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IntensiveShortTermDynamicPsychotherapy:AnIntroduction

ByJonFrederickson,MSW

Whatcausessuffering?EversincetheBuddha,hundredsofanswershavebeenoffered
andoverfourhundredtherapies!Andeachoftheseanswers,whethermaladaptivecognitions,
maladaptivebehaviors,unconsciousconflict,dysregulatedanxiety,etc.isanimportantpieceof
thatpuzzlewecallthehumanperson.Butasinthestoryoftheblindmenandtheelephant,
wemustnotmistakeonepieceofthepuzzlewiththeentirepicture.
Thatiswhytodaymanyresearchersaredevelopingmorecomplexandintegrative
modelsofpsychotherapythatrecognizetheroleofmultipledimensionssuchasdevelopment,
unconsciousconflict,cognitions,behavior,andthebody.OnesuchmodelisISTDPwhich
synthesizesmultipletheoreticalperspectiveswithinanintegrativetheoryofthemind,which
translatesdirectlyintoatheoryoftechniqueatechniquewhoseeffectivenesshasbeen
demonstratedinoversixtyresearchstudies.
Inlifeweinevitablyexperienceconflictswithothers.Whenconflictsoccur,we
experiencefeelings.Thesefeelings,providedbyevolution,telluswhatwewantandmobilize
ustoactonourdesires.However,mostpatientsseektherapybecausetheycannotchannel
theirfeelingsintoeffectiveaction.Instead,theybecomeanxiousandusedefenses.These
defensescreatethepresentingproblemsandsymptomsfromwhichourpatientssuffer.
Sofar,sogood.Seemssimple.ButISTDPdefineseachofthesetermsfeeling,anxiety,
anddefensedifferentlyinresponsetorecentresearchinethology,biophysiology,and
neuroscience.Andtheseunderstandingsresultintechniquesandapproachesthatcanoften
leadtoamorerapidandeffectivelevelofchange.
NeuroscientistssuchasAntonioDamasiohaveshownusthatfeelingisonlypartofa
largernonconsciousemotionsystemthatwesharewithanimals.Thisunderstandingradically
changesthewaywethinkaboutfeelings,whytheyareunconscious,andwhytherapistsneed
toworkwiththem.Biophysiologistsandneuroscientistshavecompletelychangedour
understandingofanxietytoo.ISTDPintegratesthosefindingswhichresultsinanewand
complexsetoftechniquesfortreatinganxietydisordersandtheresultingsomaticsymptoms.
ISTDPalsointegratesfindingsfromneuroscience,biophysiology,andpsychoanalysiswhich
changethewayswethinkaboutandworkwithdefenses.Whenwerecognizethatdefenses
andcharactertraitsareformsofimplicitmemorynotencodedinverbaldeclarativememory,
wemustshiftfromapurelycognitivetoanintegrativesetoftechniquestoworkwithdefenses
experientiallyinthehereandnowintherapy.

ThisintegrationoftheoriesandtechniquesgivesISTDPauniqueunderstandingofthe
multipleunconsciousprocessesoperatingintherapy.Wecannolongerthinkofittermsofonly
therepressedunconscious.Instead,thatisonlyatinypartofthespectrumofunconscious
processesinthebrain.Mostofourunconsciousprocessingisnotandneverhasbeenencoded
inverbaldeclarativememoryandwasneverrepressed.Forinstance,anxietyanddefensesare
usuallyunconsciousbuttheyarenotpartoftherepressedunconsciouswhichcanbe
accessedthroughverbalinterpretations.Asaresult,ISTDPcliniciansuseanumberofnon
interpretivetechniquestoworkwithunconsciousprocessesthatareencodedinmotoric,
implicit,andproceduralmemory.

ISTDPalsohasdevelopedanintegrativemodelofthinkingaboutattention.Eversince
Freudrecognizedtheimportanceofanobservingego(1923),alltherapistshaveunderstood
thecentralityofattentiontothechangeprocess.Nowneuroscience(Damasio1999)showsus
thatourabilitytopayattentiontoourbodilyexperienceofemotionisthepreconditionforcore
consciousness.Wemustbeabletopayattentiontobodilyexperiencemomenttomomentin
ordertodevelopselfregulation(Schore,Stern).Andthiscapacityformindfulnessmomentto
momentattentiontofeeling,anxiety,anddefenseisthecentralskillISTDPdevelopsin
patients.Onlythroughthiskindofmindfulnesscanthepatientseewhattriggershisanxiety
andwhatdefensescreatehissymptomsandpresentingproblems.Onlythroughthis
understanding,canthepatientknowwhattofaceandwhattoworkonintherapymomentby
moment.
Themaladaptivecognitionsofcognitivetherapy,themaladaptivebehaviorsofbehavior
therapy,thedefensemechanismsofpsychoanalytictheory,andthemovingawayfromthe
moment(Buddhism)areallseenasdefensesinISTDP.Why?Theydistractourattentionaway
fromourinnerlifeinthismoment.ISTDPintersectswithBuddhismintheirsharedfindingthat
defensescausesufferingbecausetheyalwaysfunctionasaresistancetofacingemotional
realityinthismoment.AndlikeBuddhism,ISTDPholdsthatpainisinevitableinlife.Everytime
welove,wewillbehurteitherbydisappointmentsorthroughdeath.Painissomethingwe
mustbear;itcannotberemoved,simplyfelt.Butsuffering,whichiscausedbyourdefenses,is
somethingwecanovercomeintherapy.

TheRelationshipbetweenSufferingandWhatWedoinTherapy

Patientscometotherapybecausetheysufferfromsymptomsandpresentingproblems.
Toendthissuffering,wemustfindoutwhatcausesit.Soweaskthepatientwhatproblemshe
isseekingourhelpfor.Thenweexploreaspecificsituationwherehisproblemoccurs.By
exploring,wefindoutwhatfeelingheavoidsduetoanxietyandthedefensesthatcausehis
suffering.Nowwecanhelpthepatientseewhathemustdointherapy:1)seeandturnagainst
defensesthatcreatethepresentingproblemsandsymptoms;2)faceratherthanavoidwhat
makeshimanxious;and3)feelhispreviouslyavoidedfeelings.Ifhecanfaceandfeelhis
feelings,hedoesnthavetosufferfromanxietyandsymptomsinstead.Hecanchannelhis
feelingsintoadaptiveactionratherthanusemaladaptivedefenses.


Butarentdefensesgoodforus?youask.Somecanbeadaptive.Butpatientscome
tousbecausetheyareusingmaladaptivedefensesthatcausetheirsuffering.Defensescreate
thepresentingproblemsandsymptomsforwhichpatientsseekourhelp.
Butifdefensesareharmful,whydoweusethem?Mostpatientshavebeenhurtinpast
relationships.Buttherapyinvitesacloserelationship.Ourinvitationtriggersfeeling,anxiety,
anddefensesinthepatient.Inourstudiesofsessionvideotapeswenoticepatientscanuseas
manyasfivedefensesperminute!Andwiththreehundreddefensesanhouralldaylong,it
shouldbenosurprisethatpatientssufferfromthesymptomsandpresentingproblemscreated
bythosedefenses.
So,howdowehelpthepatientinISTDP?Everyinterventioninvitesamoresecure
autonomousrelationshipwiththepatient.Thenextsecondthepatienthasafeeling.The
secondafterthat,thepatientgetsanxiousinherbody.Thesecondafterthat,thepatientuses
adefense.Everytimethepatientusesadefense,hersymptomorpresentingproblemwill
increase.

Butthisiscauseforhope.Ifwecaninterrupteverydefensethathurtsthepatientand
helpthepatientseeandturnagainstherdefenses,hersymptomswilldiminishanddisappear.
Sothetherapistmustsystematicallypointouteachdefense,helpthepatienttoseeit,helpher
seethepriceofthedefense,andturnagainstitsoshecanfacewhatshehasavoided.
Butyoumayask,Arentyouinterruptingthepatient?Whataboutfreeassociation?
Weneverinterruptthepatient.Weinterruptthedefensesthathurtthepatient.Aslongas
patientstalkfreelyabouttheirfeelings,welistencarefully.But,whenpatientsusedefensesto
avoidfeeling,weinterrupttheirdefensessotheycanexperiencetheirfeelingsinstead.The
ISTDPtherapistactivelyaddressesanydefensethatpreventsthepatientfromhavingadeeper
connectionwithherselfandcauseshersuffering.
InISTDP,defenseinterruptionisviewedasanactofcompassiontowardthepatient.
Acceptingdefensesinthesessioncollaborateswithdestructiveness.Onedayapatienthadnot
shownupforhersession.Iwonderedifshemightbeinthehallway.Iwentoutthereandsure
enough,thereshewas,sittingonthefloor,cuttingherwristwithanExactoknifewhile
watchingtheblooddripontoapileofnapkinsonthefloor.Ididnotjustwatchherdefense
thecuttingofherwrist.Itooktheknifeawayfromher.Everydefenseofselfattack,self
dismissal,orselfneglectisacuttothesoul.Andifthesedefensesarenotblockedthepatient
maydiethedeathofathousandcuts.

TheTriangleofConflictasaGuidetoFocusingEffectively


Howdowehelppatientsseetheirdefenses,turnagainstthem,andfacefeelingsthey
havealwaysavoided?Themanwhodevelopedthismethod,HabibDavanloo,realized
somethingveryimportant;everypatientstatementisanexpressionofeitherfeeling,anxiety,
ordefense.Ifyouknowwhatisgoingon,youknowwhattodo.Ifthepatientexpresses
feeling,weencouragefeeling.Ifthepatientistooanxious,wehelpthepatienttoregulatehis
anxietythenexplorefeeling.Ifthepatientusesadefense,wehelpthepatienttoseeandturn
againstthedefensethenexplorefeeling.
Aftereachpatientstatement,thetherapistasks:isthisfeeling,anxiety,ordefense(the
elementsthatconstitutethetriangleofconflict)?Oncethisisdetermined,thetherapistknows
howtoproceed.Ifitisfeeling,helpthepatienttomaintainthefocusonfeeling.Ifitisnot,
helpthepatienttoseethedetourtoanxietyanddefensewhichhasjusttakenplacesothat
hecanreturntoafocusonfeeling.

Feelings

Ourbrainsnonconsciouslyassesstheenvironmentallthetime.Afterall,ifamammal
doesnotkeepassessingtheenvironmentitcanbecomedinner!Oncethebrainassessesthe
environment,itnonconsciouslymobilizesthebody.Thisnonconsciousactivationofthebody
iscalledemotion.Emotionsorganizeanimalbehavior.Thedogthatishappyrunsuptoyou
andlicksyourface.Thedogthatisscaredbarksatyouandattacks.Injustthesameway,
emotionsorganizehumanbehavior.Butwehavesomethinganimalsdonthave:anawareness
ofthisbodilyactivationofemotion.Thisawarenessofourbodilyactivationiswhatwecall
feeling(Damasio1999).

Animalsjustfeelwhattheyfeel.Sowhydofeelingsbecometheengineforconflictsin
humans?Emotionsaretheprimarywayinwhichinfantscommunicatewiththeircaretakersfor
thefirsttwoyearsoflife.Thesurvivalofinfantsdependsonthesecurityoftheircaretakers
attachmenttothem.Soifachildsfeelingstriggeranxietyorangerinthesecaretakers,the
childsbrainappraisesthisasdangeroustoitssurvival.Inresponse,infantsandchildrenuse
defensestohidetheirfeelingsinordertopreservetheattachment.

Initially,defensesareanadaptivemechanismforpreservingarelationship.Butthey
becomehabitualmechanismsthatautomaticallykickinwheneverfeelingsariseinany
relationship.Defensesthatwereadaptiveinpastrelationshipsturnouttobemaladaptivein
currentrelationships.Theysolvedaprobleminthepast,buttheycreatethepresenting
problemsoftoday.Hence,wemusthelppatientsturnagainstthesehabitual,automatic
defensesthatbeganininfancyanddevelopedthroughoutchildhoodsothattheycanfacetheir
feelingsinstead.Inthiswaytheycanregainthefreedomtofeel,tobeintimatewithothers,

andtochanneltheiremotionsintohealthyadaptiveactions.ThatswhyinISTDPwefocuson
feelings.
Primaryfeelingsincludeanger,sadness,fear,joy,andsurprise.Buttobeintouchwith
yourfeelings,tofeeltheminyourbodyyouneedthreeelements:
1) Acognitivelabel:Iamsad.
2) Awarenessofphysiologicalarousal:heavinessinthechestandtears.
3) Themotoricimpulse:crying.
Letslookatanotherfeeling.
1) Acognitivelabel:Iamangry.
2) Awarenessofphysiologicalarousal:sensationofheatrisingfromthesolarplexus.
3) Themotoricimpulse:handsclenchedandarmsareraised.
Whenpatientscanexperiencethesethreeelements,theyhavefullaccesstotheirfeelings.
However,mostpatientsdonothavethisfullaccessbecausetheirdefensesinterfere.Tohelp
patientsrecognizewhattheyfeel,wemusthelpthemseethedefensestheyusetoavoid
payingattentiontoandexperiencingtheirfeelings.

Anxiety

Havingtalkedaboutfeelings,wenowmovetothesecondcornerofthetriangleof
conflict:anxiety.WhenwetalkaboutanxietyinISTDP,wedonotrefertoitasacognitive
thoughtsuchasfearofloss.Thisisnotaformofanxiety.Itisastimulusthatcantrigger
anxiety.

InISTDPweunderstandanxietyasabiophysiologicalpatternofactivationinthebody.
Wehaveinheritedthroughevolutionafearsystemfrommammals.Whenwebecomeanxious
oursomaticandautonomicnervoussystemsbecomeactivated.Oursomaticnervoussystemis
comprisedofyourskeletalorstriatedmuscles,theoneswecanmovevoluntarily.Sowhenwe
getanxiousourmusclesbecometenseandpreparedforaction.Atthesametimeour
autonomicnervoussystemgetsactivated.Ourautonomicnervoussystemiscomprisedoftwo
branches:thesympatheticandparasympatheticnervoussystems.Ifoursympatheticbranch
getsactivatedourheartraces,ourbreathingrateincreases,andourbloodpressuregoesup.If
ourparasympatheticbranchgetsactivatedourheartratedrops,ourbreathingratedrops,and
bloodpressuregoesdown.Sowhatdoesthismeanfortherapy?

Davanloo(2000)discoveredthreebasicunconsciouspathwaysforanxietydischargein
thebody.Whenpatientsgetanxious,theiranxietycanbedischargedintostriatedmuscles,

smoothmuscles,orcognitiveperceptualdisruption.Andeachofthesepathwaysofanxiety
dischargehasimportantimplicationsforhowtodotherapy.

Patientswhoexperiencetheiranxietyinthestriatedmusclesbecometenseinthe
sessionandsighwhenyouaskaboutemotionallyimportantmaterial.Thesepatientsare
usuallyawareoftheirandanxietyandknowwhattriggersit.Thesepatientscantolerateahigh
riseoffeeling.

Ontheotherhand,somepatientssufferfromanxietythatisdischargedintothesmooth
muscles.Theysufferfrommigraineheadaches,upsetstomach,anddiarrhea.Orpatientsmay
experienceanxietydischargedintocognitiveperceptualdisruption.Whentheybecome
anxiouspatientswhoseanxietyisdischargedinthispathwaybecomedizzy,haveblurryvision
orringingintheears,dissociate,orlosetrackoftheirthoughts.Patientswhoseanxietyis
dischargedintothesmoothmusclesorcognitiveperceptualdisruptionrequireanxiety
regulationbeforeweexploretheirfeelings.

Toassesspatientsanxietywemustexploretheirfeelingsintherapy.Exploringfeeling
inthesessiontriggersanxietyinthebodysowecanobservewhereinthebodythepatients
anxietyisdischarged.Thatletsusknowwhathercapacityforaffecttoleranceisandhowwe
needtotailorthetherapytofitherneeds.Patientswhoseanxietyisdischargedintosmooth
musclesorcognitiveperceptualdisruptioncantoleratelessintensityoffeeling.Asaresult,
theyrequiremoreworkonanxietyregulationandbuildingtheircapacitytoobserveand
toleratetheexperienceoftheirfeelingsandanxiety.

Bythisstageinthehistoryofpsychotherapy,weknowthatdifferentpatientshave
differentcapacitiesrequiringdifferentformsoftreatment.ISTDPhasdevelopedseveral
differentkindsoftreatmentformoderateresistant,highresistant,fragile,depressed,and
somatizingpatients.Eachofthesegroupsrequirestailoredtreatmentsbasedonthepatients
affecttolerance,patternofunconsciousanxietydischarge,typeofdefensesused,resistances,
andselfobservingcapacity.Buttoknowwhichtreatmentformattooffer,youfirstneedtobe
abletomaketheseassessments.

Defenses

Havingaddressedfeelingsandanxiety,wenowmovetothethirdcornerofthetriangleof
conflict:defenses.Defensesarethestrategiespatientsusetokeepthethoughts,feelings,and
impulsesthattriggeranxietyoutofawareness.InISTDPwegroupdefensesintodifferent
categories.
Repressivedefensesrepressfeelingssothepatientwillnotbeawareofthem.Theyinclude
intellectualization,rationalization,minimization,displacement,andreactionformation.

Regressivedefensesinvolvesomeregressioninthepatientscapacitytoseereality.These
defensesincludesplitting,projection,somatization,externalization,actingout,anddischarge.
Characterdefensesarebasedonidentificationswithpunitivefiguresinthepast.SoImight
dismissmyfeelingsasIwasdismissedbymyfather,orImightignoremyfeelingslikemy
motherdid,orImighttreatmyselfasIdontmatterlikesomeonetreatedme.Incharacter
defenses,Idotomyselfwhatsomeonedidtomeinthepast.
Tacticaldefensesrepressfeelingbut,moreimportantly,theyfunctionastacticstokeepthe
therapistatadistance.Theyareinterpersonaldefenses.Forinstance,ifyouaskmewhatI
wouldlikehelpwith,Imightrespondwiththetacticaldefenseofvagueness:Imnotsureits
aspecificproblem.Itmaynotbeaproblematall.Maybeitsjustamidlifecrisis.Nota
problematall.Myvaguenessservesasatactictokeepyouatadistance.Itismywayof
resistingyou,preventingyoufromhavingacloserrelationshiptome.Tacticaldefensesinclude
sarcasm,changingtopics,arguing,avoidingeyecontact,crossingonesarmsandlegs,or
laughingoffcomments.

Thetypeofdefensetellsyouhowtointervene,whattypeofpatientyouareworking
with,andhowgreattheircapacityforselfobservationis.ISTDPhasdevelopedanumberof
noninterpretivetechniquestohelppatientsobservetheirdefenses,recognizethepriceand
functionofthedefenses,andtoturnagainstthedefenses.ISTDPhasalsodeveloped
specializedtechniquestohelppatientswhopresentwithhigherleveldefenses,regressive
defenses,resistance,oratransferenceresistance.

Withthisbriefoutlineofthebasicconceptsandgoaloftreatment,letstakealookat
thesequenceofinterventionsweuseinISTDPtohelppatientsbecomefreeoftheirdefenses.
Thisisknownasthecentraldynamicsequence.

HowdoWeHelpthePatient?TheCentralDynamicSequence

DeclarationofanInternalProblem

Inquiry

Webegintherapybyaskingthepatientwhatherinternalproblemisforwhichshe
wantsourhelp.Thenweaskaboutthepatientsdifficulties,theiroriginandtheirhistory.Of
course,thepatientsanswerswilltelluswhatherbasicconflictsareandherabilitytodealwith
them.Weneverexploreproblemsofotherpeoplethepatientmentions.InISTDPweexplore
thepatientsconflictsbetweenherfeelings,anxiety,anddefensesastheyoccurinthe

situationswhereshehasproblems.

DeclarationofPatientsWill

Oncethepatienthasdeclaredaninternalemotionalproblemtoworkonintherapywe
checktomakesurethepatientwantstobeintherapy.Apatientmayclaimhedoesnotwant
tobetherebutisrequiredtobeintherapybyhisboss,hiswife,hisdoctor,ortheparoleboard.
ButinISTDPwetakethepositionthatwehavenorighttotreatapatientwhoismerely
complyingwiththewillofothers.Ifitisnothiswilltodotherapy,wehavenorighttoaskhim
todoso.

DeclarationofaSpecificExample

Oncewehavesurveyedthepatientsproblemsandthepatientdeclareshiswillto
engageintherapy,weaskforaspecificexampleofwhereherproblemoccurs.Interestingly,
patientsoftenusedefensesatthispoint.Ratherthangiveaspecificexample,thepatientmight
becomevagueandsay,Imnotsuretheresaspecificexamplereally.Itsmoreofanin
generalkindofproblem.Inresponse,theISTDPtherapistaddressesthedefenseofvagueness
andmaintainsthefocusonaspecificexample.Thetherapistmightsay,Whatyouaresayingis
vague.Itsimportantthatyoubespecificsowecanbesuretohelpyou.Couldyougiveusa
specificexampleofwherethisproblemoccursforyou?

InvitationtoFeeling

Oncethepatienthassaiditishiswilltodotherapyandhasgivenusaspecificexample
wecanbeginthenextphaseinthecentraldynamicsequence:invitingfeeling.Weexplorethe
specificexamplewherethepatientsproblemoccurs.

ClarifytheStimulustoFeeling:WhatHappened?

Aswedosowetrytofigureoutwhathappenedinthisexamplethattriggeredthe
patientsfeelings.Didhesufferaloss?Didsomeonerejectorinsulthim?Oftendefenseswill
emergewhenwetrytoclarifywhatthestimuluswasthattriggeredthepatientsfeeling.

InvitingFeeling

Onceweclarifywhathappenedweaskthepatientwhathefeels.Whatisthefeeling
overyourdaughtersdeath?Whatisthefeelingtowardyourbossforrejectingyour
proposal?Asweaskaboutherfeelingsthepatientcanrespondinoneofthreeways.She
mayrespondwithfeeling.Shemightbecomeanxiousinstead.Orshemightuseadefenseto
avoidherfeeling.Mostpatientsdonotrespondwithfeeling.Instead,theyavoidtheirfeelings
byrespondingwithanxietyordefense.InISTDPwedonotfollowthesedetourstoanxietyand
defense.Instead,weidentifyeachofthesedetoursandtheninvitethepatienttoreturntothe

focusonhisfeeling.Maintainingthisconsistentfocusinthemidstofthepatientsdetoursis
oneofthemostimportantskillsfortherapiststolearn.
Ifthepatientgoesonadetourtoanxietywelabelheranxietyandthenreturntothe
focusonfeeling.Ifthepatientgoesonadetourtodefensewehavetohelpherseethe
defenseanditsprice,turnagainstit,andreturntofocusingonherfeeling.Ifpatientscontinue
todetourtoanxietyanddefensetheywontarriveattheirdestination:adeepfeeling
connectionwiththemselves,withtheirdesires,withothers,reality,andlifeitself.

DefenseWork

Assoonasweinvitethepatienttorevealherfeelingsdefensesarise.Eachtimeshe
usesadefensewepointitoutandhelpherseethepriceofusingthedefense,actively
addressinganydefensethatcouldcausesufferingtothepatient.Andthen,eachtime,we
invitehertoreturntothefocusonherfeeling.
Th:Whatisthefeelingtowardyourhusbandforsayinghewantedtohavesexwithsomeone
else?
Pt:Ithoughtitwasrude.[Defenseofintellectualization.Shedescribeshisstatementrather
thanherfeeling.]
Th:Itwas.Butifwedontcoverthefeelingwiththisthought,whatisthefeelingtoward
him?
Pt:Ithinkheisangrywithme.[Projection:thepatientspeculatesaboutsomeoneelses
feelingratherthanrevealingherown.]
Th:Wecanonlyspeculateabouthisfeelingbutwecouldgetabsolutelyclearaboutyours.If
wedontspeculateabouthim,whatisyourfeelingtowardhimforsayinghewantssexwith
someoneelse?
Pt:Ifeeldetached.[Defense]
Th:Butdetachedisnotyourfeeling.Detachingishowyoudealwithyourfeeling.You
detach.Ifyoudontdetach,whatisyourfeelingtowardhim?
Asyoucansee,thetherapisthelpsthepatienteachtimesheusesadefense.Ourgoalis
tohelpthepatientfaceandexperiencethefeelingssheusuallyavoids.Todothatwecarefully
helpthepatientseeeachdefensesheuses.Thenwehelpherseethepriceofherdefenses:
theycreatehersymptomsandpresentingproblems.Thenwehelpthepatientturnagainsther
defenses.Ifshestillhastroubleturningagainstherdefensesweconfrontthem.


Butsomepatientswhoeventuallyseetheirdefensesdonotturnagainstthem.Why?
Theythinktheirdefenseshelpthem.
Pt:Ithinkdetachinghelpsmedealwithmyhusband.
Tohelpthepatientturnagainstherdefenses,wemustshowherhowherdefensescreateher
presentingproblemsandsymptoms.Ideallythepatientcanmakethisconnectionifweaskher
aquestionabouttheimpactofherdefenses.
Th:Butifyoukeepdetachingandavoidingyourfeelingsherewithme,whatimpactwillthat
haveonourwork?
Pt:Iwontgetanywhere.

BreakthroughtoFeelings

Whenthepatientrelinquishesherdefenses,shebeginstoexperiencefeelingswhichshe
hasalwaysavoided.Thesefeelingsareusuallytowardfamilyfigureswithwhomthepatient
hadatroubledrelationship.Sometimesthefeelingsaretowardpeoplewhoabusedthe
patient.Eitherway,thepatientfacesdeep,previouslyavoidedfeelingsinanemotional
breakthroughtofeeling.

Withthebreakthroughtofeelingthepatientexperiencesawaveofmixedfeelings
towardearlierfiguresinherlife.Nowsheexperiencestheemotionalconnectionsbetweenher
pastandtheproblemsshesufferstoday.Throughtheseexperientialinsightsherlifebeginsto
makesenseinanewfeelingway.Andwecanexploreherpastemotionally,meaningfully
withoutherdefensesbeingintheway.

Consolidation

Mosttherapiesuseinterpretationtobringunconsciousmaterialtothesurface.But
interpretationcanreinforcethepatientsintellectualizationandrationalization.SoinISTDPwe
interpretonlyafterthebreakthroughtotheunconscioussointerpretations,emotionally
experienced,willleadtogenuineintegration.

Thereliefofexperiencingpreviouslyavoidedfeelingsandthedeeperunderstanding
thattheybringmotivatethepatienttoseekadeeperconnectiontoherinnerlife.Nowhertask
isclear:tohelpherturnagainstherdefenses,facewhatshefears,andtoexperienceher
feelingsasdeeplyaspossibleinordertogettothebottomofherdifficulties.Andindoingthis
wehelpthepatientchannelthosefeelingsintoadaptiveactionssoshecanachievehergoalsin
life.


Byhelpingthepatientturnagainstherdefenseswehelpherhavecompassionfor
herselfandherlongingswhichherdefensesdefeated.Atthesametime,byhelpingthe
patientturnagainstherdefenseswedemonstrateourcompassionforherandherrightto
reclaimherlife.InalettertotheexistentialistpsychiatristLudwigBinswanger,Freudonce
wrotethatpsychoanalysisisacurethroughlove.Throughourconstantattentiontothe
patientsinnerlifeandbyblockingthedefensesthatstrangleit,ISTDPalsoisalsoacure
throughlove.Throughourconstantmomenttomomentattentiontothepatientsfeelingswe
activelydemonstrateourconcernforherrighttobefreefromthoseinhibitingdefensesthat
haveperpetuatedhersuffering.For,asFriedaFrommReichmannsaid,Toredeemoneperson
istoredeemtheworld.

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