Writings/Blog

Yanni and Laurel, The Romance that Will Improve Therapy (and may save the world…)

I make no bones about the fact that I am a huge fan of Jonathan Haidt, the moral psychologist who is now tenured at NYU in the business school to help improve ethics in business.

Therefore, I would like to take this topic up again in light of a new romance that I am following on the web – The Romance of Yanni and Laurel.

For those of you who don’t know of this blossoming love story, I deposit here a video for your consideration. Please look at the video before you read any further.

OK, now take a moment to think about what this means. What did you hear? Did you hear Yanni? Laurel? You will only hear one.

As a therapist, It’s my duty to understand the world through a patient’s subjective experience, to the best of my ability. That means, I must begin treatment by accepting the way they see the world, even if this view is causing them suffering, which it often is. It also means I must understand their belief systems, to the best of my ability, whether moral, religious, political, sexual or otherwise.

This is one of the reasons I love why Jonathan Haidt. A meticulous scientist, he devoted years to his “Moral Foundations Theory”.  Haidt, in The Righteous Mind (2012) demonstrates that human morality is based on these five foundations: Care/Harm, Fairness/Cheating, Loyalty/Betrayal, Authority/Subversion, and Sanctity/Degradation. Here it is in a Ted Talk, where Haidt explains the concept:

What Haidt discovered is that the moral systems of people with different political and temperamental inclinations vary. This theory states that, the more left of the spectrum one is inclined, the more the moral domains of Care and Fairness dominate a person’s moral system. The more to the right, the more Loyalty, Authority and Sanctity. Towards the center and on the center right, all 5 domains are distributed more or less equally.

This means that good people can see the world through entirely different moral lends. This also means that the other side might seem, unfortunately, to possess an inferior morality.

When I met the seperate singles, Yanni and Laurel, my first thought gravitated to Haidt in that if we are ensconced in a moral system, whatever that may be, that is the filter through which we understand the world. And these filters can be entirely different, yet what we perceive through these filters is what we absolutely believe to be true. We either hear Yanni or Laurel.

So, now we see that people have different moral systems. Each thinks they are moral beings and the other, as demonstrated by our divided world, less moral, or even immoral. You hear Yanni or you hear Laurel, and ne’er the twain shall meet. Or shall they? Two lovers passing like ships in the night. What can bring them into the daylight so they can see each other?

Ok, now take what you thought you were hearing and decide to hear the opposite. If you hear Yanni, try to hear Laurel. Keep trying. Leave the computer and go back. It took me about 30 times. Come on, make an effort! Keep doing it until…Aha! You heard Laurel!

If you make a decision to look at the world through a different filter, suddenly your subjective reality changes. Suddenly, you hear things in a different way, as someone else does.

So, here’s the amazing thing. Once you train yourself to hear the other name, you will be able to cycle back and forth at will. You can hear both sides of the story!

Now, you try to imagine what it is like to be in the opposite moral system? If you are more liberal, try to imagine valuing Loyalty as much as Fairness? Or, if you are on the right side of the spectrum, on the other side, valuing Fairness as much as Sanctity? Try it. Take some time. It will be worth it. Do the same exercise with envisioning an alternate moral system. Practice until it feels real. Honing this skill allows you to see the world in your way and your opposite’s way at will.

Doesn’t mean you have to change, but this exercise may yield some insight. Can you imagine how healing it would be to understand the experience of your “opponent”? To see the world through their eyes?

Sometimes a therapist sitting with a patient and hearing Yanni when the patient is saying Laurel takes some time to reconcile. Dedication to this task makes for good therapy.

Dedication to the task of envisioning another person’s moral system might heal our divide.

Now, let’s play matchmaker!!

 

Postscript:

If you need to practice, here is an easier one to get you started:

Shame, Guilt and Self Loathing.

Shame. We all know what it feels like. That devastating moment when you realize somehow you’ve crossed the line from “good person” to “bad person”. At least, with that visceral feeling of a knife in your heart, that is certainly what it seems.

Shame is contingent on a desire to belong. When we do or say something that causes a breach in our relationships with others. Sociologically speaking, we fear being ousted from society. Evolutionarily speaking, this shame is hardwired to keep us alive by restricting our behavior to fall within the parameters of what has evolved as best for the tribe.

But let’s look at shame. There are two kinds. One is the shame of knowing you have harmed someone, inadvertently or worse, purposely – through anger or resentment. The other is the shame you feel about your self; that something is essentially wrong with you.

The first kind of shame is useful, it tells us when we have betrayed the social contract. We could call this guilt.The second kind is not useful. It is based on early patterns that carry over into adulthood. It manifests in self-loathing. We could call this a maladaptive defense.

The good news is, both have a remedy. The remedy for the first is simple, make amends. The remedy for the second is not so simple. It will require a psychological and, for some people, spiritual intervention.

Naturally, since I am a therapist, I will focus more on the second, but I want to say something about the first before I go there, as there are certainly psychological difficulties implied by “making amends” as well. While the solution of making amends, of apologizing, of mending a relationship rupture as an antidote to guilt is self evident, it can be challenging. This is a time where we must take a good look at our action, assess it, and determine the best course of action to repair the damage.

Logically, your thoughtless action is not you. You must use your higher self, your “observer” to separate your self from the action in order to chart the best course of repair. Look at the action itself. How can you remedy it? Did you call someone “stupid” in the heat of an argument? Your apology might be: “I’m sorry, I was just so overcome with anger that I misspoke. I don’t think you’re stupid, I have respect for you, and I was wrong to say what I said. I hope you will accept my apology, and I value you as a person”

That sounds easy enough. And it should be. And it is an excellent mindful practice to make it a point to do so. It’s obvious to most of us that discrete, often momentary actions do not necessarily define us.

However, let’s look at this situation from the standpoint of self-loathing; an attribute many of us may possess, to varying degrees. For some reason, even though we know our bad action is separate from who we really are, it certainly doesn’t feel that way. Why? What happens when, even after we apologize, we go home and ruminate over what we did and how bad we are, even with the offended party might have accepted the apology and may never even think about it again?

The answer to this can be complicated, and of course will vary greatly from person to person. What happens essentially, is a misstep triggers inherent shame about oneself. This is a deep shame whose roots may be very early. This is the shame of self-attack and self-loathing.

So how does this kind of shame develop?

We are hardwired to attach to our parents/caregivers. This is so critical a truth that there is not even any reason for me to provide evidence. We know this. Therefore, a small child will do anything and everything to maintain that bond. Optimally, this bond is reciprocal. The parent and child are attuned, and each bonds to the other as the relationship develops and thrives.

Of course, the real situation is not always optimal. Parents are subject to all manner of stressors, problems, mental health issues. At the far end of the spectrum, some parents are downright abusive, and some worse than that….

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From these sub-optimal parenting situations come varying degrees that the child must hide, as D.W. Winnicott phrased it, her “true self”. This natural and authentic expression of the child’s selfhood often gets the message that some or all of it must go into hiding in order to appease or please the parent. These early mechanisms to hide or stifle are formed with the inchoate worldview of a child, who can only determine, by her parent’s rejection, that she is bad and the parent is good.

So where does shame come in? Again, shame is an evolutionarily hard-wired behavior inhibitor. Give a child the message often enough, and a pattern develops where the shame shuts down the true expression of self. As the child grows, these early patterns of stifling the true self remain embedded as patterns of relating. This maladaptive defense continues to serve to keep relationships intact.

Trauma expert Dr Janina Fisher sees the young shamed self as a separate entity that “hijacks” the adult with shame when triggered by something in the adult relationship that reminds us, consciously or unconsciously, of that early bond rupture.

In the adult, this shame that once served a valuable purpose to the child carries on in the adult as self-loathing as in, “I am bad for my tendency to upset others”. This self-loathing in turn contributes to depression, anxiety and other psychological problems.

The remedy for this is therapy. In psychodynamic therapy, we go back to these early parts and unravel their pull on the adult, often by exploring unconscious expressions, so that they can be resolved and integrated. Using Fisher’s parts work as a tool, we open a dialog with the younger parts, and in doing so, become more acquainted with the part of the “true self” that the child had to hide.

How long will this take? I wish I could say. Often, resolution is rapid…but this work, especially in the case of significant childhood trauma, can be ongoing. However, clients frequently find that even discovering the origin of this self-loathing shame is freeing and hopeful. This kind of insight can release that shame from being tied so tightly to sense of self.

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Spiritual intervention can be a useful tool as well. For people who are inclined to be spiritual; who have contact with their, as Frankl puts it, “Noetic” dimension, spirituality can help ease the burden of self-loathing.

Inherent in most spiritual practices is a sense of unity with something larger, which puts us in connection with a Goodness that we are part. And, if we are part of that, how innately bad can we really be?

Also, spiritual practices encourages mindfulness and contemplation. The practice of mindfulness strengthens our “observer”, so we can indeed learn to separate our self from the triggering situation, which is why it is an integral aspect of Fisher’s work.

Guilt, shame, and self-loathing – indeed they are painful. But the pain of these very human states, when they emerge, are a call to action – whether it be making amends, or the deep work of resolving maladaptive defenses. Thankfully, we have the tools to, if not resolve them, to ease the burden in which they influence our lives, and in doing the work in therapy, discover how much more of our “true selves” we really possess available to relate to others and feel comfortable in our own skin.

Tao de Ching #10 – Use the Emptiness

We join spokes together in a wheel,
but it is the center hole
that makes the wagon move.
We shape clay into a pot,
but it is the emptiness inside that holds whatever we want.
We hammer wood for a house, but it is the inner space
that makes it livable.
We work with being,
but non-being is what we use.

 

What is Tao is the void. It can be “used any way you want”. So with emptiness, to contain it properly, as enclosed by the shape of a bowl, is to find it’s optimal use. That is somewhat of the nature of Tao – how can it be used well, not wastefully. It is always present and always has been. We cannot relate to the universe without it, as it is the silent “way” that we connect. We can connect badly, with force, and in this way Tao is elusive. We get what we want, but lose and waste much and by obtaining what we want in this way, many lose ends remain. Tao is never too much, never too little. To work with Tao, to to some extent, let things happen and act on what happens rather than the reverse – this increases fluidity and decreases resistance.

Transforming Psychic Pain and Isolation through Transcendence and Connection

There is something about the notion of spiritual transformation in psychotherapy that really appeals to me, and I think this is partially based on my respect for the work of one man in particular – William James. James is considered the father of psychology, and his best known work – Varieties of Religious Experience – extracted from a series of lectures over 100 years ago (1911), is still a classic.

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Throughout the book is the ongoing theme of spiritual transformation, or to put it more concretely, a change, sudden or gradual, in the way we relate to the entirety of our being. In terms of spiritual transformation, this can mean feeling closer to God, or more connected to the Universe – but optimally for the purposes of therapy – to humanity. Ultimately, spiritual transformation allows a person to connect with some universal truth, and the essence of themselves that remains pure despite misfortune, trauma, depression etc.

Detriments to therapeutic progress can often be characterized as a feeling of isolation from or inferiority to others. But in terms of our collective humanity, this doesn’t make sense. We are all in this together. We know this, but this knowledge does not change what someone who is suffering from depression and anxiety actually feels. To feel a sense of separateness from others can be both a symptom and a cause of psychic distress.

What if we were able to see beyond that, to the truth of our connectedness? This may require some kind of transformation in our worldview. However, to have some insight into the totality of being can be a powerful experience. But how can this be achieved? I have a few ideas based on experience and on research that might be helpful.

 

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Meditation is often regarded as the most accessible way to achieve this connection. Not only does this put us in touch with the spiritual dimension through contemplation and silence, but  importantly, ongoing practice increases grey matter in the prefrontal cortex, the part of the brain that maneuvers social relationships, in terms of decreasing fear responses and increasing connectedness.

 

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Ritualistic practice of other sorts have always been prescribed for the existential issue of mortality, limitation and misfortune. Even if one is not religious – and by no means does one have to be to have a spiritual practice – the ritual of practicing being connected to something greater can the “true self” at the core of us all. Practicing a ritual, whether within the context of organized religion or more secular forms of practice such as yoga, meditation, being in nature, a regular volunteer gig, or other personal rituals can be invaluable in providing the sort of connection to transcendence that allows us to see a way beyond our material and psychological limitations.

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Read the spiritual masters. There is a plethora of spiritual and transformational literature out there to help you make sense of things.  Go for the classics, and use YouTube to help you along. Some of my personal favorites: Buddhist Dharma, the Bible, Carl Jung – Modern Man in Search of A Soul, Plato, of course William James – Varieties of Religious Experience. Two fantastic books that really get to the bottom of it: Viktor Frankl – Man’s Search for Meaning and the great Tao de Ching, of which I am slowly blogging away. These books contain wisdom for the ages, and in the case of some of the ancient texts, the collective wisdom of generations.

 

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While still somewhat controversial and of course illegal, the use of hallucinogens to achieve this is not a method that should be disregarded. James himself reported powerful feelings of connectedness through his own experimentation. The MAPS (Multidisciplinary Association for Psychedelic Studies) has taken the transcendental hallucinatory experience seriously for therapy of substance abuse, PTSD and depression. In the throes of a hallucinogenic state, many report connecting to the totality of being and can emerge from the experience with a new sense of connection and of feeling that one’s place in the universe is solid and that one’s being is valuable. MAPS ongoing research that continues to yield promising results will likely change the illegal status of certain substances in the near future.

 

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Above is the great Carl Rogers, whose method was to cultivate “congruence” – to enable us to line up what we really are with what we feel we are and how we act.

Last, but far from least, transcendence is something that can be accomplished through therapy, no doubt – and as a therapist I truly believe this. Therapy itself, through connecting with an attuned and welcoming therapist allows a patient to explore themselves and their totality with encouragement and without judgment of their “true selves”. Ongoing exposure to the therapeutic relationship in which one discovers and gives voice to parts of the self that were stunted through a variety of developmental and environmental factors are allowed to blossom, and old defenses that are not longer needed can diminish and can cease “hijacking” the patient. As the “true self” strengthens, so does the capacity to tolerate others flaws and to empathize, and ultimately feel connected.

 

 

A Brief Therapy Model for Adult-Onset PTSD Based on the work of Dr. Russell Carr, MD

Paper: Combat and Human Existence: Toward an Intersubjective Approach to Combat Related PTSD

Understanding trauma and how to treat it is a serious and important area of consideration in my line of work. Most of the research and methods I have used including Van der Kolk, Janina Fisher, material pertaining directly to dissociative disorders, Gabor Mate and others focus on early childhood trauma, the ACE study, and how disorganized attachment disorder leads to significant distress and maladaptive defenses in adulthood. Therefore I was very pleased to encounter another “tool”, so to speak, for managing trauma, specifically adult onset PTSD. This is a brief psychodynamic therapy based on Dr. Russell Carr’s experiences in the working as a psychologist in the combat arena of the Middle East, and is informed by Dr. Robert Storolow’s intersubjective systems theory and Storolow’s phenomenological-contextualist psychoanalytic perspective as applied to adult onset trauma.

 

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Carr developed this modality based on Storolow’s short book Trauma and Human Existence (2007), which Carr said he carried around with him during his deployment, reading, re-reading, and gradually integrating Stolorow’s Intersubjective Systems Theory approach to trauma into a brief therapy modality. In his book, Stolorow encourages a clinician to focus on how the subjective experience of trauma that has caused the presenting distress has shattered the patients relationship with being. Two methods Stolorow uses to perform therapy with a traumatized patient are empathic introspection (getting a sense of how the trauma feels to the patient) and contextualization of affect (understanding how the trauma affects the patient’s emotional reactions in his day-to-day life). In using this approach, it is necessary to develop a relational stance with the patient – to understand the subjective experience of the patient with as much of the clinician’s self as possible.

Carr determined that due to the logistical challenges of performing therapy in wartime, brief therapy was often all that could be provided to soldiers. Carr found a need form this approach due to the fact that most short-term therapies for trauma orient themselves around CBT. These therapies, while initially effective, have a high dropout rate (over 50 percent), and its effects often are not sustained in the long-term. Carr found necessity in a psychoanalytically informed approach, as he knew that psychoanalytic methods have a lower drop-out rate, and are ultimately more effective in the long term (Shedler, 2010) than CBT. Carr chose the intersubjective approach, because besides this approach, psychoanalytic theories do not address specifically adult-onset trauma without the presence of developmental trauma, and that many of Carr’s patients had relatively stable upbringings.

At the conclusion of the article, Carr states that he would ultimately like to make this brief modality appropriate to other individuals who are suffering from adult-onset PTSD, but who are not combat active or veteran military. In my work, I presently am not treating soldiers in active duty, nor am I treating veterans, per se. Therefore, I am leaving out elements that pertain to this specific origin of trauma. For example, In terms of a critical element of combat trauma, shame, being a soldier would likely add a layer of shame (potentially being seen as weak, and possibly more critically, not being united with his fellow soldiers) that a civilian may not possess. So whether working with shame would predominate the focus therapy with a civilian to the same degree or not is a matter of the individual. I am summarizing the method in terms of treatment of adult-onset trauma the general in a way I might use in my present practice. I am attempting some rudimentary variation of what Carr proposes, as I found his approach meaningful and potentially useful, in my own practice. I strongly encourage anyone interested in what I present to read the full article.

To inform his brief therapy method, Carr is using Storolow’s “intersubjective attitudes” to understand trauma:

Trauma is not the traumatic event, rather it is unbearable affect, or as Stolorow articulates, “an excruciating sense of singularity and solitude”. Besides manifesting as unbearable affect, there are other ways in which trauma presents, which includes loss of time – where past, present and future can seem indiscernible, “ontological unconscious” or loss of sense of being, loss of “absolutisms” or the things we take for granted in life (such as ones’ sense of safety of making it through the night), and informed by the philosopher Heidegger, a “being-toward-death”, or an immediately tangible and pervasive sense of one’s own mortality. Because the experience often has a very negative effect on the patient’s emotional navigation of day-to-day activity, and because trauma can often be extreme, the lack of attunement or even rejection from others can result in shame. Shame is a barrier to becoming attuned with others, and therefore is a barrier to healing overall.

The inability to bear emotions related to trauma is where the problem lies. Intersubjectively, traumatic emotion must be processed with other people through their understanding and empathy to be integrated. The patient must feel held by an attuned other or others who emotionally share the burden pain, with empathy and without judgment. Otherwise, this unendurable emotional state will be necessarily soothed in maladaptive ways – escaping them through dissociation or relegating through the body, where trama is expressed as physical symptoms. According to Carr/Stolorow, only through putting words to these dissociated or somatized traumatic experiences in the presence of an empathetic and attuned individual (or group) can it be processed and integrated.

 

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A Summary of the Method of Brief Intersubjective Therapy for Adult-Onset Trauma:

There are many methods of short-term psychodynamic therapy. I have previously written about two of them in the last blog, and the underlying structure is similar:

1. The intervention is prompt

2. the therapeutic alliance is built rapidly and with a more active stance on the part of the therapist in comparison with longer treatment

3. Goals are specific and time limited

4. A clear focus is identified and maintained throughout

5. That the treatment is time-limited is established from the onset. Elements of the treatment are defined through the specific theoretical lens used.

Phases of Treatment

Phase 1: Initial Consultation and Consent to Treatment

Due to the short-term nature of the treatment, the screening is basic, and looks for factors that would render the treatment appropriate for the patient, or if another intervention is warranted : Is the patient suicidal? What is the source of trauma? Is there co-occurring substance abuse? Is there developmental or brain trauma? In this phase, the therapist engages rapidly, educating the patient on the process (which is uncommon for standard psychodynamic approaches). During the screening, an alliance can begin to be built. The duration of this brief treatment, mutually agreed upon treatment goals, and what the expected partial recovery will look like.

Treatment begins during the first meeting, which in longer term therapy would be reserved for assessment. This method has a basis in the elements of Storolow’s intersubjective systems theory: empathetic attunement, faillability (allowing the patient to inform on trauma more than the therapist’s previous education), and the personal experiences of the therapist pertaining to trauma, as to create a subjective, empathetic alliance is the goal of this first phase.

Phase 2: Address Shame as the Therapy Begins

Shame is a real factor for patients, second only to lack of finding a “relational home” for the trauma. As I mentioned earlier, shame is likely to be present due to the lack of comprehension or even blame and rejection by others as to the way the trauma manifests emotionally in the patient, and transforms their affect, possibly is mitigated with dissociation, which is confounding to others, and effects societal functioning among many other possible symptoms. It is critical that the therapist not participate in this rejection, which will require tolerating the nature of the trauma, as horrifying as it could be, understanding the context for the patient’s feelings through empathic introspection, and refraining from minimizing the emotional experience in attempts to “make things better”. The therapist must always keep in mind the necessity of this trauma to be processed through empathetic attunement, and attunement must be maintained regardless of what material the patient brings.

Phase 3: Sessions About the Phenomenology of Trauma

Once shame is addressed, the next phase is determining how, through the subjective lens, understanding the trauma. This means that the therapist will optimally engage with the patient on the basis of the therapist’s own experience with trauma to understand the patient’s empathetically. However, due to this being short term therapy, the therapist must conceptualize the subjective experience of the patient with some efficiency, so Carr suggests that the therapist describe some possible experiences based on the present understanding of trauma in the form of psycho-education to see if any resonate with the patient. Carr uses, again, descriptions articulated by Storolow (for example, the experience of “flashbacks”). This comparison exercise is done with the stance of fallibility, in that just because these are common experiences on average, they may or may not describe the patient’s experience. As is inherent in this approach, the patient’s subjective experience is paramount.

Putting language to the experience is a necessary step in bearing the trauma, and the psycho-educational approach may be able to hasten that process. Once the words are facilitated, a patient can begin to feel that the therapist “gets it”, and both can begin a dialog. Once the patient feels understood, he can begin to connect with the therapist and the two can start to create the “relational home” where the trauma will be processed, and the “excruciating sense of singularity” is gradually undermined.

Phase 4: Seeking an Intersubjective Key with the Patient

This is a phase that may prolong therapy, as it is akin to a treasure hunt. However, Carr states, “it is probably the most important (phase) for the treatment to be effective”. There will be present in the traumatic experience, a key piece of information that needs to be uncovered that encapsulates the full impact of the traumatic experience. It’s importance lies in its cross-temporality; that it is a unifying factor over the often subjectively fragmented dimensions of time.

The intersubjective key may be happened upon through the therapist articulated some connection he has noticed, which the patient has felt but not been able to isolate through verbalization. Carr finds this discovery often happens unexpectedly, and often weeks into therapy. By this point, the patient feels safer understanding his shame and intense emotion. The therapist follows the basic intersubjective principle of following affect within an empathetic stance, and the opening of the patient’s emotional tableau provide material for the therapist to notice, draw attention to, and therefore the chance of the intersubjective key emerging is more likely at this juncture. As an example, the intersubjective key in the case Carr presents is a sense that the patient held his command leader at fault for what he felt was continually exposing them to unnecessary risk, one case which resulted in the death of his friend.

The emergence of the intersubjective key will almost invariably result in intense emotions. It is critical that these emotions be borne together by both, and regardless of the content of the experience or magnitude of the emotions, and that the therapist remain empathetic. To not do so may result in a catastrophic rupture of the connection between therapist and patient, and a loss of the sense of safety of the relational home. Ross states, “Again, this is why maintaining and empathetic introspective stance throughout each session is so important”.

Phase 5: Providing a Relational Home

The intersubjective key, as discussed in the last section, may result in the peak of emotional processing of the trauma. With a therapist operating from the stance of intersubjective empathy, the relationship in this modality transcends from patient/therapist to “two frail humans caught in the same finitude. The, therapist, through the introspective empathetic stance he has been employing since the first session, may even be reduced to tears himself as the two process the traumatic emotions. This relational home brings words to previously unexpressed emotion, which is how the trauma is acknowledged and integrated. The patient finds the attunement in the therapist that he was unable to find in the “real world”, and this is what allows him to bear and process the pain.

It is important that any relational expression by the therapist, be it tears or even offering a hand to hold, is done through the therapists experience of the patient and in the service of the patient. This is not a time for the therapist to process his own trauma, even if he has used his experience of trauma to understand the patient’s experience, and to share in this experience.

Phase 6: Terminating and Both Moving On

If the termination date is firm (and in Carr’s case, in military setting it almost always is), then both patient therapist may feel a bittersweet resolution to having processed the presenting trauma, but often a desire to continue therapy in more depth and of more conventional material – the patients past, defenses, relationship patterns etc., although sometimes the patient is ready to go, having made headway or even resolved the presenting problem and it is the therapist who wishes to continue.

This is a time for both to recognize that the patient is in the process of improving and has given words to the previously unarticulated nature of the emotional trauma. Perhaps further therapy is indeed warranted. Patient and therapist could make arrangements for this to occur, and possibly with each other.

As stated earlier, Carr indicates in this article that he would like to further develop this modality (specifically for the veteran’s administration. , which would require manualization and testing. He indicates that one avenue might be “phenomenology research”, in which military service members with PTSD report and possibly compare their subjective experience. As a clinician, I certainly see value in the relational approach to addressing PTSD in the population at large as it relates to adult-onset trauma. I am aware of scads of trauma literature, and certainly see reflected in this Carr’s assertion that rarely is adult-onset trauma the focus without also including childhood trauma. Therefore, I appreciate this method for that focus, as well as an opportunity to begin to practice the relational method and to expand my toolbox with another form of brief therapy, and overall approach which I find valuable.

 

 

 

Tao de Ching #9 – Pushing too hard

Fill your bowl to the brim
and it will spill.
Keep sharpening your knife
and it will blunt.
Chase after money and security
and your heart will never unclench.
Care about people’s approval
and you will be their prisoner. Do your work, then step back.
The only path to serenity.

We are a goal-driven species. We have an emotional system deep in our brain identified by the neuroscientist Jaak Panksepp as the “Seeking” system. This emotion gives us drive, and undergirds just about everything we do. It let’s us know what is “better”, whether it’s acquiring something or running away from something. Evolutionarily, we “seek” what will keep us alive long enough to procreate.

We also have the capacity to abstract, and to understand what we do now will pay off in the future. Therefore, if we find something good, we want it all…just in case. Thus, sometimes we get the impression that more of a good thing is better, but is this the case? This is where our seeking system gets waylaid. To be in harmony with Tao is to know when to stop. When the bowl is full enough, when the knife is sharp enough, and how much money is adequate for anything we want to do. If we want more and more, then the seeking system is in overdrive, is out of balance, has taken over our capacity to step back and appreciate.

A Word on Two Styles of Psychodynamic Brief Therapy

I love practicing psychodynamic therapy. To me, no other approach embraces the depth of what it means to be a human being more thoroughly than the psychodynamic approach. Psychodynamic therapy is a method that originates with Freud, and while now presents quite differently from the daily free-association of the psychoanalytic couch, retains some of the essential elements of Freudian psycho-analysis, including (but certainly not limited to):

The Unconscious: Stored away out of the realm of our perception, unconscious processes, whose development begins in very early childhood (even infancy), can profoundly influence our thoughts and behavior. As we look for the roots of painful or problematic thoughts or patterns, therapists help their patients access the unconscious through dreams, exploration of transference and noticing patterns in relationships, and use of defenses.

Insight: This therapy fosters insight into the unconscious influences of past experiences and relationships, by bringing this unconscious material to light. Once exposed, through the safety and authenticity of the therapeutic environment, therapist and patient collaborate to “re-frame” past experiences, dress and heal old wounds, and bring a sense of personal agency into how a patient can function now and into the future.

Childhood: Our earliest relationships and experiences often set the trajectory for subsequent ways of relating to others and of our worldview. Adaptions surrounding the preservation of the attachment relationship can become ingrained into the unconscious. These internalized adaptions can play out again and again in relationships, long past their “expiration date”, and what was adaptive in the past can be maladaptive in the present. Disappointments and trauma in childhood can manifest in seeing the world as threatening and hostile.

The Therapeutic Relationship: In a safe and thoroughly confidential environment, the relationship between client and therapist has great therapeutic value in uncovering, through transference, repetitive relationship patterns. A good therapeutic relationship can foster a sense of a secure attachment relationship with the therapist in which the client can express his authentic self, have it met with acceptance and encouragement, and subsequently grow an develop the neglected or suppressed “true self”.

As a therapist focusing on the use of psychodynamic therapy, I am aware of the implicit long-term nature of this approach and that open-ended therapy may not be appropriate or possible for a number of reasons. DC is a city of transience, and sometimes a patient is in the area for a limited period of time. Perhaps someone only wants to address a specific issue, of which a full course of dynamic therapy is overkill or for the depths of which they are not yet prepared. Possibly logistical or financial constraints don’t permit anymore than a few sessions.

Often immediate issues or short-term concerns are addressed with approaches whose main modality is Cognitive Behavioral Therapy (CBT), which assesses behavioral problems or maladaptive thoughts, and provides specific and effective tools to minimize these issues.

While I understand and appreciate the benefits of CBT, and may occasionally adapt some CBT methods for short-term symptom relief, I do not consider myself a CBT therapist. Therefore, I want to discuss a two short-term therapies based on the psychodynamic approach. While these therapies may integrate elements of CBT and of other affect and anxiety regulation methods such as mindfulness, the driving force of these therapies are psychodynamic. As a caveat, I am neither an expert in any of these therapies, nor do I have a certificate to indicate myself as such. However, I do have varying degrees of training, supervision in and knowledge of them. As my training progresses and my competence grows, I am increasingly integrating their strategies into my practice, so far with beneficial results.

 

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Intensive Short Term Dynamic Psychotherapy (ISTDP)

Often we are hijacked by anxiety, and this anxiety is triggered by relationships or other factors. ISTDP addresses the origin of this anxiety, which typically are underlying and often disavowed feelings. These feelings may long ago have been deemed “dangerous” by messages from caretakers or peers. Therefore, when they emerge, these feelings provoke anxiety that they are unacceptable and are met with defenses which have been evoked and learned to mitigate the painful sensation of anxiety. Sometimes these defenses are adaptive, but often they are not. Most of the symptoms and problems a patient experiences are due to these outdated defenses.

In ISTDP, the origin of this anxiety is met, which is the underlying feeling (often anger, but also grief, sadness, fear etc.). Through ISTDP method, whose primary paradigm is the triangled pattern of feeling-anxiety-defense, the therapist helps the client to become aware of the anxiety leading to the defense, block the defenses and reveal the underlying feelings. Once the feelings are identified, using the CBT method of exposure to the feelings, the patient becomes more able to tolerate these feelings. Once these feelings are able to be tolerated, the patient can begin a more authentic relationship with themselves and their true desires, and find usefulness and agency in these feelings. ISTDP typically is resolved when the defenses are exposed and managed, and feelings become tolerable and even useful.

ISTDP was developed by Dr. Habib Davanloo, a Montreal psychiatrist, as a way to cut through straight to the defenses, and in this way, to make therapy more efficient. Some of the world experts in this method are local clinicians, such as Jon Frederickson, and I am fortunate to be the beneficiary of their wisdom.

 

Object Relations Brief Therapy

Object Relations is a theory that focuses on the human need for relationship. This is a theory that originally developed from psychoanalysis by a loosely-related group of British analysts including Donald Winnicott, D.W Fairbairn, and Melanie Klein. Common to their theory was highlighting the earliest developmental experiences of the child in relation to their mother and other early caregivers, and how these relationships became internalized as “objects” (early conceptions of mother/caregivers which have become internalized) and how these objects significantly affected a patients subsequent relationships. Later John Bowlby, provided the capstone to this conception of the human psyche with his theory of Attachment to the primary caregiver and the ways the quality of this relationship strongly influenced a variety of factors in a person’s life. Object Relations Therapy uses the therapeutic relationship to strengthen and transform the patient’s defective internal objects into “good objects”, which impart a sense of security and self-worth.

Object Relations Brief Therapy begins by rapidly developing a therapeutic alliance and setting dual specific foci. This foci are symptomatic (for example, decrease a patient’s depression) and/or dynamic (become less reactive to mother in law). A working alliance is established through specific questions pertaining to a patient’s psychiatric, psychodynamic history, relational patterns, and whether/how a client tends to project his perceptions onto others. As the therapy progresses, patterns of behavior and relationship are revealed and worked through. Transference is used actively, as patient and therapist interpret and experience what happens between them. A paradigm of therapist-self-other is used as a guide to identify a patient’s view of their past relationships to those of the present.

Therapy uses interpretation of interactions between self and other to give insight into maladaptive patterns, and capitalizes on (as does ISTDP) the triad of feeling-anxiety-defense to further gain insight. The therapist also integrates some CBT or other non-psychodynamic symptom relief including stress management and cognitive restructuring to help address symptoms. Termination is addressed at the beginning of therapy, and the way the presenting focus of therapy will look when it has been satisfactorily addressed, in the context of brief therapy, is determined as an end goal. This modality typically lasts 6-26 sessions. After the first course of brief therapy is complete, subsequent sessions may be desired and encouraged in the future.

Objects Relations Brief Therapy was developed by highly regarded local psychologist, Dr. Michael Stadter, who, along with a primary emphasis on object relations and the therapeutic relationship, also drew on the brief therapy framework of Davanloo and other clinicians who were instrumental brief psychodynamic therapy.

Amongst my colleagues, and based on evidence, ongoing and open-ended therapy is the optimal “Gold Standard”. However, time and other constraints are often an unavoidable factors. Both of these therapies offer, colloquially, a lot of “bang for the buck”, while still incorporating the valuable time-honored tenets of psychodynamic psychotherapy. Also, some of the more targeted methods of rapidly exposing defenses can be useful in longer-term therapy when the patient is “stuck”. Brief therapy and methods within these modalities are often a valid and beneficial options. It is for these reasons I offer these methods within the realm of my competence, and continue to pursue training in brief therapy