The Exorcist

The Exorcist: childhood
trauma and loss
Jon Frederickson, MSW
Multiple Sclerosis and
 Extensive research shows that stress triggers relapses in multiple
 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;
Buljevac D, Hop WC, Reedeker W, et al. Self reported stressful
life events and exacerbations in multiple sclerosis: prospective
study. Bmj 2003; 327:646.
 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.
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 muscles
Sympathetic Nervous
Dry mouth and eyes
Dilated pupils
Increased sweating, Cold hands and feet
Increased heart rate, blood pressure, and respiration
Gastrointestinal tract (decreased motility)
Piloerection muscles contract (hair stands on end)
Bladder (constrict sphincter---urinary retention)
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, limpness
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. Hypoperfusion in the brain.
 Amnesia and memory loss. Hippocampus shuts down.
 Hallucinations.
 No tension, but cognitively confused.
 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, autoimmune disorders, diabetes, and other chronic
diseases. See Schulkin’s, Allostasis, Homeostasis, and
the Costs of Physiological Adaptation.
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 .
 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."
 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.
 Find out the internal emotional problem for which
the patient seeks our help.
 Assess responses to intervention moment-tomoment to discern the triangle of conflict.
 Assess anxiety discharge pattern and defenses to
understand what causes the patient’s problems and
Anxiety Assessment
 Discern where anxiety is discharged in the body.
 Striated muscles
 Smooth muscles
 Cognitive/perceptual disruption.
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.
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.
Conscious Therapeutic
Alliance: Consensus on the
 To know what to do, the patient must know the
 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
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.
Conscious Therapeutic
Alliance: Consensus on the
 To let go of defenses which hurt the patient.
 To face rather than avoid what makes the patient
 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.
Pressure to Feeling in the
Graded Format: Building
 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.
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.
Repressive Defenses
 Intellectualization
 Rationalization
 Rumination
 Denial
 Forgetting
 Negation
 Slowing down
 Isolation of affect
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.”
Projection of the Superego
 Triangle of conflict: Anger, anxiety, self-judgment.
 I project: “You judge me.”
 Spectrum of projection: anxiety, defenses, reality
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
 Any fact can be misused in the service of selfpunishment.
Mobilizing Self-Observing
 Not, “Do you see how you punish yourself?”
 Instead, “You are able to observe a reaction inside
 “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.”
Undoing Identification
 “I punish myself” = identification = a failure in selfobservation.
 “I dreamt.” Dreaming occurred without you doing
 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.
 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.
Defense of Identification
 Rage, anxiety, identification with the object of one’s
 “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.
Adaptive Function of the
 Relocate the danger within himself.
 Control over the danger.
 Retain hope that the father is all-good.
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
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.
Pressure to SelfAcceptance
 Superego pathology = rejecting reality, especially of
 Success in therapy: successful self-acceptance of
your inner life.
 Deactivating self-rejection by inviting selfacceptance.
 Weakening of defense = rise in feelings, and anxiety
related to self-punishment.
Undoing Splitting
 Splitting: keeping opposing feelings or facts
 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.
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
 Undo defenses.
 Response: rise of grief.
Process II
 Intervention: invite acceptance of his ‘inner
panther.’ Invited him to face rage toward father.
 Response: identification with father, splitting, and
 Intervention: undo splitting.
 Response: ability to bear complex feelings without
splitting. Understanding clear.
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
 Pathological mourning must be addressed first for
rage to become accessible.
Smile as a Character
 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.
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.”
 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.
Compassion for
the Origin of the Defenses
 Self-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 selfacceptance.
 Patients can easily misuse defenses for the purpose
of self-hatred as if that is therapy.
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.”
Portrayal and Pathological
 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.
Undoing Splitting and
 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.
 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.
One Year Follow-up
 “My legs are perfectly responsive to sensation in
every place. Nobody understood why this is the
 “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.”
 Go to for articles, blogs,
dvds, skill building audio studies, and webinars on
 Co-Creating Change: Effective Dynamic Therapy
Techniques, May 2013. Seven Leaves Press.
 Go to for
answers to your clinical questions.

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