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ISTDP and emotion regulation (ISTDP i regulacja emocji) - Jon Frederickson - YouTube
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that's a great question when we enter
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therapy with a patient patients become
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ill because they have feelings that make
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them anxious and then they avoid those
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feelings by using avoidance strategies
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that we call defenses and the problem is
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when we have feelings that make us
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anxious and then we avoid them
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our avoidance strategy is what we call
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defenses cause the problems so the whole
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purpose of therapy is to see the way to
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avoid the truth and then helping
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patients face what they usually avoid
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and that's something that Freud himself
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made very clear in his papers in 1923 we
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have to help patients see how they avoid
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so that they can face what they usually
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avoid 1936 Anna Freud said the same
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thing we have to help patients avoid
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what makes them anxious so therapy
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always involves facing what makes us
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anxious so in that sense from the very
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beginning we have the sense of the
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importance of facing what makes us
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anxious problem was is that an early
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psychoanalysis there wasn't a theory
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about anxieties that's discharged in the
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body so my early training and
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psychoanalysis I knew about conflict I
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knew about helping patients face it with
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me than anxious but I didn't have a
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theory that would enable me to regulate
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anxiety when it was too high
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I knew about anxiety regulation but I
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didn't know when it was too high so the
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interesting thing about iced EDP is that
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it enables us to assess when anxiety is
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going into the strided muscles when we
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tense up or sigh versus patients who
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when we explore feelings they get sick
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to their stomach they get diarrhea they
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I have to go to the bathroom they get
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migraine headaches they get dizzy they
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can't think right they get ringing in
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the ears and then I began to see that
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from this perspective that there was a
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way to objectively see when anxiety was
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too high so that it could regulate it so
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as feelings are being explored at an
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optimal level of arousal so I think that
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was the key difference that I learned in
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making the shift from standard cycle
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index ico therapy to i CDP was that
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there was really a theory of anxiety so
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that Anna Freud and Freud the Freud in
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particular in 1926 talks about signal
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anxiety that anxiety is a signal that
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this feeling is dangerous but now we can
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also regulate anxiety to make sure when
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we face things with patience that it's
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at a level of anxiety that they can bear
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and it's also at a level of anxiety
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where the brain is still functioning the
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problem is a lot of times therapists
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explore feelings with patients when
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anxiety is too high and that prevents
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the brain from functioning and so in
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that way if the prefrontal cortex and
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hippocampus are shut down by your neural
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hormones because some anxiety is too
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high patient literally can't think
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straight
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they can't reflect on their projections
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they believe projections they can't
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reflect so I think ice TDP added a great
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deal to psycholytic psychotherapy
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through this theory of anxiety in the
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way that it's discharged through the
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central nervous system
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you
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I'm understanding it looks like there's
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several questions here obviously when we
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work with patients in this is true for
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all therapists we want to achieve the
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most benefit for patients in the most
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time-efficient way that's true for
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everybody that's not true just for ICD
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no therapist is interested in patients
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suffering for eternity so the question
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really becomes what's the most time
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efficient way to help patients get
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better and that and we do find that
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helping patients face what they avoid
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particularly feelings that they avoid
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it's what we need to do now your
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question had to do first do patients
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think that's a good idea initially most
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of them think not let's face it if we've
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been avoiding things when we come into
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therapy we know that our life isn't
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working but we want to keep avoiding
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what we're avoiding we've all had the
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experience that someone says I think you
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need to look at such and said no it's
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not that important I don't feel
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comfortable maybe later
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right we always want to avoid what makes
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us uncomfortable so in a sense that's
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human but most of us come into therapy
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wanting to still avoid what we need to
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face so in that sense every therapy
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really involves helping the patient see
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how the ways they avoid feelings and
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issues actually doesn't protect them
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that actually is creating their problems
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so when we can help them see that what
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they do creates their problem then they
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begin to realize wow that's not really
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helping me okay it makes sense that I
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want to face the feelings I usually
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avoid so of course we should expect that
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patients are going to resist a focus on
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feelings and what we avoid because when
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we focus on what they usually avoid it's
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gonna trigger anxiety and we all what
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makes us anxious so I think it's
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important to understand it's normal to
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avoid what makes us anxious so in a way
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we have to work very hard to help them
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see how and avoiding the strategy causes
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the problems rather than resolves a
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problem now how soon should they expect
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to see change this varies very much by
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patience it varies very much by the
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disability of the servants there are
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some patients very few that can just
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need a few sessions and they already
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experience
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a symptom change but you know is there
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anything else we see a spectrum of
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patients some patients can be seen in a
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few sessions some patients may need 150
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or more sessions right there's a
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spectrum for patients they need a
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spectrum of time and it probably be a
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spectrum of time in which will see
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significant character change so you can
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have some patients respond a few
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sessions but other patients it may take
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a while before we can bring their
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anxiety down the patient I saw today by
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20 sessions we had very significant
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change was a complete now he needed a
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lot more work was he better in the
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second session this anxiety was better
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but other symptoms hadn't changed yet
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I wouldn't expect them in someone who's
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really severely ill the more severely
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ill a patient is the more work we have
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to do more with the regulate anxiety the
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more projections we have to deactivate
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the poor the reality testing of course
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the longer the therapy needs to be and I
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think it's just important understand
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there's a spectrum of patients so
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there's going to be a spectrum of
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approaches and as a result the spectrum
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of time we try to be time efficient but
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that doesn't mean that all our cases are
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going to be short
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that wouldn't be therapy that would be
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magic
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you
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there's again there's several questions
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here the first one is how much feeling
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and it really depends on how much
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feeling dissipation need to face
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obviously someone who's had a very good
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upbringing it's not going to have a
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whole lot of feeling they need to face
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someone who's been really abused
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obviously it's gonna have massive rage
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towards this abuser so it's gonna be a
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much higher level of feeling that kind
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of person has to face the question then
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becomes are we open to the full spectrum
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of what patients need to face and and of
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course you know that we we sometimes
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forget how much murderous rage figures
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in our lives
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anyone who has children knows that when
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you look at a in a sandbox where
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children are playing you see these
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soldiers and their heads are being
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ripped off and their arms are being
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ripped off and they get put in or they
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get buried in the sand and pulled out of
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the sand
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you see doll houses where people are
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kicked out of the house and got off and
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heads are ripped off we also have fairy
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tales that children love which usually
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involve like a wicked stepmother who's
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being eaten by a wolf
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I mean these fantasies of murderous rage
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they're they're very normal in childhood
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and these and we we feel these massive
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feelings of rage in childhood and of
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course over time they're moderated but
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in the course of therapy yes some
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patients have a massive amount of rage
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and if they had physical or sexual abuse
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by parents we certainly expect a lot of
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rage to come up and hopefully we're open
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to that now we have no right to push a
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patient to feel anything they don't want
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to face and that's the other part it's a
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summary we have right no no right to ask
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a patient to do anything they don't want
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to do this is a collaboration where help
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hope we're willing to help patients feel
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as much a feelings they want to help
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them face as much as they want but
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wherever they want to put a stop we have
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to respect their stop then you know this
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is therapy it's not brainwashing right
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it had there has to be a profound
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respect after all if you're trying to
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force a patient to face something they
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don't want to face we become a
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psychological abuser right and it's
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extremely important there was a
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this book written by Theodore Dorpat a
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psychoanalyst who talked about how in
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psychoanalysis if you're not sensitive
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to these issues you end up
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psychologically abusing your patients so
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this is a problem not just in ICD beer
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of psychoanalysis in any therapy if
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we're not really attuned to the
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patient's will we we run the risk of
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engaging some kind of psychological
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abuse so it would be very harmful
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Konnor therapeutic couldn't really
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shouldn't be in therapy
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you
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I find that sort of thing exasperated
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you know it's just you know when you
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present you have an educational task and
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you want to show patience or the rather
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therapist
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what's the nitty-gritty basic work we do
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in psychotherapy yes it's nice if
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there's an emotional breakthrough and so
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on but basically we all like that moment
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but the hard thing is how do we teach
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the methodical work that helps patients
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have breakthroughs that are healing
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unfortunately oftentimes therapists do
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too narcissistic motivations want to
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present you know one breakthrough after
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another after another and it's a very
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destructive on many levels first of all
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it gives a totally unrealistic view of
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the work I have seen articles where you
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see a little bit of inquiry they do a
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little bit of defense work and by the
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second page you're already in this
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unlocking and unconscious like where'd
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that come from that's just totally weird
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reality is that we're starting out
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sometimes we have to regulate anxiety we
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help the patient see defense as they use
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we help them see how to let go of those
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defenses they begin to face feelings
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they usually avoid we're building their
[722]
capacity we're building alliance for
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building an understanding of what's
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causing their problems there's a very
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methodical step-by-step process by which
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we build an alliance and an
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understanding between the patient as a
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result of which yes a patient will have
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some break through two emotions that
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they've usually avoided but
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unfortunately yes it's it's a terrible
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thing when people lose sight of the
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educational function which is to show
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the methodical work you do rather than
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to show off some emotional moment the
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other reason that this is a problematic
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is a in session when you are exploring
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feelings you're building the patient's
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capacity gradually to bear intense
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emotions and anxiety in likewise you
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should do the same thing with an
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audience because as they see emotions
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they haven't seen if they see a kind of
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work they haven't seen they see
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something they don't quite understand
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they're going to become anxious and then
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you're gonna have a misalliance with
[780]
your audience
[781]
so you want to really explain moment by
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moment everything you're doing so
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everyone can understand what you're
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doing they may not agree but at least
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they understand and you're managing
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their anxiety and so that then in the
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end when there is a breakthrough to
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feeling it doesn't seem like some kind
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of crazy madman activity but again this
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is a big problem I think an ist DP in
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the way it's oftentimes presented in
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ways that are very distorted and so
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naturally people think my god this is a
[813]
crazy thing I'll tell a story one time I
[816]
had davon lo himself the founder of ICD
[818]
be present in Washington DC and in one
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day he shows five cases right five cases
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and so we see a little bit of the
[827]
problem a little bit of inquiry and then
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a murderous rage we see five times in a
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day so what do people think after a day
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like that they think well this approach
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is all about murder
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you know cuz if you present your work in
[840]
a crazy way people should think this is
[843]
a crazy approach so it's it's something
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that's upset me very much because I
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think that it's if you present your work
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in a distorted way you shouldn't be
[853]
surprised when people have distorted
[855]
ideas about it same thing I think is
[858]
true actually if psychoanalysis
[859]
oftentimes people have very distorted
[861]
about ideas about psychoanalysis instead
[863]
of understanding how systemic and how
[865]
thoughtful it is so this is always a
[868]
problem I think in how and how we
[871]
present our work and of course this is
[873]
new for us because in a way it's new to
[875]
actually present a videotape of your
[877]
work so people can actually see what
[879]
happens and that's very arousing for
[881]
everybody
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you
[901]
that's a good question there is a lot of
[904]
research to show that CBT is an
[907]
effective model what's also clear in the
[910]
CBT literature however is that they have
[912]
a big problem with relapse in follow-up
[914]
and the United States the big study we
[917]
did with our National Institute of
[918]
Health 50% of these depressed patients
[922]
responded to CBT which is good however
[925]
when they examine those same patients
[928]
two years later at the three sites
[931]
between 77 and 88 percent of the
[934]
patients who had gotten better had
[936]
relapsed so there's a very big relapse
[938]
problem in CBT and among the researchers
[941]
in CBT they've begun to realize that you
[943]
need to look at unconscious issues that
[946]
are that affect long-term follow-up so
[949]
you're seeing a lot more attention to
[950]
emotion within CBT you have Jeffrey
[953]
Young's focus on transference schema
[955]
therapy right so they're including a lot
[958]
more about emotion and a few years ago
[960]
Barlow a major CBT theorist said hey
[963]
look our Theory anxiety is wrong because
[965]
neuroscience is showing that anxiety is
[967]
not triggered by conscious thoughts it's
[969]
triggered by unconscious neuroception
[971]
and he said we actually have to rewrite
[974]
our theory of anxiety and CBT now in
[978]
terms of research basis a very important
[982]
article came out a few years ago in the
[984]
American Psychological associations
[986]
major journal by Jonathan Shetler and in
[989]
that he did a meta-analysis of the
[991]
outcome research and CBT and the outcome
[994]
research and dynamic psychotherapy and
[996]
the research shows that dynamic therapy
[999]
is at least as effective as CBT the
[1003]
other thing that's unique though is that
[1005]
whereas CBT has a problem with relapse
[1008]
and follow-up and in dynamic therapies
[1011]
what we find is that we have much less
[1013]
relapse and we also have many patients
[1016]
who continue to improve after treatment
[1018]
this is a kind of follow-up that we're
[1020]
not finding in the CBT studies is TEP
[1023]
has about 60 Studies on the
[1026]
effectiveness of the model and we're
[1028]
finding significant effect sizes its
[1030]
effective with per scientist orders
[1032]
depression
[1033]
anxiety panic attacks and so on and and
[1037]
also with psychosomatic disorders in
[1039]
fact with short-term therapies is TDP is
[1044]
the only model in short term therapy
[1046]
that's effective with somatic disorders
[1048]
so there's about 60 studies and the
[1051]
effect sizes are very good when we look
[1053]
at effect size that's also important
[1055]
it's a placebo effect is about 0.25 of
[1058]
an effect size medication is about 0.3
[1062]
of an effect size so about 80% of the
[1065]
effectiveness of psychotropic
[1066]
medications is due to placebo effect the
[1069]
average effect for cognitive therapy is
[1073]
about 0.5 so significantly above the
[1075]
point two-five and point 3 5 the CBE is
[1078]
TDP studies we have though where we're
[1081]
seeing effect sizes ranging from 0.7 to
[1084]
1.4 so we're seeing very large effect
[1086]
sizes now those effect sizes in ICD B
[1089]
which are very large are also probably
[1092]
due to the fact that we're working with
[1093]
sicker patients because in a sense the
[1096]
worse off a patient is the more he can
[1099]
approve so in that sense it shows the
[1102]
difficulty of really assessing is I see
[1104]
me better than we can't there's no
[1107]
head-to-head study we can't make that
[1109]
claim we don't make that claim in fact
[1112]
what's interesting when you look at
[1113]
outcome research the difference is an
[1116]
outcome between models of therapy is
[1118]
actually not so great what is huge is
[1121]
the differences between the worst and
[1123]
the best practitioners in any model so
[1126]
what that's showing us is that is that
[1129]
what we really need to be paying
[1130]
attention to is how do we improve the
[1132]
education of psycho therapist so that we
[1135]
get a much greater quality within each
[1139]
model because what we can see is that
[1141]
the issue here is probably not so much
[1143]
the effectiveness of any model but the
[1145]
effectiveness of our teaching given
[1147]
models and that that may be actually a
[1149]
more serious issue in terms of outcome
[1151]
at this point but again we'll have to
[1153]
see what research tells us but I do
[1155]
think it's important that when you look
[1156]
at the research it's very important very
[1159]
modest there some people try to make
[1160]
really grand claims but the research
[1163]
doesn't support grand claims
[1165]
sort of supports that that therapy is
[1167]
very effective but it doesn't there's no
[1169]
model at succeeding with a hundred
[1171]
percent of patients so no one's in a
[1173]
position to brag or claim theirs is the
[1175]
best
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