Monthly Archives: July 2018


“How would you work within an ISTDP framework with someone who has a diagnosis of dissociative identity disorder and who switches during sessions into very distinct ego states?” Thanks to Anne for a fascinating question!

First of all, the term dissociation is often used so widely for so many phenomena that it has lost its specific meaning, referring sometimes to daydreaming, to detaching, to distancing, all the way to distinct personalities. In ISTDP we reserve the term dissociation for the defense used as part of the resistance system of projection, where the patient engages in splitting and projection, and dissociation is the result of splitting. Further, we view dissociation proper as a defense that occurs when the patient’s anxiety is discharged into cognitive/perceptual disruption.

Often patients claim they are “dissociating” but their anxiety is in the striated muscles, and they have the capacity to isolate affect through intellectualization and rationalization. In these cases, patients are simply detaching. Sometimes they will intellectualize about different “parts” of their personality, but their anxiety is in the striated muscles and their ability to intellectualize lets us know that their so-called “dissociation” is really a form of detaching within the resistance system of isolation of affect.

I note these distinctions because I have seen a number of cases in treatment and supervision where patients or therapists wrongly thought dissociation was in operation. In fact, it is quite rare in the form described here: a defense resulting from splitting within the resistance system of projection where anxiety is discharged into cognitive/perceptual disruption.

Within the spectrum of fragility, dissociation can take various forms: mind blanking out, feeling outside the body, or experiencing oneself as a separate personality. These correlate sequentially with increasing levels of anxiety discharged into cognitive/perceptual disruption. Thus, the sooner you intervene when anxiety shifts into cognitive/perceptual disruption, the sooner you can stop the regression into more severe forms of dissociation.

For the mind blanking out or an out of body experience, classic anxiety regulation techniques plus a summary of the process are usually enough to bring anxiety down into the striated muscles. Then we ask for feelings toward the therapist to build the patient’s capacity to bear feelings without resorting to splitting and dissociation. Many examples of this are in the anxiety chapter of my book, Co-Creating Change, and there is a case on the website on dissociation: the man who awoke from a coma.

If anxiety does not get regulated soon enough and the patient continues to regress, then we can see the separate personalities described in the literature of dissociation. Sometimes anxiety regulation restores brain functioning enough for these symptoms to remit. In these cases of severe fragility, the patient can tolerate only very slight amounts of mixed feelings. Thus, the work tends to be quite cognitive initially, focusing on integrating split off feelings. The therapist will remind the patient of split off feelings to build the patient’s capacity to cognize about separate experiences at the same time. Then gradually the therapist will help the patient experience the mixed feelings. Again, the rationale is always to help the patient bear mixed feelings inside so they don’t have to be projected outside, whether onto other people or, in this case, onto separate “personalities.”

Allan Abbass’ recent book, Reaching Through the Resistance, has a lovely chapter on severe fragility where he shows how to work with splitting.

Th: So we notice there’s a wish to look into this and at the same time a wish to pull back. Two urges inside you at the same time, and we’re just noticing these contradictory urges that come up. [Pressure to consciousness: reminding the patient of the split experiences to bring them together and undo splitting.]

Pt: [looks confused]

Th: Are you getting a little dizzy?

Pt: Yeah. [Cognitive/perdeptual disruption. Undoing splitting causes anxiety to rise.]

Th: So as we notice these two urges inside, for some reason you get a little anxious and your head gets dizzy. Something about noticing two urges triggers anxiety. Do you notice that too? [Regulate anxiety and remind the patient of the two split off urges to build the capacity to tolerate this awareness at this level.]

Pt: [tenses up in chair] Yeah, I feel like I want to pull back. [Ability to intellectualize. Progress]

Th: Yeah. There’s a wish to look into this and a wish to pull back and noticing these two urges inside you, how these two urges can exist inside you at the same time. And something about noticing this complexity in you stirred up some anxiety. [Cognitive summary brings the split experiences together and encourages her to observe and intellectualize rather than split.]

Pt: Yeah. I hadn’t thought of it as two urges inside me. [Patient can now intellectualize about her mixed feelings without splitting. Next we will move to higher levels of feeling to keep building her capacity.]

In ISTDP we do not explore the content of the “selves” because they are the products of defense. Instead, we help the patient gradually integrate and bear internally the previously split off aspects of her inner life. The goal is not just “integrating selves” as it is called in other approaches. The goal is to bear and integrate the mixed feelings inside for which the selves are merely defenses.


How can I keep from being boring by focusing on feelings?

I am a beginning therapist in ISTDP with a question that is probably due to my lack of experience with the approach. When I’m with patients, I can’t stop worrying about how they might find my sessions repetitive as I keep working with their feelings, anxiety, and defenses every session, starting from revealing the feeling, to trying for showing an impulse and going for a breakthrough. This concern sometimes leads me to get a little distanced from the approach, as if it will bore the patient if I go on with the same process (although the content is different every time). Am I totally misunderstanding something here?

Things are already getting clearer in my mind as I’m going further with your book, Co-Creating Change, and hopefully I will soon get more comfortable with this very interesting approach. Thank you very much for your time.” Thanks for an excellent question!

Of course, the last thing we want to do is “bore” the patient with our obsessional disorder masquerading as therapy:-)

An important way to avoid this problem is to make sure you and the patient agree on the problem she wants help with. Second, make sure the two of you develop a consensus on what is causing the patient’s problems. If you don’t have this consensus, the patient won’t understand why you focus on feelings. Third, make sure you get consensus on the therapeutic task.

If you get consensus on these three things, the patient knows what the problem is, what causes it, and why a focus on feelings will help. Then she will not feel bored, but, in fact, encouraged by your systematic focus on what she has trouble focusing on. Another thing you can do is continually mobilize her will to the task: “would you like to take a look at the feelings so you don’t have to feeling anxious instead?” Frequent mobilizations of will to the task remind the patient of what we are here to do and why we do it. Then, neither she nor you will be bored.

Often, when we are afraid the patient will be bored, we are ourselves unsure of where we are on the triangle of conflict. As a result, we can’t feel confident we are exploring the right area of the triangle. This is a normal phase in learning ISTDP or any therapy, really. To get better on that, in your self supervision, examine each patient response to see if it is feeling, anxiety, or defense. Then say out loud to the videotape how you would respond to the patient now, given your better information. When you go through your videotape this way, you can improve the speed of your psychodiagnosis and the speed of your response.