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The unconscious Therapeutic Alliance 7 th Norwegian Immersion in ISTDP

The unconscious Therapeutic Alliance 7 th Norwegian Immersion in ISTDP. Allan Abbass MD, FRCPC Dalhousie University, Canada www.allanabbass.com. Upcoming Courses.

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The unconscious Therapeutic Alliance 7 th Norwegian Immersion in ISTDP

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  1. The unconscious Therapeutic Alliance7th Norwegian Immersion in ISTDP Allan Abbass MD, FRCPC Dalhousie University, Canada www.allanabbass.com

  2. Upcoming Courses • August 16-18, 2019: Berne Switzerland: 2 Day Immersion and 1 day Supervision Focusing on Psychosomatic Disorders  https://istdp.ch/de/node/283 • August 22-24, 2019: Copenhagen: Danish ISTDP Immersion focusing on the Unconscious Therapeutic Alliance: http://reachingthroughresistance.com/wp-content/uploads/2019/04/5.-Danish-ISTDP-Immersion-with-dr.-Abbass-2019.pdf • August 29-31, 2019: Stockholm: 8th Sweden ISTDP Immersion: Focus on the Unconscious Therapeutic Alliance  http://istdpsweden.se/wordpress/wp-content/uploads/2019/01/8th_Swedish-Immersion_2019.pdf • September 26-28, 2019: Boston: IEDTA International Conference  Ihttps://iedta.net/iedta/iedta-conferences/conference-2019/ • September 30-October 2: 16th Halifax Immersion: Focus on the Unconscious Therapeutic Alliance: https://bit.ly/2yyn6WJ • Sign up for research updates: http://reachingthroughresistance.com/sign-up-to-receive-emails/ Dr Allan Abbass

  3. The loving actions of an honest, caring other person activates, and in some cases, creates, the UTA Dr Allan Abbass

  4. Overall plan for the course • Overview of ISTDP model • The UTA • UTA across the Rise, across treatment phases, and by spectrum • Emphasis on early UTA across series of cases in spectrum Dr Allan Abbass

  5. BOND With Parents Dr Allan Abbass

  6. BOND With Parents Dr Allan Abbass

  7. BOND With Parents Dr Allan Abbass

  8. BOND With Parents BOND With Others Dr Allan Abbass

  9. BOND With Parents Dr Allan Abbass

  10. BOND With Parents Trauma PAIN FEAR Dr Allan Abbass

  11. BOND With Parents Trauma PAIN FEAR Rage, Guilt about the Rage Dr Allan Abbass

  12. BOND With Parents Trauma PAIN FEAR Rage, Guilt about the Rage Avoid closeness Depression Character Disorder Somatic Symptoms Intergenerational Transmission of Trauma Dr Allan Abbass

  13. Transference (Therapist/ Doctor) Current person Past person Dr Allan Abbass

  14. Unconscious Defense Unconscious Anxiety Unconscious Impulses & Feelings Dr Allan Abbass

  15. Complex Transference Feelings (CTF) • Feelings mobilized by trying to therapeutically attach to patient • = appreciation plus irritation toward the therapist • Linked to the past bond, trauma, pain, rage and guilt about rage. Dr Allan Abbass

  16. Unconscious Therapeutic Alliance • Davanloo’s major discovery • The unconscious healing force • Mobilized by activating the complex transference feelings • Works to oppose the resistance • Brings mental images of past relational trauma and clear linkages to trauma Dr Allan Abbass

  17. Memory and Emotion Systems Mid rise in CTF High rise in CTF Partial unlocking Major unlocking R>>UTA Whispers from the alliance: concise understanding of dynamics R >UTA Negation, slips of the tongue R< UTA Rage, grief: clear linkages R<< UTA Rage and Guilt: image transfer R= Resistance UTA= Unconscious Therapeutic Alliance Dr Allan Abbass

  18. Spectrum of Psychoneurotic Disorders(NON FRAGILE) Spectrum of Patients with Fragile Character Structure Severe/ Borderline Low Resistant Moderate Resistant Highly Resistant Mild Moderate Striated Muscle + Isolation of affect Smooth Muscle/Conversion + Repression Cognitive-Perceptual Disruption + Primitive Defenses Dr Allan Abbass

  19. Tactical defenses Loss: grief Attachment No Rage and Guilt Dr Allan Abbass

  20. Therapeutic Alliance Inquiry Pressure Resistance Grief is felt P R Th Dr Allan Abbass

  21. Moderate Resistance Major resistance: isolation of affect Guilt Murderous rage Trauma: Pain Attachment Dr Allan Abbass

  22. Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Low R Moderate R High R Repression Fragile Initial Phase Capacity Building Repeated Unlocking Working Through Termination Dr Allan Abbass

  23. Mid rise in CTF: WHISPERS Low R Initial Phase Dr Allan Abbass

  24. Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Moderate R Initial Phase Repeated Unlocking Termination Dr Allan Abbass

  25. Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS High Resistance Initial Phase Repeated Unlocking Working Through Termination Dr Allan Abbass

  26. Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Repression Initial Phase Capacity Building Repeated Unlocking Working Through Termination Dr Allan Abbass

  27. Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Fragile Initial Phase Capacity Building Repeated Unlocking Working Through Termination Dr Allan Abbass

  28. UTA Across Time • Initial Phase • Capacity Building Phase • Repeated unlocking • Working through • Termination Dr Allan Abbass

  29. UTA over Treatment Phases Power of UTA versus Forces of Resistance UTA: Memories, Vivid Images, Losses due to neurosis, Grief >> Rage UTA: Losses, Goodbye Therapist. Poetry Grief Partial and Major unlocking: Links and Images High rise in CTF: Negation Mid rise in CTF: Whispers Capacity Building Repeated Unlocking Working Through Initial Phase Termination Dr Allan Abbass

  30. Ongoing Functions of the UTA • Keep eye on the defenses • Share insights with therapist • Keep remembering • Keep images in mind until guilt passes • Flashes of the unconscious • Dreams that are memories or breakthroughs • A voice or presence in the mind guiding healthy activity Dr Allan Abbass

  31. ISTDP: Steps to Mobilize the UTA!! • 1. Handle barriers to engagement • 2. Assess the Front of the System • 3. Psychodiagnosis • 4. Monitor and work with parameters • These will determine next interventions, pace and expected processes Dr Allan Abbass

  32. STEP 1: Barriers to engagement • Barriers to collaborative engagement must be undone to see anxiety and defense manifestations Dr Allan Abbass

  33. STEP 2: Find the Front of the System 1. Activated and avoided complex feelings 2. Active defenses at the front 3. Active Unconscious Anxiety 4. No activation Dr Allan Abbass

  34. STEP 3: Psychodiagnosis 2. Monitor Anxiety & Defense responses Unconscious Defense Unconscious Anxiety 1. Pressure on Feelings or Defenses Unconscious Impulses & Feelings Dr Allan Abbass

  35. 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

  36. Unconscious Anxiety • Striated Muscle: Voluntary muscle tension • See with isolation of affect/ self reflection of affect • Smooth Muscle: Body organs • See with repression • Cognitive –perceptual Disruption • See with primitive defenses Dr Allan Abbass

  37. Complete treatment in 1 or 2 sessions Breakthrough of grief about loss Low Resistance Inquiry 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 Resistance Clarify, Challenge, Head on Collision 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

  38. Spectrum of Psychoneurotic Disorders Spectrum of Patients with Fragile Character Structure Severe/ Borderline Low Resistant Moderate Resistant Highly Resistant Mild Moderate Striated Muscle + Isolation of affect Smooth Muscle/Conversion + Repression Cognitive-Perceptual Disruption + Primitive Defenses Dr Allan Abbass

  39. STEP 4: Monitor and Work with 5 Parameters • Unconscious anxiety pathways • Active major defense • Degree to which resistances are syntonic versus dystonic • Degree of rise in the transference/ UTA • Presence of thresholds and how high thresholds are Dr Allan Abbass

  40. Moderate Resistance Resistance Mid rise: Resistance crystallizing in transference Clarify + Challenge Complex Transference feelings “Unlocked” Unconscious therapeutic alliance Low rise: Inquiry and Pressure P P R R Th Dr Allan Abbass

  41. Pressure: Encourage good actions • All efforts encouraging the patient to do something healthy • Cementing the Bond • Reaching to the person stuck under the resistances • Pressure should target front of the system Dr Allan Abbass

  42. Mid Rise Resistance Mid rise: Resistance crystallizing in transference. Clarify and Challenge, Maintain pressure “Unlocked” Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass

  43. Clarification: Question unhealthy behaviors Examples: • Pointing out • Questioning • Exploring impact of defense Keep up pressure Dr Allan Abbass

  44. Challenge: help patient to stop destructive actions • Interrupting and Blocking Defenses • If you don’t detach, if you dont shut down Challenge is always done in concert with the patient and the growing UTA Challenge is always done while maintaining Pressure Dr Allan Abbass

  45. Partial Unlocking Resistance HELP EXPERIENCE THE FEELINGS “Unlocked”: Emotion and Memory Function Greater than inhibitory functions Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass

  46. Striated Muscle Anxiety Goes Down Body Neurobiological Pathway of Rage: goes up same system displacing anxiety Dr Allan Abbass AMA Atlas online

  47. Unlocking • Partial Unlocking: somatic pathway of love, rage, guilt and grief are experienced to small degree: UTA  vivid link to past person. • Major Unlocking: UTA Image of current person or therapist changes to past person with passage of guilt. • Extended unlocking: Rage starts with the therapist then via UTA  becomes the past person with major passage of guilt Dr Allan Abbass

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