The Exorcist: childhood trauma and loss Jon Frederickson, MSW 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. Bmj 2003; 327:646. 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. 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 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) 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. 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, 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 . 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." 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. Inquiry 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 symptoms. 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 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. 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 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. 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. 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 testing. 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 selfpunishment. 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.” Undoing Identification “I punish myself” = identification = a failure in selfobservation. “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. 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. 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. Adaptive Function of the Defense 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 you.” 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 you. 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 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. 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. 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. 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. 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. 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.” 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. 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 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. 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. 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. 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.” 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.