Introduction to Davanloo’s Intensive Short-Term Dynamic Psychotherapy With Highly Resistant Patients
Directors: Date: Time: Tim e: Location:: Location
Alan Beeber Beeber,, M.D. Gary Gala, M.D. Monday,, May 5, 2014 Monday 8 AM - 12 noon New York Hilton Midtown Bryant Suite
Seminar 9 American Psychiatric Association
New York, NY, May 3 - 7, 2014
167th Annual Meeting
Seminar 9 Educational Objectives: At the conclusion of this of this session, the participant should be able to: 1) Identify the psychodynamic forces underlying human psychopathology in a broad range of patients; 2) Identify and diagnose the manifestations of Major of Major Resistance in the psychotherapeutic process; 3) Identify and describe the main elements of Davanloo's technique; and 4) Acquire an understanding of the of the crucial elements of
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Seminar 9
COURSE FACULTY
Director:
Alan Beeber, M.D.
Faculty:
Gary Gala, M.D.
Agend Agen da Te materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time o print. Any changes to the material that were were made afer the review deadline are the responsibility o the course/seminar directo director(s). r(s).
Introduction to Davanloo’s Intensive Short ‐Term Dynamic Psychotherapy in Highly Resistant Patients Schedule of Presentations 1:00 1:10 1:30 2:30
Introduction and Announcements Overview, and History Davanloo’s Metapsychology Break
10 min. Dr. Beeber 20 min. Dr. Gala 1 hr. Dr. Beeber
2:45
Audiovisual presentation I
45 min. Dr. Beeber
This presentation will focus on the early phase of an initial interview with a highly resistant patient with mixed symptom disturbance and syntonic character pathology. The emphasis will be on the psychodiagnostic process. The technique of application of the phases of inquiry, pressure and crystallization of the character defenses in the dimension of the transference will be demonstrated. Time will be divided as follows: 10 min. introduction of the case and central concepts 25 min. video vignette 10 min. discussion by Dr. Gala and questions from participants 3:30
Audiovisual presentation II 1 hr. Dr. Beeber This presentation will focus on the later phases of the initial interview with the same patient. The emphasis will be on the technique of mobilization of the transference component of the resistance, “head on collision with the resistance” and removal of the major resistance. Mobilization of the direct experience of the transference feeling will be demonstrated which leads to direct access to the unconscious pychopathological nuclear structure.
Time will be divided as follows: 10 min. introduction of the case and central concepts 30 min. video vignette 20 min. discussion by Dr. Gala and questions from participants 4:30 4:55
Group discussion by Faculty and Participants Feedback and Adjourn
25 min.
Outline Te materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time o print. Any changes to the material that were made afer the review deadline are the responsibility o the course/seminar director(s).
Introduction to Davanloo’s Intensive Short ‐Term Dynamic Psychotherapy in Highly Resistant Patients Outline of presentations
Introduction and Announcements
Dr. Beeber
Overview, and History Dr. Gala History of the development of short‐term dynamic psychotherapies Development of Davanloo’s technique based on clinical research Development of Davanloo’s metapsychology, the problem of resistance Davanloo’s Metapsychology Dr. Beeber Spectrum of psychopathology treatable with Davanloo’s Intensive Short‐Term Dynamic Psychotherapy (DISTDP) Psychopathological dynamic forces. The role of Fusion. Central Dynamic Sequence Adverse phenomena avoided by DISTDP Contraindications to DISTDP
Audiovisual presentation I
Dr. Beeber
Video vignettes of the early phase of an initial interview with a highly resistant patient with mixed symptom disturbance and syntonic character pathology. Focus will be on the psychodiagnostic process. Technique of application of the Central Dynamic Sequence, phases of Inquiry and Pressure will be demonstrated. Rapidly identification of the discharge pattern of unconscious anxiety and the patient’s capacity to tolerate anxiety. Nature of the defensive structure including tactical and characterological defenses will be illustrated. Pathway to direct access to the Unconscious will be elucidated. Further application of the phase of Pressure to crystallize the patient’s characterological defenses in the dimension of the Transference. Preparation for turning the patient against his destructive defenses (making syntonic defenses dystonic).
Audiovisual presentation II Dr. Beeber Video vignettes of the later phases of the initial interview with the same patient. Technique of mobilization of the Complex Transference Feeling (CTF), the Transference Component of the Resistance (TCR), “Head on Collision with the destructiveness of the resistance” and removal of the Major Resistance. Mobilization of the direct experience of the CTF, which leads to dominance of the Unconscious Therapeutic Alliance over the forces of the Major Resistance Mobilization of the Neurobiological Pathways (NBP) of Murderous Rage, the NBP of Guilt‐laden and Grief‐laden unconscious feeling. Direct access to the unconscious with the first view of the unconscious pychopathological nuclear structure. Recap and Consolidation.
Group discussion by Faculty and Participants
Slides Te materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time o print. Any changes to the material that were made afer the review deadline are the responsibility o the course/seminar director(s).
INTRODUCTION TO DAVANLOO S INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY WITH HIGHLY RESISTANT PATIENTS ’
Course Director: Alan R. Beeber, MD. Professor Emeritus of Psychiatry Faculty:
Gary J. Gala, MD. Associate Professor of Psychiatry UNC School of Medicine Chapel Hill, NC
Disclosure: Disclos ure: Alan Beeber Beeber,, MD • No significant financial or affiliation interest with
goods/organizations regulated by Food and Drug Administration that may have have a direct or indirect indirect interest in the subject matter of this program.
Disclosure: Gary Gala, MD • No significant financial or affiliation interest with
goods/organizations regulated by Food and Drug Administration that may have have a direct or indirect indirect interest in the subject matter of this program.
Ac A cknowledgments
• Habib Davanloo, MD • Professor Emeritus, McGill University
DAVANLOO S INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY : OVERVIEW AND HISTORY ’
Gary J. Gala, MD. Associate Professor of Psychiatry Associate Chair for Education UNC School of Medicine Chapel Hill, NC
Disclosure: Gary Gala, MD • No significant financial or affiliation interest with
goods/organizations regulated by Food and Drug Administration that may have a direct or indirect interest in the subject matter of this program.
Overview • History of the development of short-term dynamic
psychotherapies • Development of Davanloo’s technique based on clinical
research • Development of Davanloo’s Metapsychology, the problem
of Resistance
History of STDP: Contributions of Habib Davanloo • Psychoanalytic background • Influenced by Zetzel, Deutsch, Alexander • Disillusioned with the increasing length of analysis • Disillusioned with intractable Transference Neurosis/analysis
interminable
• Developed Short –Term Dynamic Psychotherapy • Initial focus on highly responsive patients • Emphasis in early work was on interpretation of T-C-P link
• Expanded the spectrum of patients who could be treated
with Intensive STDP
Davanloo, H. , (2001) Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, M.D.
The Problem of Resistance • Resistance was central to Freud’s theory of
Psychoanalysis and of the Unconscious • Secondary and primary gains from neurotic disturbances
derived from resisting giving up the neurotic illness
The Problem of Resistance II • "It may thus be said that the theory of psycho-analysis is
an attempt to account for two observed facts that strike one conspicuously and unexpectedly whenever an attempt is made to trace the symptoms of a neurotic back to their source in his past life: the facts of transference and resistance. Any line of investigation, no matter what its direction, which recognizes these two facts and takes them as the starting-point of its work may call itself psychoanalysis, though it arrives at results other than my own” •
Freud, S. (1959). "Inhibitions, symptoms, and anxiety". In J. Strachey (Ed. & Trans.) The standard edition of the complete psychological works of Sigmund Freud (Vol. 20, pp. 75–175). London: Hogarth Press. (Original work published in 1926.)
Resistance of Repression Freud wrote optimistically in 1914,
…the doctor uncovers the resistances which are unknown to the patient; when these have been got the better of, the patient often relates the forgotten situations and connections without any difficulty. “
”
Freud S. Remembering, Repeating and Working-through. In: Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 12. London: Hogarth Press; 1996:145–156.
Resistance of the Superego I
In 1926 Freud wrote pessimistically,
The unconscious sense of guilt represents the superego's resistance. It is the most powerful factor, and the one most dreaded by us. “
‘
’
”
Freud S. The Question of Lay Analysis. In: Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 20. London: Hogarth Press; 1996:177–250.
Resistance of the Superego II In Analysis Terminable and Interminable, 1937 Freud wrote much more pessimistically,
For the moment we must bow to the superiority of the forces against which we see our effort come to nothing “
”
Freud S: Analysis Terminable and Interminable. In: Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 23. London: Hogarth Press; 1996:209–254.
Davanloo’s contributions: • Developed technique of Mobilization of the Unconscious • Developed technique of Total Removal of the Resistance • Developed the techniques of ISTDP and Block Therapy,
as well as a method of psychoanalytic investigation and Multidimensional Unconscious Structural Change
Davanloo, H. , (2001) Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, M.D.
DAVANLOO’S METAPSYCHOLOGY
Alan R. Beeber, MD. Professor Emeritus of Psychiatry UNC School of Medicine Chapel Hill, NC
Davanloo’s contribution III: • Developed technique of Mobilization of the Unconscious • Rapid mobilization of tactical and characterological defenses • Rapid activation of transference feeling • Crystallization of the Resistance in the Transference • De- fusion of primitive murderous rage, sexualized feeling and guilt • Direct access to the psychopathological dynamic forces (Davanloo,
1988)
Davanloo, H. , (2001) Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, M.D.
Mobilization of the Unconscious • Depends heavily on the development of the Twin
Factors of: • Transference Component of the Resistance • Complex Transference Feelings
Davanloo, H. (2010). Annual Audiovisual Immersion Course: the technique of the Removal of Resistance. Montreal, Que. , October 2010.
Mobilization of the Unconscious • Affective responses predominate over Cognitive
responses • Unconscious Therapeutic Alliance predominates over
the forces of the Resistance
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Mobilization of the Unconscious • Major mobilization of the Transference Component of
the Resistance • Major mobilization of the Neurobiological Pathway of
Primitive Murderous Rage in the Transference • Major mobilization of the Neurobiological Pathway of
Guilt
Davanloo, H. (2010). Annual Audiovisual Immersion Course: the technique of the Removal of Resistance. Montreal, Que. , October 2010.
Mobilization of the Unconscious • Creates fluidity in the Unconscious • Provides a vivid portrait of the Pathogenic
Organization of the Unconscious • Brings about intrapsychic reorganization of the
defensive system; and increases capacity to tolerate anxiety and painful affects.
Davanloo, H. (2010). Annual Audiovisual Immersion Course: the technique of the Removal of Resistance. Montreal, Que. , October 2010.
Spectrum of Psychopathology
Highly responsive; single focus; low resistance
High resistance; complex symptom and character pathology
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Low Resistance
• Highly Responsive • Circumscribed Problem • Single Psychotherapeutic Focus
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Moderate Resistance
• Diffuse Psychoneurotic Disturbances • Presence of Character Pathology • Multi-foci Core Neurotic Structure
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
High Resistance
• Character Neurosis • Diffuse Symptoms and Character Disturbances • Highly complicated Core Pathology
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Extreme Resistance
• Diffuse Symptoms and Major Character Disturbances • Extremely Complex Core Pathology
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Psychopathologic Dynamic Forces 1
Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 2
Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 3
Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 4
Sexual Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 5
Guilt Sexual Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 6
Grief Guilt Sexual Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 7 Character Resistance Grief Guilt Sexual Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Psychopathologic Dynamic Forces 8 Resistance Against Emotional Closeness Character Resistance Grief Guilt Sexual Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Triangle of Persons Transference
Current
Past
Triangle of Conflict Defense
Anxiety
Impulse/Feeling
Unconscious Discharge Patterns of Anxiety
• Striated muscle tension • Smooth muscle e.g. irritable bowel or migraine
headaches • Cognitive and Perceptual system e.g. drifting of
thoughts or hallucinations
Benefit
Anxiety
Physiological Concomitants of Feelings • Rage • Fireball in abdomen, moves upward to chest, arms, hands; jaw,
biting.
• Guilt • Deeply painful, high amplitude waves, chest, upper
bronchi/pharynx, gasping, +/- nausea
• Grief • Lower amplitude, lower in chest, sobbing
Mobilization of the Unconscious • Major mobilization of the Transference Component of
the Resistance • Major mobilization of the Neurobiological Pathway of
Primitive Murderous Rage in the Transference • Major mobilization of the Neurobiological Pathway of
Guilt
Davanloo, H. (2010). Annual Audiovisual Immersion Course: the technique of the Removal of Resistance. Montreal, Que. , October 2010.
Resistance and the Unconscious Therapeutic Alliance R
R - Resistance UTA - Unconscious Therapeutic Alliance
UTA
Resistance, Transference and Unconscious Therapeutic Alliance Resistance y t i s n e t n I
Complex Transference Feelings Unconscious Therapeutic Alliance
Time H. Davanloo unpublished used with H. Davanloo unpublished used with permission permission
Spectrum of Psychopathology
Highly responsive; single focus; low resistance
High resistance; complex symptom and character pathology
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Spectrum of Capacity to Tolerate Anxiety
CAPACITY: high
moderate
low
DISCHARGE PATHWAY :
striated muscle tension
autonomic
cognitive and perceptual
Adapted fromDavanloo, H. (1995). Intensive Short-Term D Journal of Short-Term Psychotherapy, 121-155 ynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International
10(3,4),
Spectrum of Psychopathology II
PROBLEMS:
focal
diffuse symptoms
RESISTANCE:
low
mild
moderate
high
syntonic
diffuse and primitive
CHARACTER PATHOLOGY: absent or mild
dystonic
Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Spectrum of Psychopathology III
TRAUMA:
mild
moderate
severe
very serve - early and/or repetitive
RAGE:
absent
murderous
absent or mild
moderate
primitive murderous
primitive torturous mr
GUILT: heavy
extremely heavy guilt laden unc. feeling
Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Fusion • Fusion of Guilt and Primitive Murderous Rage : • “ a pathogenic destructive dynamic system in the unconscious.” • A major task of the therapist is the rapid removal of this destructive
system
• Age at the time of Trauma: • The earlier and more intense the trauma: • The more tenacious the fusion and the more resistant the feelings are
to mobilization • The more intense and primitive the unconscious rage • The more complexity in and hence the longer the duration of therapy
Davanloo, H. (2010, 2011), 31 st and 32nd Annual A/V Immersion Courses on the Metapsychology of the Unconscious
Psychopathologic Dynamic Forces 8 Resistance Against Emotional Closeness Character Resistance Grief Guilt Sexual Primitive Murderous Rage Pain of Trauma to Bond Bond, Attachment Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal of Short-Term Psychotherapy, 10(3,4), 183-240
Fusion
Fusion of Murderous Rage, Sexual Feeling and Guilt
Trauma to Bond
H. Davanloo unpublished used with permission
Bond, Attachment
Central Dynamic Sequence (overview)
• Phase 1 Inquiry • Phase 2 Pressure • Phase 3 Challenge • Phase 4 Transference Resistance • Phase 5 Direct Access to the Unconscious
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient---Part I. Partial Unlocking of the Unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181
Central Dynamic Sequence (overview cont d) ’
• Phase 6 Systematic analysis of the
transference • Phase 7 Dynamic exploration of the unconscious • Phase 8 Consolidation/psychotherapeutic planning
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient---Part I. Partial Unlocking of the Unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181
Conscious Preconscious
Discharge Pathway of UCS Anxiety
Character Defenses Unconscious
Pathogenic Organization
Conscious
Discharge Pathway of UCS Anxiety
Preconscious
Character Defenses Unconscious
Pathogenic Organization ( fused rage/guilt)
Resistance and the Unconscious Therapeutic Alliance Partial Mobilization
UTA
R
R - Resistance UTA - Unconscious Therapeutic Alliance
Resistance and the Unconscious Therapeutic Alliance Major Mobilization UTA
R
R - Resistance UTA - Unconscious Therapeutic Alliance
AUDIOVISUAL PRESENTATION I THE DIAGNOSTIC PROCESS
Alan R. Beeber, MD. Professor Emeritus of Psychiatry UNC School of Medicine Chapel Hill, NC
Central Dynamic Sequence
• Phase 1 Inquiry. • Phase 2 Pressure
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient---Part I. Partial Unlocking of the Unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181
Central Dynamic Sequence 1 Phase 1, Inquiry: • Exploring the patient s difficulties: initial ability to ’
respond. • Psychodiagnostic in function
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 2 Phase 2, Pressure: • The aim of the pressure phase is to mobilize
resistance until resistance is tangibly crystallized between the therapist and the patient.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Resistance, Transference and Unconscious Therapeutic Alliance Resistance y t i s n e t n I
Complex Transference Feelings Unconscious Therapeutic Alliance
Time H. Davanloo unpublished used with H. Davanloo unpublished used with permission permission
Conscious Preconscious
Discharge Pathway of UCS Anxiety
Character Defenses Unconscious
Pathogenic Organization
Conscious
Discharge Pathway of UCS Anxiety
Preconscious
Character Defenses Unconscious
Pathogenic Organization ( fused rage/guilt)
Case Presentation • 23 year old man referred for ISTDP by a resident • Past history of polysubstance abuse (amphetamines,
cocaine, hallucinogens) with mood symptoms and paranoid ideation. Abstinent for 11 mos. • Depression, paranoid ideation, generalized and social anxiety, remote history of panic attacks
Case Presentation II • Difficulties in IPR s. Few friends, anxiety in intimate ’
relationships, strained relationship with Grandfather Difficulties with anger. Temper tantrums, revenge fantasies. Treatment: Sertraline, quetiapine, atomoxitene. Referred for psychotherapy, then for ISTDP.
Case Presentation III • Past personal history • Born/raised in NC • One brother 6 yrs. His junior. • Father was closest friend. Suicided when patient 8 years old. “
”
Distinct memories of events. Mother looked like a corpse. “
”
• Strained relationship with Grandfather. • Graduated #2 in high school class, accepted to an Ivy but couldn t ’
go for financial reasons.
Video Vignette
Spectrum of Psychopathology
Highly responsive; single focus; low resistance
High resistance; complex symptom and character pathology
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term 10(3,4), (3,4), 121-155 Short-Term Psychotherapy, 10
Spectrum of Capacity to Tole olerate rate Anxi Anxiety ety
CAPACITY: high
moderate
low
DISCHARGE PATHWAY :
striated muscle tension
autonomic
cognitive and perceptual
Adapted fromDavanloo, H. (1995). Intensive Short-T Short-Term erm D Journal of of Short-Term Short-Term Psychothera Psychotherapy py,, 121-155 ynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. Internationa Internationall
10(3,4),
Spectrum of Psychopathology II
PROBLEMS:
focal
diffuse symptoms
RESISTANCE:: RESISTANCE
low
mild
moderate
high
syntonic
diffuse and primitive
CHARA CHA RACTER CTER PATHOLOGY ATHOLOGY:: absent or mild
dystonic
Adapted from: Davanloo, H. (1995). Intensive Short-Term Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal Journal of Short-Term Short-Term Psychotherapy Psychotherapy,, 10(3,4), 121-155
Spectrum of Psychopathology III
TRAUMA:
mild
moderate
severe
very serve - early and/or repetitive
RAGE:
absent
murderous
absent or mild
moderate
primitive murderous
primitive torturous mr
GUILT: heavy
extremely heavy guilt laden unc. feeling
Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
AUDIOVISUAL PRESENTATION II MOBILIZATION, REMOVAL OF RESISTANCE , DIRECT ACCESS TO UCS
Alan R. Beeber, MD. Professor Emeritus of Psychiatry UNC School of Medicine Chapel Hill, NC
Central Dynamic Sequence (overview)
• Phase 1 Inquiry • Phase 2 Pressure • Phase 3 Challenge • Phase 4 Transference Resistance • Phase 5 Direct Access to the Unconscious
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient---Part I. Partial Unlocking of the Unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181
Central Dynamic Sequence (overview cont d) ’
• Phase 6 Systematic analysis of the
transference • Phase 7 Dynamic exploration of the unconscious • Phase 8 Consolidation/psychotherapeutic planning
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient---Part I. Partial Unlocking of the Unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181
Central Dynamic Sequence 3 Phase 3, Challenge: • Resistance needs to be crystallized to the point at
which it can be systematically challenged meaningfully and effectively.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 4 Phase 4, Transference Resistance: • Intensification of the resistance and its transference
component, transference resistance • Mounting the challenge to the transference resistance
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 5 Phase 4, Transference Resistance (cont.): • Head-on collision with the transference resistance to
bring the patient face to face with the selfdestructiveness of his or her resistance
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 6 Phase 4, Transference Resistance (cont.): • Mobilization of the unconscious therapeutic alliance
against the resistance, which leads to the state of intrapsychic crisis, or tension between the resistance and unconscious therapeutic alliance
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Resistance, Transference and Unconscious Therapeutic Alliance Resistance y t i s n e t n I
Complex Transference Feelings Unconscious Thrapeutic Alliance
Time H. Davanloo unpublished used with permission
Central Dynamic Sequence 7 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • Mobilization of the neurobiological pathway of the
primitive murderous rage and its passage in the transference. This is immediately followed by
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 8 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • The emergence of sadness, a further affective
response indicating that the intense guilt feelings are mobilized but have not yet been experienced consciously.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 9 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • The patient attentively looks at the visual imagery of
the murdered damaged body of the therapist, and then
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 10 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • The visual imagery of the murdered body of the
therapist is transferred to the visual imagery of the murdered body of the biological figure of the early life orbit of the patient—mother, father, sibling, grandparent, and so on.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 11 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • It is important to note that, in this mental imagery, the
visual imagery of the murdered body of the therapist appears exactly as does the visual imagery of the murdered body of the mother, father, or sibling—in terms of the color of the hair, eyes, and so forth.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 12 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • This visual imagery is extremely intense—for example,
the patient sees the visual imagery of the dead body of the mother with blond hair and blue eyes, and the visual imagery of the dead body of the therapist is no longer present.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 13 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • The actual experience of intense guilt-laden
unconscious feeling, which is an intense affective response—a very painful experience that involves the neck and the upper part of the chest.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 14 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • The duration of the passage of the guilt averages 8 to
12 minutes in the first major unlocking. This is followed by • The emergence of intense positive feeling toward the people of the past and the actual experience of the grief-laden unconscious feeling
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 15 Phase 5, Direct Access to the Unconscious, Major Direct Access to the Unconscious: • Now, both the patient and the therapist have a first
direct view of the psychopathological dynamic forces responsible for the patient's symptom and character disturbances.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 16 Phase 6, Systematic Analysis of the Transference:
• This is extremely important, particularly in patients with
panic, somatization, functional, and depressive disorders.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 17 Phase 7, Dynamic exploration into the unconscious: • With the breakdown of the major resistance and major
mobilization of the unconscious therapeutic alliance, the unconscious introduces the pain of trauma and vivid incidences of traumatic events of the past, with repeated breakthrough of the guilt and painful feelings.
Davanloo, H: " Intensive Short-Term Dynamic Psychotherapy ", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Central Dynamic Sequence 18 Phase 7, Phase of Con onso soli lidati dation on:: • Extensive recapitulation and analysis of the whole
process • Exploring the patient's response and setting up
psychotherapeutic psychothera peutic planning
Davanloo, H: " Intensive Short-Term Short-Term Dynamic Psychotherapy Psych otherapy", in: Kaplan H., and Sadock B. (eds), Comprehensive Textbook Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628-2652, Lippincot Williams & Wilkins, Philadelphia, 2005
Video Vignette II
AU A UDIOVISUAL PRESENTATION III GRADED TECHNIQUE: PATIENT WITH LOW CAP CAPACIT ACITY Y TO TOLERATE TOLERATE ANXIETY ANXIETY
Alan R. Beeber, Beeber, MD. Professor Emeritus of Psychiatry UNC School of Medicine Chapel Hill, NC
Spectrum of Psychopathology
Highly responsive; single focus; low resistance
High resistance; complex symptom and character pathology
Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term 10(3,4), (3,4), 121-155 Short-Term Psychotherapy, 10
Spectrum of Capacity to Tolerate Anxiety
CAPACITY: high
moderate
low
DISCHARGE PATHWAY :
striated muscle tension
autonomic
cognitive and perceptual
Adapted fromDavanloo, H. (1995). Intensive Short-Term D Journal of Short-Term Psychotherapy, 121-155 ynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International
10(3,4),
Spectrum of Psychopathology II
PROBLEMS:
focal
diffuse symptoms
RESISTANCE:
low
mild
moderate
high
syntonic
diffuse and primitive
CHARACTER PATHOLOGY: absent or mild
dystonic
Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
Spectrum of Psychopathology III
TRAUMA:
mild
moderate
severe
very serve - early and/or repetitive
RAGE:
absent
murderous
absent or mild
moderate
primitive murderous
primitive torturous mr
GUILT: heavy
extremely heavy guilt laden unc. feeling
Adapted from: Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders. International Journal of Short-Term Psychotherapy, 10(3,4), 121-155
AUDIOVISUAL PRESENTATION IV PROCESS OF WORKING THROUGH
Alan R. Beeber, MD. Professor Emeritus of Psychiatry UNC School of Medicine Chapel Hill, NC
Psychopathologic Dynamic Forces 8 Resist esistance ance Agains Againstt Emotional Closeness Character Resis Resistance tance Grief Guilt Sexual Prim rimitiv itive e Murd Murde erou rous s Rage Pain of Trauma to Bon B ond d Bond,, Attachment Bond Davanloo, H. (1995). Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious-Part II. The Course of the Trial Therapy After Partial Unlocking. International Journal 10(3,4), (3,4), 183-240 of Short-T Short-Term erm Psychotherapy, 10
Fusion
Fusion of Murderous Murd erous Ra Rage, ge, Sexual Se xual Fe Feeling eling and Guilt
Trauma to Bond
H. Davanloo unpublished used with permission
Bond, Bon d, Att Attachment achment
Conscious
Discharge Pathway of UCS Anxiety
Preconscious
Character Defenses Unconscious
Pathogenic Organization ( fused rage/guilt)
Resistance, Transference and Unconscious Therapeutic Alliance Alliance Resistance y t i s n e t n I
Complex Transference Feelings Unconscious Therapeutic Alliance
Time H. Davanloo unpublished used with H. Davanloo unpublished used with permission permission
DAVANLOO S METAPSYCHOLOGY: PERSPECTIVES FROM A NON ISTDP THERAPIST ’
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Gary J. Gala, MD. Associate Professor of Psychiatry Associate Chair for Education UNC School of Medicine Chapel Hill, NC
Perspectives •
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Settings in which to apply ISTDP—other than outpatient: strategies and rationale Durability of the effect: What is the evidence? How far away is the unconscious anyway? ISTDP as a more direct approach. What do we mean when we talk about parts of the self? Is the perpetrator a homunculus?
Cochrane Review of STPP •
Abbas et al: Short term psychodynamic psychotherapies for common mental disorders: Cochrane Database:2006 Issue 4, Art. No. CD004687 ‐
Efficacy of STPP vs. minimal or non treatment
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23 studies/1431 pts. In RCT s ’
Measured general sx, anxiety, depression and social adjustment
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Cochrane Review of STPP II •
Results –
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Significantly greater improvement in treatment group vs. controls Maintained in medium/long term follow up Modest to moderate often sustained gains for a variety of patients Limited data and heterogeneity between studies. ‐
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Abbass AA, Hancock JT, Henderson J, Kisely SR. Short term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004687. DOI: 10.1002/14651858.CD004687.pub3. ‐
STDP Empirical Basis •
•
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Targets unconscious emotional processes >60 CT s. >40 RCT s ’
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Efficacious with anxiety, depression, personality disorder, and somatic symptom disorders. Gains are held in long term follow up ‐
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(Anderson and Lambert, 1995, Leischering 2004, Abbass, Kisely, Henderson and Hancock, Cochrane review, 2006) •
Equal other therapies for symptom reduction Superior to wait list and minimal treatments Superior to medication alone
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Evidence for persistent Cost Effectiveness (Abbass, 2002, 2003)
Systematic Review STDP for Symptom Disorders •
•
23 studies: 13 RCT, 10 Case Series Conditions: IBS, Chronic Pain, Urethral Syndrome, Chronic dyspepsia, Ulcer, Ischemic Heart Disease, COPD, Crohn s D., Rheumatoid D., Dermatitis, Functional Movement Disorders 91.3% had sig symptom reduction 91.6% had sig social occupational gains 76.2% had sig psychological improvement 77.8% had reduced Healthcare Utilization: less surgery in Crohn s and Ulcer disease. Less hospital days in Crohn s ’
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Systematic Review II Metaanalysis: •
• •
Sig effects for Somatic Symptoms, anxiety, depression in ST and LT Significantly fewer dropouts in STDP patients. Heterogeneity means interpret results with caution.
Short‐Term Psychodynamic Psychotherapy for Somatic DisordersAbbass A. Kisely S. Kroenke K. ∙
Psychother Psychosom 2009;78:265–274 (DOI: 10.1159/000228247)
∙
Overview of ISTDP Outcome Studies
•
N=7 RCT s N=109 patients, mostly with PD s All but 1 main measure statistically sig gains Robust effect sizes Superior to wait list/minimal contact controls Equal to other similar models Effects maintained in Mean 1.5 year follow up N= 1 CT N = 166, Robust effects versus wait list control N=9 Case Series N = 578 Robust effect sizes. Broadly effective in the real world Evidence of persistent cost effectiveness Mean 2.5 year follow up shows gains maintained ISTDP technique appears more powerful than older STDPs ’
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•
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•
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Davanloo s ISTDP Empirical Basis ’
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Efficacious with PD: Winston, 1991, 1994, Hellerstein, 1998, Abbass in press
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Better than Meds alone for panic: Wiborg, 1996 Effective with treatment resistant depression, (Abbass, 2006) functional movement disorders (Hinson, 2005), Headaches (Abbass, Lovas, Purdy in press Cephalalgia). Efficacious with pelvic pain, urethral syndrome (Baldoni 1995) and chronic back pain (Hawkins, 2003). 86% of psychiatric office referrals were candidates. Abbass 2002a Outcome proportional to degree of emotional experience. Abbass 2002a
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Clinically Effective and cost effective in real world Abbass 2002a Data show it is learnable Abbass, 2004 Single Session brings symptom reduction Abbass et al in press
Background Materials Te materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time o print. Any changes to the material that were made afer the review deadline are the responsibility o the course/seminar director(s).
References Te materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time o print. Any changes to the material that were made afer the review deadline are the responsibility o the course/seminar director(s).
Introduction to Davanloo’s Intensive Short ‐Term Dynamic Psychotherapy in Highly Resistant Patients References Beeber A: The Perpetrator of the Unconscious in Davanloo’s new metapsychology, Part I: Review of classic psychoanalytic concepts. Intl J Intensive Short‐Term Dyn Psychother 1999; 13(3): 151‐157. Beeber AR.: The Perpetrator of the Unconscious in Davanloo’s new metapsychology, Part II: Comparison of the Perpetrator to classic psychoanalytic concepts. . Intl J Intensive Short‐Term Dyn Psychother 1999; 13(3): 159‐176. Beeber A.: The Perpetrator of the Unconscious in Davanloo’s new metapsychology, Part III: Specifics of Davanloo’s Technique. . Intl J Intensive Short‐Term Dyn Psychother 1999; (3): 177‐189. Davanloo H: Basic Principles and Techniques in Short‐Term Dynamic Psychotherapy. New York: Spectrum, 1978 Davanloo H: Short‐Term Dynamic Psychotherapy. New York: Jason Aronson, 1980 Davanloo, H. Unlocking the Unconscious: Selected papers of Habib Davanloo, MD. Chichester, England. John Wiley and Sons, 1990
Davanloo H: Intensive Short‐Term Dynamic Psychotherapy: selected papers of Habib Davanloo, MD. Chichester, England. John Wiley and Sons, 2000 Davanloo H: Intensive Short‐Term Dynamic Psychotherapy: Extended Major Direct Access to the Unconscious. Euro Psychother 2001, 2(1): 25‐70.
Davanloo H: Intensive Short‐Term Dynamic Psychotherapy , in: Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, Edited by Kaplan H and Sadock B. Philadelphia, Lippincott Williams & Wilkins, 2005, pp2628‐2652.
Self-Assessment
Te materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time o print. Any changes to the material that were made afer the review deadline are the responsibility o the course/seminar director(s).
Introduction to Davanloo’s Intensive Short ‐Term Dynamic Psychotherapy in Highly Resistant Patients Self ‐ Assessment Questions
1.
2.
3.
4.
5.
6.
Which of the following disorders can be treated with Davanloo’s Intensive Short‐Term Dynamic Psychotherapy (DISTDP)? a. schizophrenic disorders b. antisocial personality disorder c. anxiety disorders with somatic symptoms d. ulcerative colitis e. advanced Alzheimer’s Dementia Which of the following represents a contraindication to DISTDP? a. highly resistant patients with functional disorders b. highly resistant depressed patients c. highly resistant manic patients d. highly resistant patients with life‐long characterologic difficulties e. patients suffering from somatization disorders Which of the following is a phase in the Central Dynamic Sequence? a. interpretation b. bypassing character resistance c. mirroring transference responses d. direct access to the unconscious e. avoidance of feelings The Central Dynamic Sequence is applied: a. in strict order b. randomly to keep the patient off guard c. with a Head on Collision at the beginning of the interview to boost the transference feeling d. with a Head on Collision at the end of the interview so that the patient leaves the interview with a heightened level of transference feeling e. in a fluid, spiral fashion determined by the patient’s responses A major aim of the phase of Pressure is to: a. tilt the character defenses in the dimension of the Transference b. mobilize and intensify erotic transference feelings c. lower the Complex Transference Feeling d. activate regressive defenses e. reassure the patient The phase of Pressure: a. mobilizes the tactical organization of resistance b. mobilizes character defenses c. allows the therapist to determine the discharge pattern of anxiety d. all of the above
7.
8.
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e. none of the above The phase of systematic Challenge should begin: a. before the phase of Pressure b. when resistance is clearly crystallized in the transference c. only after the unlocking of the unconscious d. during telephone contact prior to the initial interview to boost the transference feeling e. immediately following the phase of Inquiry A major aim of the Head on Collision is to: a. develop a transference neurosis b. promote compliance with the therapist c. challenge the patient’s sense of self d. mobilize the Unconscious Therapeutic Alliance against the Major Resistance e. create a state of tension between the therapist and the patient The Head on Collision: a. is the most powerful intervention in DISTDP b. is a total blockade of all the forces of the Major Resistance c. undoes defiance and compliance d. all of the above e. none of the above The Head on Collision: a. is used only with patients with low capacity to tolerate anxiety b. should be done piecemeal to allow the defenses to recover c. consists of 17 interventions which must all be applied d. all of the above e. none of the above A major component of the Head on Collision with the resistance is: a. emphasizing the destructive nature of the resistance b. challenge to the libido c. interpretation of the resistance d. interpretation f the transference e. pressure for compliance Head on Collision with Resistance Against Emotional Closeness (RAEC): a. reverberates with the early feelings of attachment, bond, love and trauma. b. mobilizes transference feeling c. can mobilize grief‐laden unconscious feeling d. all of the above e. none of the above
Introduction to Davanloo’s Intensive Short ‐Term Dynamic Psychotherapy in Highly Resistant Patients Self ‐ Assessment Answers 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
c. c. d. e. a. d. b. d. d. e. a. d.
