Long ago I found that ideas from the theory and practice of family or group therapy could be well-applied to individual therapy.
In family or group dynamics, individuals can find themselves in particular types of roles (e.g. observer, leader, critic, outsider, social butterfly, scapegoat, etc.). Sometimes these roles can be "typecast", entrenched through repetition. Such entrenchment of roles may not allow a person's full range of emotion & personality to flourish.
Similarly, within one's own individual mind, it is possible to "typecast" oneself, through repetition of assumed roles.
The same tactics that can help in a group or family setting (e.g. encouraging a deliberate exploration of entrenched roles, and experimenting with taking on different role styles) could be beneficial for an individual.
Another dynamic which is explored in family therapy is the type of boundaries that exist between different members, in conjunction with the strength of the bond between each different member.
There may be "detached" relationships (a weak bond and little involvement), or so-called "enmeshed" relationships (in which people are extremely involved in each other's affairs, sometimes not allowing the individual to have an experience of autonomy).
Boundaries may be weak, absent, or atypical (in different cases, leading to different types of abuse, or to young children taking on the role of parent or confidante with their mother or father). Or boundaries may be extremely rigid, lacking flexibility (perhaps leading to an uncomfortable authoritarian atmosphere in the relationship or household).
In family therapy, reflection and work can be done on building healthy relationship bonds, encouraging a relaxation of enmeshments, so as to permit more individual autonomy. And work can be done to encourage healthy boundary formation.
Similarly, in an individual therapy setting, personal boundaries and "inner relationship bonds" can be a source of problems. "Enmeshments" may occur on an inner level, perhaps in the form of ruminative or obsessive preoccupations. "Detached" inner relationships may occur, in which parts of self or behaviour are held separate, and leading to a non-integrated sense of self, or a sense of self consisting of numerous independent facades or personas. Boundaries could be weak (perhaps leading to impulse control problems), or inflexible (perhaps leading to an inability to adapt easily, or to adjust to another person's style in a relationship).
In individual therapy, similar work can be done to build healthy "inner bonds", and healthy "inner boundaries".
I consider this comparison between family/group and individual therapy to be metaphorical. In the theory of so-called "object relations" such metaphorical ideas may be considered quite literally, i.e. that external relationships become literally "internalized" in the formation of a healthy self.
In practice, I think some of the ideas from family therapists can be imaginatively applied in an individual therapy setting.
As a concluding--but practical and concrete-- tangent, an exercise in one form of family therapy is to research your family tree, and to collect information about the life stories of different members of your family tree. This would include immediate relatives, but also more distant ancestors.
I think this is an interesting exercise in individual therapy for a variety of reasons:
1) because psychological symptoms, problems, personality styles, etc. are substantially influenced by genetic factors, it can be interesting to examine the life stories of those who are genetically related to you. It may also be true that the SOLUTIONS that work best for various life problems are also influenced by genetic factors (e.g. there is some evidence that a particular medication, if it works extremely well, has a higher chance of working extremely well for another person who is genetically similar). In a broader, "life story" sense, you may find stories in your family of various adversities that are similar to your own, and you may come to understand how these different ancestors coped. Some of these stories may be cautionary (i.e. warnings about how NOT to cope with certain problems), but some of the stories may be inspiring, and may guide or reassure you in your own pathway to solving your life problems.
2) the process of examining stories from family and ancestors can increase your sense of connectedness, identity, and meaning. Many families in our modern culture have become quite disconnected, and perhaps this disconnectedness fosters loneliness, materialism, or a cultural vacuum. As you gather information about these family stories, you may end up re-connecting with distant cousins, etc. and this could expand or enhance your network of friendships.
3) If many of the stories you find are very negative, this type of information could be upsetting, traumatic, or exacerbate more recent post-traumatic symptoms. If this is the case, such an exploration may need to be taken very slowly, if at all. But sometimes, if you feel ready, the process can become part of healing from the trauma. The exploration of a full story--even if the story is very negative--can sometimes be a prelude to healing. This task encourages the exploration of stories from distant relatives, as well as immediate relatives--this increases the likelihood that you will find some positive, inspirational stories, even if many of the stories are traumatic or turbulent.
Thursday, February 5, 2009
Wednesday, February 4, 2009
Vitamin D & other vitamins
I'm re-posting this as a separate entry, because I think it's important.
I recommend multivitamin supplements as standard advice, because I think there is negligible evidence of risk (other than the effect on your wallet), and potential benefit.
The role of vitamin supplements ought not to be overvalued -- I think they are unlikely to cause a pronounced change in any symptom. But a vitamin deficiency could possibly prevent other treatments for depression from working optimally. Many people with psychiatric symptoms have less than optimal nutrition, for various reasons; therefore I feel that vitamin and mineral deficiencies are more likely.
There is some evidence of vitamin supplements being used to augment antidepressant medications, but the level of evidence is quite weak.
Vitamin D in particular is probably important to supplement, particularly for those of us who experience dark, cold northerly winters (vitamin D is normally produced in the body when our skin is exposed to the ultraviolet rays from direct sunlight). Furthermore, most of us wisely use sunscreen when it is sunny and warm, so most of us are getting less vitamin D from the sun. There is some evidence that the RDA for vitamin D (200-400 IU per day) is too low, particularly when we consider that brief whole-body skin exposure to sunlight generates an equivalent of perhaps 10 000 IU.
Here is a reference to a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation (people received the equivalent of about 3000-6000 IU per day, for a whole year); the study is from a major, highly respected internal medicine journal:
http://www.ncbi.nlm.nih.gov/pubmed/18793245
Here is an excellent reference examining the issue of vitamin D safety, dosage, and toxicity:
Vieth, Reinhold. "Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety", American Journal of Clinical Nutrition 1999;69:842–56
A recent study by Bischoff-Ferrari et al. (2009) showed that elderly hip fracture patients given 2000 IU per day of vitamin D for 12 months, had a 60% reduction in fall-related injuries and a 90% reduction in infections leading to hospitalization, compared to a group given only 800 IU per day of vitamin D.
Here's a reference to a 2008 study from a clinical biochemistry journal showing toxicity from prolonged very high-dose vitamin D, of over 40 000 IU/day over several years. It concludes that the lowest dose at which hypercalcemia can occur is about 3800 IU per day:
http://www.ncbi.nlm.nih.gov/pubmed/18275686
Based on the evidence I recommend supplementing with an extra 2000 IU of vitamin D daily (possibly up to 3000 IU), in addition to the 400 IU that is present in most vitamin supplements, unless you have a medical condition associated with abnormal calcium metabolism or abnormal sensitivity to vitamin D (e.g. sarcoidosis).
If you are taking high-dose vitamin D you should have serum calcium levels checked periodically, and possibly a serum vitamin D level.
I do not recommend "mega doses" of any other vitamin, since I do not see a good evidence base for this being helpful, and higher doses of many such nutrients can be toxic or dangerous. A few recent studies have shown that people taking certain vitamin supplements, such as vitamin A or E, actually do more poorly than the control group.
I recommend multivitamin supplements as standard advice, because I think there is negligible evidence of risk (other than the effect on your wallet), and potential benefit.
The role of vitamin supplements ought not to be overvalued -- I think they are unlikely to cause a pronounced change in any symptom. But a vitamin deficiency could possibly prevent other treatments for depression from working optimally. Many people with psychiatric symptoms have less than optimal nutrition, for various reasons; therefore I feel that vitamin and mineral deficiencies are more likely.
There is some evidence of vitamin supplements being used to augment antidepressant medications, but the level of evidence is quite weak.
Vitamin D in particular is probably important to supplement, particularly for those of us who experience dark, cold northerly winters (vitamin D is normally produced in the body when our skin is exposed to the ultraviolet rays from direct sunlight). Furthermore, most of us wisely use sunscreen when it is sunny and warm, so most of us are getting less vitamin D from the sun. There is some evidence that the RDA for vitamin D (200-400 IU per day) is too low, particularly when we consider that brief whole-body skin exposure to sunlight generates an equivalent of perhaps 10 000 IU.
Here is a reference to a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation (people received the equivalent of about 3000-6000 IU per day, for a whole year); the study is from a major, highly respected internal medicine journal:
http://www.ncbi.nlm.nih.gov/pubmed/18793245
Here is an excellent reference examining the issue of vitamin D safety, dosage, and toxicity:
Vieth, Reinhold. "Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety", American Journal of Clinical Nutrition 1999;69:842–56
A recent study by Bischoff-Ferrari et al. (2009) showed that elderly hip fracture patients given 2000 IU per day of vitamin D for 12 months, had a 60% reduction in fall-related injuries and a 90% reduction in infections leading to hospitalization, compared to a group given only 800 IU per day of vitamin D.
Here's a reference to a 2008 study from a clinical biochemistry journal showing toxicity from prolonged very high-dose vitamin D, of over 40 000 IU/day over several years. It concludes that the lowest dose at which hypercalcemia can occur is about 3800 IU per day:
http://www.ncbi.nlm.nih.gov/pubmed/18275686
Based on the evidence I recommend supplementing with an extra 2000 IU of vitamin D daily (possibly up to 3000 IU), in addition to the 400 IU that is present in most vitamin supplements, unless you have a medical condition associated with abnormal calcium metabolism or abnormal sensitivity to vitamin D (e.g. sarcoidosis).
If you are taking high-dose vitamin D you should have serum calcium levels checked periodically, and possibly a serum vitamin D level.
I do not recommend "mega doses" of any other vitamin, since I do not see a good evidence base for this being helpful, and higher doses of many such nutrients can be toxic or dangerous. A few recent studies have shown that people taking certain vitamin supplements, such as vitamin A or E, actually do more poorly than the control group.
Tuesday, February 3, 2009
Self-Injury
Self-injurious behaviour is common. Cutting skin is probably the most common specific behaviour, but there are many other varieties of self-injury.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
There are different reasons why it might arise, or factors that might be motivating the behaviour.
Quite often self-injury leads to a feeling of relief, of focus, of emotional intensity, in the midst of deep anger or sadness. Sometimes a long-suffering person may feel as though the capacity to feel has been lost--he or she may feel numb or empty--and self-injury gives rise to some type of feeling for a moment. Also, an act of self-injury may cause someone to feel "in control" during that moment, while they may feel "out of control" in other parts of life.
Another common motivation is self-hatred. Physical pain may be desired. The sequence of self-hatred, leading to self-injury, leading to a sense of relief, leading perhaps to guilt or worsened self-hatred afterwards, can become a powerfully reinforced, self-perpetuating behavioural pathway.
Another motivation is a wish to experiment with the idea of suicide, perhaps with the thinking that cutting skin deeply enough could cause death, but then discovering that the act of non-suicidal self-injury creates a feeling of focus, control, excitement, or relief.
Self-injury can be a very private act, but sometimes can be an overtly interpersonal act, a type of non-verbal communication. Such communication can sometimes become part of an interpersonal dynamic. This dynamic can sometimes (but not always) be part of a vicious cycle, making symptoms worse (David Dawson's ideas, as expressed in Relationship Management of the Borderline Patient, can sometimes apply here).
Self-injury can become part of a person's sense of identity or personal culture, particularly if it has arisen during adolescence or young adult life.
Regardless of the various motivations, I believe that self-injury is an addictive behaviour. Just like alcohol or opiates, it may create some form of relief in the moment, with consequences to pay afterwards. The person engaging in it may recognize that it isn't "healthy" but may continue, or may feel unable to stop.
In the treatment of any addictive behaviour, I believe there are a number of therapeutic principles which can help:
1) If there are underlying problems which are driving the behaviour, or triggering it, then these problems may be addressed with whatever help is available. For self-injury, these problems may include depression, loneliness, irritability, boredom, struggling with issues having to do with identity, meaning, personal culture, etc. Sometimes addressing these underlying problems satisfactorily will solve the problem of self-injury.
2) The self-injury itself could be understood as a psychological defence. If a defence is to be lowered or set aside, it has to be with the will, motivation, and consent of the individual. Without the defence, there may be periods of more intense discomfort ("withdrawal symptoms"), at least initially . I do not believe that a person should be urged or told to "stop cutting". I do believe that a gentle, frank discussion about addiction, triggers, abstinence, etc. could be introduced, with the patient's consent. Addiction treatment programs have a stronger sense of the dynamics here -- a person cannot and should not be forced or "contracted" to stop something. Such a dynamic is unlikely to help, certainly not for very long.
The will to change has to come from the person seeking help, particularly if a strong theme for the person is having self-control, autonomy, freedom--and particularly if the person's problems have in part been caused by past trauma, in which self-control, autonomy, and freedom were oppressed.
3) Alternative strategies to deal with emotional distress can be found and practiced. Common triggers could be identified (e.g. feeling frustrated, feeling bored, feeling lonely, craving sensation of some type), and plans could be formed to negotiate through these moments. A cognitive-behavioural model could be useful (e.g. using journaling), and meditative practices could be helpful (e.g. mindfulness exercises).
Sometimes "substitute" activities such as rubbing ointment on the skin, snapping an elastic band on the wrist, marking the skin with an erasable pen, etc. can be part of a transition away from more harmful self-injury behaviours.
4) If there is guilt or secrecy around the behaviours, it can help to have a forum--such as psychotherapy-- to talk openly about the issue, without the fear of the dialog leading to a highly charged or panicked emotional exchange. The power of guilt or the power of secrecy can be perpetuating factors. In addiction treatment models, it is acknowledged that a person may not have the power within themselves to stop -- help may be needed -- acknowledgment of this fact may break the cycle of guilt.
In practice, I find that self-injury can gradually settle down as other problems settle. In many cases it may--ironically-- settle best when it does not become a primary focus of therapeutic dialog. It may resurface from time to time under stress. If the problem is very intense and acute, people may have a hard time making it through the day or the week, and may feel that the existing help is not enough (e.g. the therapy may feel inadequate). But I think that sticking to a very stable, regular, open-ended therapeutic framework is important.
Modern Physics Metaphors
I hesitate to indulge in metaphors having to do with modern physics, for a couple of reasons:
1) while I love physics, from classical mechanics to quantum mechanics & relativity, I am of course am a mere amateur with respect to deep understanding and expertise.
2) many others have indulged in philosophizing on the nature of life using ideas from modern physics. Some such authors have quite inspired ideas, but others have gotten a bit carried away on the mystical side of things. I can imagine many physicists rolling their eyes at yet another amateur scientist philosophizing about quantum mechanics.
But--I just HAVE to indulge though--because modern physics is just too interesting and important! Also I feel that most physicists are so busy doing physics--much of which perhaps a daily grind through highly esoteric research--that they may not be applying their minds very often to considering the philosophical import of their work.
Another practical reason I have for dabbling in this area is that quantum mechanical phenomena are undoubtedly relevant in the workings of the brain. The behaviour of a neurotransmitter at a synapse, the motions and contortions of molecules within neurons, the energy sources which power these motions, the role and dynamics of electrical phenomena in neuronal stimulation--all of these phenomena require quantum-mechanical formulations to understand fully.
Relativistic phenomena, while immensely interesting, are perhaps less obviously relevant with respect to neurophysiology. Yet, who knows? Relativity is a ripe area to form metaphors, though.
Here are a few metaphors borrowed from quantum mechanical ideas:
1) "the energy of a ground state is non-zero": to some degree, a statement of hope--no matter how low things get, even in a "vacuum", the potential for energy is always present.
Perhaps, even in the freezing void of empty space (is your life like this?) , there is always the possibility for something new.
2) Positions and movements are best understand as probability distributions, rather than as precisely knowable entities. The probability distribution may be quite accurately knowable, but perhaps not more detail than that. This encourages the idea of letting go of the need to view nature in terms of absolutes.
It encourages the idea of possibility.
It discourages "black and white thinking" (though, ironically, a core feature of quantum mechanics is its description of energy states which occur as integers, and its description of energy which occurs as "quanta").
For some people it may be disconcerting to admit the probabilistic nature of phenomena (whether it be in the universe as a whole, or within the mind). But on the other hand, it may be a source of comfort, hope, connectedness, and possibility.
...there are many more such metaphors to build on, which could be applied to psychology. Feel free to correct or adapt mine...I may add to this post gradually.
1) while I love physics, from classical mechanics to quantum mechanics & relativity, I am of course am a mere amateur with respect to deep understanding and expertise.
2) many others have indulged in philosophizing on the nature of life using ideas from modern physics. Some such authors have quite inspired ideas, but others have gotten a bit carried away on the mystical side of things. I can imagine many physicists rolling their eyes at yet another amateur scientist philosophizing about quantum mechanics.
But--I just HAVE to indulge though--because modern physics is just too interesting and important! Also I feel that most physicists are so busy doing physics--much of which perhaps a daily grind through highly esoteric research--that they may not be applying their minds very often to considering the philosophical import of their work.
Another practical reason I have for dabbling in this area is that quantum mechanical phenomena are undoubtedly relevant in the workings of the brain. The behaviour of a neurotransmitter at a synapse, the motions and contortions of molecules within neurons, the energy sources which power these motions, the role and dynamics of electrical phenomena in neuronal stimulation--all of these phenomena require quantum-mechanical formulations to understand fully.
Relativistic phenomena, while immensely interesting, are perhaps less obviously relevant with respect to neurophysiology. Yet, who knows? Relativity is a ripe area to form metaphors, though.
Here are a few metaphors borrowed from quantum mechanical ideas:
1) "the energy of a ground state is non-zero": to some degree, a statement of hope--no matter how low things get, even in a "vacuum", the potential for energy is always present.
Perhaps, even in the freezing void of empty space (is your life like this?) , there is always the possibility for something new.
2) Positions and movements are best understand as probability distributions, rather than as precisely knowable entities. The probability distribution may be quite accurately knowable, but perhaps not more detail than that. This encourages the idea of letting go of the need to view nature in terms of absolutes.
It encourages the idea of possibility.
It discourages "black and white thinking" (though, ironically, a core feature of quantum mechanics is its description of energy states which occur as integers, and its description of energy which occurs as "quanta").
For some people it may be disconcerting to admit the probabilistic nature of phenomena (whether it be in the universe as a whole, or within the mind). But on the other hand, it may be a source of comfort, hope, connectedness, and possibility.
...there are many more such metaphors to build on, which could be applied to psychology. Feel free to correct or adapt mine...I may add to this post gradually.
Monday, February 2, 2009
Short Term Intensive Dynamic Psychotherapy
Here's yet another interesting therapy style.
A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.
Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.
I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.
Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):
First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.
The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).
The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.
Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.
The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.
The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.
Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.
The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.
The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.
One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!
In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.
The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.
There is a small but positive evidence base for the technique in the mainstream literature.
There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.
Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112
A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.
Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.
I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.
Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):
First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.
The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).
The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.
Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.
The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.
The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.
Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.
The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.
The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.
One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!
In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.
The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.
There is a small but positive evidence base for the technique in the mainstream literature.
There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.
Reference:
http://www.ncbi.nlm.nih.gov/pubmed/15583112
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