Monthly Archives: September 2018

PTSD, ISTDP, and Anxiety

“The most common complaint from my patients with complex PSTD, is the nightmares about war, torture, and fleeing with their family. Sometimes the dreams are replays of actual events or a mix of real events and symbols that could represent themes of conflict, flight and persecution. A patient will usually come to the session very tired with cognitive/perceptual disruption, which I can usually help regulate. When asked what caused this anxiety, they will usually answer that it has been like this all night because they could not sleep and had nightmares. Can you give some advice on how to proceed?” Thanks for this question!
When supervising therapists working with PTSD, I find that the anxiety is usually not as well regulated as we might believe. I remember the first time I found this in my work. A patient said she was now calm and did not have the symptoms we look for. Something made me wonder if that was the case so I asked her to try out “relaxing rhythms” a biofeedback program that regulates anxiety and measures heart rate and heart rate variability. The truth arose: her heart rate was bouncing all around, it was elevated, the patient had trouble regulating her breath speed, and, according to the computer readout, her anxiety was not regulated well at all.
I had a traumatized psychotic patient where I spent an entire session regulating her anxiety. Then after the session I had her sit in my waiting room with my laptop, hooked up to this biofeedback program. Suffering from paranoid delusions for months, this program got her so relaxed, she fell asleep in the waiting room—this after months of not being able to fall asleep.
We have to remember that traumatized people have experienced terror beyond what most of us will even get a glimpse of in this lifetime. As a result, once they have experienced 100% terror, if their anxiety is down to 50%, they think that is ok, whereas it would be horrible for us. Further, their anxiety level after the trauma did not return to homeostasis (normal) but to allostasis (a permanently elevated level). (See Steve Shulkin’s work on this.) Thus, when you do your usual anxiety regulation, if the patient experiences a reduction to the point where obvious signs of cognitive/perceptual disruption have stopped, the patient feels better. However, he is still sick! Usually,(if you are lucky), he is now in repression, feeling tired, exhausted, sick, and without energy. So there is still more work to do.
But I did say, if you are lucky. You see, cognitive perceptual disruption can be present when we see the following markers, which we easily overlook: racing speech, impulsive speech, talking over you, inability to maintain a consistent focus, or hyper-mentalization. When higher level defenses fail, the patient’s speech will race over feelings and anxiety. Impulsive speech and talking over you can be a way patients deal with projections they place upon you, fearing the judgments they fear from you, as the projection. Inability to maintain a consistent focus is often a subtle form of thought disorder, indicating that each topic is triggering anxiety, leading the patient to skip from topic to topic. Hyper-mentalization, or what Davanloo called hyper-intellectualization, involves the patient sharing multiple thoughts about the motivations of others without evidence to support them. It’s a form of projection.
All of these markers are signs of a brain on fire, suggesting that anxiety regulation is necessary in order to build the capacity to face mixed feelings, your eventual goal. When regulating anxiety with this group of patients, don’t be surprised if you must spend a lot of time doing so. Since they have relied on projection and splitting as their primary defenses, they are not accustomed to directing their attention to their own body. When you ask how they experience anxiety in their bodies, they often have trouble describing a PHYSICAL experience in the body. They will offer metaphors and thoughts instead. This is your signal to keep the focus on the body and build their capacity to attend to internal signals in the body.
Rather than allow these markers to continue, interrupt and block defenses immediately, slow the patient down, and direct attention to signs of anxiety in the body. Ask the patient, “How present are you right now?” Keep your focus on anxiety regulation, attention to anxiety, and building the capacity to be present physically in the body. In a recent case I showed work with a borderline patient. After thirty minutes of this kind of work, she said, “I’ve never felt this calm before. Can you bottle it?”
I know you want to get to feelings, you want to get the breakthroughs, you want to have unlockings: I do too. But first we have to build the capacity to bear mixed feelings without using the resistance system of projection or the anxiety pathway of cognitive/perceptual disruption. Only when anxiety is regulated, the patient is present, projection and splitting is gone, and sighing has resumed, is it safe to begin to explore traumatic experiences in a graded fashion.
Some of you may ask about Foa’s work on trauma work using exposure therapy. I have seen some of this and it is very effective. However, the case I saw was a traumatized man who did not project and whose anxiety was in the striated muscles, sighing heavily. Thus, this form of therapy looked very much like the standard format of ISTDP. He was able to tolerate much higher levels of feeling, but many traumatized patients cannot.
Briefly, we must tailor our therapy to the patient’s capacity. One size does not fit all. In a case like the one we heard above, anxiety regulation is extremely impaired and needs to be built. More in the next blog on why this patient is unable to tell you why he is anxious.

Unconscious Phantasy or Conscious Fantasy

At our summer school this past week a wonderful question arose that I thought would be useful to explore for those of you who are trying to do ISTDP. As you know, we explore avoided feelings as deeply as possible with the patient in order to restructure the pathway of anxiety, restructure the system of resistance, and to to help the patient experience the complex mixed feelings as deeply as possible so that the engine of self-punishment has been dismantled.
And as part of that process, when we help patients experience their complex feelings as deeply possible, a phantasy arises of how those feelings would be expressed: the portrayal. When done correctly, we mobilize these feelings as intensely as possible, helping the patient let go of his defenses, so that an unconscious phantasy can arise spontaneously from the patient. Unconscious phantasies are ideas that were previously repressed, unknown to the patient, arising due to the rise of previously repressed feelings.
Instead, therapists often make a mistake: rather than mobilize the feelings as highly as possible, when a little movement occurs they ask the patient for a conscious fantasy: if you let those feelings out on me what would that look like? This question merely invites the patient to offer conscious thoughts, a defense, which is not helpful. After several times, the patient will begin to feel that therapy is just a case of Scheherezade: “Ok, if I give him another gory story, he’ll be happy, and then we can go back to doing therapy.” Then these pseudo-portrayals lead to a kind of ritualism where the therapist demands a “story” each time, the patient gives it, and both think, “Ah, this is ISTDP.” Nope.
Instead, mobilize feelings as highly as you can and keep addressing defenses and the resistance. Don’t worry about getting the almighty “portrayal.” Instead, mobilize unconscious feelings as highly as possible while removing the resistance. As you do so, the unconscious will come to you. Rather than ask the conscious thoughts to come to you, work hard and let the unconscious come to you. It will come to you when you have done your work. So be patient, go back to your work, and stop begging for conscious fantasies.