlocked Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass
Pressure: Encourage good actions All efforts encouraging the patient to do something healthy Cementing the Bond Reaching to the person stuck under the resistances Several foci of pressure Identify Feelings Feel feelings Specifics Be present Be active Care for self Dr Allan Abbass
UTA, CTF AND RESISTANCE RISE Resistance Unlocked Mid rise: Resistance crystallizing in transference. Clarify and Challenge, Maintain pressure Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass
Clarification: Question unhealthy behaviors Pointing out Do you notice you go detached now? Questioning Are you slowing down? Exploring impact of defense What will it do to our work if you go detached? Always keep up pressure - So let s see what you are going to do about it. Dr Allan Abbass
Challenge Interrupting and Blocking Defenses If you don t detach, if you dont shut down AGAIN you slow down and go passive AGAIN you go vague Pointing out non verbal resistance Do you see the way you hold your hands and now you now you smile Challenge is always done in concert with the patient and the growing UTA Challenge is always done while maintaining Pressure Dr Allan Abbass
Head on Collision Therapists most powerful intervention Confronts patient with reality Puts responsibility for change where it belongs with the patient Mobilizes patient to become involved in therapeutic task and increases CTF Addressed to UTA to go into battle against the R Inter-locking chain of Clarification and Challenge to major defense Followed by Pressure to do something about the Defense Dr Allan Abbass
Head on Collision II Head on Collide with the Resistance in the Transference Point out the destructiveness of the R Point out the benefits of giving up the R Verify the patient s will to overcome the R Underline the partnership Deactivate any defiance Get out of the shoes of parent : deactivate the transference Undo notion of therapist omnipotence Pressure: encourage them to give it their best effort Result: Complex feelings are experienced: the triggering mechanism for direct access to unconscious feelings Dr Allan Abbass
Head on Collision III Short Range HOC: for low to Mid Rise Interlocking Chain: For Syntonic High Resistant cases Comprehensive: For unlocking at High Rise Dr Allan Abbass
High rise: Resistance in transference. Challenge, Maintain pressure, Head on collide Resistance Unlocked Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass
Striated Muscle Anxiety Goes Down Body Neurobiological Pathway of Rage: goes up same system displacing somatization Dr Allan Abbass AMA Atlas online
Breakthrough First breakthrough: some passage of grief with linkage to past or recent person Partial Unlocking: somatic pathway of love, rage, guilt and grief are experienced to small degree: vivid link to past person. Dr Allan Abbass
Dynamic Exploration UTA leads process to key areas Feelings are experienced Recapping in between Deepening insight and planning the work that needs to be done Case example Dr Allan Abbass
Unlocking First breakthrough: some passage of grief with linkage to past or recent person Partial Unlocking: somatic pathway of love, rage, guilt and grief are experienced to small degree: vivid link to past person. Dr Allan Abbass
RESISTANCE DROPS: UTA DOMINATES Partial Unlocking Resistance Partial passage of rage guilt and grief UTA: Links Unlocked Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass
High rise: Resistance crystallized in transference. Head on collision Resistance Complex Transference feelings Mid rise: Resistance crystallizing in transference. Clarify and challenge First breakthrough Unconscious therapeutic alliance Low rise: inquiry and pressure
Locked Zone Violent rage Guilt Murderous Rage Grief
Partial Unlocking of the Unconscious CTF are mobilized and all aspects are partly experienced Rage and guilt partly experienced Anxiety and defences drop in proportion UTA give clear link or image of person from the past
Locked Zone Violent rage Guilt Murderous Rage Grief
Resistance High rise: Resistance crystallized in transference. Head on collision Complex Transference feelings Partial Unlocking Mid rise: Resistance crystallizing in transference. Clarify and challenge Unconscious therapeutic alliance Low rise: inquiry and pressure
Major Unlocking: Major Dominance of UTA over R Murderous rage passes in the transference Images transfers to past person Guilt passes for several minutes UTA is dominant Powerful effects: resistance is put down markedly
