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CHAPTER FOUR. Assessment of a patient’s anxiety

Neborsky, Robert J.; ten Have-de Labije, Josette Karnac Books ePub

When there is anxiety at the onset of the therapeutic encounter, we could say that the patient’s anxiety is somewhere on the continuum between anxiety as a transference reaction and anxiety as a sign of generalized anxiety.

In patients with a high capacity to regulate anxiety, signs of anxiety will be reflected by a pattern of facial muscle behaviour and by tension of other striated skeletal muscles, by a pattern of sympathetic reactivity and sensory vigilance. The proportion of somatomotor manifestations would be higher than the proportion of autonomic manifestations. The rise of the respective manifestations would be slow, and the duration of the manifestations would be relatively short. Such a patient would report various concerns in terms of (subjectively) perceived reality and cognitions, and he would accurately perceive the internal state of his periphery and label it as anxiety.

In practice, we seldom meet such patients at the initial interview. Mostly, we meet patients whose pattern of physiological anxiety manifestations reveals that they are less or not at all capable of adequately regulating their anxiety for their own benefit. In these cases, the proportion of autonomic manifestations is higher than somatomotor manifestations and/or there is cognitive and/or perceptual dysfunctioning. The rise and spread of physiological manifestations is fast and high and the duration of the respective manifestations is relatively long and the velocity of fall of anxiety manifestations is slow. Often, although they suffer from their symptoms, such patients do not report anxiety because they are not (accurately) processing their internal state, and in this way—of course—they maintain their inability to self-regulate their anxiety and, in due time, their anxiety will continue to grow worse and will eventually generalize.

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CHAPTER EIGHT. The independent variables: ISTDP techniques to change red traffic lights into green

Neborsky, Robert J.; ten Have-de Labije, Josette Karnac Books ePub

Although Davanloo’s intensive short-term dynamic psychotherapy is theoretically based on the psychoanalytic reference realm, his techniques are derived from structured psychotherapy methods such as behaviour therapy or cognitive-behaviour therapy.

The term “structured” refers to the fact that the therapist takes an active and directive stance. It is the therapist who—at each time in the therapeutic process—determines the focus of investigation. Especially in the early phase of the therapeutic process, the therapist also may take the position of a teacher, teaching the patient how to look and to understand his problems.

At each time in the therapeutic process the timing and selection of the specific technique, the dosage of that technique, and its duration are dependent on the momentary state of the patient’s variables and the patient’s reaction to the interventions.

However, a therapist’s clinical judgement can never be fully manualized and, although the therapist’s use of the techniques is prescribed by the therapeutic method, in this case by the ISTDP method, we advise our colleagues not to forget to use their common sense and to apply their interventions with flexibility and creativity.

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CHAPTER NINE. An initial interview with a transport-phobic patient

Neborsky, Robert J.; ten Have-de Labije, Josette Karnac Books ePub

The DSM-IV classifies phobias as agoraphobia (with and without panic attacks), as social phobia and as specific phobia. Agoraphobic persons have an irrational fear of activities outside of the home. They often have anticipatory anxiety of becoming physically unwell/ill. Or they are afraid they will go fainting, thus losing control and thereby causing public disturbance/nuisance. In addition, agoraphobics misapprehend causal antecedents of painful feelings and they develop their symptoms in a climate of notable interpersonal conflict (Goldstein & Chambless, 1978).

Social phobia, or social anxiety disorder, is characterized by extreme anxiety in social and performance situations. A social phobic person is mostly preoccupied with doing something inappropriate and being devalued, judged, or blamed because of that or because others will notice their anxiety symptoms (blushing, sweating, shaking).

A specific phobia is an extreme fear of a specific object or situation that is not in proportion with actual danger or threat. Mostly, five types of specific phobias are defined:

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CHAPTER ONE. Davanloo’s ISTDP, psychoneurosis, and the importance of attachment trauma

Neborsky, Robert J.; ten Have-de Labije, Josette Karnac Books ePub

In the early 1960s, Davanloo decided to break away from the traditional psychoanalytic approach. In 1980, in his chapter, “A Method of Short-Term Dynamic Psychotherapy”, Davanloo briefly presented his method of ISTDP which was based on three systematic studies, involving psychotherapy with respectively 130, 24, and 18 clients with psychoneurotic problems.

His work, which from the start was all audiovisually recorded, was received with enthusiasm as well as with scepticism and criticism.

Now, more than thirty years later, we have many clinical studies and outcome research confirming the efficacy of this method.

Davanloo (1990) describes that Freud believed that the superego establishes itself relatively late in developmental history and comes into operation after the resolution of the Oedipus complex. Evidence from his work with patients and from his clinical case studies has led Dav-anloo to modify analytic theory in emphasizing that it is already in the early months of life that the superego may play an active role in the causation and maintenance of neurosis. Neurotic disturbances arise as a result of a variety of possible traumatic experiences, involving damage to or disruption of the affectionate bond between the child and his caretakers. The child unconsciously reacts to this damage/disruption with a sadistic, murderous rage. It is this sadistic, murderous rage and the consequent loss (of the beloved murdered person(s)) which leads to guilt and grief as well as to punitive, sadistic reactions of the superego towards the child’s ego. The traumatic experience(s), murderous rage and its result(s), guilt and grief, are repressed into the unconscious. Various symptom patterns and character pathology develop as the ego of the developing child attempts to keep functioning under the mandate of the punitive/sadistic superego in such a way that it will not be overwhelmed by the impulses and feelings themselves, by anxiety nor by the defences. The earlier, the more intense, and the more frequent the traumatic experiences, the more sadistic the impulses, and the more the ego will be trapped between the sadism of the id and the sadism of the superego, and the more the ego will become paralysed in managing the resistance of repression and the resistance under the mandate of the superego. Davanloo’s view on the development of neurosis is depicted in Figure 1.

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CHAPTER TEN. Steps on the roadmap to the unconscious and its application to patients suffering from depressive disorders

Neborsky, Robert J.; ten Have-de Labije, Josette Karnac Books ePub

Depression is one of the most common disorders seen in clinical practice. Depression is a complex diagnostic construct that casts a large umbrella over diverse conditions. Some of the varieties of depression as defined by psychiatrists are summarized in Table 5. This chapter cannot do justice to the entire topic of depression, but it is designed to give the reader an organized method to assess whether a depressed patient is suitable for intensive short-term dynamic psychotherapy. Suffice it to say, just as in traditional approaches, all organic causes of depression (thyroid, endocrine, metabolic, drug withdrawal) must be ruled out before undertaking psychotherapy.

Classically depressive neurosis (dysthymia) was seen as responsive to dynamic psychotherapy, but recent research indicates ISTDP can address many forms of depression. The central symptoms of all depression are, of course, a depressed mood and loss of interest in life’s activities. Table 6 illustrates the entire spectrum of depressive symptoms. In contrast to the normal emotional responses to unwanted and stressful events, depression is a mental disorder which, because of its severity, tends to recur and places a high cost on the individual as well as society. It is important to note that up until the present time, no common causes for depressive disorders are known which would allow for aetiological-based valid classification. Despite the current trend in ICD-10 and DSM-IV to pigeonhole depression according to timing and severity, there is little evidence to support that major depression is any more than a syndrome. It is most likely that major depression is a diagnostic construct which we impose upon a continuum of depressive symptoms.

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