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.

Unconscious Therapeutic

Alliance

Complex T Feelings

“Unlocked”

Resistance

PR P RP

Th R

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

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

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:

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.

Common Tactical Defenses

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

CUT OFF FROM EXPERIENCE OF FEELINGS

ISOLATION OF AFFECT

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”

Negation “I am not angry”, “I didn’t want to punch him”, I don’t know what I am feeling”, etc.

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

RAGE IS TURNED AGAINST THE SELF. RESULTS IN SHUTTING DOWN FEELINGS

CLIENT WILL POWERING DOWN, CRUMBLING, GET WEAK, ETC Self

Repressive Barrier

Feelings

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 one-dimensional view of self or people

• Precludes complex feelings and contradictory feeling states

• Associated with Cognitive Perceptual disruption

• Found with more severe and traumatized cases

Defense Example

Projection “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, self-destructive behaviors

PROJECTION AND SPLITTING

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

Defense Example

Self-harm Cutting, addictions, risky behaviors, impulsive, missing sessions

Anger at self, Self-hatred

“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

Examples of Supergo Patholgy:

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.

CLOSED SYSTEM

• 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

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

Identify the client response

Client response Defense type or feeling?

(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

“I notice you are tense and anxious right now. What feelings generate this tension here with me?”

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.

Continued…

SPECTRUM OF PSYCHONEUROTIC

DISORDERS

PATTERNS OF PROBLEMS FROM ATTACHMENT TRAUMA

1. Low Resistance2. Moderate Resistance3. High Resistance

4. High Resistance with Repression5. Mild- Moderate or Severe Fragile Character Structure: repression,

splitting, and projection dominant

Spectrum of Psychoneurotic Disorders

Fragile Spectrum

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. 1995. Abbass 2002

LOW RESISTANT PATIENT

Grief

Tactical Defenses

Eg. Maybe, perhapsEg. Kind of, a little

Eg. vaguenessEg Smile

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. 1995. Abbass 2002

MODERATE RESISTANT CLIENT

Violent Rage, Guilt, Grief, Craving

Major Resistances: Isolation of affect

Eye avoidanceDetaching

RationalizingEg Smile

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• 15-25 sessions

THE HIGHLY RESISTANT PATIENT: THE LOCKED UNCONSCIOUS

Murderous Rage and Guilt

Major Resistances

Slowing downHelpless

ExternalizingDefiance

Grief

ArguingDevaluing

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

DONEC QUIS NUNC

HIGHLY RESISTANT PATIENT WITH REPRESSION

Primitive Rage, Guilt, Grief, Craving

Major Resistance: Repression

RepressionGoing flat

Hopeless

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

• 45-200 sessions to treat

Davanloo, H. 1995. Abbass 2002

Dr Allan Abbass 2017

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 a few sessions

Inquiry

Resistance Rises

Resistance crystallizes in the transference

Clarify, Challenge,

Head on Collision