AEDP West Sunday Seminar
with AEDP Faculty Member STEVE SHAPIRO, Ph.D.
March 27, 2011 | San Anselmo, CA
TRANSFORMING RESISTANCE: Working with Personality Disorders, Substance Abusers, Adolescents and Other Populations Typically Considered Poorly Motivated or Challenging

REVIEW by Glenn Francis

Until I attended Steve's splendid presentation I was ignorant of how much resistance I had to resistance. That is, going in I experienced a vague unexamined disquiet about this topic – and about these more difficult populations. But my resistance, my uncomfortable wriggling away from this examination got in the way of quietly dissolving it. That dissolution – or perhaps some of the illumination preceding it – happened during this afternoon with Steve.

Sharing his enthusiasm for working with resistance, Steve said "Resistance is defenses that are manifest in the therapy relationship." When it feels difficult to make a connection in the therapy relationship, when it feels like we're lecturing our clients, when we feel conflict emerging, when we are missing the big picture – all of us work with resistance. I wish I could share with you the cartoons Steve showed us that made us all ruefully laugh at the variety of situations where we're working with resistance and find ourselves in some kind of a standoff. We know this is not rapport (which he defined, after Malan as the degree of emotional contact between the patient and therapist.) And despite knowing it’s not rapport, we just can’t quite get to where we know we can be with them.

Just as Steve was getting into his stride, preparing us to watch a video of an impulsive, drug and alcohol-using, self-harming recently-hospitalized young man who a month before had made a suicide attempt – letting us know this was the least resistant of the patients he was going to show us – the power went out.

Steve proceeded to model emotional regulation and restraint. Come to think of it, how he was with the power outage exemplified how he was on screen (later . . .) with his patients: reflective, real, genuinely joining – and ready for things to be different. So once it had been established that there was no power to our entire locality he set off into a non-electrical PowerPoint presentation the old-fashioned way, using printed pages and a personally-projected voice.

He made good use of what I'm going to call here his ‘pointing board’, a swathe of panels pinned up in the front of the room with some of the basic elements of AEDP in short diagrammatic and written form (would love to include a picture, but cannot.)

This is a really effective device for didactic and video illustration purposes. Later he accompanied session video by indicating with his laser pointer the crucial principle or place in the process just then appearing on the video screen. The pointing board and his use of it was helpful and a definite improvement over having to stop the video and speak. However, writing this I sometimes have to wordily describe something that Steve referred to with a flick of his laser pointer: a shift from red to green signal affect, or indicating a positive transition from affective experience unfolding into meta-processed narrative. I sometimes found myself wishing I could use that laser pointer to move my clients themselves with the same ease . . .

What Steve shared with the power out was very useful. A smattering:
  • What is the therapist doing inside themselves? Slowing down, deepening, not being sure where the work is going – and then being as surprised as the patient when something emerges.

  • Can we support a patient to go with the uncomfortable and unfamiliar moment of a glimmer of self–at–best, instead of the familiar, comfortable, defensive self–at–worst position?

  • Why do we ask people how they feel? In addition to seeing how patients experience feelings, we also want to observe how they don't feel – how they block and inhibit, how they don't feel things – and to reframe that, not as something negative but as something we want to see, something we want to join with. This avoids repeatedly asking them how they feel – and they can't tell us.

  •  "Getting there faster by going slower" in the work with the patient.

  • Moment to moment tracking is going where they are and what we do is going to be determined by them: with one person a lot of defense restructuring, with another very little, for example. We have much less control than we think. . .

  • When we think about defense work we tend to think adversarially – but we can use our tracking skills, moving flexibly, "what's that like for you?"; "What's this feel like?"; "How is this uncomfortable?" This also avoids the subtle criticism of the patient that they're not doing it the way we want them to, with adversarial consequences.

Writing this I'm struck again by the quality Steve shared with us, which I think of as akin to aikido, although it also has an alchemical or energy-transformative quality for me. Quietly, without fanfare or any particularly technical moves we found ourselves encouraged to enter into a deepening alignment with the person. This included a curiosity about the moment-by-moment nature of their process, even an alignment (mixed-with-curiosity) with their resistance in which the resistance imperceptibly but rapidly melted. It was as if my resistance to resistance began to dissolve through the afternoon and I barely noticed it going – but the difference in me between the beginning of the afternoon and the end was palpable and remarkable. Some more smatterings:

  • A useful metric: someone of lower resistance invites us to slow down, follow, deepen and be less structured. Perhaps more right brain. A person with higher resistance particularly invites a curious exploration of the barriers to affect, with the therapist leading that. And more structure – left brain. (People who are well-defended really appreciate the provision of active, focused structure-provision – "because otherwise they are just going to do what they do and we're going to be colluding with that some extent.")

  • What do we do when defenses don't "just melt"? Steve shared his background in STDP (Short-Term Dynamic Psychotherapy), sharing an insider comment that this is more an ‘anxiety-provoking’ approach by contrast with AEDP, which he termed an ‘anxiety regulating’ approach. Steve said, by the way that Diana says he does AEDP using STDP informed defense work.

  • We can expect a certain mixture of transformance and resistance. Resistance is "the blood of the work," and a surgeon cutting open a body and exclaiming "Yikes! Blood!!" would be akin to a therapist…. resisting the presence of resistance.

  • Fear of the other and shame about self in childhood development: How these get bundled together so that patients may find an apparently simple experience – being mistreated by somebody, for example – very difficult to simply become angry about. Because the bundle has anger, and shame, and fear all mixed together in it – then the person feels alone with it. Clinically, we'll see a red signal affect.

  • If you can process your feelings interpersonally in development you don't have to develop intrapsychic defense mechanisms. Put another way, limitations in a caregiver’s own affect regulation prompts the development of compensatory defense mechanisms; the dyadic affective regulation system (and its lapses and voids) gets internalized as the child's own intrapsychic affect regulation system.

  • Optimal dyads, whether parental or therapeutic "motivate repair while maintaining connection." Within such a dyad disruptive experiences and intense affect can be metabolized.

  • In pathogenic dyads disruption leads to disconnection, withdrawal, and aloneness. There's failure to metabolize disruptive experiences and intense affect.

  • Steve spoke about working in a hospital emergency room early in his career and at 3 AM dealing with somebody on PCP screaming and threatening, certainly "resistant" and not interested in receiving help.  He said he learned more from the security guards than from his psychologist supervisor, because they were actively endeavoring to regulate these under-regulated patients – and help the patient regulate themselves.

  • Being in the "optimal range of affect tolerance": constantly monitoring so the patient isn't beyond what they can tolerate – and on the lower side, we are not just having a nice conversation. Dissociation, flooding, acting out, stomach pains, these are from the range beyond optimal. And, just because someone's getting upset doesn't mean they're outside the range of affect tolerance – we may be tapping into something there. The experience of anxiety can often be understood as a signal that important internal experiences (often previously prohibited) are being activated. In this sense, the presence of anxiety could be considered a helpful cue and not necessarily a negative one.

  • Steve reminded us (Fosha, 2000, p.2): "Patients and psychic phenomena prove quite robust; for the well-trained clinician, the danger of ineffectiveness and avoided action looms much larger than the danger of damage from direct intervention."

  •  Defensive exclusion excludes core affective experiences, somatic resources, action tendencies, somatic memories – all are excluded by the action of defenses. Defensive exclusion creates disconnection from self and others. Empathically join with the defenses and aloneness dissolves.

  • Syntonic and dystonic defenses: a big difference between a patient who comes in and says "I need help with doing this (problematic behavior) less" – a dystonic defense; and someone who wonders, for example how they can be more aggressive so they won't be taken advantage of – a syntonic defense. With this kind of identified-with-defense, addressing their defense is like addressing them. Steve suggested in this latter case of an  ego-syntonic defense we are going to want to separate them from their defense and address the defense not the person:

    "Then you can work with some of the most difficult people because the idea is to get the defense out over there where we both can look at it and address it, it's not me confronting you. Let's both of us look at both sides – the side of you that wants to stop drinking and using drugs, and the side of you that doesn't want to stop."

This is a whole lot more workable than the therapist saying ‘you should stop using drugs’ and the patient saying ‘there's nothing wrong with me using drugs’. Then struggle ensues and the therapist-patient pair becomes "polarized."

I found this syntonic/dystonic nuancing one of the most aikido-like aspects of Steve's presentation – mysterious initially but very illuminating and helpful by the end of the afternoon. It represents a technical aspect of alignment with the person not all that easy to become conscious of, in my experience. "That's why it's so important to have a sense of where we are in respect of these clinical maps," remarked Steve. Smatterings, continued:

  •  When someone doesn’t consider their experience different from acting out: "Did you let your wife know you were angry at her?"; "Oh yes, she knows, I was throwing dishes at her last night." Really not distinguishing the feeling and healthy expression of it from the acting out defense. In this situation, introduce some left brain, over and over, help them see these patterns. "Every time we talk about this you start to get those stomach pains again – let's really look and see what's happening." Helping them step back and develop more of an observing ego.

  • Regulating a dysregulated person by using sensations in an SE (Somatic Experiencing) way rather than cognitions or emotions – or the personal. A much more neutral approach, focusing simply on physical sensations without labels (anger, sadness, etc), emotional meaning or associated thoughts, often leading to discovery.

  • Defenses are both adaptive, useful, and protective – and simultaneously maladaptive, harmful, and destructive: "I love you just the way you are, but too much for me to want you to stay that way." Yes, there was a historical need but is that really necessary now?

  •  Defenses are automatic and unconscious – the situation would be very different if we were dealing with ordinarily volitional action and expression – but we are not.

  • Defenses aren't necessarily negative: "The truth will set you free, but first it will make you miserable." The "good friend" of necessary pain – which the defenses protect us against. And because of that, defense restructuring isn't necessarily an adversarial process – the same empathy, the same curiosity, the same validation that you give to all other work with the person. If we can think of work with the defenses as very similar to all the other work we can do it really takes a lot of the stigma away.

  •  If we can reframe defenses as a coping strategy, as protection, and as safety – and as the role the person probably took historically: if you were criticized, you learned to criticize yourself.

  • Corrective emotional experience in therapy offers the patient repeated demonstrations that affective experiences previously defensively excluded can even eventually become part of a healthy, more integrated relationship, one that includes creating coherent narratives.

  • Defense restructuring involves recognizing links to the presenting problem, exploration of the defense itself (not the patient…), exploration of patterns/costs/historical needs/current usefulness in life and in the therapy relationship - and the emergence of a different experience, along with the transformational affects (such as relief) that come with it.

  • More on the balancing-mixture of resistance and transformance: "Part of me wants to and part of me doesn't." People get polarized, with friends, in couples, in therapy. So useful in conflict resolution, said Steve for both people to look at both sides: to avoid the temptation as therapist, when Mr. Jones says he wants to stop drinking, to jump on the bandwagon of that, to stay connected with the reality that when there is a part of him that wants to stop drinking, there is another part that doesn't. To help Mr. Jones look at both sides, as opposed to becoming polarized or taking reciprocal roles.

Working with a very defended client today, I was struck by how much my sense of aloneness stemming from my incapacity to deal with her defenses had been diminished by Steve’s presentation. I found myself actively in dialogue with her defenses, and I was aware – because of Steve's presentation – that I wasn't blindly blundering through, resisting my resistance to her resistance. There was more curiosity, more open interest – "How does that feel? What is that like for you?"

  • Assessing defenses: giving someone what they need: doing different things with different people.

  • Recognizing defenses, with the possibility of having better, restructured defenses >> Understanding the function of defenses >> Seeing and feeling the cost of defenses – possibility of defense relinquishing – helping them start to see the function of defense >> Aligning with therapist against defense (or, a very different case, seeing being against their defense as being against them) >> Insight into the origins of defenses >> Processing affective experience, tolerating anxiety >> Formulating a compassionate and coherent narrative understanding.

  • Looking with them at what gets in the way of core affective phenomena, not core affective phenomena themselves. It's still affect – it's just inhibitory affect. Patients get very confused when therapist says "that's not really feeling" when a defense comes up when what we really mean is that it's not really a healthy adaptive, expressive feeling. This is why true moment to moment tracking is so important, because then there's the possibility of exploring with them what really happens.

  • The thing is not to argue with them about it and try to convince them – which we often do (I hear two very different tones in which to ask the question "How is that working for you?" – oppositional, or curious). Can you help them see that what they do links back to the presenting problem? Can they see the costs of that and the function of that? Can you validate that in an empathic way – "Wow, I can really see how that would be a very effective way of not feeling these feelings towards your mother…" And, asked with true curiosity "What's the cost of doing that – of blaming yourself, and so forth – to you?" And, "What's the function of that for you?" Cultivating observing ego.

During the break the PG&E deities smiled on us and power supply resumed. Steve went on to show us inspiring videos of work with people who used to make me blench when they walked into my office. Suicidal, overwhelmed by immobilizing or mobilizing defenses, intensely anxious or depressed, tired beyond depletion, these patients met Steve's practical, realistic, no-fanfare-but-real-anyway empathy, and began to change in front of our eyes. In twenty minutes, one hospitalized woman went from remarking "Yeah, I'll kick your ass," to saying to Steve "Is it okay to love you?" Another immobilized patient said things to her father – in the form of Steve – that catapulted her from overwhelming exhaustion to crackling energy. "This exhaustion is the shell under which I am hiding," she said, and Steve complimented her work and she said ‘thank you’, so presently, so softly.

We were due to end at 5, and wound up disbanding closer to 6, aware of our fascination with the simple-yet-subtle, obvious-yet-hidden work we all saw on the screen. A number of attendees I have spoken to since remarked on how Steve’s presentation catalyzed their work with people. As one outstanding clinician after another presents their work at AEDP West, we are all graced, and multiply that grace many-fold in the form of our work with clients. ‘Grace’ comes from the Sanskrit root-word grnati: "Sings, praises, announces": ‘Gratitude’ comes from the same root. I feel grateful for the graceful work Steve shared with us.

STEVE SHAPIRO, PhD, a licensed psychologist, has been practicing various forms of Experiential Dynamic Therapy (EDT) since the mid-1990’s and has been studying AEDP with Dr. Fosha since 2003. Dr. Shapiro provides AEDP training seminars, group supervision and individual supervision. He has lectured on AEDP and given workshops to the mental health community through various agencies and organizations. He is the former Director of Psychology and Education at Montgomery County Emergency Service (MCES), an emergency psychiatric hospital, where he worked primarily with severe personality disorders and those involuntarily committed to treatment.

Dr. Shapiro also presents seminars and workshops on his other areas of specialization, which include: adolescents and their families, parenting, communication, personality disorders, involuntary treatment (adolescents and others), psychiatric emergencies and crisis intervention. He has held adjunct professor positions at Drexel/Hahnemann University and the University of the Sciences. Dr. Shapiro maintains a full-time private practice in suburban Philadelphia.