The Unconscious Therapeutic Alliance 16 th Halifax Immersion

The Unconscious Therapeutic Alliance 16 th Halifax Immersion in ISTDP Allan Abbass, Dr Joel Town Dalhousie University Guest Presenter Filip Mhyre ISTDP Norway

The loving actions of an honest, caring other person activates, and in some cases, creates, the UTA Dr Allan Abbass 2019

• Overall plan for the course • Overview of ISTDP model • The UTA • UTA across the Rise, across treatment phases, and by spectrum • Emphasis on early UTA across series of cases in spectrum Dr Allan Abbass 2019

BOND With Parents BOND With Others Dr Allan Abbass 2019

BOND Trau ma With Parents PAIN FEAR Rage, Guilt about the Rage Intergenerational Transmission of Trauma Dr Allan Abbass 2019 Avoid closeness Depression Character Disorder Somatic Symptoms

Transference (Therapist/ Doctor) Current person Past person Dr Allan Abbass 2019

Unconscious Defense Unconscious Anxiety Unconscious Impulses & Feelings Dr Allan Abbass 2019

Complex Transference Feelings (CTF) • Feelings mobilized by trying to therapeutically attach to patient • = appreciation plus irritation toward therapist • Linked to the past bond, trauma, pain, rage and guilt about rage. Dr Allan Abbass 2019

nconscious Therapeutic Alliance • Davanloo’s major discovery • The unconscious healing force • Mobilized by activating the complex transference feelings • Works to oppose the resistance • Brings mental images of past relational trauma and clear linkages to trauma Dr Allan Abbass 2019

Memory and Emotion Systems Mid rise in CTF R >> UTA Whispers from the alliance: concise understanding of dynamics High rise in CTF Partial unlocking R > UTA R < UTA Negation, slips of the tongue Rage, grief: clear linkages Major unlocking R << UTA Rage and Guilt: image transfer R= Resistance UTA= Unconscious Therapeutic Alliance Dr Allan Abbass 2019

Spectrum of Psychoneurotic Disorders (NON FRAGILE) Low Resistant Moderate Resistant Spectrum of Patients with Fragile Character Structure Highly Resistant Mild Moderate Severe/ Borderline Striated Muscle + Isolation of affect Smooth Muscle/Conversion + Repression Cognitive-Perceptual Disruption + Primitive Defenses Dr Allan Abbass 2019

Tactical defenses Loss: grief Attachment No Rage and Guilt Dr Allan Abbass 2019

Therapeutic Alliance Inquiry Pressure Resistance P Th R Dr Allan Abbass 2019 Grief is felt

Moderate Resistance Major resistance: isolation of affect Guilt Murderous rage Trauma: Pain Attachment Dr Allan Abbass 2019

Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Low R Moderate R High R Repression Fragile Initial Phase Capacity Building Repeated Unlocking Working Through Termination Dr Allan Abbass 2019

Mid rise in CTF: WHISPERS Low R Initial Phase Dr Allan Abbass 2019

Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Moderate R Initial Phase Repeated Unlocking Termination Dr Allan Abbass 2019

Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS High Resistance Initial Phase Repeated Unlocking Working Through Termination Dr Allan Abbass 2019

Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Repression Initial Phase Capacity Building Repeated Unlocking Working Through Termination Dr Allan Abbass 2019

Major unlocking: IMAGES Ongoing functions of UTA Partial unlocking: LINKS High rise in CTF: NEGATIONS Mid rise in CTF: WHISPERS Fragile Initial Phase Capacity Building Repeated Unlocking Working Through Termination Dr Allan Abbass 2019

UTA Across Time • Initial Phase • Capacity Building Phase • Repeated unlocking • Working through • Termination Dr Allan Abbass 2019

UTA over Treatment Phases e f o s ce r A f UT o r e ow o F s ersu v P Mid rise in CTF: Whispers Initial Phase c n a t is Res High rise in CTF: Negation Partial and Major unlocking: Links and Images UTA: Memories, Vivid Images, Losses due to neurosis, Grief >> Rage Capacity Building Repeated Unlocking Working Through Dr Allan Abbass 2019 UTA: Losses, Goodbye Therapist. Poetry Grief Termination

Ongoing Functions of the UTA • Keep eye on the defenses • Share insights with therapist • Keep remembering • Keep images in mind until guilt passes • Flashes of the unconscious • Dreams that are memories or breakthroughs • A voice or presence in the mind guiding healthy activity Dr Allan Abbass 2019

ISTDP: Steps to Mobilize the UTA!! • 1. Handle barriers to engagement • 2. Assess the Front of the System • 3. Psychodiagnosis • 4. Monitor and work with parameters • These will determine next interventions, pace and expected processes Dr Allan Abbass 2019

STEP 1: Barriers to engagement • Barriers to collaborative engagement must be undone to see anxiety and defense manifestations Dr Allan Abbass 2019

STEP 2: Find the Front of the System 1. Activated and avoided complex feelings 2. Active defenses at the front 3. Active Unconscious Anxiety 4. No activation Dr Allan Abbass 2019

STEP 3: Psychodiagnosis 2. Monitor Anxiety & Defense responses Unconscious Defense Anxiety 1. Pressure on Feelings or Defenses Unconscious Impulses & Feelings Dr Allan Abbass 2019

Major Resistance: 4 Types • Isolation of affect: see with voluntary muscle anxiety • Repression: see with smooth muscle anxiety and conversion • Primitive Defense: See with cognitive-perceptual disruption • Resistance of Guilt: Punitive Superego: need to defeat and sabotage Dr Allan Abbass 2019

Unconscious Anxiety • Striated Muscle: Voluntary muscle tension • See with isolation of affect/ self reflection of affect • Smooth Muscle: Body organs • See with repression • Cognitive –perceptual Disruption • See with primitive defenses Dr Allan Abbass 2019

Breakthrough of grief about loss Low Resistance Striated muscle anxiety plus feel complex transference feelings Moderate Resistance Inquiry Resistance Rises Pressure Resistance crystallizes in the transference Clarify, Challenge, Head on Collision GO FLAT: No striated muscle anxiety Striated muscle anxiety plus feel complex transference feelings Depression, smooth muscle anxiety or motor conversion Cognitive-perceptual disruption or primitive defenses Dr Allan Abbass 2019 Complete treatment in 1 or 2 sessions Repeated unlocking, working through, termination High Resistance with Repression Fragile Character Structure Capacity Building Formats

Spectrum of Patients with Fragile Character Structure Spectrum of Psychoneurotic Disorders Low Resistant Moderate Resistant Highly Resistant Mild Moderate Severe/ Borderline Striated Muscle + Isolation of affect Smooth Muscle/Conversion + Repression Cognitive-Perceptual Disruption + Primitive Defenses Dr Allan Abbass 2019

STEP 4: Monitor and Work with 5 Parameters 1. 2. 3. 4. 5. Unconscious anxiety pathways Active major defense Degree to which resistances are syntonic versus dystonic Degree of rise in the transference/ UTA Presence of thresholds and how high thresholds are Dr Allan Abbass 2019

Moderate Resistance Mid rise: Resistance crystallizing in transference Clarify + Challenge Complex Transference feelings Low rise: Inquiry and Pressure P R “Unlocked” Unconscious therapeutic alliance P Th Dr Allan Abbass 2019 R

Pressure: Encourage good actions • All efforts encouraging the patient to do something healthy • Cementing the Bond • Reaching to the person stuck under the resistances • Pressure should target front of the system Dr Allan Abbass 2019

Mid Rise Resistance Mid rise: Complex Resistance crystallizing in Transference transference. Unconscious feelings Clarify andtherapeutic Challenge, Maintain pressurealliance Dr Allan Abbass 2019 “Unlocked”

Clarification: Question unhealthy behaviors Examples: • Pointing out • Questioning • Exploring impact of defense Keep up pressure Dr Allan Abbass 2019

Challenge: help patient to stop destructive actions • Interrupting and Blocking Defenses • If you don’t detach, if you dont shut down Challenge is always done in concert with the patient and the growing UTA Challenge is always done while maintaining Pressure Dr Allan Abbass 2019

Partial Unlocking Resistance HELP EXPERIENCE THE FEELINGS Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass 2019 “Unlocked”: Emotion and Memory Function Greater than inhibitory functions

Striated Muscle Anxiety Goes Down Body Neurobiological Pathway of Rage: goes up same system displacing anxiety Dr Allan Abbass 2019 AMA Atlas online

Unlocking § Partial Unlocking: somatic pathway of love, rage, guilt and grief are experienced to small degree: UTA vivid link to past person. § Major Unlocking: UTA Image of current person or therapist changes to past person with passage of guilt. § Extended unlocking: Rage starts with therapist then via UTA becomes the past person with major passage of guilt Dr Allan Abbass 2019

Dr Allan Abbass 2019

Dr Allan Abbass 2019

Dr Allan Abbass 2019

Dr Allan Abbass 2019

Locked Zone Violent rage Guilt Murderous Rage Primitive Murderous Rage Grief Dr Allan Abbass 2019

High rise: Resistance crystallized in transference. Head on collision Mid rise: Resistance crystallizing in transference. Clarify and challenge Low rise: inquiry and pressure Resistance Complex Transference First breakthrough feelings Unconscious therapeutic alliance Dr Allan Abbass 2019

Locked Zone Violent rage Guilt Murderous Rage Primitive Murderous Rage Grief Dr Allan Abbass 2019

Partial Unlocking of the Unconscious • CTF are mobilized and all aspects are partly experienced • Rage and guilt partly experienced • Anxiety and defences drop in proportion • UTA give clear link or image of person from the past Dr Allan Abbass 2019

Locked Zone Violent rage Guilt Murderous Rage Grief Dr Allan Abbass 2019

Resistance High rise: Resistance crystallized in transference. Head on collision Mid rise: Resistance crystallizing in transference. Clarify and challenge Low rise: inquiry and pressure Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass 2019 Partial Unlocking

Major Unlocking: major Dominance of UTA over R • Murderous rage passes in the transference • Images transfers to past person • Guilt passes for several minutes • UTA is dominant • Powerful effects: resistance is put down markedly Dr Allan Abbass 2019

Locked Zone Violent rage Guilt Murderous Rage Primitive Murderous Rage Grief Dr Allan Abbass 2019

High rise: Resistance crystallized in transference. Head on collision Mid rise: Resistance crystallizing in transference. Clarify and challenge Low rise: inquiry and pressure Resistance Complex Transference feelings Unconscious therapeutic alliance Dr Allan Abbass 2019 Major Unlocking

Head on Collision • Therapists most powerful intervention • Confronts patient with reality • Puts responsibility for change where it belongs – with the patient • Mobilizes patient to become involved in therapeutic task and increases CTF • Addressed to UTA to go into battle against the R • Inter-locking chain of Clarification and Challenge to major defense • Followed by Pressure to do something about the Defense Dr Allan Abbass 2019

Head on Collision II • Head on Collide with the Resistance in the Transference • Point out the destructiveness of the R • Point out the benefits of giving up the R • Verify the patient’s will to overcome the R • Underline the partnership • Deactivate any defiance • Get out of “the shoes of parent”: deactivate the transference • Undo notion of therapist omnipotence • Pressure: encourage them to give it their best effort • Result: • Complex feelings are experienced: • the triggering mechanism for direct access to unconscious feelings Dr Allan Abbass 2019

Head on Collision III • Short Range HOC: for low to Mid Rise • Interlocking Chain: For Syntonic High Resistant cases • Comprehensive: For unlocking at High Rise Dr Allan Abbass 2019

Goals of ISTDP • Remove destructive forces of the guilt • Free space in the person to Love, Work and Play • High rates of return to work, Symptom relief and interpersonal gains with short course Dr Allan Abbass 2019

Conscious Feelings Threshold to experiencing impulse/feelings o t d ol h s e hr T Unconscious Anxiety Severe Repression e r p Re n o i ss Striated Muscle Anxiety Isolation of Affect Moderate Repression Dr Allan Abbass 2019 Mild Repression

Dr Allan Abbass 2019

Conscious Feelings n o i ss o t ld o h s e r h T 2 Unconscious Anxiety 2 1 3 1 e r p Re 3 Striated Muscle Anxiety Isolation of Affect 1. Pressure or Bracing 2. Rise in complex transference feelings and anxiety 3. Recap to bring isolation of affect Dr Allan Abbass 2019

Conscious Feelings 3 ld o h s e r h T Unconscious Anxiety 1 2 Dr Allan Abbass 2019

Pressure Use when below thresholds Evoke feelings Activate somatic pathway of rage Develop images Fire limbic areas including amygdala BRACING Use to optimize rise without being over threshold Combine both self -reflection and pressure Train brain to fire both functional regions together Dr Allan Abbass 2019 Reflection: Recap Use when above thresholds Self-reflect Link phenomena Observe the body Observe thoughts Fire brain selfreflective centers Abbass, Reaching Through Resistance, 2015

Conscious feelings CPD primitive defenses or repression Unconscious anxiety and defense ES ECH T G CIN U RED Y ET I ING X C N A RE BR nd A U a S P ES A R C P RE Severe fragile, borderline Moderate fragile Dr Allan Abbass 2019 U NIQ Isolation of affect Striated muscle Mild fragile

How to recap and/or reduce anxiety • Link Phenomena • Link triangles past-current-therapist • Link feelings-anxiety-defenses • Focus on body cues • Move to different situation T or C Dr Allan Abbass 2019

Portraying • Portraying rage can build capacity to isolate affect • Needs be done with some contact with impulse (mid rise at least) • Use 3 rd or 4 th parties to make it easier to feel and see the rage • Focus on guilt about the rage to build capacity Dr Allan Abbass 2019

UTA in Repression Cases • Capacity Building: Whispers negation Dreams Links • Early rises in UTA are swamped by repression and symptoms • Repeated unlocking: Images and feelings felt • Working through: Grief and putting all together • Termination: past losses, grief and moving forward Dr Allan Abbass 2019

UTA as Thresholds Rise Conscious feelings R >> UTA Whispers from the alliance: concise understanding of dynamics R > UTA Negation, slips of the tongue ld o h es Thr Guilt Rage Unconscious anxiety and defense R < UTA Rage, grief: clear linkages R << UTA Rage and Guilt: image transfer Grief Dr Allan Abbass 2019

First Breakthroughs: Bracing • Session 4: • Links but limited capacity to feel guilt • Press to guilt to build capacity and raise thresholds Dr Allan Abbass 2019

Immersive Approach to Building Capacity Conscious Feelings 3 2 1 3 2 Unconscious Anxiety 1 d l o sh e r h T Striated Muscle Anxiety Isolation of Affect 1. Pressure to experience rage 2. Rise to above threshold 3. Press to feel Guilt and regulate down anxiety as needed 4. Extensive Recapping Dr Allan Abbass 2019

Somatic pathways of feeling: rage, guilt, grief • Love: rising warmth, urge to smile and embrace • Rage: rising heat up chest to head then down arms: tension and anxiety stop • Guilt about rage: Hard waves, pain in upper chest. Feel as if have just murdered loved one. • Grief: tears, painful feeling in chest. Waves not as hard and distinct as guilt. Not as loud or painful. Dr Allan Abbass 2019

Fragile Character Structure Patients • Early neglect, abuse, invalidation • Absence of parental figure with anxiety tolerance: usually fragile parents project on child • Cognitive-perceptual disruption at some level of rise in anxiety • Projection, splitting, projective identification • Need capacity building • Anxiety to striated/voluntary muscle • Defense to self reflection on feelings/isolation of affect Dr Allan Abbass 2019

WEAK Trau ma BOND PAIN Rage, Guilt about the Rage Self-destruct Symptoms Dr Allan Abbass 2019

Economy of Suffering: Fragile Patients Anxiety Deception Masochism Paranoia Sadism: abuse power Somatization/ Paralysis Dependence/ Addiction Social Isolation No work or $$$ Dissociation Depression

Mild Fragility n o i t a c i tif al n u t e p e d c I r e P ve n e i v i t t n i c tio o n i t e g j p Co Disru ro ojec n o i P s s , e r pr g e P R n i cle s t u t M i l th o o Sp m S Isolation of affect Striated Muscle Severe Fragile Borderline Moderate Fragile Dr Allan Abbass 2019 Mild Fragile

Conscious feelings 1. Pressure 2. Rise in CTF 3. Recap Unconscious anxiety and defense o D P o. C t d l o esh Thr ti u e ap r e h T Severe fragile, borderline ndo i w c w ve i t i m r pri 3 3 2 1 Moderate fragile Dr Allan Abbass 2019 s e s n defe 2 1 Isolation of affect Striated muscle Mild fragile

UTA RISES WITH CTF Conscious Feelings d l o h es Thr CTF Unconscious Anxiety UTA Dr Allan Abbass 2019

Rapid rotation of the front • Often within seconds the defenses shift from • • Projection Repression Self Attack CPD • This is a hallmark of fragile character structure patients Dr Allan Abbass 2019

Rapidly Rotating Fronts Cognitive Perceptual Disruption Self attack or seek punishment Projection: Afraid Repression: Flat, weak, depressed

Treatment Phases in FCS • Capacity Building • Repeated Unlocking • Working Through • Termination Dr Allan Abbass 2019

Capacity building Phase • Psychic integration • Graded format • Anxiety tolerance • Voluntary muscle anxiety and reflective capacity • Start to mobilize the UTA • Maybe few sessions to 25 sessions or more depending on level of fragility Dr Allan Abbass 2019

CTF/ UTA in Mild Fragility • When CTF rise, UTA may be seen with whispers, negation or even links • This tends to cause cognitive disruption with drifting • May cause rotating fronts to fire • Easy to deal with by recap • Press to guilt to bring capacity • May project the guilt on you: see you as punitive until they feel the guilt Dr Allan Abbass 2019

Results of Capacity Building Phase • Anxiety in striated muscle • Ability to self reflect • Ability to reduce own anxiety • Understanding of the trauma • Reduction of paranoia/projection and grief about it • Emerging empathy for family Start to have Repeated Unlocking Dr Allan Abbass 2019

on i t ca fi i t n e d n I o i e t iv jec t c oje Pro Pr al u t p e c r e P e v i t n i o n i t g p Co Disru n o i s s e Repr cle s u M th o o m S Isolation of affect Striated Muscle Severe Fragile Borderline Moderate Fragile Dr Allan Abbass 2019 Mild Fragile

Moderate to severe fragility • Transgender woman • Was stuck in hospital for months with multiple somatic symptoms: wheel chair bound • Self injury • Pseudoseizures • Diagnosed Dissociative Identity Disorder, severe abuse history • Beginning of trial: projective processes and severe anxiety Dr Allan Abbass 2019

Rapidly Rotating Fronts Cognitive Perceptual Disruption Self attack or seek punishment Projection: Afraid Repression: Flat, weak, depressed

Psychic Integration on i t ca fi i t n e d n I o i e t iv jec t c oje Pro Pr al u t p e c r e P e v i t n i o n i t g p Co Disru n o i s s e Repr cle s u M th o o m S Isolation of affect Striated Muscle Severe Fragile Borderline Moderate Fragile Dr Allan Abbass 2019 Mild Fragile

Conscious feelings 1. Pressure 2. Rise in CTF 3. Recap Unconscious anxiety and defense n o i t p u r s i ld a u n t o p i e s c s er re p p e e r. R tiv i o n s g Co efense 3 o t d 3 ld o e h v 2 i s t i e r m 1 h i r T 2 or p 1 ow Isolation of affect d n i w tic u Striated muscle e p a r The Severe fragile, borderline Moderate fragile Dr Allan Abbass 2019 Mild fragile

Pressure Use when below thresholds Evoke feelings Activate somatic pathway of rage Develop images Fire limbic areas including amygdala BRACING Use to optimize rise without being over threshold Combine both self -reflection and pressure Train brain to fire both functional regions together Dr Allan Abbass 2019 Reflection: Recap Use when above thresholds Self-reflect Link phenomena Observe the body Observe thoughts Fire brain selfreflective centers Abbass, Reaching Through Resistance, 2015

Conscious feelings CPD primitive defenses or repression Unconscious anxiety and defense ES ECH T G CIN U RED Y ET I ING X C N A RE BR nd A U a S P ES A R C P RE Severe fragile, borderline Moderate fragile Dr Allan Abbass 2019 U NIQ Isolation of affect Striated muscle Mild fragile

Moderate to severe fragility • Transgender woman • Was stuck in hospital for months with multiple somatic symptoms: wheel chair bound • Self injury • Pseudoseizures • Diagnosed MPD, severe abuse history • Beginning of trial: projective processes Dr Allan Abbass 2019

Feelings/UTA in Moderate Fragility • Flash of Complex transference feelings and or grief UTA tries to link • Expect rotating fronts to try swamp the UTA • You can add pressure or recap out of this • Easier to handle than with severe fragile patient • Expect this and handle it Dr Allan Abbass 2019

Moderate to Severe Fragility n o i t a c i tif al n u t e p e d c I r e P ve n e i v i t t n i c tio o n i t e g j p Co Disru ro ojec n o i P s s , e r pr g e P R n i cle s t u t M i l th o o Sp m S Isolation of affect Striated Muscle Severe Fragile Borderline Moderate Fragile Dr Allan Abbass 2019 Mild Fragile

Economy of Suffering: Fragile Patients Anxiety Deception Masochism Paranoia Sadism: abuse power Somatization/ Paralysis Dependence/ Addiction Social Isolation No work or $$$ Dissociation Depression

Feelings and UTA in severe fragility • Small spike of complex feelings, grief or positive feelings fires up massive guilt fires the rotating gun of Projection, Repression, cognitive disruption and self attack • This small spike may be seen with UTA whispers or negation which are swamped out by guilt anxiety and rotating fronts • Be prepared for this when they like you, or feel empathy for self Dr Allan Abbass 2019

Psychic Integration • With severe fragility • Linking things together so things fire and function together • Both triangles • Between parts of self • Between superego, healthy self • To have a single anxious person to work with Dr Allan Abbass 2019

Conscious feelings 1. Pressure 2. Rise in CTF 3. Recap l o h s Thre 3 Unconscious anxiety and defense ti u e ap r e h T Severe fragile, borderline ndo i w c w 2 1 Moderate fragile Dr Allan Abbass 2019 d 3 2 1 Isolation of affect Striated muscle Mild fragile

UTA RISES WITH CTF Conscious Feelings d l o h es Thr CTF Unconscious Anxiety UTA Dr Allan Abbass 2019

Immersive Approach to Building Capacity Conscious Feelings 3 2 1 3 2 Unconscious Anxiety 1 d l o sh e r h T Striated Muscle Anxiety Isolation of Affect 1. Pressure to rage 2. Rise to above threshold 3. Press to Guilt and regulate down anxiety as needed 4. Extensive Recapping Dr Allan Abbass 2019

Resistant Repression or Fragile Low Rise Little anxiety or defense: some tension and isolation of affect Tension and isolation of affect Mid Rise Defenses going into the T, Tense, UTA Whisper Start to oppose repression or fragility, anxiety varies, UTA: Whisper High rise Defenses in the T, Tense, UTA: negation Dislike the repression or fragility, anxiety varies, one part of mind fighting the other: UTA Negation Partial Unlocking Feel grief rage and some guilt. Link or image of past Major Unlocking Feel rage, guilt and grief. Image transfers with passage of guilt Dr Allan Abbass 2019

Why bring rise in CTF • Reduces conscious anxiety • Increases hope • Makes them confident in themselves • Desensitizes to mixed feelings • Makes it easier for them to express anger with you in treatment • The CTF CREATES the UTA Dr Allan Abbass 2019

Results of Capacity Building Phase • Anxiety in striated muscle • Ability to self reflect • Ability to reduce own anxiety • Understanding of the trauma • Reduction of paranoia/projection and grief about it • Emerging empathy for family Dr Allan Abbass 2019

Repeated Unlocking Phase • In longer cases, phase is a year or more long • Repeated partial then major unlocking of the unconscious • Draining the pathogenic reservoir of rage and guilt • Mobilizing positive feelings which mobilizes more rage and guilt • In longer term case maybe 2 -300 unlockings Dr Allan Abbass 2019

Unlockings in previously fragile cases • Break through the defense of repression, not through character defenses • Cleaner process in some ways • Repeated extended unlockings: long passage of rage and guilt/grief • Rage at times has torturous impulse with huge guilt • Emergence of empathy for victim and love Dr Allan Abbass 2019

Somatic pathways of feeling: rage, guilt, grief • Love: rising warmth, urge to smile and embrace • Rage: rising heat up chest to head then down arms: tension and anxiety stop • Guilt about rage: Hard waves, pain in upper chest. Feel as if have just murdered loved one. • Grief: tears, painful feeling in chest. Waves not as hard and distinct as guilt. Not as loud or painful. Dr Allan Abbass 2019

Projective Identification and Symptom Formation: Sympathy symptoms • Patient experiences what the rage wanted to do to others • • Choking: rage to strangle Eye pain: rage to damage eyes Head pain: rage to damage head Strange sensations: rage to cause same sensations: e. g. electricity through body • Symptom is removed by experience of the guilt about the rage • Very common phenomenon in fragile patients Dr Allan Abbass 2019

Ongoing UTA in Repeated Unlocking • Spontaneous unlockings in week • Imagery pops in head • Dead bodies • Sensations in body • Dreams that are breakthroughs • Vivid content allow strong guilt to be felt • Sense of Presence: UTA Dr Allan Abbass 2019

Trends in unlockings • Get less to more intense • Go from later in development to earlier to infancy • Go from primitive to more torturous rage • Early rage is more jaw (baby) • With each breakthrough of rage and guilt there is more capacity for compassion and love. Dr Allan Abbass 2019

Results of repeated unlocking phase • Next to no signs of fragility • Emotions are separated: de-fused • Compassion for self • Empathy and love for others: survivor guilt • Grief about psychopathology • Functional gains • Growing mastery of psychodynamics • Altruism: wish to give to others Dr Allan Abbass 2019

Working Through Phase • Mobilization of grief and self compassion as guilt is removed • De fusion of punitive superego from self • Drives for attachment • Healthy activity in life • Return to function • Pockets of rage and guilt still emerge • Grief is dominant • Empathy/love for family members Dr Allan Abbass 2019

UTA in Working Through • Links Everything: Fluidity in the unconscious • Imagery and Memories • Philosophy • Presence: self caring and compassion for self and others • Education for the Therapist Dr Allan Abbass 2019

Course of Intensive “Long-term” DP Capacity Building Repeated Working Unlocking Through Start Termination End Dr Allan Abbass 2019

Course of Time Limited ISTDP Capacity Building Partial Unlocking Start Termination 20 sessions End Dr Allan Abbass 2019

Termination Phase • In longer term cases phase is several months long • Looking ahead in life • Functioning or on the way • Looking to intimate relationships • Empathy and guilt about leaving family behind • Grief about loss of therapist • Grief about past losses • Maybe few pockets of rage and guilt but mostly grief • UTA: Grief, links, compassion, few breakthroughs of CTF Dr Allan Abbass 2019

Economy of Suffering: Fragile Patients Anxiety Deception Masochism Paranoia Sadism: abuse power Somatization/ Paralysis Dependence/ Addiction Social Isolation No work or $$$ Dissociation Depression

Growth Cycles Healthy Behavior Change More early intense Feelings come up Reduced self destructiveness Dr Allan Abbass 2019

Resistant Repression or Fragile Low Rise Little anxiety or defense: some tension and isolation of affect Tension and isolation of affect Mid Rise Defenses going into the T, Tense, UTA Whisper Start to oppose repression or fragility, anxiety varies, UTA: Whisper High rise Defenses in the T, Tense, UTA: negation Dislike the repression or fragility, anxiety varies, one part of mind fighting the other: UTA Negation Partial Unlocking Feel grief rage and some guilt. Link or image of past Major Unlocking Feel rage, guilt and grief. Image transfers with passage of guilt Dr Allan Abbass 2019

Dr Allan Abbass 2019

Feelings Anxiety Feelings Defences Anxiety Defences Transference Current Transference Past Bond Separation Fear and Grief Rage Split parts inside Current Separation Fear and Grief Rage Guilt Split parts outside Split parts Current Split parts Past Split parts Current Split parts Transference Split parts Past Split parts Transference Dr Allan Abbass 2019

From Joel Town

Cylinder Model of the Mind CSC UCS I/F Dr Joel Town 2019 UCS

Anxiety about rising conscious awareness of unconscious impulse/feelings is aborted with unconscious defences CSC UCS I/F Defences Dr Joel Town 2019 UCS

Accurate focus on front of system to mobilise UCS Pressure to Stay on topic UCS I/F 1. Pressure to specificity 2. ID & CL General talk Generalisation Diversification Dr Joel Town 2019

Accurate & well-timed focus brings new structure to intrapychic system: Pressure to stay on topic 1. Pressure to Specificity 2. ID & CL general talk UCS I/F Dr Joel Town 2019

Accurate & well-timed focus brings new structure to intrapychic system: Rise in twin factors Pressure to stay on topic 1. Pressure to Specificity 2. ID & CL general talk UTA Dr Joel Town 2019 CTF

New defences in the system may emerge to block awareness of impulse/feelings requiring focus on new front to system 1. ID & CL defence 2. Pressure to I/F Pressure to be active Somatise Passivity UTA Dr Joel Town 2019 CTF

Further change to structure & ‘whispers form the alliance’ 1. ID & CL somatising 2. Pressure to I/F CTF UTA Pressure to be active Rise in twin factor Dr Joel Town 2019

Efficient focus & timing of interventions to target front of system = optimal mobilisation Dr Joel Town 2019 CTF UTA Unlocking of the Unconscious

From Filip Mhyre

Filip Myhre Abbass & Town, 2013

Mild – Moderate - Severe How long does it take to regulate down To what extent this will affect the process How to regulate/build capacity differently in different patients Filip Myhre

Simple model Filip Myhre

To understand the complexity in symptoms • More complex mental representation • From window to a cup • Start to predict and make meaning from “tired” “Afraid of the other” “drifting” and “self attack”. Co-create new meanings Filip Myhre

C/P Filip Myhre Feelings

C/P Self reflection Filip Myhre Feelings

Self attack Projection Repression C/P Filip Myhre Feelings

Self attack Intellektualis ering Projection Intellektualis ering Repression Intellektualis ering C/P Filip Myhre Intellektualis ering Feelings

Filip Myhre

Filip Myhre

Why is it adaptive with low self worth It’s just something fundamentally wrong with me There is no one to blame What they did to me is no big deal I’m worthless Filip Myhre

Why it’s hard to have a positive regard for one self Guilt Anger My traumas are crimes committed to me I’m worth something Filip Myhre

Fronts rotating • 1# C/P • 2# Self attack • 3# Repression • 4# Projection Filip Myhre

Level of rise wanted for effective capacity building Filip Myhre

Splitting/projection Repression Self attack Filip Myhre

Filip Myhre

Splitting/projection Repression Self attack Filip Myhre