childhood trauma and loss Jon Frederickson MSW Multiple Sclerosis and Stress Extensive research shows that stress triggers relapses in multiple sclerosis Psychosomatic Medicine NovDec 2002 ID: 477049
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Slide1
The Exorcist: childhood trauma and loss
Jon Frederickson, MSWSlide2
Multiple Sclerosis and Stress
Extensive research shows that stress triggers relapses in multiple sclerosis.
Psychosomatic Medicine
Nov-Dec 2002
Mohr DC,
Goodkin
DE,
Bacchetti
P, et al. Psychological stress and the subsequent appearance of new brain MRI lesions in MS.
Neurology
2000; 55:55-61
Mohr DC,
Goodkin
DE, Nelson S, et al. Moderating effects of coping on the relationship between stress and the development of new brain lesions in multiple sclerosis.
Psychosom
Med
2002; 64:803-809
Buljevac
D, Hop WC,
Reedeker
W, et al. Self reported stressful life events and exacerbations in multiple sclerosis: prospective study.
Bm
j
2003; 327:646.Slide3
Why?
Feelings trigger anxiety.
Anxiety is discharged in the somatic, sympathetic, and parasympathetic nervous systems.
These systems prepare the body internally to response externally to a threat.
Muscles: to fight or flee.
Sympathetic nervous system: to support actions.Slide4
Somatic Nervous System:
Striated Muscles
Sighing
Clenching of the hands
Arms, neck and chest tense. Tension headaches.
Chest pains
Back pain and pain in the joints.
Tight stomach musclesSlide5
Sympathetic Nervous System
Dry mouth and eyes
Dilated pupils
Increased sweating, Cold hands and feet
Blushing
Increased heart rate, blood pressure, and respiration
Shivering
Gastrointestinal tract (decreased motility)
Piloerection
muscles contract (hair stands on end)
Bladder (constrict sphincter---urinary retention)Slide6
Parasympathetic Nervous System: Smooth Muscles and c/p disruption
Salivation
,
teary eyes
Constricted pupils
Warm hands
Migraine headaches
Decreased heart rate, blood pressure, and respiration
Gastrointestinal tract (increased motility)
Bladder (relaxed sphincter)---urge to urinate
Dizziness, foggy thinking
Bodily
anaesthesia
,
limpnessSlide7
Parasympathetic Nervous System II
Localized weakness.. “Jelly legs”. Trouble walking.
Deafness, ringing in the ears, and roaring in the ears .
Blindness, blurry vision, and tunnel vision.
Fainting, loss of consciousness, or dizziness. Hypo-perfusion in the brain.
Amnesia and memory loss. Hippocampus shuts down.
Hallucinations.
No tension, but cognitively confused.Slide8
Balance
Sympathetic and parasympathetic nervous systems ideally are in balance.
When the parasympathetic nervous system cannot function properly, the immune system malfunctions resulting in an increase in Th1 cytokines (inflammation) and TNF production.
This imbalance is a factor in heart disease, auto-immune disorders, diabetes, and other chronic diseases. See
Schulkin’s
,
Allostasis
, Homeostasis, and the Costs of Physiological Adaptation
.Slide9
What to Do?
Regulate the patient’s anxiety by improving the functioning of the parasympathetic nervous system.
This will reduce TNF production.
Shock
, April
2010 - Volume 33
(4): 363
-
368 Relationship of basal heart rate variability to in vivo responses
after endotoxin
exposure
And inhibit production of pro inflammatory cytokines.
Psychosomatic Medicine
October
2007.
Stimulated Production of
Proinflammatory
Cytokines
Covaries
Inversely With Heart Rate
Variability. Also see,
Nature
420:853-9, 2002
.Slide10
How?
Psychotherapy
. Neurology
July
2012.
Patients who attended six months of stress-management sessions had fewer brain lesions and a slower disease progression compared to people who didn't attend the sessions
.
Their
lesions were measured by magnetic resonance imaging. Two types of brain lesions in the study participants were observed — gadolinium-enhancing and T2. Patients with stress management therapy had fewer of each. "This is the first time counseling or psychotherapy has been shown to affect the development of new lesions."
Slide11
Today
Purpose today is to show how to help regulate anxiety in a patient with MS to improve anxiety regulation, immune function, and reduce the risk of MS relapses.
Stress, emotion activation, and anxiety occurs in all of us. Life.
Causation.Slide12
Inquiry
Find out the internal emotional problem for which the patient seeks our help.
Assess responses to intervention moment-to-moment to discern the triangle of conflict.
Assess anxiety discharge pattern and defenses to understand what causes the patient’s problems and symptoms.Slide13
Anxiety Assessment
Discern where anxiety is discharged in the body.
Striated muscles
Smooth muscles
Cognitive/perceptual disruption.Slide14
Graded Format
Explore feeling.
When anxiety goes out of striated muscles or the patient uses regressive defenses, pause.
Restructure the pathway of anxiety discharge or the regressive defenses.
Then explore feeling again.
Step by step build the patient’s capacity to bear feelings while anxiety is regulated.Slide15
Cognitive Recapitulation
To regulate anxiety, help the patient see the anxiety symptom and identify it as anxiety.
Point out causality.
Offer repressive defenses.
When anxiety returns to the striated muscles, explore feeling again.Slide16
Conscious Therapeutic Alliance: Consensus on the Triangle
To know what to do, the patient must know the task.
To know the therapeutic task, the patient must understand what the triangle of conflict is.
To learn the triangle of conflict, the patient must be shown moment-to-moment how it is active in session.Slide17
Conscious Therapeutic Alliance: Mobilizing Will to a Positive Goal
Positive vs. negative goals.
Aversion vs. approach
Clarifying the therapeutic task: why we do this.
Patient’s vs. therapist’s goals.Slide18
Conscious Therapeutic Alliance: Consensus on the Task
To let go of defenses which hurt the patient.
To face rather than avoid what makes the patient anxious.
To feel feelings as deeply as possible.
To overcome the patient’s difficulties and to achieve the patient’s positive goals.
Without consensus on task: no conscious therapeutic alliance.Slide19
Pressure to Feeling in the Graded Format: Building Capacity
Invite feeling.
Restructure the pathway of anxiety discharge.
Restructure regressive defenses which create the patient’s presenting problems.
Excessive anxiety and regressive defenses are not “problems”: they indicate the next thing you need to heal. They are good information.Slide20
Going Over the Threshold of Anxiety Tolerance
When anxiety goes out of striated muscles into the smooth muscles or cognitive/perceptual disruption.
Pause.
Immediate anxiety regulation.
Failures: regression.Slide21
Repressive Defenses
Intellectualization
Rationalization
Rumination
Denial
Forgetting
Negation
Slowing
down
Isolation of affectSlide22
Character Defenses
Based on identification.
I do to myself what others did to me.
I ignore my anxiety. “I’m always like this.”
I dismiss my anxiety. “It’s no big deal.”
I ridicule my anxiety. “It’s stupid.”Slide23
Projection of the Superego
Triangle of conflict: Anger, anxiety, self-judgment.
I project: “You judge me.”
Spectrum of projection: anxiety, defenses, reality testing.Slide24
Misuse of Reality
In the service of self punishment.
Do not dispute the reality or fact.
Point out the function it is being asked to serve: to punish.
Any fact can be misused in the service of self-punishment.Slide25
Mobilizing Self-Observing Capacity
Not, “Do you see how you punish yourself?”
Instead, “You are able to observe a reaction inside you.”
“There’s an awareness of something inside you that wants to criticize.”
“As we take a look, we can observe some urge inside you that seems to have a life of its own.”Slide26
Undoing Identification
“I punish myself” = identification = a failure in self-observation.
“I dreamt.” Dreaming occurred without you doing it.
In fact, urges occur, thoughts happen, and automatisms are activated in the patient without his will or intent.
We simply help him see that as a first step.Slide27
Portrayal
When a physical impulse occurs, that often signals that feeling has risen enough and defense has dropped enough that the unconscious is available.
“In thoughts, words, and ideas, how do you picture this impulse going out onto him.”
As in every other form of pressure, we will observe the response to intervention.Slide28
Defense of Identification
Rage, anxiety, identification with the object of one’s rage.
“I’m not me. I’m him.”
“I’m not terrified of him. I’m terrified of me.”
Manic defense against the experience of terror.
Unconscious form of self-punishment for
murderour
rage toward a predator.Slide29
Adaptive Function of the Defense
Relocate the danger within himself.
Control over the danger.
Retain hope that the father is all-good.Slide30
Denial Through Fantasy
Rather than relate to reality, relate to a fantasy of how you wished reality would be.
“You should know what you don’t know.”
“You should be able to do what you cannot do.”
“You should see what you don’t see.”
“You should be like someone else instead of like you.”Slide31
Regressive Defenses to Avoid Complex Feelings
Splitting: I will keep dad’s good qualities separate from his bad qualities.
Identification: I will identify with dad’s bad qualities, so he remains good.
Idealization: Dad is all-good.
Devaluation: I am all bad.Slide32
Pressure to Self-Acceptance
Superego pathology = rejecting reality, especially of you.
Success in therapy: successful self-acceptance of your inner life.
Deactivating self-rejection by inviting self-acceptance.
Weakening of defense = rise in feelings, and anxiety related to self-punishment.Slide33
Undoing Splitting
Splitting: keeping opposing feelings or facts separate.
Undoing splitting: remind the patient of opposing feelings and contradictory facts.
“Pressure to consciousness.”
Father who saved your life, nearly took a life.
Father who loved, also hated.
Range of responses in spectrum.Slide34
Process I
Invited portrayal.
Response: identification with father, splitting of mixed feelings, projection and introjection.
Intervention: undo all defenses until the patient can bear mixed feelings. Then portrayal will be possible.
Undo defenses.
Response: rise of grief.Slide35
Process II
Intervention: invite acceptance of his ‘inner panther.’ Invited him to face rage toward father.
Response: identification with father, splitting, and introjection.
Intervention: undo splitting.
Response: ability to bear complex feelings without splitting. Understanding clear.Slide36
Pathological Mourning
Freud: Rage toward lost figure; anxiety; identification with the figure.
“I did not want to kill you; I want to be you.”
“I have not lost you; I am you.”
Defense against rage and grief; simultaneously allows self-punishment by turning rage onto oneself.
Pathological mourning must be addressed first for rage to become accessible.Slide37
Smile as a Character Defense
By smiling, I reject my feelings.
By smiling, I am cruel and dismissive to myself.
By smiling and cynicism, I hide my love.
By hiding my love, I hide my grief.Slide38
Identification as a Defense
Murderous rage toward father triggers guilt toward a loved one.
Rather than bear the guilt, he punished himself.
“I must eat his sins forever to atone for my own sin of wanting to kill him. And through my sin eating, I will prove my love.”Slide39
Compassion
To undo splitting, important that he can feel compassion for his father and for himself.
Otherwise, “I feel compassion for me but not for him, is another form of splitting.”
Likewise, “I feel compassion for him, but not for me,” is also splitting.Slide40
Compassion for the Origin of the Defenses
S
elf-judgment of his defenses merely perpetuates the self-rejection of superego pathology.
Point out the adaptive function of his defenses to undo his self-rejection and increase his self-acceptance.
Patients can easily misuse defenses for the purpose of self-hatred as if that is therapy.Slide41
Compassion for Self = Acceptance of Reality
“You did what you could do and that was all you could do.”
“Yes. You managed it terribly. And it sounds like that was the best you could do at the time: terribly.”
“You didn’t know what you didn’t know.”
“You didn’t see then what you see now.”Slide42
Portrayal and Pathological Mourning
Defenses can arise which prevent the mourning process from unfolding.
Note all resistances to saying goodbye.
Note all attempts to bury his internal life, to remain dead with the lost figure and thus avoid loss and punish himself.Slide43
Undoing Splitting and Denial
Undoing splitting allows the patient to experience complex, mixed feelings toward his father.
Undoing denial allows the patient’s repressed feelings to finally rise to the surface.Slide44
Consolidation
Offers a coherent narrative of the patient’s inner and outer lives.
Describe the process of the session in terms of the triangle of conflict.
Show causality: feelings, anxiety, and the defenses which caused his presenting problems.
Make sure patient understands what the two of you have learned together.Slide45
One Year Follow-up
“My legs are perfectly responsive to sensation in every place. Nobody understood why this is the case.”
“The staff at [rehabilitation center] had me dance on a cushioned pad for one half hour…They were dumbfounded that my balance was so good.”
“That was a watershed day for me. The result was truly miraculous for me in my opinion.”Slide46
Resources
Go to
www.istdpinstitute.com
for articles, blogs,
dvds
, skill building audio studies, and webinars on ISTDP.
Co
-Creating Change: Effective Dynamic Therapy Techniques
, May 2013. Seven Leaves Press.
Go to
www.facebook.com/DynamicPsychotherapy/
for answers to your clinical questions.