Plan

1. Intensive Short-Term Dynamic Psychotherapy for Treatment-Resistant DepressionAllan Abbass MD, FRCPC www.allanabbass.com

2. Plan • ISTDP evidence • Patient categories • Key processes with video examples • Some slides courtesy Dr Joel Town

3. Short-term Psychodynamic Therapies • About 200 RCTs • Meta-analyses show moderate large effects that tend to increase in follow-up for Depression, PD, Somatic Symptoms • Outperforms controls • As effective as Bona Fide models

4. ISTDP • Developed by Davanloo with videotape large case series research • Broad application: developed since the 1970s for treatment resistant populations • Emphasis on the direct experience and working through of feelings related to attachment trauma: • Access by “unlocking the unconscious”: Unconscious Therapeutic Alliance • Capacity building as needed • Over 40 randomized controlled trials • 11 studies of complex or refractory populations: Effect Size (N=10) d=1.59 (Very large) • Meta-analysis 2016: outperforms bona fide controls in follow-up

5. ISTDP

6. Halifax Treatment Resistant Depression Trial Town et al, 2017

7. 90% had Personality disorders91% had comorbid chronic illnesses 80% of participants’ depression symptoms severe/very severe

8. 6 month Outcomes Town et al, 2017HAM-D

9. 1 yr Follow-up: Treatment Received 7 – 18 months • ISTDP group less ongoing treatment • STDP group less likely to have medications added/changed • ISTDP on significantly less medications • ISTDP group more likely to be on zero psychiatric medications

10. Distribution of Depression Severity at 18 months40% fully remitted in ISTDP Group 80% at baseline had severe depression Only 5% of ISTDP group had severe depression at 18 months

11. Impact of Major Unlocking during Treatment N=500. Johansson, et al 2014

12. Impact of Major Unlocking on Healthcare Costs Impact of Major Unlocking ** Town et al, 2013

13. BOND With Parents BOND With Others

14. BOND With Parents Trauma PAIN FEAR Rage, Guilt about the Rage Intergenerational Transmission of Trauma Depression Character Disorder Other Symptoms

15. Transference (Therapist) Current person Past person

16. Unconscious Defense Unconscious Anxiety Unconscious Impulses & Feelings

17. 2. Monitor Anxiety & Defense responses Unconscious Defense Unconscious Anxiety 1. Pressure on Feelings or Defenses Unconscious Impulses & Feelings

18. 4 main patterns • Muscle tension (Hands clench and Sigh) and Isolation of Affect (Intellectual defenses, Isolation of Affect) • Smooth muscle anxiety and Repression of Affect • Conversion: Muscle weakness and Repression of Affect • Cognitive perceptual disruption and projection/primitive defense • All relate to intensity of underlying rage and guilt

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

20. Spectrum of Psychoneurotic Disorders Spectrum of Patients with Fragile Character Structure Low Resistant Moderate Resistant Highly Resistant Severe/ Borderline Mild Moderate Violent Rage Murderous Rage Primitive Murderous Rage Primitive Torturous Rage

21. 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

22. 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

24. Transference (Therapist) Current person Past person

25. Unconscious Defense Unconscious Anxiety Unconscious Impulses & Feelings

26. 2. Monitor Anxiety & Defense responses Unconscious Defense Unconscious Anxiety 1. Pressure on Feelings or Defenses Unconscious Impulses & Feelings

27. Initiating ISTDP: Steps • 1. Handle barriers to engagement • 2. Find the Front of the System • 3. Psychodiagnosis • 4. Monitor and work with anxiety/defense/dynamic parameters • These will determine next interventions, pace and expected processes

28. 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

29. 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.

30. 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. Flat with no activation: Take history. Explore problem areas searching for signs of anxiety and resistance.

31. 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

32. 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

33. Complete treatment in 1 or 2 sessions Breakthrough of grief about loss Low Resistance N=0 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 High Resistance with Repression Depression, smooth muscle anxiety or motor conversion Capacity Building Formats Go flat: No striated muscle anxiety Cognitive-perceptual disruption or primitive defenses Fragile Character Structure Reaching through Resistance, Allan Abbass MD

34. Inquiry Resistance rises N=1 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 High Resistance with Repression Depression, smooth muscle anxiety or motor conversion Capacity Building Formats Go flat: No striated muscle anxiety Cognitive-perceptual disruption or primitive defenses Fragile Character Structure Reaching through Resistance, Allan Abbass MD

35. Moderate resistant patients • Tend to respond to most treatments • Have some buried rage and guilt and grief • Anxiety is all striated • Main defense is isolation of affect • Focus on feelings mobilizes the unconscious therapeutic alliance

36. Unlocking of the Unconscious Moderate Resistance • Pressure: Complex Transference Feelings are experienced: anxiety and defence are removed or reduced • Unconscious Therapeutic Alliance becomes higher than resistance • Images of the unconscious emerge: UTA • Exploration with experience of feelings • Recap and treatment planning • Short course up to 10 meetings

40. Inquiry Resistance rises Pressure Repeated unlocking, working through, termination Resistance crystallizes in the transference N=3 Striated muscle anxiety plus feel complex transference feelings High Resistance Clarify, Challenge, Head on Collision High Resistance with Repression Depression, smooth muscle anxiety or motor conversion Capacity Building Formats Go flat: No striated muscle anxiety Cognitive-perceptual disruption or primitive defenses Fragile Character Structure Reaching through Resistance, Allan Abbass MD

41. 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

42. Why no signals? • Blockers of Primary Engagement in the Process • Anxiety goes other places • Hiding the anxiety • Character defenses • Organic factors • Psychotic/Projective processes • Repression • Suicidal or homicidal intention • Absence of unconscious Problem • Technical Problems

47. Inquiry Resistance rises Pressure Repeated unlocking, working through, termination N=10 High Resistance with Repression Depression, smooth muscle anxiety or motor conversion Capacity Building Formats Go flat: No striated muscle anxiety Cognitive-perceptual disruption or primitive defenses Fragile Character Structure Reaching through Resistance, Allan Abbass MD

49. Conscious Feelings Threshold to experiencing impulse/feelings Threshold to Repression Striated Muscle Anxiety Isolation of Affect Unconscious Anxiety Severe Repression Moderate Repression Mild Repression

50. Conscious Feelings Threshold to Repression 3 2 1 3 Striated Muscle Anxiety Isolation of Affect 2 Unconscious Anxiety 1 1. Pressure to feelings or to defenses 2. Rise in complex transference feelings and anxiety 3. Intellectual recap to bring isolation of affect