Therapy in LA

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September 2013

DISCOVERING DYNAMIC EMOTION FOCUSED THERAPY
“JOURNEY TO THE CORE”

by Susan Warren Warshow, LCSW, LMFT

Bearing the intensity of emotional states, both positive and painful, challenges everyone throughout the lifespan. The sense of feeling connected and not alone is the sole mitigating force that provides relief and freedom from our anxiety, psychosomatic symptoms and defensive positions. Most importantly, this includes an active relationship to oneself… one in which we become a caring friend to the person we are in this present moment. Also, for many people seeking therapy, a spiritual relationship is central to their healing. Many DEFT therapists share this experience and will acknowledge and support this dimension if the client initiates the topic. The challenge facing every therapist is how to create deeply felt connection within TWO relationships to optimally alleviate suffering: that between therapist and client and that between client and self.

Dynamic healing capacity lives in everyone but for many people seeking therapy, it is dormant or restrained to varying degrees. Some are hoping the therapist will figure out the problem and fix it, but there is no easy, passive path. In DEFT, a deeply engaged therapist uses compassionate interventions to disarm defenses and regulate defensive affects to unleash this healing force and mobilize a partnership that focuses intently on moment-to-moment internal process. One man told his wife with a mix of grief, hope and joy, having had over a decade of therapy, “I have never had therapy like this before. It goes straight to the heart of what I’ve been doing to myself all my life.” Through this type of treatment, it is possible to gain a viscerally felt, comprehensive, non-judgmental and empowering awareness of the self.

There is an exquisite sense of risk and shame for most people just in walking into a therapist’s office, anticipating the exposure to a stranger of flawed, frightening and unknown parts of the self. And yet, psychological healing requires a type of uncovering in the presence of a caring, empathic other that involves facing and integrating intensely painful emotions as well as feelings of love and joy. The sooner this new territory is entered, the more rapid the relief. Because DEFT actively facilitates this type of risk-taking, it often provides accelerated relief. Paradoxically this comes about by slowing down the process and entering into awareness of moment-to-moment phenomena, a type of meditative state.

How is DEFT similar to and different from ISTDP?

DEFT is informed by psychodynamic theory, especially Intensive Short Term Dynamic Psychotherapy (ISTDP) which is evidence-based, and incorporates Malan’s triangle of conflict (feeling leads to anxiety leads to defense/symptoms). Healing involves reversing this progression to work one’s way back through defenses and defensive affects towards the original core affects and desires and a newly formed sense of secure attachment. This involves:

Processing of unconscious guilt-laden complex feelings towards parental figures (rage, guilt over rage, grief and love) and consolidating the insights that result (including the exploration of their practical application).
Distinguishing self-harming from self-enhancing parts of the self. Developing personal responsibility for continued healthy risk-taking and self-care
Moment-to-moment tracking and attention to the physiological sensations of anxiety and feelings. DEFT gives equal attention to the recognition of the physiology of shame and guilt.
Mobilization of will to attend to the self.

DEFT emphasis on shame is a departure from ISTDP and it has its own signature features (see below). In ISTDP, working through trauma that occurred in parental relationships is the primary goal and this is accomplished through maintaining a focus on feelings aroused in a current or past primary relationship. DEFT also focuses on and deeply explores feelings such as shame and rage that may or may not be directly related to the family of origin, e.g. feelings in relation to abusive institutions, poverty, the horrors of war, irresolvable medical conditions, physical abnormalities, et al.

DEFT and Other Therapies:

Like AEDP, DEFT places strong emphasis on positive affects and increasing tolerance for them. It is indebted to Leigh McCullough’s work on affect phobia and relies heavily on self-other restructuring. DEFT incorporates elements from many dynamic therapies as well as CBT, SE, Reality Therapy, Focusing, et al. In addition, DEFT draws from hope research, neurobiology, sociology, philosophy and spirituality (e.g. mindfulness practice; modeling humility that is not shame based; showing generosity; and making amends).

DEFT’S Emphasis on Shame

DEFT conceptualizes that when feelings/impulses/desires are met with chronic mal-attunement in the early years, this often evokes shame that triggers anxiety/fear of unbearable separation, which then leads to defensive self-preservation and symptoms. (Researchers identify shame at age 3 months).

In DEFT, shame is seen as a primary inhibitory affect that frequently arises around any aspect of internal exploration, often due to transference reactions and defensive projection of self-judgment and loathing. It can also be provoked by therapist countertransference reactions and human error. It can be very curative for the therapist to own these occurrences. Shame often skates under the radar and is given insufficient attention. DEFT views shame states as highly correlated with trauma-related emotional suffering and defensive adaptation, (a concept preferred to “psychopathology”). Therefore, all of its interventions are guided by a sensitive awareness to this affect, and the dismantling of shame’s toxic forms in both client and therapist is central to its success.

DEFT, like ISTDP, recognizes the activity of the punitive superego (unconscious need for punishment to avoid guilt over rage). However, DEFT also holds the view that trauma, symptom formation and damaging behaviors can directly derive from modeling and internalizing shaming treatment associated with not only family of origin but also with cultural, religious, peer group, educational, medical, and socio-economic influences et al.

Signature Features of DEFT:

DEFT embraces attachment theory, and its training programs help therapists become more aware of their own attachment styles and how to practice with neuro-biological attunement.

It accentuates attuned verbal and non-verbal, embodied responses while intervening to help reduce inhibitory affects (toxic forms of anxiety, shame and guilt).

Emphasizes the building of sense of self, which may or may not occur alongside symptom reduction. Thus, DEFT frequently inquires, non-rhetorically, into permission to use its interventions. Non-authoritarian, collaborative stances are recommended throughout treatment, including decisions regarding area of focus and exploration of meanings and applications in the consolidation phase.

Agrees with Positive Psychology’s emphasis on strengths over deficits (e.g., ideally in DEFT, a strength would be pointed out at least as often as a defense).

Views all new and difficult types of self-disclosure as “breakthroughs to intimacy,” e.g. revealing a childhood incident of molestation for the first time or sharing with the therapist that cognitive disruption is occurring, i.e. “I keep losing my train if thought.” These “breakthroughs” are disclosures that carry significant shame, anxiety or guilt. DEFT views these moments as curative, representing courage and accomplishment, so long as there is accompanying emotional activation. Thoroughly identifying such risk taking as strengths contributes greatly to the building of hope, the engine of treatment. This also allows the therapist to appreciate such moments of progress that carry value, even when not “full unlockings.”

Teaches a style of drawing attention to defenses that takes care to convey compassion for their cost through embodied responses as well as with the language and inflection used in verbal interventions. These often add context for the developmental need for the defense, e.g. “You were resourceful to develop detachment from such an abusive father, but won’t it hurt you here with me?”

Views the best therapy as a process in which both client and therapist are learning from one another and are engaged in self-reflection, mutual vulnerability and personal growth.

Gives as much attention to the therapist’s internal process as to the client’s. The therapist’s state of well-being and personal awareness is central to helping others.

DEFT places particular value on the quality of the therapeutic attachment relationship, involving:

The ability to not only feel compassion but to convey it, e.g.
addressing defenses with attention to prosody, choice of non-shaming language, engaged and attuned body signals.

Spontaneity and authenticity: retaining that which makes the therapist unique and real, sometimes involving self-disclosure in the interest of the client. Therapist creativity can be very fruitful when there is careful observation of responses to interventions.
Therapist intuition (instinctive knowing) based on observable and sensed phenomena.
Play and humor, which can help reduce defense and form connection.

Conclusion

In summary, the traumatized individual is a guarded individual. Affects that are buried do in fact continue to live within the body, tying up energy and creating toxicity for self and others. When they are allowed to move through the body to conscious awareness, they generate connection to self and others, unleash creativity and guide one’s direction. DEFT is a partnership effort to penetrate layers of inhibitory affects and defenses in order to reroute the barriers that prohibit the emergence of underlying intense emotional states.

There is cross-fertilization in most therapies, including DEFT, and it can become artificial to try to absolutely separate them. Thus, DEFT is a non-linear, integrative treatment that operates from principles rather than uniform agendas, which can restrict awareness of treatment possibilities and impede optimal healing for a unique individual. There are many valuable tools and techniques to help manage symptoms. DEFT supports the integration of any such tools within its approach.

DEFT promotes self-actualization as well being a treatment for trauma, seen as a universal experience and a condition of being alive. As psychiatrist Mark Epstein’s said, “Trauma … does not happen to only some people. An undercurrent of trauma runs through ordinary life, shot through as it is with the poignancy of impermanence.” He goes on to say that “we are not suffering from post-traumatic stress disorder, we are suffering from pre-traumatic stress disorder. There is no way to be alive without being conscious of the potential for disaster.” DEFT views recovery and resiliency in relation to trauma as a lifelong process and not an absolute destination. Who we are and how we behave must also take into account the ultimately incomprehensible, complex forces that brought both nature and mankind into being. This is why our understanding of the psyche will always involve emergent phenomena and never be complete. Hence, DEFT places great value on healthy humility deriving from our recognition of the limitations of theory, of those who practice and teach it, and those we try to help.

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Susan Warren Warshow is a Licensed Clinical Social Worker and Licensed Marriage and Family Therapist practicing in Woodland Hills, CA. She is a member of the Independent Psychotherapy Network. Contact Ms. Warshow at (818) 703-1145. Email: swarshow@me.com. Website for therapists: www.deftinstitute.com; Website for clients: www.warrenwarshow.com

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