Rear view of person sitting on grassy beach area looking out toward the water and horizonA recent randomized controlled study of therapy for treatment-resistant depression produced evidence that a brief trial of intensive short-term dynamic psychotherapy (ISTDP) may have large advantages in outcome over a “treatment-as-usual” approach, including counseling, cognitive behavorial therapy (CBT), CBT group therapy, and increased medication (Town, et al., 2017). This study expands upon previous studies that support ISTDP as an effective first-line treatment for depression (Driessen, et al., 2015), treatment-resistant depression (Abbass, 2006; Solbakken and Abbass, 2015), other treatment-resistant conditions (Solbakken and Abbass, 2014), and for depression complicated by co-occuring personality issues (Abbass, Town, and Driessen, 2011).

This new study supports what I and other clinicians practicing ISTDP have long observed in our practices, and may signal hope for the 20%-50% of people with depression who do not derive satisfactory benefits from treatment (e.g., Lambert, 2013). In this article, I will contextualize these results by discussing the psychological factors that can make a depression “treatment resistant” and highlight the features of ISTDP that may make it uniquely effective in addressing these factors. I will also reflect upon and review in detail the results of the study.

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What Factors Can Make a Depression “Treatment Resistant”?

To understand what makes ISTDP useful for treatment-resistant depression, it is important to understand factors that can make a depression treatment resistant (Abbass, 2015). Here are a few:

Relationship Difficulties with the Therapist

Even if your therapist uses a structured or systematized approach to therapy for depression, the therapy is always more than just a technique—it is a relationship. Many of us have difficulties in approaching relationships of all kinds, and the therapeutic relationship is rarely an exception. Some of us withdraw and detach from the opportunity for closeness. Some of us become fearful and hide or attack. Some of us take a passive role, a controlling role, a codependent role, etc., and we often have a variety of roles we switch between at different times.

These roles or interpersonal stances are often learned in our developmental history. They usually occur automatically and habitually, and they can have real advantages in certain situations—it’s not always smart to be honest and close with everybody in our lives. However, when we take on certain automatic interpersonal roles with our therapist, these can become barriers to engagement in therapy and can render the treatment less helpful.

For instance, if I am passive with my therapist, I may shirk the aspects of therapy only I can do for myself. If I am scared of my therapist, I may spend sessions shaking or attacking rather than feeling safe to communicate my needs. If I withdraw and detach from my therapist, I won’t be able to form the secure attachment that can help me explore my inner world and learn from my experiences. Needless to say, when we take on roles in therapy that form barriers to optimal engagement with our therapist, treatment efforts can fail and our depression may be labeled “treatment resistant.”

Self-Worth Difficulties

People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?

Absolutely. Many kinds of self-hatred arise in and can be addressed in therapy. A sense of worthlessness or unworthiness, hopelessness, self-doubt, withholding from oneself, wanting to hurt oneself—all of us are capable of feeling this way, and usually these feelings and attitudes contribute significantly to depression. These ways of relating to ourselves can come up in therapy, and if they are not addressed adequately they can interfere with the progress of therapy, rendering depression “treatment resistant.”

People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?

Repression

Repression is an unconscious (read: automatic, unintentional) psychological mechanism that can contribute to worsening depression. In repression—used differently here than in Freudian psychoanalysis—when anger is stirred up toward people we love, the anger unconsciously reflects back against ourselves. This symbolically “protects” the loved person from our anger. Because of our guilt about our anger, it is channeled into punishing us. In an unconscious effort to protect our beloved from our anger, our unconscious mind can shut down our body to prevent the anger from being felt or thought about. This can be an emotional root of the “vegetative” symptoms of depression, such as feeling heavy, weak, and tired, and can contribute to the physical pain that can come with depression—in repression, the body can become the target of our angry feelings.

Many therapy models attempt to address unconscious repression processes with conscious techniques, such as behavioral activation, education, or medications, which can all help. However, behavioral changes, education, and medications alone cannot help people overcome the unconscious repression process. When repression is contributing to the depression and not being addressed adequately, behavioral activation techniques or medications may fail and the depression may be deemed “treatment resistant.”

Why Choose ISTDP?

Intensive short-term dynamic psychotherapy (ISTDP) has distinctive features that target specific factors that can make a depression harder to overcome in therapy:

Addressing the Therapeutic Alliance

As described above, interpersonal barriers, such as passivity, dependency, opposition, or detachment, can hamper the therapeutic alliance, limiting the effectiveness of any therapist and any therapy approach. For that reason, ISTDP therapists are trained in specific techniques for assessing the intensity of people’s interpersonal barriers and then helping people with them. A good ISTDP therapist will notice and then help you see the ways you wall off from interpersonal contact, and can help you see the damage this is doing in your therapy, your relationships, and your depression. With this new information, you may become more motivated to overcome the barriers you put up, and a good ISTDP therapist will have a variety of ways to support you in that process. Once these interpersonal barriers begin to come down, which can only occur when you are ready to bring them down, it can become possible to get to the root of your depression and resolve it together.

Addressing Self-Defeating Tendencies

In the same way certain interpersonal tendencies can become a barrier between you and the therapist, your tendencies toward self-defeat, self-neglect, and self-attack become a barrier between you and self-compassion. This can severely hinder your ability to let yourself engage in and benefit from therapy. A good ISTDP therapist will make efforts to help you see the ways you treat yourself, notice how they impact your ability to use the therapy, and see how entrenched these patterns have become. Sometimes this process can reignite the self-compassion that is necessary to get a good therapy result. Once you can begin to see yourself with more positive regard, the therapist can support you in getting to the roots of why you had to turn against yourself and become depressed in the first place.

Overcoming Repression

An unconscious and thus out-of-awareness emotional process like repression cannot be overcome unless your therapist can help you see it, which will make it conscious and help you gain some control over it. In ISTDP training, we learn about the verbal and nonverbal cues that let us know repression is occurring, and we learn skills for helping people begin to become consciously aware of their unconscious emotional processes so that they can begin to think about how they feel rather than automatically and unconsciously have those emotions convert into physical symptoms and depression. When people can consciously recognize, reflect upon, and feel the feelings that get buried by repression, this is the antidote to the unconscious repression process, which can help relieve a major contributor to treatment resistance in depression (Abbass, 2015).

Anxiety and Treatment-Resistant Depression

One final dimension of ISTDP that may make it uniquely effective for treatment-resistant depression is the therapist’s ability to optimize the intensity of the work by paying careful attention to the level of anxiety you are experiencing, and tailoring the therapy to your unique anxiety tolerance. ISTDP therapists are trained to observe bodily patterns of anxiety. Some bodily anxiety signals (such as muscle tension) tell us, “We are on the right track, and this is a level of anxiety I can cope with,” while other signals, like stomachaches or dizziness, say, “We are over my threshold of anxiety tolerance. Time to slow down, regulate anxiety, and understand what’s happening.”

This ability to carefully track and work with anxiety signals from the body can help therapists optimize your therapy experience, and can help prevent a situation in which either too-low anxiety (such as boredom) or too-high anxiety (flooding, dissociation) becomes a barrier to treatment. This systematic attention to bodily anxiety signaling does not exist in any other therapy model, and can help ISTDP therapists to optimize your therapy in a unique way, reducing the likelihood your depression will not respond to treatment (Abbass, 2015).

Results of the Study

The study lasted six months and included 60 participants who were randomly assigned to two groups: ISTDP and “treatment-as-usual,” which included counseling, CBT, CBT group therapy, and increased medication. Self-report measures and observer ratings were used to assess outcomes, and were taken at baseline, three months, and six months from the start of therapy. Here are some of the results found at the six-month mark:

Reflections on the Results and Limitations

The study is limited by its duration, sample size, and the fact it took place in a clinic that has highly focused ISTDP training for its clinicians. Further studies are needed before we can assess the strength and duration of outcomes and the applicability of these findings to people in other settings.

However, the study provides evidence of large, significant effects—including full remission in some cases—of a brief trial of ISTDP for treatment-resistant depression. It also shows ISTDP had a significant advantage over the counseling, CBT, CBT group therapy, and increased medication approaches that were included in the “treatment-as-usual” group. This may be useful information for those experiencing treatment-resistant depression and finding unsatisfying results with treatment-as-usual, secondary care approaches.

While there is much research to be done to learn more about therapies for treatment-resistant depression, the Town, et al. (2017) study is a promising contribution that may pique the interest of clinicians, researchers, and people in therapy interested in a cutting-edge, efficacious approach for treatment-resistant depression.

References:

  1. Abbass, A. (2006). Intensive short-term dynamic psychotherapy of treatment-resistant depression: A pilot study. Depression and Anxiety, 23, 449-452.
  2. Abbass, A. (2015). Reaching through resistance. Kansas City, MO: Seven Leaves Press.
  3. Abbass, A., Town, J., & Driessen, E. (2011). The efficacy of short-term psychodynamic psychotherapy for depressive disorders with comorbid personality disorder. Psychiatry, 74, 58–71.
  4. Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (169-208). Hoboken, NJ: Wiley.
  5. Solbakken, O.A., & Abbass, A. (2014). Implementation of an intensive short-term dynamic treatment program for patients with treatment-resistant disorders in residential care. BMC Psychiatry, 14, 516-522.
  6. Solbakken, O.A., & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant depression. Journal of Affective Disorders, p://dx.doi.org/10.1016/j.jad.2015.04.00
  7. Town, J.M., Abbass, A., Stride, C., & Bernier, D. (2017). A randomized controlled trial of intensive short-term dynamic psychotherapy for treatment-resistant depression: The Halifax depression study. Journal of Affective Disorders, 214, 15-25.

Man in business wear sits on bench, holding his headAnxiety can manifest in a variety of ways in the human body. It can make us tense in our large, voluntary muscles, activate the involuntary muscles of our internal organs, and even cause changes in our thinking, sensation, and perception. I want to focus here on one particular pattern of anxiety—anxiety in the smooth muscles—and the style of self-punitive thinking that is associated with it.

Smooth muscle anxiety is linked with a wide range of physical problems that are emotional in origin but can be mistaken as medical, which can lead to misspent health care dollars, lost time, and dashed hopes. It is my hope to help you identify manifestations of smooth muscle anxiety, learn about the thoughts linked with smooth muscle anxiety, and gain exposure to intensive short-term dynamic psychotherapy, a model that has demonstrated effectiveness in treating smooth muscle anxiety.

What Are the Smooth Muscles?

The smooth muscle systems of the body include the gastrointestinal system, the vascular system, the bronchi, and the urogenital system. There are also smooth muscles in our skin and eyes. The muscles are called smooth because they are made up of small, mushy, somewhat elastic cells. They differ from our skeletal muscles, which have long, striated fibers that are less flexible.

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When our smooth muscles are functioning as they should, they regulate our blood pressure, digestion, sexual and excretory functions, and breathing—functions that are essential to human survival. However, the smooth muscles are linked to the emotional center of the brain by the nervous system, and they can be activated in response to anxiety (Janig, 2003). So what happens when anxiety impacts the smooth muscles? What symptoms are linked with dysregulation of the smooth muscle systems?

Conditions Linked with Smooth Muscle Activation

The following conditions are associated with involuntary tensing of the different smooth muscle systems (Abbass, 2015):

Are Types of Thoughts Associated with Smooth Muscle Anxiety?

Clinical researchers, especially in the literature on intensive short-term dynamic psychotherapy, have noted an association between self-attacking thoughts and smooth muscle symptoms. While it is not clear whether the self-punitive thoughts can cause a stomachache or migraine, harsh thoughts and smooth muscle symptoms do seem to show up together.

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack.

Here’s a smattering of thoughts I have heard lately that have shown up alongside smooth muscle symptoms in people I work with:

As these examples from my practice demonstrate, negative thoughts going against the self seem to co-occur with nausea and migraines. If you find that these kinds of thoughts co-occur with your IBS, migraine, or other physical symptoms, or seem to trigger them, you may be experiencing smooth muscle anxiety that has been diagnosed as a medical syndrome.

What Triggers Self-Attack and Smooth Muscle Anxiety?

Clinical research in ISTDP has demonstrated a link between complicated, mixed emotions toward loved ones, tendencies toward self-attacking thinking, and smooth muscle anxiety (Abbass, 2015). The theory of smooth muscle anxiety in ISTDP, which has been repeatedly supported by my experiences as a therapist as well as in case series data (Abbass, 2002) and empirical research (Creed, et al., 2003; Guthrie, et al., 1993), is that mixed emotions toward our attachment figures trigger anxiety. These mixed emotions are anxiety- and guilt-laden because it feels dangerous to have rage toward people whom we long to be close with and depend on.

Because of the anxiety and guilt associated with these feelings, the feelings are repressed—not thought about or reflected on. In fact, self-attacking thoughts seem to have the function of turning the anger toward the loved one back against the self with harsh thoughts and against the body with smooth muscle activation. The beloved person is protected from the anger, and the body and the self are punished. It is almost as though an unconscious, automatic part of the mind says, “How dare you have rage toward your beloved! You must redirect the rage toward yourself and your stomach to protect them!”

The Role of ISTDP in Healing

In ISTDP, we use collaborative, exploratory questions to support people as they learn to reflect on the emotions that are making them anxious and triggering self-attack. Increased reflective awareness of emotions seems to reduce the anxiety connected to them—if it can be thought about, talked about, and felt, it is no longer as scary or guilt-ridden. The complicated emotions we have about our loved ones are no longer unconscious (out of awareness) and frightening but can be seen and felt by the light of day and recognized for what they are—just feelings! People learn that they have been getting punished for emotions, which are mental, bodily events that are not inherently dangerous or wrong. Fear and guilt about emotions are replaced with thoughtfulness, openness, and comfort (Abbass, 2015).

If you are experiencing self-attacking thoughts and smooth muscle anxiety and are looking for systematic support in overcoming the automatic emotional factors that trigger your symptoms, ISTDP may be a useful treatment for you.

References:

  1. Abbass, A. (2002). Office based research in ISTDP: Data from the first 6 years of practice. Ad Hoc Bulletin of Short-term Dynamic Psychotherapy, 6, 5-14.
  2. Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.
  3. Creed, F., Fernandes, L., Guthrie, E., Palmer, S. Ratecliffed, J., & Read, N. (2003). The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology, 124, 303-317
  4. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A randomized controlled trial of psychotherapy in patients with refractory Irritable Bowel Syndrome. British Journal of Psychiatry, 163, 315-321.
  5. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.

Young man wakes up in bed with head painEvery system of the body is vulnerable to physical illness. This is common sense. But did you know every system of the body is vulnerable to emotional discord as well? The nervous system, an elaborate network of cells that facilitates communication between our brains and the rest of our bodies, directly links our physical selves to our emotional life. Voluntary muscles, involuntary muscles, and our five senses can all be influenced by the emotional responses of our bodies, so we can manifest a nearly infinite variety of physical responses to stress. While these reactions can sometimes be adaptive and helpful signals (e.g., preparing for flight when in danger), they can also cause distress, leading to visits to doctors.

When our physical symptoms are caused by an injury, bacteria, or an allergen, for instance, medical treatments can work. A visit to primary care, emergency care, or a specialist will likely yield desired results, at least eventually. However, when our physical ailment is caused or worsened by emotional factors, the potential of traditional medicine is limited. At best, a placebo effect may create some relief; at worst, the frustration caused by failed medical treatments can lead our emotion-driven symptoms to worsen.

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In this article, I will identify and elaborate upon four empirically supported ideas that may be useful to all of us. No one is immune to the physical reactions caused by emotional stress, so we are all equally vulnerable to developing medically unexplained physical symptoms when emotions overwhelm our coping capacities. If we can more readily identify them and seek appropriate treatments, we may be able to significantly reduce the burden on ourselves (and our health care system) that these symptoms can cause.

1. Emotional Factors Can Contribute to or Cause a Range of Physical Conditions

Emotional centers in the brain link with many important structures of the body, including our large voluntary muscles (anything you can flex) and our involuntary muscles, such as the gastrointestinal system (Janig, 2003). As you will read below, anxiety can trigger activation in any of these muscles, triggering a huge variety of physical symptoms that can be misdiagnosed as having a purely medical origin.

Any of the symptoms described here, and many more, can be triggered by anxiety-provoking emotional experiences, and may be most effectively diagnosed and treated by the methods discussed below.

2. Emotional Factors Contribute to a Large Percentage of Costly Emergency Visits

Medically unexplained physical symptoms can have a sudden onset and can be terrifying to the person experiencing them, which can lead to visits to emergency services and referrals to specialists. It is important for all health care consumers and practitioners to be aware of the high rate of patients who present with medically unexplained symptoms—and the significant efficacy of a short course of psychotherapy for treating these symptoms.

One unpublished study cited by Abbass, et al. (2010) found that 16% of emergency department (ED) referrals leave the hospital without a medical explanation for their presenting symptoms. This included 75.8% of people who presented with chest pain. Other common health concerns that left the ED without a medical diagnosis include headaches and abdominal pain. Regarding visits to specialists, Abbass (2004) reported on studies that found:

Eighty-four percent of 567 common internal medicine complaints—such as chest pain, dizziness or weakness—yielded no new diagnosis and cost a great deal to investigate. A recent British study found that one quarter of all new specialty referrals studied resulted in no diagnosis. This included almost one-fifth of surgical referrals and over one-third of some medical specialty referrals (p. 6).

According to this data, between 10% and 20% of ED visits and between 20% and 84% of specialist referrals yield no medical explanation, and it seems the most common medically unexplained symptoms can be linked with the bodily manifestations of anxiety described above. Fortunately, advances in mental health assessment and treatment are helping to change these worrisome statistics.

3. Emotional Contributors to Physical Symptoms Can Be Diagnosed Quickly

In his article about “emotion-focused interviewing” to diagnose somatization (the term for the process by which emotional factors affect physical health), psychiatrist and researcher Allan Abbass (2005) provides examples of brief conversations between doctor and patient that help reveal a clear link between emotional upsets and increases in symptoms. This interviewing technique, which has become an important part of my practice, is based on principles and techniques from a model of brief psychodynamic psychotherapy called intensive short-term dynamic psychotherapy, or ISTDP (Davanloo, 2000).

Clinicians who learn ISTDP are trained to monitor a variety of verbal and bodily signals so they can detect an increase or decrease in the physical symptoms as thoughts and feelings are explored during an interview. According to Abbass (2005):

An increase in symptoms with emotional focus suggests that emotions aggravate or directly cause the problems. A decrease in symptoms during the test also suggests a linkage to emotions. Disappearance of the symptoms by bringing emotional experiences to awareness is the best direct evidence that somatization of these emotions was causing the patients symptoms (p. 235).

Abbass suggests this diagnostic process can be accomplished in as little as 15 minutes of conversation. Considering the financial and time costs of the procedures that are often used to diagnose medically unexplained physical symptoms (e.g., fMRI), Abbass makes a compelling case for the utility and efficacy of an emotion-focused interview based on ISTDP that can help establish whether emotional factors are playing a role in physical symptoms.

4. Psychological Treatments Show Cost-Effectiveness

Seeing a psychotherapist to rule out emotional factors earlier in the diagnostic process can save money and heartache, which is especially important because the emotional upset associated with failed medical procedures and treatments can cause symptoms to worsen.

Seeing a psychotherapist to rule out emotional factors earlier in the diagnostic process can save money and heartache, which is especially important because the emotional upset associated with failed medical procedures and treatments can cause symptoms to worsen.

Abbass (2003) calculated an average health care cost reduction of $1,573 per patient by one year after a course of ISTDP. Only two of the seven studies reviewed for cost-effectiveness by Abbass (2003) were specific to medically unexplained physical symptoms (irritable bowel syndrome and chronic functional dyspepsia); however, even those who were being treated specifically for psychological concerns experienced a large reduction in their overall health care cost burden. This is strong evidence for the cost-effectiveness of ISTDP in reducing health care costs for folks with medically unexplained physical symptoms and general mental health concerns.

Another finding that supports this line of research is that the use of ISTDP therapists in the ED described above led to a 69% reduction in ED visits by those who had a very brief course of psychotherapy (3.2 sessions on average). Those who did not have the therapeutic consultation had anywhere from a 15% reduction to a 43% increase in ED use over the course of the next year (Abbass, et al., 2009). Average health care cost savings among the treated group was $910 in the follow-up year (Abbass, et al., 2010). This is strong evidence for the potential advantages of a medical system that takes emotional factors into account, both for those suffering and for the health care system overall.

Looking at the Data and Looking Forward

Thanks to the work of Davanloo, Abbass, and others, we have helpful tools for understanding the ways emotions impact the body and create medically unexplained symptoms. We know medically unexplained symptoms burden the people who experience them and the medical system with lost time, lost resources, dashed hopes, and continued suffering. Finally, we have tools and methods for diagnosing and treating somatization of emotions that have shown efficacy and cost-effectiveness. To me, as Abbass (2004) has argued, these data make the case for the importance of heightened awareness of this information among health care consumers and practitioners.

It is my hope that with greater awareness of the ways emotions can impact health, doctors and patients alike will be more open to referrals to emotion-focused assessment services like the one described by Abbass (2005) and to therapies, such as ISTDP, that have demonstrated efficacy in treating medically unexplained symptoms. However, until this becomes part of standard medical practice, we can advocate for ourselves by asking questions about whether our symptoms could possibly be linked to stress, anxiety, or other issues, and by seeking out appropriate assessments and treatments.

While we should not flip radically in the opposite direction and assume all our physical woes are psychosomatic, we may save ourselves from needless expenditures of time, money, and hope by having an emotion-focused interview early in the diagnostic process to establish whether emotional factors are contributing to our medically unexplained physical issues.

References:

  1. Abbass, A. (2003). The cost-effectiveness of short-term dynamic psychotherapy. Expert Review of Pharmacoeconomics Outcomes Research, 3, 535-539.
  2. Abbass, A. (2004). The case for specialty-specific core curriculum on emotions and health. Royal College Outlook, 1, 5-7.
  3. Abbass, A. (2005). Somatization: Diagnosing it sooner through emotion-focused interviewing. The Journal of Family Practice, 54, 215-224.
  4. Abbass, A., Campbell, S., Magee, K., & Tarzwell, R. (2009). Intensive short-term dynamic psychotherapy to reduce rates of emergency department visits for patients with medically unexplained physical symptoms: Preliminary evidence from a pre-post intervention study. Canadian Journal of Emergency Medicine, 11, 1-6.
  5. Abbass, A., Campbell, S., Hann, G., Lenzer, I., Tarzwell, R., & Maxwell, D. (2010). Cost savings of treatment of medically unexplained symptoms using intensive short-term dynamic psychotherapy by a hospital emergency department. Journal of the Academy of Medical Psychology, 1, 34-43.
  6. Davanloo, H. (2000). Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. Chichester: Wiley.
  7. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.

Storm clouds gathering over waterIn the face of our depressed moods, friends, loved ones, and even our therapists may say things like, “Stop doing that to yourself!” or “Get over it!” We may even say to ourselves, “Why can’t I just get over it?” These forms of “psychotherapy” usually come from a loving place but often turn out to be ineffective. But why? Why is it that we can stop ourselves from doing certain things (touching a hot stove, for instance), but when it comes to the low energy, hopelessness, helplessness, and self-attacking thoughts of depression, we can’t “just get over it”?

When ‘Get Over It’ Does Work

Believe it or not, as a therapist I spend a fair chunk of my day using a form of “Stop It!” therapy, often with success. When a person is (1) in conscious control of a behavior, (2) no longer wants to do it, and (3) wants my help to stop, challenge (Abbass, 2015) or response-prevention interventions can be quite effective.

“Get over it!” is a form of challenge or response prevention—it says, “Stop doing the thing that hurts you!” When you look at it that way, you can see the loving core of the comment. When someone asks me for help with a pattern they know is self-defeating, such as stubbornness or detachment, but they intentionally continue to do it, challenging them with a “don’t” intervention is one of the most compassionate, helpful things I can do.

When ‘Get Over It’ Doesn’t Work

When someone has conscious control over a behavior, “get over it”-type interventions can help, but my clinical work looks much different when the self-defeating pattern is unintended or unconscious, habitual, or automatic. Decades of clinical research in intensive short-term dynamic psychotherapy (e.g., Abbass, 2015) have shown that a portion of those experiencing depression have symptoms driven by an unconscious emotional process—a process that, at least at the start of therapy, occurs automatically and is entirely beyond their control.

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In ISTDP, we call this process “repression” or “instant repression”—the process by which mixed emotions toward another person are instantaneously and unintentionally shunted back against the self, either in the form of depression or somatic symptoms (this is a slightly different definition of repression than in psychoanalysis).

Often, people who experience repression-driven problems never recognize they were mad at someone else; instead, they are instantly overcome by a process of self-blame and self-torture that leaves them feeling fatigued and hopeless. At no point did they decide to do this. Before therapy, this is just how their brains are wired; they automatically say, “When I feel anger toward someone I love, I protect them by pointing it back at myself.” Considering the people we love most are the most likely to irritate us, this is a potentially dangerous state of affairs.

Saying ‘Get Over It’ to Someone with Repression

So what happens when we say “get over it” to someone with depression that is driven by unconscious repression? Here, the “get over it” confronts the depressed mind with an impossible task: (1) gain conscious control of an unconscious process that is currently operating out of your awareness, or (2) do a thing you simply can’t do (yet).

When people, especially people we love, challenge us to do something that is impossible, it triggers anger, and in the depressed mind where instant repression is still active, that anger will deflect right back onto the self. Instead of lovingly reducing the person’s symptom burden, then, the “get over it” would actually make symptoms worse by activating anger that will be sucked back in via repression.

When people, especially people we love, challenge us to do something that is impossible, it triggers anger, and in the depressed mind where instant repression is still active, that anger will deflect right back onto the self.

‘Get Over It’ and Psychotherapies for Depression

Some therapies encourage us to challenge, question, or detach from our depressive thoughts and moods. Other therapies encourage us to get up and do something even when we have no energy. Sometimes, for some people, these approaches produce positive benefits.

My concern, however, is that for folks who have depression caused by unconscious repression processes, questioning their thoughts implies, “Don’t think that,” and encouraging different behaviors implies, “Don’t be like that.” These both sound a lot like saying “get over it” to someone who is not in conscious, intentional control of the symptom; asking them to do something different when they literally cannot. This could trigger anger toward the therapist that will get shunted into repression and lead to worsened therapy outcomes. No one wants that.

How ISTDP Can Be Useful

ISTDP is an ideal therapy for building the capacity to become consciously aware and tolerant of the mixed emotions that usually get deflected back on the self in repression-driven depression and somatization. When working with people with depression in ISTDP, the therapist is in a largely supportive mode, helping people self-reflect on and feel the feelings that were previously getting automatically and unintentionally converted into depression or somatic symptoms. This builds affect tolerance—the ability to feel feelings while still being able to think clearly and channel them in a satisfying way.

This process helps people with repression because, rather than telling them what not to do or what they should do, it gives them another option—it helps them become more comfortable with their emotional reactions so they can then decide how to channel their emotions. In ISTDP, what people wind up “getting over” is the destructive way their mind would unconsciously bury mixed emotions. Once they can think clearly while being in touch with their emotions, rather than being unconsciously overwhelmed by those emotions, they can then make wise, authentic decisions about what to do.

Reference:

Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.

Couple Holding Hands OutdoorsIntensive short-term dynamic psychotherapy (ISTDP), like all psychotherapy models, is a set of ideas and strategies used to form a healing relationship with another human being. Like therapists using other models of therapy, ISTDP therapists strive to create a relationship in which a person in therapy feels safe and secure. Experience shows that people need to feel safe in order to experience the emotions that their symptoms are designed to hide, and that experience of emotions within a secure bond will likely reduce their symptom burden (Davanloo, 1990; Frederickson, 2014; Abbass, 2015).

Sounds simple enough, no?

How ISTDP Therapists Use Attachment to Create Safety

[fat_widget_right]All psychotherapy models are ways of connecting and creating safety, but many assume a willing, motivated person will show up to the first session, which is not always the case. Some people arrive terrified of emotional contact with the therapist. They may come in and, intentionally or unintentionally, do things that interrupt their therapy goals without knowing why. Many therapists get stumped by these situations.

I love learning, teaching, and practicing ISTDP because the model offers an elegant system for reaching out to and supporting people to overcome the automatically deployed avoidance mechanisms that can defeat therapy. In ISTDP, we create safety by inviting a secure attachment, and then help people overcome the automatic thoughts, feelings, and behaviors that would otherwise create an insecure attachment.

Why People Create Walls and How We Can Invite Them Out to Play Again

Those of us who set out to create healing relationships, in therapy and elsewhere, quickly become aware of the many barriers people erect to keep love and concern from others out. We learn about the many rationalizations and self-recriminations that buttress people’s interpersonal walls. We understand that for many people the wall was once a survival mechanism, but we also see how it hurts them now. This presents a challenge: How do we create safety and security with someone who won’t let us in? How can we heal a heart if we can’t get close enough to see it?

We understand that for many people the wall was once a survival mechanism, but we also see how it hurts them now. This presents a challenge: How do we create safety and security with someone who won’t let us in? How can we heal a heart if we can’t get close enough to see it?When we reach out to meet a person and instead we meet a wall, therapists and non-therapists alike have a variety of reactions. We might feel angry toward the person we reached out to so lovingly. We might act out that anger and turn it into efforts to control or cajole. We might pretend the walls are not there and carry on a chronically disappointing pseudo-relationship with whatever parts of the person are not walled off. Often, we transiently forget our love, feel only our anger, and become harsh. We might even respond with our own walls.

In psychoanalytic thinking, we call the above reactions “enactments” (Sandler, 1976; Chused, 1991). In other words, we start acting out the relationship that the wall invites us to have, rather than the healing relationship that the person behind the wall needs from us. We end up relating to the character armor (Reich, 1945) or “resistance” rather than the wounded person who is stuck underneath. For therapists, the trick is learning how to step out of or around the enactment and reach out to the person behind the walls.

ISTDP therapists are trained to try to channel our mixed feelings of love and anger into communication. In this case, we talk about the wall with phrases like:

For ISTDP therapists, our first step in connecting with someone who is pushing us away is to describe the behaviors that make up the wall so they can be seen, considered, and discussed. Like any survival mechanism, our walls are built automatically and often unconsciously. To overcome these automatic barriers to connectedness, people often need help slowing down, self-reflecting, and noticing what is happening.

First, help the person see the wall. Let him or her know you see it too. Only then can you start talking about why it’s there and how it’s hurting the person, which may help him or her begin the work of overcoming the wall so you can create a safe, healing space together.

The wall, Davanloo’s (1990) vivid metaphor for the psychoanalyst’s “transference resistance,” will push many friends away, and often deflect any otherwise helpful therapeutic intervention. The wall is often a major driver of symptoms and presenting problems. By talking about the wall in ISTDP, we can sidestep the “enactment” and its destructive potential, and make a safe space where a new kind of relationship—a healing relationship—can take root.

References:

  1. Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Kansas City, MO: Seven Leaves Press.
  2. Chused, J. (1991). The evocative power of enactments. Journal of the American Psychoanalytic Association, 39, 615-640.
  3. Davanloo, H. (1990). Unlocking the unconscious: Selected papers of Habib Davanloo, M.D. Hoboken, NJ: Wiley.
  4. Frederickson, J. (2014). Co-creating change: Effective dynamic therapy techniques. Kansas City, MO: Seven Leaves Press.
  5. Reich, W. (1945). Character analysis. New York: Noonday Press.
  6. Sandler, J. (1976). Countertransference and role-responsiveness. International Review of Psycho-analysis, 3, 43-47.
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