Restructuring the Sense of Self by Building Self CompassionLeigh McCullough Ph.D.Associate Clinical Professor, Harvard Medical SchoolSlides from the IEDTA Conference (International Experiential Dynamic Therapy Association UCLA, Los Angeles, CA., September 2005 • The point of this lecture was to demonstrate that compassion can • be dealt with similarly to grief and anger in Short Term Dynamic Psychotherapy; i.e., patients who are self attacking or self destructive need to be desensitized to positive feeling for self by exposure to feelings of care, concern, compassion for self and by the prevention of defensive and inhibitory responses. This approach is presented in detail in the following books (on the next two slides) and the website, www.affectphobia.com STDP Workshop - Leigh McCullough Ph.D.
Short Term Dynamic PsychotherapySTDP Short Term Anxiety-Regulating Psychotherapy for Restructuring Defenses, Affects and Attachments Basic Books, 1997 To Order: 1-800-386-5656
Treating Affect Phobias:A Manual for Short Term Dynamic Psychotherapy Each chapter presents: 1) Basic concepts of STDP, and 2) Exercises for reader practice www.affectphobia.com To order: 800 – 365 -7006 STDP Workshop - Leigh McCullough Ph.D.
Go to our Website: www.affectphobia.com For information on our Training Programs in 2006-7 in the Boston Area (Details to be posted in the Fall of 2005) STDP Workshop - Leigh McCullough Ph.D.
COMPASSION Synonyms: Sympathy, empathy, pity, concern, kindness, consideration, care softhearted, tenderhearted Antonyms: Hardhearted, stoneyhearted, callous, insensitive, pitiless STDP Workshop - Leigh McCullough Ph.D.
Thoughts on Compassion Compassion is the antitoxin of the soul: where there is compassion even the most poisonous impulses remain relatively harmless. Eric Hoffer U.S. Philosopher STDP Workshop - Leigh McCullough Ph.D.
The Triangle of ConflictDavid Malan DEFENSES Behaviors, Thoughts, and Feelings INHIBITIONAnxiety, Guilt, Shame, Emotional Pain ACTIVATING FEELINGS Adaptive forms of grief, anger, closeness, And...POSITIVE FEELINGS FOR SELF (Interest/excitement, Enjoyment-joy) The emotional bases of self-care, concern, compassion, pride, and esteem STDP Workshop - Leigh McCullough Ph.D.
Compassion and its’ Blocks on the Triangle of Conflict DEFENSES Self Attack, Self-Hate Low Self Esteem ANXIETY/ CONFLICT I am afraid to be too big. I am ashamed to feel proud. It is too painful to feel good about myself. • ADAPTIVE FEELING • JOY OR INTEREST IN SELF • Self Compassion, Self Care, Self Esteem, Pride, • Self Confidence, Self Worth, Self Respect, Trust in Self STDP Workshop - Leigh McCullough Ph.D.
RESPONSE PREVENTION EXPOSURE Desensitization of Affect Phobias in STDP INHIBITORY AFFECTS SHAME, Guilt, Pain DEFENSIVE AFFECTS Self Hate ACTIVATING AFFECTS Positive Self Feeling, Self Interest, Self Care, Self Compassion STDP Workshop - Leigh McCullough Ph.D.
A Bit of Exposure fromGrapes of WrathSteinbeck, Chapter 6 Muley Graves: (After talking about wanting to kill the people who threw his family off their land;) “Fella should maybe keep stuff like that in his head.” Casey (Former Preacher): “Yes, you should talk,” he said. “Sometimes a sad man can talk the sadness right out through his mouth. Sometimes a killin’ man can talk the murder right out of his mouth an’ not do no murder. You done right. Don’t you kill nobody if you can help it.” STDP Workshop - Leigh McCullough Ph.D.
Triangle of PersonDavid Malan • Identify the Adaptive and Maladaptive Relationships at each pole • Exposure to care & concern (or lack thereof) from each person; • CHANGING PERSPECTIVES ON THE SELF CURRENT PERSONS(Spouse, boss, friends, etc.) THERAPIST ORIGIN VERSUS MAINTENANCE OF DESTRUCTIVE DEFENSES PAST PERSONS (Family of Origin, Lost Loves, Teachers, Friends ) STDP Workshop - Leigh McCullough Ph.D.
Interventions to Restructure the Sense of Self • Insight: Identify the self attacking defenses • Motivation to change the self attack Origin versus Maintenance of Defenses (You didn’t cause the problem, but you have to resolve it.) • Exposure & DESENSITIZATION to compassion/care by: Changing Perspectives - THERAPIST (How do I feel about you?/Shared feeling.) - others (What do they feel for you?) - self (How do you feel about yourself?) • Expression of Compassion: The ability to treat self with compassion and care outside the session STDP Workshop - Leigh McCullough Ph.D.
Theory in Restructuring the Self • Retranscribing the Memory Trace Changing patients’ world view about the self …or ”Self View” • Building new neuronal networks STDP Workshop - Leigh McCullough Ph.D.
Caveats There are inevitable problems that arise when you work with positive feelings. What might those be? STDP Workshop - Leigh McCullough Ph.D.
Problems (More frequently occurring as GAF becomes lower, especially. under 50) • Sexual feelings that arise with closeness • (Need exposure and desensitization when conflicted, but take care not to let sexual feelings act as defenses to closeness with the therapist. • Fear of boundaries being violated • (There are clear boundaries here, remember that we imagine murderous feelings, but no one actually is murdered.) • Over-idealizing the therapist • (Sometimes a necessary phase with more regressed patients, but eventually the therapist must been seen as fully human.) • Never wanting to leave therapy (We need to set you free…Can you take me with you?…Can you take these feelings with you? Generalize to caring feelings of others.) …..OTHER EXAMPLES? STDP Workshop - Leigh McCullough Ph.D.
More Expressive treatment SELECTING TREATMENT FOR PATIENTSBASED ON LEVEL OF FUNCTIONING GAF 100 Short termRestructuringof Feelings Short Term Restructuringof Defenses 75 Build defensesCognitive RxSupportive RxRestructuringself/others 50 Build supports, Inpatient Care 25 More Supportive treatment 0 STDP Workshop - Leigh McCullough Ph.D.
Some Old Things & Some New Things COMPASSION follows the same principles as other affects, (e.g.,desensitization) but has some different mechanisms. • There seem to be no “breakthroughs” to compassion as with grief or anger. One builds, or develops this capacity incrementally. • There can be no full sense of compassion without comparable acceptance of grief and rage. STDP Workshop - Leigh McCullough Ph.D.
Global Functioning, Affective Competence, and underlying Ego Strength Patient Adm GAF 1st Grief 1st Anger GAF SESSION SESSION Lesser Twin 60 1 2 TBA Caged Man 55 ~ 2 TBA Spiritual Chemist 52 3 ~ (FU) 89 Grandmother 50 10 30~ 75 Tortured Student 48 20 2 75 Lady Cloaked in Fog 42 50 54 85+ STDP Workshop - Leigh McCullough Ph.D.
Are There Stages in Achieving Compassion? • Denial and Anger • Bargaining • Acceptance STDP Workshop - Leigh McCullough Ph.D.
The Spiritual Chemist 37 year old divorced female; fired from job as a lab technician, estranged from son • Came to Rx for help during divorce • Initial GAF: 65 Current GAF: 89 (7 year follow-up) • Sense of Self: “An amino acid with legs” • Session 3: Exposure to closeness with and acceptance from me. STDP Workshop - Leigh McCullough Ph.D.
The Superior Unchanging Grandmother 68 year old married female; 45 years of therapy, and almost as long on anti-depressants. • Admission GAF: 55 Current GAF: 75 (2yr F-U) • Sense of Self: “There’s something horrible about me.” • Sessions 1, 5, 10 and 12 • Off anti-depressants by Session 11 STDP Workshop - Leigh McCullough Ph.D.
IT TAKES COURAGE TO BE KIND IT TAKES COURAGE TO BE … COMPASSIONATE … SOFTHEARTED STDP Workshop - Leigh McCullough Ph.D.
When time is limited: • Point out self-attacking defenses • Build compassion for self • Find loves that have been lost (people who found them special): ’Whose eyes lit up when they saw you?’’ • Explore positive feelings in the therapist-patient relationship • Use Socratic dialogue; What do you think I... • Feel for you? • Want for you? • Hope for you? STDP Workshop - Leigh McCullough Ph.D.
Three Treatment Objectives Defense Restructuring Affect Restructuring Self/Other Restructuring Defense Recognition (Can the patient see the self attack?) Giving Up Defenses (Is the patient motivated to give up self attack?) Affect Experiencing (Degree of felt care or compassion for self) Affect Expression (Can the patient treat self compassionately?) Sense of Self (Positive and compassionate?) Sense of Others (Realistic, adaptive?) FOCUS: RELATIONSHIP & ANXIETY FOCUS: DEFENSES & ANXIETY FOCUS: FEELINGS & ANXIETY STDP Workshop - Leigh McCullough Ph.D.