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Understanding Davanloos

Intensive Short-Term Dynamic


Psychotherapy
Understanding
Davanloos Intensive
Short-Term Dynamic
Psychotherapy

A Guide for Clinicians

Catherine Hickey
First published in 2017 by
Karnac Books Ltd
118 Finchley Road
London NW3 5HT

Copyright 2017 by Catherine Hickey

Copyright for Neuroimaging and Intensive Short-Term Dynamic Psychotherapy:


psychotherapy and the brain 2017 to Robert Tarzwell

The right of Catherine Hickey to be identified as the author of this work has
been asserted in accordance with 77 and 78 of the Copyright Design and
Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in


a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.

British Library Cataloguing in Publication Data

A C.I.P. for this book is available from the British Library

ISBN-13: 978-1-78220-401-5

Typeset by Medlar Publishing Solutions Pvt Ltd, India

Printed in Great Britain

www.karnacbooks.com
This book is dedicated to
David and Josephine Hickey and
the late Margaret Howell
Contents

Acknowledgements xi

About the author and contributor xiii

Preface xv

Part I: Basic theoretical principles of Davanloos


Intensive Short-Term Dynamic Psychotherapy:
an introduction

Introduction to Part I 3

Chapter one
A review of Davanloos metapsychology of the
unconscious 5

Chapter two
Davanloos discoveries: an overview of the Montreal
closed circuit training programme 13

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viii contents

Chapter three
Davanloos discoveries, 20052015: an overview
of important terminology and teachings 17

Part II: Application of new theoretical


principles

Chapter Four
The initial evaluative interview: the major mobilisation
of the unconscious and the total removal of resistance 27

Chapter five
The transference neurosis: Part I 37

Chapter six
Transference neurosis: Part II 47

Chapter seven
Multidimensional unconscious structural
changes: Part I 67

Chapter eight
The neurobiological pathways of murderous
rage and guilt 79

Chapter nine
The transference neurosis: Part III 87

Chapter ten
The destructive competitive form of the
transference neurosis 97

Chapter eleven
The transference neurosis: Part IV 109

Chapter twelve
Unconscious defensive organisation and brainwashing 117
c o n t e n t s ix

Chapter thirteen
Pathological mourning and the mobilised unconscious 129

Chapter fourteen
Intergenerational transmission of psychopathology 141

Chapter fifteen
The turning away syndrome 153

Chapter sixteen
Following the trail of the unconscious 161

Chapter seventeen
The neurobiological destruction of the uterus 171

Chapter eighteen
The character resistance of the idealisation of destructiveness 181

Chapter ninteen
Being a mother to ones own mother 189

Chapter twenty
Multidimensional unconscious structural changes: Part II 199

Chapter twenty one


The transference neurosis: Part V 207

Chapter twenty two


The metapsychology of forgiveness 215

Chapter twenty three


The transference neurosis: Part VI 227

Part III: Future directions

Chapter twenty four


Competency-based psychotherapy education and research:
an introduction 237
x contents

Chapter twenty five


Neuroimaging and Intensive Short-Term Dynamic
Psychotherapy: psychotherapy and the brain 241
Dr Robert Tarzwell

References 261

Index 269
Acknowle dgements

I am indebted to Dr Robert Tarzwell for providing a chapter on neu-


roimaging that is beyond what any other psychiatrist can write. Thank
you, Dr Tarzwell, for making the complex simpler. The members of the
Montreal closed circuit training programme have been my friends and
colleagues for seven years now. Their tenacity and spirit have inspired
me countless times. Thanks to you all for your patience, encourage-
ment, and dedication. Faith and Darren Esau remain the purpose for
which I live. I am grateful for the joy and love that they have both
shared with me. I am also grateful for the shining lights of love given
to me by David, Josephine and Lisa Hickey, Jeannie Hann and Cynthia
Fontaine. And finally, I thank Dr Habib Davanloo, who has offered
me the most extraordinary learning experience a psychotherapist can
have. It has been an honour and privilege to study your approach to the
human mind.

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A bout the author and co n tributor

Author
Catherine Hickey, MD, MMEd, FRCPC, ABPN, is a psychiatrist in
St. Johns, Newfoundland, Canada. She is an Assistant Professor at
Memorial University of Newfoundland where she earned her medical
degree. She did her residency in psychiatry at Dalhousie University
and completed her fellowship in psychosomatic medicine (medical
psychiatry) at Harvard University. She is certified by the American
Board of Neurology and Psychiatry. She is also certified in psychiatry
and geriatric psychiatry by the Royal College of Physicians and
Surgeons of Canada. Her interests lie in geriatric psychiatry, medical
education and Davanloos Intensive Short-term Dynamic Psychother-
apy. She has completed a twelve-year traineeship with Dr Davanloo of
McGill University and holds a Masters in Medical Education from the
University of Dundee. She is the author of several peer-reviewed pub-
lications, most of which focus on the themes of Davanloos IS-TDP and
competency-based psychotherapy education.

xiii
xiv a b o u t t h e a u t h o r a n d c o n t r i b u to r

Contributor
Dr Robert Tarzwell is certified in both psychiatry and nuclear medicine,
and he actively practises both specialties. He also conducts scientific
research in the functional brain imaging of psychiatric disorders.He is a
co-author of the largest review examining neuroimaging changes caused
by psychodynamic psychotherapy. He began his training in IS-TDP
during his psychiatry residency at Dalhousie and furthered this train-
ing directly with Dr Davanloo.He is a Clinical Assistant Professor on
the Faculty of Medicine at the University of British Columbia.
P reface

The last few decades have witnessed a move towards more evidence-
based approaches to treating mental illness and distress. With this,
there has been an emergence of studies that have demonstrated
the efficacy of various modalities of psychotherapy across several
psychiatric disorders (Fonagy, 2015; Prajapati, 2014). While many
complain that the field of psychiatry has become more biological in
nature (Verhulst, 1991), there has been a psychotherapeutic renais-
sance of sorts, whereby the field is beginning to revisit the value of
non-medication approaches to illness. In this context, several train-
ing bodies (ACGME, 2007; RCPSC, 2013) have greatly enhanced the
psychotherapy training requirements for psychiatry residents in
Canada and the United States, respectively.
Simultaneous to this psychotherapy renaissance has been the emer-
gence of a trend towards competency-based education. No longer are
medical educators satisfied with the status quo of the apprenticeship
model. Now, there is a focus on the active evaluation of important clini-
cal and supervisory activities. Psychotherapy educators in our current

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xvi p r e fa c e

generation must ask themselves several important questions. These


include the following:

1. What does it mean to be a competent psychotherapist?


2. What does it mean for a trainee to achieve competency in any given
psychotherapeutic modality?
3. How do I evaluate for competency in my trainees?
4. How do I evaluate for competency in myself?
5. Are traditional methods of supervision and training enough?

I would argue that no other individual has embraced competency-based


psychotherapy education to the extent that Dr Habib Davanloo, Professor
Emeritus in psychiatry at McGill University in Montreal, Canada, has.
After developing his method of Intensive Short-Term Dynamic Psy-
chotherapy (otherwise known as IS-TDP) in the 1970s1990s, Davanloo
went on to refine his discoveries in the last decade. He further expanded
his understanding of the human unconscious (which he calls the meta-
psychology of the unconscious) and now focuses on the major mobili-
sation of the unconscious and the total removal of resistance. He has
actively worked on sharing his discoveries and has trained numerous
therapists in his unique, experiential and competency-based Montreal
closed circuit training programme.
This programme is unique for many reasons. For one, all clinical
interviews are videotaped, and repeatedly viewed and analysed. The
clinical interviews transpire between trainees, although sometimes
Dr Davanloo conducts interviews himself. While Dr Davanloo is the
official supervisor, participants are encouraged to offer both peer feed-
back and self-assessment. It is a training programme that offers par-
ticipants the opportunity to identify their own unconscious blocks that
prevent them from practising psychotherapy in the most efficient and
effective way.
This programme has been met with both great acclaim and great
criticism. Those who applaud it speak of its unique experiential ele-
ment; participants are able to experience not only important elements
of the technique, but are also able to experience profound emotions
that had previously been unconscious. With this, they are able to work
through some of the unconscious blocks that may have resulted in long-
standing professional impasses.
p r e fa c e xvii

However, it must be stressed that this programme does not offer par-
ticipants definitive treatment. That said, the case that is outlined in this
book does actually consist of treatment. The majority of the patients
interviews occurred outside of the closed circuit training programme in
the setting of private small group treatment. However, some of them did
occur inside of the programme. These sessions (regardless of whether
they were in the smaller private treatment group or the larger training
group) were frequently viewed inside of the closed circuit training pro-
gramme. So while the correct nomenclature for this particular case is
patient and therapist, this is only because the patient had arranged
for private treatment outside of the closed circuit group. If not, the
proper nomenclature would be interviewer and interviewee.
This book is intended to educate the reader about the precise and
powerful techniques of Dr Davanloo. It must be stressed that much of
Davanloos career has been focused on the use of video technology in
the teaching of psychotherapy. He does not use process notes because of
the inherent recall and subjective biases associated with these. Instead,
he focuses on careful analyses of both the visual and verbal commu-
nications from patient (or interviewee) and therapist (or interviewer).
What results is a live, objective assessment of what actually happens in
the psychotherapy room.
What transpires in Dr Davanloos psychotherapy room is no fire-
side chit-chat. Indeed, Davanloo encourages the economical use
of time and suggests that a prolonged course of therapy is not only
counter-intuitive but dangerous. His ability to work successfully with
resistance is not simply a claim or a suggestion. He invites scrutiny of
his work at his yearly metapsychology meeting in Montreal. Those who
directly watch his videotapes often comment that there is something
unique about his approach; while it is relentless and targeted it has also
been described as spiritual, profound, and invigorating. It combines
both the science of the metapsychology with the art of human empathy
and compassion. However, readers are invited to view his work directly
to determine their own opinions on this matter.
Some have criticised the Montreal closed circuit training programme
as having insufficient parameters and boundaries (Frederickson, 2016).
It is true that participants interview each other. It is also true that they
often share their intimate thoughts and feelings. As a result, many par-
ticipants know each other on a very deep level. This degree of honesty,
xviii p r e fa c e

openness, and franknesswhile threatening to someresults in a


unique degree of group cohesion and universality. Overall, it should be
experienced, or at least witnessed, before it is criticised and dismissed
as unethical.
The purpose of this book is to allow the reader to witness, to
some degree, what transpires in the Montreal closed circuit training
programme. One patient will be reviewed in significant detail over the
course of her therapy. Her demographic details will be changed to pro-
tect her anonymity. However, she has given her informed consent to
have her interviews described in this book. While the text alone cannot
convey the depth of emotion that she experienced in this work, it will at
least supply the reader with the content of the interviews, each of which
reflects Davanloos newer discoveries, techniques, and approaches.
At the end of the day, it is hoped that the reader will make an informed
decision on this approach. This case and this approach are likely to stir
up emotions, reactions, and conclusions. The reader is encouraged not
to make premature conclusions but to sit on it, as Dr Davanloo likes
to say. It is only with reflection and stillness that the truth of this teach-
ing can emerge.
Part I
Basic theoretical principles of
Davanloos Intensive Short-
Term Dynamic Psychotherapy:
an introduction
Introduction to Part I

O
ver the past forty years, Dr Habib Davanloo has developed a
method of dynamic psychotherapy (IS-TDP), which has been
highly effective in treating even the most resistant psychoneu-
rotic disorders. By using audiovisual recording, Dr Davanloo has been
able to research his technique and to provide extremely comprehensive
teaching to those attempting to learn it.
Davanloo has written prolifically about his discoveries. His text-
books lay an extremely important foundation for any student wish-
ing to learn more about his technique. In the last five years, however,
Dr Davanloos discoveries have skyrocketed. His research and teaching
have focused heavily on his revolutionary closed circuit training pro-
gramme. Participants are practising therapists who wish to master his
technique. They meet in Montreal several times per year. Participants
interview one another and are sometimes interviewed by Dr Davanloo
himself. All interviews are recorded and watched by the other partici-
pants. In such a unique environment, there is a repeated breakdown
of resistance, and participants have the profound experience of uncon-
scious emotions.
The purpose of this book is to incorporate the recent research findings
of Dr Davanloo with his previously published metapsychological and
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4 U n d e r s ta n d i n g Dava n l o o s IS - TD P

technical discoveries. In order to do this, there will first be a brief syn-


opsis of his published findings. Following this, there will be a review of
Davanloos newer discoveries from the last decade. Many of these are
unpublished and are the result of the development and implementation
of the closed circuit training programme, which will also be explained.
Not only will Davanloos new discoveries be reviewed, but readers can
see how they are precisely applied in the context of one single case. The
initial evaluative interview will be highlighted in detail early on. Sub-
sequent interviews will be presented consecutively. Every effort will be
made to incorporate Dr Davanloos latest findings into this work.
C hapter one

A review of Davanloos metapsychology


of the unconscious

T
hrough the use of video technology, Dr Davanloo has made many
discoveries about the human unconscious. He has applied these
discoveries to a wide variety of patients, including those who
are highly resistant (Davanloo, 2000). These discoveries are based upon
empirical evidence, not theory or intuition, and form the basis of his
metapsychology of the unconscious (Davanloo, 2001). His work of the
early 1980s focused mainly on patients with phobic, obsessional, panic,
depressive and functional disorders (Davanloo, 1987a, 1987b, 1989;
Zaiden, 1979). Following this, Dr Davanloo began to focus on treating
patients with psychosomatic conditions and fragile character pathology.
He was able to demonstrate that these patients could be treated suc-
cessfully with some modifications of the technique (Davanloo, 1999a,
1999b). In this technique, direct access to the unconscious, and to all
of the pathogenic dynamic forces that contribute to a patients symp-
toms and character disturbances, is possible (Augsburger, 2000). The
technique of rapid and direct access to the unconscious will be high-
lighted through a detailed case presentation in this book.
Dr Davanloo has presented extensively on his technique of Unlock-
ing the Unconscious (Davanloo, 1975, 1976a, 1976b). Using this tech-
nique, the patient and therapist have a unique opportunity to obtain a
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6 U n d e r s ta n d i n g Dava n l o o s IS - TD P

direct view of all of the pathological dynamic forces that maintain the
patients symptom and character disturbances.

The twin factors of transference and resistance


Four decades ago, Dr Davanloo developed a technique of steady and
relentless therapist intervention. His technique brought the patients
resistance to the forefront in a maximal fashion, with the aim to elimi-
nate it completely, thus allowing the patient to have a complete experi-
ence of unconscious feelings. In doing so, he discovered the important
interaction of resistance with transference feelings. He went on to refer
to the twin factors of transference and resistance, which became the
central dimension of the technique.
One of Dr Davanloos important early discoveries was that the degree
of the unlocking of the unconscious was directly proportional to the
degree of transference feelings that the patient experienced (Davanloo,
1992). Another important early discovery was that direct access to the
unconscious was influenced not only by transference feelings but also
by the interaction between the patients resistance and a very powerful
force called the unconscious therapeutic alliance (UTA) (Davanloo,
1988a, 1988b).

The unconscious therapeutic alliance (UTA)


Just as the patients resistance seeks to defeat the process, the UTA
becomes the therapists ally and seeks to enable the patient to experience
the most painful and repressed unconscious emotions. In Dr Davanloos
technique, the mobilisation of this very powerful force, the UTA,
against the forces of the resistance is made possible (Davanloo, 1977).
As the UTA gradually strengthens, and as the resistance proportion-
ally weakens, the UTA takes command of the process. The resistance
is subsequently rendered useless and direct access to the unconscious
becomes possible (Davanloo, 1985).
Dr Davanloo has shown that dominance of the UTA and direct
access to the unconscious is made possible by expertly seeking out and
handling the resistance of the patient. In general, the more highly resis-
tant the patient, the more intense the patients unconscious feelings of
murderous rage and guilt. In highly resistant patients, there is often a
high degree of primitive murderous rage and intense guilt-laden feelings
towards one or both parents and/or siblings (Davanloo, 2000). In more
a r e v i e w o f dava n l o o s m e ta p s y c h o l o g y o f t h e u n c o n s c i o u s 7

responsive and low-resistance patients, there is often a single, circum-


scribed psychotherapeutic focus and an absence of murderous rage in
the unconscious. Resistance is primarily tactical in nature (Davanloo,
1995, 1996b).

The transference component of the resistance


Dr Davanloo has shown that the main factor that affects the progress of
the interview is the patients degree of resistance, and the transference
component in it. This transference component of the resistance (TCR)
is a critical therapeutic parameter that must be monitored constantly
to ensure that unlocking of the unconscious occurs. Achieving an
extremely high TCR is essential in Davanloos IS-TDP. Unfortunately,
many therapists fail to achieve a high TCR but claim to be practising
IS-TDP all the same. Dr Davanloos closed circuit training programme
offers the only live, videotaped teaching programme, which can teach
therapists the technical considerations in achieving this goal (Davanloo,
2011, 2013b, 2014b, 2015).

The spectrum of psychoneurotic disorders


Dr Davanloo has carefully outlined the spectrum of psychoneurotic
disorders (Davanloo, 1995). On the extreme left of the spectrum are
patients who are highly responsive, have a single psychotherapeutic
focus, and a circumscribed problem (for example, a mild phobic or
obsessional neurosis). In the mid spectrum are patients who are highly
resistant, have diffuse character and neurotic disturbances, and have
murderous rage and guilt in relation to early figures. In many of these
patients, there is complicated core pathology and a fusion of sexuality
with murderous rage. On the extreme right of the spectrum are patients
who have an extreme degree of resistance, severe symptom and char-
acter disturbances, and highly complicated core pathology. In addition,
they have highly primitive, torturous unconscious murderous rage
and intense guilt and grief-laden feelings. They have a high degree of
masochistic character traits, and sexualised feelings, when present, are
deeply fused with the unconscious primitive murderous rage.

The spectrum of structural pathology


In addition to the spectrum of psychoneurotic disorders, there is also
a spectrum of patients with fragile character structure. These patients
8 U n d e r s ta n d i n g Dava n l o o s IS - TD P

are also referred to as having structural pathology. Character fragility


lies on a spectrum and can be referred to as mild, moderate, or severe
(Davanloo, 2000). As a group, these patients are unable to withstand
the impact of their unconscious during the first interview. They do
not have the capacity to tolerate anxiety and painful feelings and also
have a long-standing access to primitive defences. The therapist might
identify fragility during an interview when the patient experiences
cognitive/perceptual disruption during the phases of the interview. This
can consist of dissociation, drifting, and the experience of hallucinations.
Dr Davanloo has successfully treated such patients with modifications of
the technique: most notably by engaging in extensive structural changes
before having the patient experience the full depth of their murderous
rage (which is often highly primitive and torturous) and guilt. The treat-
ment of patients with fragile character structure has been the subject of
many past international symposia (Davanloo, 1996a, 1997, 1998).

The spectrum of direct access to the unconscious


Throughout the decades, Dr Davanloo has been relentless in continu-
ally viewing clinical vignettes and refining his techniques according to
the videotaped material. In doing so, he has developed the spectrum of
the technique of direct access to the unconscious. There are four main
techniques and these include partial unlocking of the unconscious,
major unlocking of the unconscious, extended major unlocking of the
unconscious, and extended multiple major unlocking of the uncon-
scious (Davanloo, 1997).
In a partial unlocking there is partial dominance of the UTA over
the resistance. In a major unlocking there is major dominance. In the
extended major unlocking there is a major mobilisation of the UTA and
the resistance is weakened to a great extent. In extended multiple major
unlocking there is maximum mobilisation of the UTA and resistance is
virtually absent. Partial and major unlocking are practised in IS-TDP.
Extended major and extended multiple major unlocking had previously
been referred to as Davanloos new form of psychoanalysis (Davan-
loo, 2000). However, the term psychoanalysis is no longer used and
the term major mobilisation of the unconscious is used instead.
Extended mobilisation has been the subject of numerous sessions of
the closed circuit training programme in the last five years (Davanloo,
2013b, 2014b, 2015).
a r e v i e w o f dava n l o o s m e ta p s y c h o l o g y o f t h e u n c o n s c i o u s 9

The central dynamic sequence


The central dynamic sequence is the series of steps the therapist
employs to directly access the unconscious. It consists of the phases of:
enquiry, pressure, challenge, transference resistance, direct access to
the unconscious, systematic analysis of the transference, and dynamic
exploration into the unconscious. These concepts are extremely well
explained in past scholarly articles (Gottwik, Kettner-Werkmeistter, &
Wagner, 2001; Gottwik & Orbes, 2001; Gottwik, Ostertag, & Weiss, 2001;
Gottwik, Sporder, & Tressel-Savelli, 2001).
To summarise, the therapist begins the interview with the phase of
enquiry. The therapist enquires about the disturbances she/he is seek-
ing help for. The therapist assesses the patients ability to respond and
the process becomes dynamic in nature. In this sense, the process moves
quickly into the realm of dynamic enquiry. The phase of pressure usu-
ally follows. Essentially, this phase refers to the therapists focus on a
variety of elements with the purpose of increasing feeling. The therapist
may ask for clarification of details (pressure to specificity) or the nature
of feelings (pressure to feelings, which may be in the transference). The
major aim of the phase of pressure is to develop the twin factors of
resistance and transference feelings and to tilt the patients character
defences in the transference. This leads to some degree of increase in the
TCR, the importance of which will be reviewed below.
The phase of challenge is next. Throughout the past four decades,
Dr Davanloo has expanded and refined this phase considerably. While
the therapist wants to maintain an atmosphere of complete respect
and empathy for the patient, she/he must also convey a considerable
amount of disrespect for the patients resistance. On one hand, the
patient becomes angry about this, as the resistance is often entirely ego-
syntonic. But on the other hand, the patient has intensely warm feelings
about another human being attempting to get close. With this closeness
comes the therapists complete intolerance for the destructive defences
and resistance that have maintained the patients suffering throughout
the years.
Challenge lies on a spectrum. There can be mild challenge such
as calling on a patients defence. However, in the last two decades,
Dr Davanloo has greatly refined the technique of head-on collision,
which also lies on this spectrum. The head-on collision is perhaps
the most powerful technical intervention of IS-TDP. It is a complete
10 U n d e r s ta n d i n g Dava n l o o s IS - TD P

blockade against all of the forces that maintain the patients resistance
(Gottwik & Orbes, 2001). For this intervention, there must be crystallisa-
tion of the resistance in the transference. The therapist aims to further
amplify this crystallisation, to mobilise the UTA against the forces of the
resistance, and to loosen the psychic system so that direct access to the
unconscious is possible. Direct access to the unconscious can be partial,
major, extended major, and extended multiple major as above. Follow-
ing the unlocking of the unconscious, it is very important that there is
systematic analysis of the transference. Often, the therapist incorporates
multidimensional unconscious structural changes (MUSC) into this
phase, but they should ideally be implemented throughout the entire
interview process.
Dr Davanloo has demonstrated that a psycho-diagnostic evaluation
based on a superficial phenomenological approach to symptoms has
little validity, especially when we encounter patients with predominant
or exclusive character pathology (Augsburger, 2000; Davanloo, 1993).
Classical symptomatology may be absent, but psychopathology, as
assessed within Dr Davanloos framework of IS-TDP, can be very high.
In order to proceed, one must assess the presence and distributional
pattern of unconscious anxiety, with the goal to proceed with a major
mobilisation of the unconscious.

Discharge pattern of unconscious anxiety


In the early phases of the interview, the therapist must constantly mon-
itor the discharge pattern of anxiety, as it closely relates to the resis-
tance of the patient. Some patients may have a clear pattern of striated
muscle discharge of anxiety, thereby making it easier for the therapist
to visualise the anxiety and focus the therapeutic interventions accord-
ingly (Davanloo, 2001). These patients have tension in the thumbs that
then involves the entire hand. It then moves to the muscles of the fore-
arm (supinators and pronators), shoulders, and neck. It culminates in
tension in the intercostal muscles, which results in the patient having
sighing respirations. Other patients may have a different discharge
pattern (smooth muscle, for example), making the process more chal-
lenging. These patients may complain of diarrhoea, bronchospasm, or
headache. The task for the therapist is to raise the threshold for toler-
ance of the anxiety and to eventually convert the discharge pattern to
striated muscle. The third discharge pattern is in the perceptual and
a r e v i e w o f dava n l o o s m e ta p s y c h o l o g y o f t h e u n c o n s c i o u s 11

cognitive field. These patients often have fragile character structure, as


reviewed above, and cannot withstand the impact of their unconscious
during the first interview. These patients have a low capacity to tolerate
anxiety and require a modified technique that first creates structural
changes before attempting an unlocking of the unconscious.
The therapist must use the phases of the central dynamic sequence
(not all steps are used in all interviews, and some are used in a different
order) to tilt the patients character resistances in the transference. This
leads to the crystallisation of the resistance in the transference and a
high TCR. By ensuring an extremely high rise in the TCR, the therapist
can aim for a major mobilisation of the unconscious. With this major
mobilisation, the therapist aims to completely remove the resistance,
to completely drain all guilt, and to have direct access to the uncon-
scious. In what is comparable to a fact-finding mission, the therapist
and patient collaborate during the phases of psychic integration and
MUSC. In these phases, patient and therapist become pilot and co-pilot
and work together to understand the pathogenic core of the patients
unconscious.
Such a collaborative relationshipthat of pilot and co-pilotis a key
pillar of Davanloos approach. It is one of the fundamental building
blocks of the Montreal closed circuit training programme, which will be
the subject of the next chapter of this book.
C hapter t wo

Davanloos discoveries: an overview


of the Montreal closed circuit training
programme

T
he Montreal closed circuit training programme has been in
operation since 2007. Generally, a group of therapists meet
with Dr Davanloo in Montreal for three to five blocks per year.
Each block consists of about five days of intensive immersion training.
Anywhere from five to fifteen therapists may be in attendance at each
block. The membership in the programme has fluctuated somewhat
over the last nine years. Given the time and financial commitments
involved, not all participants can maintain indefinite involvement in
the programme.
The therapists assume different roles at different times. Often,
one therapist (the interviewer) has a session with another therapist
(theinterviewee). The session is videotaped and witnessed live. Usually,
the session DVD is then viewed. Dr Davanloo watches the entire process
and gives formative feedback. This feedback occurs both live and in real
time (if the interview is stagnating or at an impasse) and retrospectively
(through the viewing of DVDs). Recorded vignettes are watched repeat-
edly and analysed in depth. While others have commented on the ben-
efits of videotape training in psychotherapy education (Abbass, 2004),
it has not been used previously in an immersion setting of this breadth
and depth.
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14 U n d e r s ta n d i n g Dava n l o o s IS - TD P

The objectives of this programme are twofold. One is to provide the


participants with timely and focused feedback on Dr Davanloos thera-
peutic techniques. The second is to identify, and hopefully remove, any
unconscious blocks a therapist may have. Since these may prevent the
therapist from correctly applying this very precise and powerful tech-
nique, it is important to identify these blocks and remove them when
possible. While this programme, itself, is intended as a training pro-
gramme (not a therapeutic programme), it can be uniquely beneficial
for all of the participants. Some participants have also sought private
treatment outside of this actual training. What results is a unique and
profound group experience. Instillation of hope, group cohesiveness
and universality have been identified as predictors of positive group
experiences and these all come into play (Yalom, 1967). A unique and
often highly emotional atmosphere results.
Most participants are professional therapists and often they are highly
resistant. Complex material is often in the unconscious. The complexity
of the unconscious material remains an issue yet one that is more readily
understood through the repeated viewing of DVDs. It should be noted
that Davanloo does not do a traditional phenomenological interview
based on DSM 5 diagnostic criteria (American Psychiatric Association,
2013). Davanloo believes that a psycho-diagnostic evaluation based on
this approach has little validity (Augsburger, 2000; Davanloo, 1993). For
this reason, Davanloo does not do a traditional psychiatric assessment of
participants in the closed circuit training programme. Rather, Davanloo
assesses whether the patient falls into one of two spectra, which were
discussed above (Davanloo, 1995).
As a general rule, participants in the closed circuit training programme
tend to fall into the spectrum of psychoneurotic disorders. Such partici-
pants do not require tremendous modifications of the technique and are
usually able to tolerate the anxiety and painful affect associated with
the process. The immersion process, therefore, offers unique opportuni-
ties. One is that participants get to experience, understand and work
with resistance, which is often easily identified in the closed circuit set-
ting. Specifically, they can see how resistance is tilted and crystallised
in the transference. The participants must be comfortable sitting on
resistance or at least tolerating it. The status of the TCR can be mon-
itored, understood, and optimised; again through the process of live
interviews and repeated watching of DVDs.
dava n l o o s d i s c ov e r i e s 15

So how does one mobilise the TCR? Many therapists throughout the
world claim to practise IS-TDP. However, like many forms of dynamic
psychotherapies, IS-TDP cannot be easily manualised. Some therapists
have suggested that the unconscious of most patients can be easily
accessed in a straightforward way using IS-TDP. However, such a
mechanical approach can be harmful and result in an untargeted course
of therapy. The closed circuit training programme discourages such an
approach. It is unique in that there is no agenda. There is an element
of spontaneity in that participants do not know if and when they will be
called to an interview. The rote application of the technique is discour-
aged and seen as futile.
In instances where the TCR fails to be mobilised, the programme
offers a clear diagnostic perspective. In these cases, Dr Davanloo and
the group analyse the vignettes to determine why. Often, there is resis-
tance in the interviewer as well as the interviewee. The programme,
therefore, allows for a unique opportunity to diagnose and strategise
around therapeutic failures. In addition, struggling therapists are able
to identify and work through their own unconscious blocks. There is a
tremendous focus on reflection, self-assessment, and peer assessment.
This type of assessment is consistent with the current trend towards
more competency-based medical education (Parker, Blyett, & Legett,
2013). To illustrate these principles throughout this book, case vignettes
will be reviewed. One case will serve as an example of how the TCR can
be optimally mobilised in the closed circuit training programme.
C hapter three

Davanloos discoveries, 20052015:


an overview of important terminology
and teachings

D
avanloos most recent publication was a chapter in the
Comprehensive Textbook of Psychiatry (Davanloo, 2005). Since then,
many other authors have written and published articles and
books on Davanloos technique. However, many of these authors have
not attended Davanloos Montreal closed circuit training programme.
As such, their writings reflect Davanloos older discoveries. While
important, Davanloos earlier discoveries have been greatly elaborated
on and refined in his newest programme. In addition, many of these
articles do not use the most up-to-date terminology. The purpose of this
chapter is to define the most recent conceptual discoveries of Davanloo.
This is essential before proceeding to further chapters, which will show
these discoveries in operation.

Fusion
The metapsychology of the unconscious is soundly based in attachment
theory. Like Bowlby (Bowlby, 1944), Davanloo believes that attachment
to important early life figures is essential for normal human devel-
opment. At the core, or the nucleus, of the unconscious is love and

17
18 U n d e r s ta n d i n g Dava n l o o s IS - TD P

attachment to these important early figures. Davanloo refers to these


figures as genetic figures. At some point in human development, the
love and attachment to these genetic figures is disrupted. This can be
a relatively minor trauma, such as the birth of a younger sibling. Or it
can be an extensive trauma, such as repeated and prolonged abuse. This
disruption results in a myriad of painful feelingsthese include rage
(which is often of a murderous quality), guilt, and grief. These feelings
are so painful that they remain unconscious in most people. Davanloo
refers to this dynamic system as the pathogenic core of the unconscious
(see Figure 1). The age at which this love and attachment is disrupted
is critical. Like Bowlby (Bowlby, 1951), Davanloo believes that the ear-
lier the disruption occurs, the more damaged the patient becomes. The
age span from birth to five years, for example, is a particularly critical
period for attachment.
The neurobiological pathways will be reviewed below. Essentially,
these pathways refer to the physiological concomitants of a variety of
emotions (amongst other things). In a healthy child, the neurobiological
pathways of murderous rage and guilt develop as a response to a
number of early childhood events. Ideally, the child has loving relation-
ships with all family members and is not abused, traumatised or turned
away from other family members. If the patient is damaged early in life,
say at age one to two years old, then the healthy development of the
neurobiological pathway is interrupted.
If the development of the neurobiological pathway is disrupted,
then the distinct columns of murderous rage and guilt do not exist as

Resistance against
emotional closeness

Character resistance

Grief
Guilt
Sexual
Murderous rage

Pain of trauma

Bond, attachment

Figure 1. The pathogenic core of the unconscious (Davanloo, 2000).


Reproduced with the permission of Wiley.
dava n l o o s d i s c ov e r i e s , 2 0 0 5 2 0 1 5 19

separate entities in the unconscious. Rather, they are fused or stuck


together. The age that the fusion occurs is especially important. In gen-
eral, the earlier it occurs, the more damaged the patient is, and the more
complicated the entry into the pathogenic core of the unconscious will
be. The goal of the major mobilisation of the unconscious and the total
removal of the resistance is to remove fusion, to allow for the distinct
and full experience of the neurobiological pathways of murderous rage
and guilt, and to have a robust psychoanalytical investigation into the
unconscious during the phase of psychic integration.
Davanloos work in the last decade has focused on removing this
fusion of unconscious feelings (Davanloo, 2013b, 2014b, 2015). In
healthier and more highly motivated patients, fusion can be more
easily removed and these unconscious feelings can be accessed and
experienced as separate streams. In more highly resistant patients,
fusion occurs at a much earlier developmental age. What results is a
more complex unconscious. Many participants in the closed circuit
training programme are such patients and the approach to removing
fusion in this group will be discussed throughout this book.

Transference neurosis
Dr Davanloo has greatly refined his approach to diagnosing and
removing transference neuroses in the last several years. But before we
focus on this, it is important to understand some historical consider-
ations and the role that transference neurosis has played in traditional
psychoanalysis.
Freud believed that the transference neurosis was an important
manifestation of treatment that required careful analysis. He believed
that this careful analysis would result in important insights and ther-
apeutic value. Unlike Freud, Dr Davanloo rejects the notion of the
therapeutic value of the transference neurosis. Freud argued that the
transference neurosis was the latest creation of the disease, emphasis-
ing it as a metamorphosis of the neurosis rather than the psychoanalytic
treatment itself (Freud, 1933a). This is in strong contrast to Dr Davanloo,
who argues that the transference neurosis is a completely morbid force
that results from an insufficient rise in TCR and a poor UTA between
the patient and therapist. In this context, there is no tolerance for the
development of the transference neurosis in Dr Davanloos technique.
Freud argued that the transference neurosis develops when the
20 U n d e r s ta n d i n g Dava n l o o s IS - TD P

treatment has obtained mastery over the patient (Reed, 1990). How-
ever, in Davanloos technique, the transference neurosis develops only
if the psychoneurotic illness has obtained mastery over the patient.
The transference neurosis is felt to be a highly destructive manifesta-
tion of the resistance and is to be avoided at all costs during the course
of therapy.
It is important to understand the evolution of the transference neuro-
sis in IS-TDP. Many therapists claim to practise Davanloos IS-TDP but
few have had adequate training from Davanloo himself. Learning how
to create an extremely high rise in the TCR is not a simple task. In this
early stage of IS-TDP research and teaching, it is a lifelong endeavour
for most learners. Suffice to say, those who do not have extensive train-
ing with Dr Davanloo are not able to create a sufficiently high rise in
the TCR to allow for a major mobilisation of the unconscious. These
therapists often claim to be experts in the technique and many continue
to treat a wide variety of patients, including professional therapists. It
is these professional therapists, then, who arrive at the closed circuit
training programme and display a transference neurosis, which must
be diagnosed and understood.

Intergenerational transmission of neurosis


It seems intuitive that neurosis, like many other diseases and traits, can
be passed on from one generation to the next. It is also intuitive that a
damaged parent will produce a damaged child. However, few develop-
mental psychologists have outlined the unconscious reasons why this
might be. Davanloo has offered some interesting explanations and each
is worthy of further examination.
Davanloo has discussed the phenomenon of The Turning of the
Son Against the Father (Davanloo, 2014b, 2015). The nouns son and
father are used here for simplicity of nomenclature. However, any
configuration of family members can be part of such a phenomenon.
This phenomenon occurs when one person (often a parent or grandpar-
ent) turns the child against some other family member (often the other
parent). Sometimes, this occurs in a dramatic fashion. But many other
times, it can be subtle. Often the individual who turns the patient against
the family member is unconscious of the phenomenon actually occur-
ring. The damage to the unconscious of the patient can be tremendous
dava n l o o s d i s c ov e r i e s , 2 0 0 5 2 0 1 5 21

and result in a long-lasting and tenacious neurosis. The patient often


has extensive murderous rage and guilt towards the genetic figure that
did the turning. This can result in a high degree of complexity in the
unconscious. The approach towards such a complex unconscious will
be highlighted throughout this text and the turning away syndrome
is the focus of Chapter Fifteen of this book.

Multidimensional unconscious structural changes (MUSC)


Davanloo has given much attention to the application of MUSC in the
last five years. Simply stated, MUSC refers to the therapists use of vari-
ous steps of the central dynamic sequence to achieve long-lasting change
in the patients unconscious emotions, anxiety, and defensive organisa-
tion. In addition, patients often report that the application of MUSC
makes the unconscious material more conscious (Hickey, 2015a). The
therapeutic task becomes clearer to the patient when MUSC are applied
and the patient begins to understand the pathogenic organisation of the
unconscious in a much clearer, and almost tangible, way.
Many therapists who have not had recent training with Davanloo
misunderstand the timing of the phase of MUSC. Many apply MUSC (or
attempt to) after the patient achieves a breakthrough during the phase
of analysis. More recently, Davanloo has renamed this phase the phase
of psychoanalytic investigation of the unconscious (Davanloo, 2015).
Ideally, however, MUSC should be applied throughout the interview
and from the beginning. Learning how to apply MUSC is a technically
precise matter. For this reason, closed circuit training with Davanloo is
essential for the therapist who wants to be skilled in this area.

Neurobiological pathway of memory


Davanloo has spoken previously about the neurophysiological con-
comitants of the feelings of rage, guilt, and grief. He refers to this under-
standing as the neurobiological pathway (Davanloo, 2005). Patients
commonly report the experience of rage as a fireball or a volcano
that starts in the pelvic plexus and rises upwards to the abdomen and
chest. It spreads to the arms and legs and is commonly felt as a desire or
impulse to launch out or attack. Sometimes, the passage of rage is mixed
with sexual feelings. Following the passage of rage, there is usually a
22 U n d e r s ta n d i n g Dava n l o o s IS - TD P

passage of guilt, which may be mixed with some grief-laden feelings.


Unlike grief, guilt is commonly reported as an extremely painful con-
striction of the upper airway and larynx. Like grief, it comes in waves.
More recently, Davanloo has integrated the neurobiological path-
ways of murderous rage, guilt and grief with the neurobiological path-
way of memory (Davanloo, 2014b, 2015). By focusing on transference
feelings and the patients resistance, the therapist is able to mobilise the
TCR. Often, the therapist can see the discharge pattern of unconscious
anxietyfor example, striated muscle tensionand can ensure that the
process is going smoothly. The optimum mobilisation of the TCR leads
to mobilisation of each of the neurobiological pathways in the domains
of rage, guilt, and grief. Often this leads to the return of memory; with
very positive results.
In the closed circuit training programme, participants, after they have
experienced large amounts of rage and guilt, often report a return of
memory. For example, they have clear and vivid memories of genetic
figures. Previously, these memories were blocked or cemented in the
unconscious. Following the experience of unconscious emotions, these
memories are often spontaneously reported. Many patients find this to be
a liberating experience that helps them to understand their genetic figures
better. Such an understanding can be woven into the phase of MUSC.

Guilt

Rage Memory Grief

Sexuality

Figure 2. The neurobiological pathway (Hickey, 2015b).


dava n l o o s d i s c ov e r i e s , 2 0 0 5 2 0 1 5 23

Projective anxiety
Projective anxiety can take on a variety of different forms. On one hand,
the patient may have unconscious anxiety that she/he will actually
murder the therapist. The patient may also have unconscious anxiety that
the therapist will murder her/him (double projective anxiety). In some
patients, the therapist may unconsciously assume the role of a past
genetic figure. In this light, the patient sees the therapist as that genetic
figure and has ongoing anxiety throughout the process. In this context,
the patient relates to the therapist as though she/he is that actual genetic
figure. Undoing such projective anxiety can be difficult and must start
with an accurate diagnosis of its presence. The detection and approach
to projective anxiety will be reviewed in subsequent chapters.
To conclude, Davanloo has refined his metapsychology in a cohesive
and comprehensive way. Understanding his terminology is essential for
understanding how he currently applies his technique in the twenty-first
century. These terms will be used throughout the book and will be illus-
trated clearly through means of case vignettes.
Part II
Application of new theoretical
principles
C hapter four

The initial evaluative interview: the major


mobilisation of the unconscious and the
total removal of resistance*

N
ow that important metapsychological principles have been
reviewed, a recent case will be discussed to visualise these in
operation. The case will be reviewed in considerable detail in
this and the following chapters. Each chapter will highlight at least one
recent major discovery of Davanloo and will explore that particular
metapsychological concept or technical consideration in great detail.
The subject of this first chapter is the major mobilisation of the uncon-
scious and the removal of resistance.

Case presentation
The patient is a 55-year-old female therapist who presents for
evaluation in the closed circuit training programme with Dr Davanloo.
Her demographic details will be camouflaged so as not to reveal her
identity. She lives in Europe and has four children. She has had lifelong

*Originally published in 2015 as The major mobilization of the unconscious and the
total removal of resistance in Davanloos Intensive Short-Term Dynamic Psychotherapy.
Part I: An introduction in American Journal of Psychotherapy, 69: 423439. Reproduced
with permission.
27
28 U n d e r s ta n d i n g Dava n l o o s IS - TD P

character disturbances that include rigidity, stubbornness, and resis-


tance against emotional closeness. She has also suffered from lifelong
migraines and has had the more recent onset of insomnia. There are
no malignant character defences and there is an absence of structural
character pathology.
She presents at the mid-right side of the spectrum of psychoneurotic
disorders. Her genetic figures include her mother and father, to whom
she was closely attached. She describes a loving relationship with both
of them. Her father was often passive and submissive to her mother
whom she describes as the more dominant one in the marriage. But
everyone in the family was completely submissive to the maternal
grandmother. She was the Queen Bee of the family and was seen by
all as the ultimate ruler and authority.
The patient had a prior course of therapy consisting of approximately
seventeen blocks of IS-TDP over the span of three years (20042007).
This treatment was provided by a private therapist and did not occur
in the context of the closed circuit training programme. It concluded
approximately two years before the patient entered the closed circuit
training programme in 2009. During this treatment, she developed a
transference neurosis towards the therapist, which consisted of ide-
alisation and sexualised feelings.While the private therapy had been
videotaped, there was no supervision from Dr Davanloo or any other
therapist. The patient herself had training in IS-TDP and was able to
identify that her feelings were consistent with a transference neurosis.
The focus of that therapy had been the patients father. Subsequent
closed circuit evaluation revealed that this was not the core neurotic
disturbance in the patient. Throughout that previous therapy, the TCR
was too low to result in a major mobilisation. As a result, an unlock-
ing of feelings towards the patients mother and grandmother did not
occur to any extent. The mother and grandmother later proved to be the
focus of the original neurosis of the patient, as illustrated in the vignette
below and in the subsequent chapters of this book.
What follows are vignettes from the patients first interview with
Dr Davanloo in the closed circuit training programme. This interview
occurred in 2012, which was five years after the termination of her
treatment with the private therapist. An attempt will be made to high-
light how each intervention serves to create a major mobilisation of the
unconscious and the complete removal of resistance.
This interview is published with the permission of the Association
for the Advancement of Psychotherapy and originally appeared in the
t h e i n i t i a l e va l u at i v e i n t e rv i e w 29

American Journal of Psychotherapy (Hickey, 2015c). However, more recent


discussion of this case occurred in Montreal and the commentary has
been updated accordingly.

The case of the mother who waited at the pier


Vignette I: recapitulation of the task and the phase
of dynamic enquiry
TH: OK, Dr, we follow the principle that the best way to approach some
issues is that we explore and honestly experience our feeling as we
progress.You accept that principle? And you are on that principle?
PT: OK.
TH: This issue with your father is very much linked with your mother and
grandmother. But now, what type of the person is your grandmother?
How would you describe her?
PT: She was very stubborn. She wanted things her own way. She was the
Queen Bee of the family. She called the shots. But she was very
devoted. She was two people. She was very loving with the kids and
grandkids and that was her life. At the same time, she was very stub-
born and could be very explosive. Definitely with my step-grandfather,
the man she married after my grandfather died.
TH: You have memories of your grandmother?
PT: Oh, yeah.
TH: What type of the memory? Could you give a name to her second
marriage?
PT: Whats his name? Grappy.
TH: Means what?
PT: Means grandfather.
PT: [Laughs.]
TH: Very nice way. Because I always hear Grandpa, they write to me. But I
never hear Grappy. W hat type of the person was he?
PT: He was someone who when he drank he was very explosive. Once
he threw a bucket of water at her.
TH: Grappy was explosive? How old were you?
PT: Five-six-seven.
TH: So you remember him. Could you describe him physically?
PT: He wore very, very thick glasses. He was always dressed up. He wore
a hat and a suit and a tie.
TH: He was from where?
30 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: Outside of the city. He was from a small town.


TH: He was a local person from the province? How old was your
grandmother when Grappy came in the picture?
PT: She must have been in her late thirties or forties.
TH: Grappy was thirty or forty?
PT: They both were probably in their thirties and forties. When she
married him she was in her thirties or forties and so was he.

Evaluation of vignette I
The therapist begins the interview with the focus on honesty. He is
aware that this patient may prefer to let sleeping dogs lie and the ini-
tial communication to the unconscious is that such an approach would
be futile for the jointly agreed-on task. This communication also high-
lights that the process will centre on what is in the unconscious and will
be devoid of intellectualisation.
He then proceeds to ask for details surrounding the early genetic
figures in the nucleus of the patients unconscious. He identifies the
grandmother and her husband from her second marriage. By asking
for details about their ages and where they were from, the therapist
is engaging in the phase of pressureparticularly pressure for more
specificity. This increases transference feelings in the patient.
The patient is able to discuss the two sides of the grandmother in
a very clear and precise fashion. The grandmother is stubborn and is
the Queen Bee of the family. She does not want anyone else in the
family to get close to one another because this would be threatening
to her. There is precision in this communication and the patient is in
command of herself. We can see in the following vignette that this
leads to unconscious anxiety, most notably discharged through stri-
ated muscle tension and sighing respirations. The task then moves on
to the search for resistance and the building of a high rise in the TCR.
The phase of MUSC begins at the onset of the interview. By enquir-
ing about the important early genetic figures in rich detail, the therapist
is laying the foundation for the phase of psychoanalytic investigation
into the unconscious, which will occur after the breakthrough of guilt.
The therapist is also engaging in the phase of dynamic enquiry. He does
not yet know the role that the step-grandfather (Grappy) plays in the
unconscious. All he does know is that the grandmother was married
twice and the second marriage was a tumultuous one. Grappy was
t h e i n i t i a l e va l u at i v e i n t e rv i e w 31

brought into the family when the patients mother was thirteen years old.
But the task of accepting him into the family was difficult for the
patients mother. On one hand she wanted to please her mother and
welcome her new husband into her life. But on the other hand, she had
major unresolved grief towards her biological father.
The therapist must ask: in what sense (if any) does Grappy tie into
the transference neurosis with the patients previous therapist? What
was the organisation of Grappys unconscious? Does he himself have
an intergenerational neurosis that he introduces into the family life?
The therapist expects that as the process unfolds we will understand
Grappy and his role in the patients unconscious better. The therapist
is not critical of Grappy but attempts to understand the reality of the
human situation.

Vignette II: the rise in the TCR


TH: Your memories that your grandmother was explosivecould you
describe an instant that she used to be explosive? You took a sigh.
PT: I am trying to pick one instance. It would usually revolve around him
drinking and getting drunk. And she would get angry and yell and
scream.
TH: You took a sigh. What she was like when she was explosive?
PT: Its hard to remember it, but I know it happened so many times. One
memory doesnt jump out.
TH: What do you account for that your memory suddenly collapses?
PT: [Sighs.]
TH: How do you feel right now?
PT: Im feeling a bit anxious.
TH: What is that?
PT: I feel some tension in my abdomen.
TH: What do you account for that?
PT: I wish I could remember more. I feel anxious that I cant remember
more.
TH: Do you think you have some resistance of the issue about the feeling
you have about your grandmother?
PT: I think so.
TH: What do you mean I think so?
PT: I have resistance. I dont want to see my grandmother as a loving
woman.
32 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: But I asked you for an instance when she was in rage and you dont
remember it. You became very defensive with me. How do you feel
here with me? Look at this. Look at the way you are with me. Y ou are
evasive with me.
PT: I feel like I am going dead.
TH: You are not dead. Y ou are resisting.
PT: OK.
TH: You are a mother. Y ou have a major responsibility ahead of you. You
want to deal with it?
PT: I do.
TH: Lets see how you feel here towards me. Y ou have a major anger.
PT: Its building.
TH: Its not building. Its there.
PT: Its there and my fists are tight.

Evaluation of vignette II
In an attempt to further build the TCR, the therapist continues asking for
details surrounding the patients grandparents. The patient uses tactical
defences and the interviewer disrupts them. The patient struggles with
finding a specific example and the therapist points out that the patients
memory collapses. This intervention, alone, causes a dramatic increase
in the TCR. The patient is a professional therapist. There is no reason to
explain her memory collapsing, only as a phenomenon under the com-
mand of the resistance. Even though the enquiry had hitherto referred
to the patients family of origin, the therapist has been working heavily
in the transference. By pushing for specificity, the therapist is commu-
nicating to the patients unconscious that there is no room for error or
evasiveness. This has a profound effect on the patient and on the UTA.
The patient states: I feel like I am going dead. The therapist rapidly
points out You are not going dead you are resisting. The resistance of
the guilt begins to move up. The resistance of the guilt is that part of the
patients resistance that wants to prevent the patient from experiencing
a massive (and liberating) column of guilt at all costs. It is important for
the therapist to move as quickly as possible to the experience of the neu-
robiological pathway of murderous rage at this point. This is in order to
prevent the rapid rise of the resistance of the guilt. When the resistance
of the guilt is removed, guilt, itself, can be experienced fully.
As the therapist said earlier on, the process must be governed by the
principle of honesty. The patient accepted this and now knows that she
t h e i n i t i a l e va l u at i v e i n t e rv i e w 33

must face the truth (or ugly trooth, as Dr Davanloo often spells out) of
her unconscious. As the TCR gets higher, the patient experiences anxi-
ety and has a high capacity to both experience and tolerate anxiety. As
the TCR gets even higher, the neurobiological pathway of murderous
rage comes into operation and the patient experiences a violent, primi-
tive impulse towards the therapist.

Vignette III: the major mobilisation of the unconscious,


the removal of resistance, and the passage of guilt
TH: How do you experience this rage?
PT: I have a knifeI start attacking.
TH: But that doesnt show how the rage goes.
[Patient has the full activation and experience of the neurobiological
pathway of murderous rage.]
TH: Dont close your eyes. Dont move too much. Thats not how you
hold a knife.
PT: Down and down. [Repeatedly]
TH: Go on. Go on. Lets see how systematically you go. Go on. Go on.
Go on.
[Patient has massive passage of guilt.]
TH: Look to my eyes.
PT: I see my grandmother and mother together.
TH: Could you describe my eyes?
PT: They are green/blue. Why did I do this to her? Why? How could
I do this?
TH: Look to my murdered body. Y ou said my eyes were green. Face with
the feeling. Face with your feeling.
PT: I love you. I love you so much.
TH: You are talking to whom?
PT: My grandmother.
TH: How does she look at you?
PT: She loves me too. I love you.
TH: How badly the body is damaged?
PT: Theres blood. I have carved. There is a big incision down her head
and down her neck and her abdomen is filled with blood. Im so sorry.
Im so sorry. I love you.
TH: Obviously you are loaded with the primitive murderous rage. Look,
you have to face the truth of your unconscious. You say you love her
but at the same time you have murderous feelings. You see the two
34 U n d e r s ta n d i n g Dava n l o o s IS - TD P

sides? A part of you wants to destroy her but another part of you
loves her. But you have to face the two sides of the ugly truth of your
unconscious. Y ou have to face it.
PT: I have to face it.
TH: One part of you wants to torture her even worse than this. Another
part wants to love her. This is the ugly truth of your unconscious. If
you want to examine it we can examine it.
PT: I want to.
TH: There is a massive primitiveness and it is extremely important you
examine this.
PT: Yes there is.
TH: You carefully want to examine it? If you want to put an end to it, and
I put emphasis on if, if you want to put an end to the suffering

Evaluation of vignette III


As a result of the very high rise in the TCR, the unconscious of this
patient has become highly mobilised. What results is full activation of
the neurobiological pathway of rage. The patient experiences a high
degree of primitive, murderous, torturous rage and has the impulse to
sadistically murder the therapist. Upon unleashing this rage and com-
pleting the murder of the therapist, the patient looks to the eyes of the
therapist and sees the green/blue eyes of her mother and grandmother.
Upon further examination, she sees most clearly the green eyes of the
grandmother.
What follows is an intensely painful wave of feeling. The patient
experiences this as a painful constriction of the upper muscles of the
chest and larynx. The feeling comes in waves and is the massive guilt
associated with the unconscious murder of her grandmother. But as
the therapist then points out, there is also massive love associated with
this primitive murder. As the patient says I love you, I love you so
much, I am so sorry, the therapist points out the reality of the two
sides of the grandmother in the patients unconscious. On one side, the
patient loved the grandmother and had a very affectionate bond with
her. On the other side, the patient had a violent, sadistic longing to kill
her in a torturous way.
Because of the tremendous love, there is also tremendous guilt. And
it is this heavy layer of guilt that fuels the perpetrator of the uncon-
scious in this patient (Beeber, 1999). Such guilt has been built up
over decades and has resulted in the characterological and symptom
t h e i n i t i a l e va l u at i v e i n t e rv i e w 35

disturbances that she has suffered from her entire life. What compli-
cates the matter is the presence of a transference neurosis in this patient.
The transference neurosis is a crippling force in her life and will be the
subject of several subsequent chapters in this book.

Conclusion
This chapter highlights the central dynamic sequence of Davanloos
IS-TDP and gives a case vignette that illustrates the major mobilisation
of the unconscious and the total removal of resistance. The therapist
begins the interview with an emphasis on honesty. While the patient
is honest, she also prefers to let sleeping dogs lie. This intervention
alone (the emphasis on honesty) tilts the resistance in the transference
and serves to create a foundation for a high rise in the TCR. After the
tone of the interview is set, the task of the therapist is to look constantly
for the twin factors of resistance and transference. The therapist must
search for the resistance at all times and mobilise the resistance wher-
ever and whenever possible. In this interview, the therapist formulates
that the main source of resistance is in the zone of the grandmother.
As the therapist applies pressure for specificity surrounding the
details of the patients genetic figures, the patients resistance crystal-
lises in the transference. While the therapist does not formally apply
pressure for feelings in the transference, the transference feelings build
regardless. The therapists focus on the figures of the patients past cre-
ates tremendous feeling in the patient. On one hand, she is appreciative
that the therapist wishes to explore these damaged people whom she
intensely loved. On the other hand, this exploration will be extremely
painful for her. The therapist will point out the ugly truth of the past.
This mobilises the patients unconscious rage towards him.
The neurobiological pathway of murderous rage is at an optimal
level of operation. But it is not at the maximum level. This is to be
expected given that this is the patients first interview with Davanloo.
In the next few interviews, the neurobiological pathway of murderous
rage is expected to be restructured. Further details of this restructuring
will be covered in subsequent chapters.
This chapter highlighted the use of the central dynamic sequence
and the steps needed to create a high TCR. The high TCR is essential in
facilitating the major mobilisation of the unconscious and the removal
of the resistance. In the subsequent chapters, we will continue to explore
these concepts with further vignettes from this case.
C hapter FIVE

The transference neurosis: Part I*

I
n the last chapter, we explored the initial session of a highly resistant
therapist who was interviewed by Dr Davanloo in his closed circuit
training programme in Montreal. In this next chapter we will continue
to focus on this case, reviewing vignettes from the second interview in
this programme. This interview is published with the permission of the
Association for the Advancement of Psychotherapy and first appeared
in the American Journal of Psychotherapy (Hickey, 2015d). What follows
is the content of the interview and some updated discussions that have
occurred since its original publication.
The focus of this chapter will be the management of the transference
neurosis in this patient. The patient had a prior course of therapy, as
mentioned in the preceding chapter. It is during this treatment that she
developed the transference neurosis towards her therapist. The TCR
had been extremely low during that course of treatment and the focus of
the therapy had been on the patients father. Subsequent closed circuit

*Originally published in 2015 as The major mobilization of the unconscious and the
total removal of resistance in Davanloos Intensive Short-term Dynamic Psychother-
apy. Part II: Treating the transference neurosis in American Journal of Psychotherapy, 69:
441454. Reproduced with permission.
37
38 U n d e r s ta n d i n g Dava n l o o s IS - TD P

evaluation revealed that this was not the core neurotic disturbance in
the patient.
The first chapter focused on the major mobilisation of the patients
unconscious and the total removal of the resistance. During the first
session, the patient had a massive passage of murderous rage towards
the therapist, an impulse to sadistically torture and murder him, and,
finally, a massive passage of guilt as she looked into the eyes of the
therapist and saw the green eyes of the grandmother. The current
chapter will lay the foundation for understanding the important meta-
psychological and technical aspects of diagnosing and understanding
transference neuroses in IS-TDP.

Vignette I: the therapeutic task and the phase of dynamic enquiry


TH: OK. Again as a reminder, the principle of honesty. That we are
together again. We want to understand the process.
PT: I want that.
TH: When you say your mother and grandmother. Obviously your grand-
mother was much earlier. How old was your grandmother when
your mother was born?
PT: About twenty-four to twenty-six.
TH: And how old was your grandfather?
PT: That I dont know. I suspect he was roughly the same age. Actually,
he was thirty.
TH: What did your grandfather do for a living?
PT: I cant believe I dont remember this. I think he was a fisherman but
he might have done something else as well. His father owned a fish-
ing ship. I think he was a captain of a fishing boat.
TH: This is where?
PT: In a rural community outside of the city.
TH: Your grandfather was a fisherman. It was a heavenly place to live.
PT: I dont think so. Not for my mother.
TH: In terms of nature.
PT: It was scenic. But the life of my mother wasnt heavenly.
TH: Then your grandfather dies of TB. That was quite a shock for your
grandmother.
PT: My sense is that it was. Because he was in the sanatorium and then
came home and my sense is that he didnt know how sick he was.
He collapsed with a pulmonary haemorrhage. They thought that he
came home because he was well but that wasnt the case.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i 39

TH: How did he die?


PT: He was working in the front yard. He died of a massive pulmonary
haemorrhage.
TH: How was this explained to your mother? How old was your mother?
PT: Nine when her father died.
TH: She was a child, not a baby. What did your grandmother have in mind
telling your mother, Anne, to dress up and go to see your father.
Anne would say my father is dead.
PT: My sense as you talk to me is that she was told he was asleep.
TH: You mean not dead, asleep? But your mother is nine.
PT: Shes a childlike person. She would want to believe that back then.

Evaluation of vignette I
As in the first session with this patient, there is a phase of dynamic
enquiry. The therapist asks for details surrounding the patients under-
standing of the early life of her grandparents. The grandmother had
married the patients biological grandfather when she was in her early
twenties. When the patients mother Anne was nine years old her father
died of tuberculosis just after coming home to the family from the sana-
torium. Clearly, this tragic and unexpected event had a lifelong impact
on the patients mother. The grandmother did not allow the patients
mother to fully grieve the loss of her father. She was not allowed to
attend the funeral and was discouraged from crying about the death of
her father. As a result, the patients mother became stuck in a perma-
nent state of pathological mourning. The therapist uses metaphor and
refers to the patients mother as waiting at the pier for the father who
never comes home.

Vignette II: the rise in the TCR


TH: Your mother was compliant?
PT: With my grandmother, for sure. Blind. Obedient. Compliant. Childlike.
TH: So your mother was a paralysed person?
PT: In relation to my grandmother she was. No doubt.
TH: Your mother becomes an annex to your grandmother.Then you were
born. Who was in charge of you? Is it your mother or grandmother?
PT: My mother was really just an instrument of my grandmother. Like
a puppet. My grandmother was in charge but not day to day in
the house.
40 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: The sentence you use was that your mother is a puppet to your
grandmother. Because this is very important in this zone. Your
mother is a child, nine years old. In your hometown theres no dum-
mies. Something about your grandmother, your mother becomes
paralysed. A puppet. Totally obedient. Totally blind. Like catatonia.
PT: [Sighs.]
TH: You took a sigh.
PT: I dont want to see her as a catatonic woman but theres truth in that.
TH: She is with your grandmother?
PT: With my grandmother she was.
TH: How was she with your father?
PT: With my father, she was a Queen Bee. My mother was a puppet
to her mother. And my father was a puppet to this puppet. Everyone
was subject to my grandmother.
TH: This is a very malignant form of the puppet. She follows her mother
in a blind way. Blind follower. And then your father comes to the
pictureanother puppet to your mother. Puppets also show they
can have lifelively puppets. But a catatonic puppet.You took a sigh.
PT: I feel something building when you talk about my mother as malignant.
I dont want to see her as malignant, completely. I dont see it that way
but I guess there is truth in that. I guess maybe I am blind to that.
TH: But our task is to face the ugly truth and nothing but the truth. But
if you say your grandmother was Queen Bee and your mother
follows her. But your mother becomes a beautiful puppet to your
grandmother. You say your father was obedient to your mother. This
is worse than catatonia.You say it mobilises feelings in you. How old
was your mother when she got married?
PT: Twenty-four.
TH: So she was twenty-four and married your father. How old was your
father?
PT: Twenty-eight.
TH: Where did your father come from?
PT: Close to the city.

Evaluation of vignette II
The therapists goal is to create an extremely high rise in the TCR. This
rise is so high that it is referred to as the vertical position. The ther-
apist points out obvious truths about the mother and grandmother.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i 41

The mother was blind, obedient and compliant in relation to the grand-
mother. Clearly, the grandmother was a Queen Bee figure and com-
pliance would obviously result in the best reception from her. With this
type of grandmother, one has to be obedient. On one hand, the patient
knows this to be true. On the other hand, she has tremendous feeling
about it. Not only does this communication address the reality of the
mothers life, which was highly destructive, it also addresses the reality
of the patients life.
The patient has the desire to protect her mother when the therapist
calls her catatonic. While she has murderous rage towards her mother,
she also has loving feelings towards her. She becomes angry that the
mother is labelled. The patient holds on to her anger and relates to the
therapist as though he is the grandmother. In this sense, projection is
in operation.
The patient herself was compliant and catatonic in order to compete
with her mother for the love of the grandmother. The patient herself
has identified with her mother and has the character traits of blind-
ness and compliance. The patient competes with her mother for her
grandmothers love and with her grandmother for her mothers love.
This destructive competitiveness becomes the hallmark of her life and
the engine of a pernicious guilt in her unconscious. At this point, it is
unclear why the grandmother had destructive competitiveness towards
her daughter and granddaughter. What is clear is that the phenomenon
of intergenerational transmission has occurred and the patient has a
need to torture her mother and herself. This results in an addiction to
suffering and torture of the self.
The trait of destructive competitiveness was evident in the relation-
ship with the former therapist and was crucial in the development of
the transference neurosis in that relationship. She had an extremely
crippled and paralysed relationship with her past therapist. She became
compliant with that therapist and, in a sense, was just like the catatonic
puppet her mother was to her grandmother and her father was to her
mother. She idealised the previous therapist despite knowing that the
course of therapy was not helping her in life. In the setting of a highly
malignant transference neurosis, the therapist in her former course of
therapy became the Queen Bee that is the patients grandmother.
The patient has the potential to excel but she has not met this poten-
tial yet. Highlighting these obvious yet painful truths has a dramatic
impact on the unconscious of the patient. This creates a high rise in
42 U n d e r s ta n d i n g Dava n l o o s IS - TD P

unconscious transference feelings and leads to the development of a


high rise in the TCR.

Vignette III: further rise in the TCR


TH: You took a sigh.
PT: Im feeling anxious. I feel my hands doing this. I have some tension in
my abdomen.
TH: What do you account for that?
PT: Examining the truth will be difficult. It will bring out a lot of feeling.
I know there is a murderous feeling in me.
TH: Your father comes from another area. What did he do for a living?
PT: He was a fireman. Then he became an electrician.
TH: So he was fighting fire. Some say you have to be aggressive to fight
fires. He was like that or they wouldnt take him as a fireman.
PT: Aggressive? I dont see my father as aggressive.
TH: I didnt say aggressive.You cant be a passive person to be a firefighter.
You have to break the door down to save the lives. You cant sit
and wait.
PT: He was a physically strong man. He would be capable.
TH: He was a fighter? Then if your mother was a Queen Bee, how could
he fight your mother? Who was the ruler of your house? Was it your
mother or him?
PT: My mother.
TH: She was the power and you have memory of it? You took a sigh.
PT: I feel anxious.
TH: Why you feel anxious?
PT: Because we are moving to the truth, right now.
TH: We decided honesty. We are here to get to the truth of your uncon-
scious. This is your decisionits not mine. Either you want to do it
or not. Then the question is what are you going to do with your life?
How do you feel towards me, if you stay with the principle?
PT: Grateful, but I feel anger.

Evaluation of vignette III


In the above vignette, the therapist focuses on the patients father. It is
important to understand the role he played in the patients core neu-
rotic structure. He had been the focus of the patients previous therapy,
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i 43

which had been characterised by the malignant transference neurosis.


What emerges in the closed circuit training programme is that the
original neurosis is towards the mother and grandmother. This will be
illustrated in this and the following chapters. The father was compliant
to both of these figures in the patients early life and was a catatonic
puppet in this triangular relationship. In this sense, he remains rela-
tively innocent in comparison to the other two.
The patient is aware of this on an unconscious level and his inno-
cence greatly increases the volume of guilt she has in relation to him.
It becomes clear that he was the wrong focus in her previous therapy.
This had disastrous consequences for the patient, as it increased the
guilt in relation to the father and resulted in an entirely inadequate
experience of guilt in relation to the mother and grandmother. Indeed,
the volume of guilt towards the mother, unexamined in the previous
therapy, becomes exponentially worse as a result of the transference
neurosis. As a result, the patients complex core pathology remained
unexamined and she continued with disabling symptom and character
disturbances.

Vignette IV: the major mobilisation of the unconscious,


the removal of resistance, and the passage of guilt
TH: How do you feel that anger towards me?
PT: I would punch you in the face with a knifego right into your eye-
ball, slash down your eye, down your face and down your chest and
abdomen. I would take a knife and put it up your rectum until it
comes out of your abdomenit is a curved knife. I slice down and
mutilate you. I tear open with massive claws your abdomendown
to your backbone and there is a river of blood coming out.
TH: And then what is my situation. If you look at me I am disastrously
mutilated.
PT: [Has massive wave of guilt-laden feeling.] Im sorry. Im sorry. Im
sorry. Im sorry. I love you. The eyes are green/blue. Im sorry.
TH: Its green/blue eyes.
PT: Its my grandmother. Im sorry.
TH: Its a major wave in you.
PT: Im sorry. I couldnt be more sorry. You loved me and I loved you.
Im sorry.
TH: The green eyes look at you.You see the eyes still? The colour is green.
44 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: They are very sad eyes. I see my grandmother before she died and
then I see her as a much younger woman. I wouldnt have known
her. In this image, she is in her forties.
TH: Your last memory when she was alive, you were how old?
PT: It was from ten years ago.
TH: You saw your grandmother. Do you remember that?

Evaluation of vignette IV
The passage of the murderous rage towards the therapist is far more
primitive than what occurred in the first closed circuit session. The
patient attacks the most sensitive and painful areasthe rectum and
eyes. In addition, the volume of rage is higher. What follows is a tre-
mendous passage of guilt. This is an intense passage of guilt because
the patient knows that her grandmother struggled in life to bring the
best to her children and grandchildren. Though the grandmother was
damaged, the patient has a deep love and appreciation for all that she
did for the family. This love results in tremendous guilt.
While the murderous rage is more primitive and reflects a higher
volume than the previous session, there is a delay in the passage. The
fundamental question is: why the delay? Most likely, the patient has
a high degree of projection towards her grandmother due to an early
phase of her life. The patient has had a massive reservoir of murderous
rage towards the grandmother from an early age. But this reservoir was
never experienced by the patient because of the loving behaviour of the
grandmother.
Because of this massive reservoir of murderous rage and guilt, the
patient has had a specific type of defensive structure throughout her
life. On one hand, she has the character trait of her mothers catatonic
obedience. In this way, she identified with the mother. On the other
side of the compliance is a tremendous stubbornness. This stubborn-
ness developed in the patients early life before her defensive system
had fully developed. Its purpose was to serve as a means to deal with
the guilt. The patients defensive structure will change as the reservoir
of guilt is drained. By evacuating the guilt in relation to the mother and
grandmother, the patient will be able to restructure her defences. Stub-
bornness will decrease as the defensive structure changes. Her approach
to her own patients should change, as that same volume of guilt will not
be dragging her down.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i 45

Commentary and group discussion


There is extensive discussion of the live interviewssometimes with
the patient in the room and sometimes as they sit in the waiting room.
While a number of technical points were discussed, the most prominent
teaching point of this case was how to deal with the metapsychological
and technical considerations of the transference neurosis.
The transference neurosis greatly increases the volume of guilt in rela-
tion to the patients genetic figures. It also greatly damages the patients
defensive structure. Throughout the process, the therapist is constantly
trying to build up the patients defensive structure with the goal of
removing the transference neurosis. This is an exercise in increasing the
patients capacity to face the transference neurosis.
Under the malignant power of the transference neurosis, the patients
unconscious is said to exist in a state of avalanche. The true and origi-
nal neurosis is obscured and unexamined because of the powerful and
destructive impact of the transference neurosis. As a result, a major part
of the patients potentiality is under the powerful force of the avalanche.
The patient begins to understand how she has abused and damaged her
potential in life.This, itself, creates a tremendous feeling of guilt. The
patient is torn between the choice of changing her life vs. remaining like
her mother and grandmother.

Conclusion
This interview has a powerful impact on the unconscious of the patient.
We are able to see with great clarity the triangular relationship with the
patient, her mother, and her grandmother. We see the destructive com-
petitiveness of the patient with her mother. This destructive competi-
tiveness focused on the need to destroy her mother in order to gain the
grandmothers love and to destroy the grandmother in order to gain the
mothers love. We also see with greater clarity the nature of her trans-
ference neurosis from her previous course of therapy. Once again, the
destructiveness of that relationship becomes immediately clear.
Davanloos IS-TDP is about human autonomy and the ability of
the individual to meet their potential in life. The patient is given the
opportunity to make a choice in her life. Change is available. She can
terminate her destructiveness and climb the peak of her potentiality in
a proper way. Or, she can continue to hold on to her eternal love of
46 U n d e r s ta n d i n g Dava n l o o s IS - TD P

destruction and live the crippled life of her mother and grandmother. It
is important to note that the two closed circuit training blocks create the
foundation for the treatment of the transference neurosis. These blocks
are not the actual treatment of the transference neurosis. The patient
needs sufficient structural changes in the unconscious to allow for treat-
ment of the transference neurosis.
The above vignettes illustrate the total removal of resistance in a
patient. We see a patient experience a primitivepassageof rage towards
a woman whom she loved very much. This love and the destruction of
that person she loved lies at the core of her lifelong neurotic structure.
On one hand, the patient has had crippling symptom and character dis-
turbances her entire life. But on the other hand, she is fully in touch
with these forces and this is very healthy. In the next chapter, we will
present the third interview in this series and will continue to focus on
the transference neurosis.
C hapter six

Transference neurosis: Part II*

T
he following case is a continuation of the previous chapter with a
continued focus on the transference neurosis that had developed
in a prior course of therapy. In the first session of the closed circuit
training programme, the patient had a massive passage of murderous
rage towards the therapist, an impulse to sadistically torture and
murder him, and, finally, a massive passage of guilt as she looked into
the eyes of the therapist and saw the green eyes of her grandmother. In
the second session, she had a similar experience of murderous rage and
guilt towards the grandmother.
What follows are vignettes from the third closed circuit training
session. This interview was first published in the International Journal of
Psychotherapy (Hickey, 2015e). This interview raises a number of impor-
tant concepts that reflect Dr Davanloos current-day understanding
of the technique. Since this interview has been reviewed in multiple
settings (Davanloo, 2013a, 2014a), there have been numerous group

*Originally published in 2015 as The management of transference neurosis in Davnaloos


Intensive Short-term Dynamic Psychotherapy in International Journal of Psychotherapy, 19:
3345. Reproduced with permission.
47
48 U n d e r s ta n d i n g Dava n l o o s IS - TD P

discussions on the themes it raises. These will be reviewed in detail at


the end of this chapter.

Vignette I: recapitulation of the task and the


phase of dynamic enquiry
TH: You see, again, the same principle: honesty, hmmm? That we face with
everything with honesty. We really experience what we feel. That is
the principle of life, isnt it?
PT: I accept that.
TH: You see you have a lot of feelings when you are not able to stand up
in your interpersonal relationships. You see you have a lot of feelings
about this therapy that you had because in a sense you allowed your-
self to be walked all over.You have a lot of feeling.
PT: I do.
TH: Because you dont like to be walked over.
PT: I hate it.
TH: Because next to you is your mother, who went to a disaster in her
life. So you see you have that feeling.
PT: I hate going catatonic. I hate that part of myself.
TH: You say you hate to go catatonic.
PT: But I do.
TH: You do.
PT: I do.
TH: How do you feel right now? You took a sigh. How do you feel right
now? Again, on the same principle, to experience. See you are holding
on this
PT: There is a rage building now.
TH: Its building.
PT: Yes. But its not at its fullest intensity.
TH: That, by itself, says something. The rage wants to build up but you fight
it. You dont want to be honest. Why dont you want to be honest?

Evaluation of vignette I
As in the previous two interviews, the therapist continues to engage in
the process of MUSC. MUSC provide an atmosphere of dialogue and
exploration. It is important for the patient to understand that she is not
being treated as a child. The therapist and patient need to work together
t r a n s f e r e n c e n e u r o s i s : pa r t i i 49

to uncover the truth of the patients unconscious, and this is a collabora-


tion between two people.
This joint collaboration reduces the possible projection (and projec-
tive anxiety) that might occur. This is especially true with this patient.
In the previous two interviews, the patient had the experience of primi-
tive, murderous rage and guilt towards her grandmother, who was the
Queen Bee of the family. This grandmother was the supreme ruler of
the family and her importance in this patients unconscious cannot be
overstated. Using MUSC, the therapist is constantly undoing the omnip-
otence that the patient may project on him. In the previous session, we
saw that the grandmother had destructive competitiveness and was
competing with the patient for the love of the mother. In this sense,
the grandmother is interfering with the process. Metaphorically, she is
wagging her finger at the patient and asking the rhetorical question:
How dare you have this enormous love for your mother?
During this process, it is important that the patient and therapist not
speculate. This is especially important, as the patient has a tendency
to agree to everything that is suggested. At this point, we still do not
fully understand the unconscious of the grandmother and her early
life orbit. However, given the high level of UTA, we can consider this
patient a reliable explorer into the depths of her own unconscious. We
are still unclear about some of her relationships with important early
life figures. It is important not to introduce conjecture at this point. But
it is also important to follow the trail of the unconscious and to better
understand her genetic figures.
There is no doubt that the patients grandmother had a difficult
upbringing. Historical data obtained outside of the interview indicated
that she was one of many children growing up in economic hardship
in a rural village. The family was not wealthy and the children were
responsible for working hard in order to survive. In this sense, the
grandmother had no autonomy in life and it is not surprising that this
resulted in a neurosis where she became extremely controlling. We can
see that this is why she became a Queen Bee. There was an atmo-
sphere of slavery in her family of origin and she did not want to allow
that system to be repeated.
The neurobiological pathway of murderous rage is mobilised earlier
in the interview compared to the first two sessions. We also see in the
vignette below that the neurobiological pathway of murderous rage is
much stronger. This is an example of the restructuring of the unconscious
50 U n d e r s ta n d i n g Dava n l o o s IS - TD P

that occurs with each subsequent mobilisation of the unconscious, total


removal of resistance, and evacuation of guilt.

Vignette II: the major mobilisation of the unconscious,


the removal of resistance, and the passage of murderous rage
TH: Why you dont want to feel it? Lets to see how you feel.
PT: Its a knife and it goes right in your nose and your eyes. Down your
face. I swipe down your face. And down your chest. I scoop out your
chest.
TH: Go on and on. Dont be a crippled mother. Go on. Go on.
PT: Then I put my fist up the vagina. I clutch the uterus and I drive it
down. And then I pound further on the genitals.
TH: Go on. Go on. Go on. Go on. Dont stop. Go on. Go on. Go on.
Go on.
PT: And theres a knife and I carve. And I mutilate.
TH: Go on. How do you mutilate?
PT: I have my hand on your hip and I carve and I mutilate.
TH: Where do you put the knife?
PT: Im holding you down and I put a knife in the vagina.
TH: And then? And then? And then? And then?
PT: I am clawing out the wall of the vagina.
TH: And then? And then? And then?

Evaluation of vignette II
It is important to examine this interview in relation to the two previous
interviews in the closed circuit setting. Metapsychologically, the neuro-
biological pathway of murderous rage is very high. The corresponding
neurobiological pathway of guilt is also very high. We see that the TCR
was extremely high during this interview and, as a result, the murder-
ous rage and guilt have become defused from one another.
The process is protected by this vertical rise in the TCR. If the
TCR was below this critical threshold, then the interview would end
in disaster. The higher the TCR, the more the passage of rage and
guilt is protected. Dr Davanloo has discussed the sequelae of a low
TCR in the past (Davanloo, 2014a, 2015). A low TCR can result in an
imbalance between the cortex and the subcortex, such that the nor-
mal regulatory mechanism of emotions malfunctions and the patient
t r a n s f e r e n c e n e u r o s i s : pa r t i i 51

either becomes confused, exhausted, or unable to experience the full


columns of rage and guilt.
Given the heavy load of primitive, torturous, murderous rage and
guilt, the therapist must be vigilant in understanding the metapsychol-
ogy of the process. The therapist must be mindful of other forces in
the patients unconscious. While there is definitely an original neurosis
involving early genetic figures, the therapist must also be vigilant in
watching for the transference neurosis, which acts as an avalanche
and obscures the original neurosis. In this case, the patient had a trans-
ference neurosis with the previous therapist. As a result, there was an
iatrogenic problem resulting in cementation of her unconscious. The
metaphor of the transference neurosis as an avalanche will be explored
further in this chapter.
One important question emerges from this vignette: where does this
degree of sadism come from? Does it belong to the patient and is it the
true rage towards her genetic figure(s)? In that sense, it would be part
of her original neurosis. But, developmentally, she was not traumatised
to the extent that she would develop this degree of unconscious sadism.
Was this rage somehow transferred to her unconscious from the previ-
ous therapists unconscious? In this case, the murderous rage would be
iatrogenic and belong to the therapist from her transference neurosis.
These are questions that must be asked but are not easily answered at
this stage.

Vignette III: the major mobilisation of the unconscious,


the removal of resistance, and the passage of guilt
TH: Could you look to see my dead body? My mutilated body. Do you see
the eyes?
PT: Yes. I see my mother.
TH: Go on.You have a massive feeling. Massive feeling. Let it go. Its heavy.
Let it go. Dont hold. Dont hold. Experience it. Experience it. Dont
hold. Let it go.Theres a lot of feeling in you. Let it go. Be human. Dont
hold on it. Theres a massive feeling. Its a massive feeling in you.
PT: I love you. Im sorry. You did your best.
TH: Do you see my eyes? Let it go. She is disastrously mutilated. She is
badly mutilated and destroyed. Could you look at her eyes?
PT: Youre the world to meIm so sorry. My mother is the world
to me. I love her.
52 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Could you describe her body. How is she mutilated?


PT: She is a young woman in her thirtiesmaybe earlier. She is dressed
in white with an apron. There is blood and tissue and bones.
TH: But that is your mother, you mean. Could you describe your mother?
You have to face the truth.
PT: She has light brown eyes and dark hair.
TH: Keep in touch with your mother.You owe it to yourself.You love this
woman. Light brown eyes?
PT: She has big puffy hair. My sister is in the crib close by. I have destroyed
her. I have destroyed her. I have destroyed her.
TH: Could you look again? This is your mother. Could you describe the
way she is lying there, dead? Mutilated. Dead human.
PT: Shes wearing a different outfit. She has brown puffy hair. She is
wearing a yellow turtle neck.
TH: You have a major painful feeling.You love her.
PT: Yes.
TH: Look at her murdered body. She is mutilated. Could you describe her
disastrously mutilated body?
PT: Its gorged out. You can see her internal organs. Her heart and her
lungs.
TH: Could you describe it?
PT: Its just blood, bones and muscles in her chest and abdomen.
TH: Shes badly mutilated. You have a lot of feeling. Experience your
feeling.
PT: Shes smiling because she still loves me. Shes smiling because she
loves me.
TH: Could you describe her?
PT: Shes smiling. Her death was peaceful. Even though I caused her to
suffer, she still loves me very much.
TH: How badly is she destroyed?
PT: I can still see her eyes.
TH: Do you hold her? How do you hold her?
PT: Im so sorry because I love you.
TH: Do you say something?
PT: I love you and Im sorry.
TH: How do you say it?
PT: Im sorry. I love you, Mom. I love you, Mom. Listen to me, I love you.
Im sorry. I love you so much. Im so sorry.
TH: So you deeply love her?
t r a n s f e r e n c e n e u r o s i s : pa r t i i 53

PT: YesI really do.


TH: Do you approach her physically?
PT: I hug her and I hold her head against my shoulder. And I rub her hair
down.
TH: Do you feel her hair?
PT: Yes.
TH: Does she say something to you?
PT: When I tell her I love herit is the intact mother. Not the destroyed
mother.
TH: She says something to you.
PT: I love you, I love you. I love my mother.
TH: Do you see her eyes at this moment?
PT: Yes, theyre brown.
TH: Light brown.
PT: Theyre darker.
TH: She says something to you?
PT: She says, I love you. I love you. You do your best just like I do my
best. Shes very proud of me.

Evaluation of vignette III: the passage of guilt with a focus


on technical issues with the interview
There are several technical issues with this interview that must be con-
sidered. For one, the therapist operates in a circular fashion. The patient
has become more familiar with the process and is more comfortable
with the activation of the neurobiological pathway and the repeated
experience of guilt. The situation is analogous to canoeing in rough
waters. As a beginner, one struggles in a rapid stream. However, with
experience, one welcomes the challenge.
Fusion will be discussed in more detail in a separate section below.
When the fusion of murderous rage and guilt occurs at an early age (one
to three years old), operating in a circular fashion is the best technical
choice. The therapist must strive for serial breakthroughs. She/he
must also allow for the resistance to come back into operation before
attempting another breakthrough. This can take up to fifteen minutes.
Otherwise, the breakthrough would not be serial in nature because the
system is still open.
The second technical issue is that this patients unconscious has
been in a constant state of mobilisation because of her participation in
54 U n d e r s ta n d i n g Dava n l o o s IS - TD P

the closed circuit training programme. The process is protected by a


high degree of activation of the neurobiological pathway. Without this
degree of activation, the process would collapse. To continue in this
direction, the patient should have repeated serial breakthroughs. One
of the keys to structural change in the unconscious is repetition of the
process. She is draining a large reservoir of guilt, but this passage is still
very painful for her.

Vignette IV: the phase of psychoanalytic investigation into


the unconscious and psychic integration
TH: If you look to this, there is a passage of intense murderous and tor-
turous quality. Thats one side. There is an intense primitive system
and intense love. Why you have this love and this need to torture?
Does this come from you or do you do this to please your grand-
mother? Its very important, dont agree with anything I say. Does
all this torturous organisation come from you or do you do this to
please the Queen Bee?
Does this volume of the torturous rage come from you as an indi-
vidual and daughter to your motheror does a huge portion come
from your grandmotherfrom the Queen Bee?
PT: I am not sure why my grandmother would want me to torture my
mother.
TH: We are working on a very important mission. Not factthis is
question. If you can answer it now, fine. If not, later. It has to be accu-
rate.This is a heavy, primitive system. Is this all from you or from your
grandmother?

Evaluation of vignette IV
Following this interview, the patient develops further fluidity in her
unconscious. She is able to spontaneously communicate more about
the grandmothers life. The grandmothers father (the patients great-
grandfather whom she never knew) had a tendency to be explosive.
At this stage, however, it is unclear if the grandmothers neurosis orig-
inally stems from her relationship with her mother or father. At any
rate, the grandmothers neurosis was severe and her mission in life
was to torture either her mother or father. This is transferred from the
grandmother to the mother and then onto the patient, who could poten-
tially transmit it to her own children.
t r a n s f e r e n c e n e u r o s i s : pa r t i i 55

We also see the emergence of the common theme of an individual


turning a family member against other family members (see
Chapter Fifteen for the turning away syndrome). The grandmother
was a master at this, as a result of her own neurosis, and turned the
mother against the father, the daughter against her father, and the
mother against her daughter. In essence, the grandmother turned
everyone in the family against each other. The patients three sis-
ters were also engaged in this. It is difficult to know exactly when
this occurred in the patients life. If it occurred when the patient was
very young, then this means that her resistance will rapidly come
back following the interview. If this occurred when the patient was
two to four years old, then this became a learned process for her. She
learned to destroy the relationships with her siblings, for example.
This became a severe and malignant psychoneurotic disease, as the
grandmother attempted to sever the ties between the family members
at a very early age.
It is important not to blame the grandmother for the turning away
syndrome. Rather, it is important to understand why she behaved this
way. The grandmother was one of thirteen children. As a child, she had
to compete repeatedly with her siblings for the love and attention of her
mother and father. Throughout her life she lived in fear, on an uncon-
scious level, that she would be left out. This is because she was left out
repeatedly when she was younger. The Queen Bees mission in life
was to ensure that this did not happen again. In this context, we see
quite clearly the basis for what Dr Davanloo calls the intergenerational
transmission of psychopathology (the subject of Chapter Fourteen).
It is likely that the behaviour of The Queen Bee was learned because
it had been repeated in the previous generation. Moreover, it is impor-
tant to understand how this destructive system impacted the patient.
At the age that this occurred, the patient was simply a loving child who
wanted her mothers love. Sadly, she struggled against the forces of the
grandmother to get this love.
Understanding these complicated yet profound dynamics between
siblings, parents and grandparents is essential and at the cutting edge
of dynamic psychotherapy. The intricate and subtle nuances of human
relationships (for example, the turning away syndrome) were never
explored to any extent with classical psychoanalytic theory or prac-
tice. It is only recently (Davanloo, 2014a, 2015) that Dr Davanloo has
incorporated these findings into this teaching in the closed circuit
training programme.
56 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Davanloo has spoken about the homeostasis of the unconscious. If a


large column of guilt is evacuated, then, with time, a large column of
guilt comes in to replace it. This is why it is so important to have fre-
quent blocks, so as to provide sufficient structural changes to prevent
the return of the guilt. Currently, the patient is at the beginning of the
journey. Each passage will be a heavier passage of a primitive, sadistic
impulse with a corresponding passage of guilt. That said, the guilt will
be easier for the patient to tolerate with each repeated passage.

Commentary and group discussion


The Montreal closed circuit training programme is a unique training
programme that has evolved at an enormous rate in the last five years.
There is a remarkable group cohesion that results from the process.
Participants have shared extraordinarily intense and personal emo-
tional experiences and have offered to share these experiences with
those learning about Davanloos discoveries during the annual meta-
psychology meetings in Montreal.
In the section that follows, some important themes will be discussed.
These themes came up as this case was discussed extensively in both
the closed circuit training programme (Davanloo, 2013b, 2014b, 2015)
and at the annual metapsychology meetings in Montreal (Davanloo,
2012, 2013a, 2014a). Many of these themes are interrelated but each
deserves attention on its own. It is important to note that some of these
concepts (for example fusion and projective anxiety) have been greatly
refined by Dr Davanloo in the last five years. This particular interview
has been viewed in the group setting more than any other interview of
the patients series and offers many important teaching points.

The role of the grandmothers sister in her original neurosis


Following this interview, the patient spontaneously introduced that her
grandmother had a conflictual relationship with her sister. This sister was
named Josephine. She had moved away and had married a wealthy
Swiss engineer. She was well-to-do in comparison to the grandmother
and would return to her home community every summer to spend time
with the family. Because of her own destructive competitiveness, the
grandmother could not tolerate closeness with this sister. Objectively, it
would make sense that she would welcome her sister and the gifts she
t r a n s f e r e n c e n e u r o s i s : pa r t i i 57

would provide. But she could not stand the closeness that would come
from accepting the sisters kindness. As a result, she destroyed her rela-
tionship with that sister and turned her daughter away from her aunt.

The grandmothers early life orbit and how


this impacted the family
It is also important to understand the grandmothers early life orbit, in
general. This is essential in understanding the making of the Queen
Bee. As a child, she had little in her life besides hard work and strug-
gling to stay out of poverty. As an adult, her existence focused solely
on the hard work of raising her children (as a single mother at times)
and running the home. Living in this hardship led to her desire to be
the Roman Emperor of everyones life. While she was loving, she also
had extensive rage in her unconscious. Her sadistic impulses are in the
unconscious realm and are all about preventing the family members
from getting close to one another. In this sense, she is preparing good
food with one hand, but has a whip in the other hand. Her first husband
died from complications of tuberculosis and she had to raise her two
children as a single mother after the Great Depression. It is important,
then, to acknowledge the hardship she had to endure.

The role of projective anxiety and the court


of the grandmothers unconscious
The patient is a bright, intelligent woman but she undeniably has another
agent in her unconscious that severely limits her potentiality in life.
Dr Davanloo refers to this agent as the court of the grandmothers
unconscious. The patient was always under the power of the grand-
mother. The patient, therefore, has never really known freedom and
autonomy in life. One must recognise, then, that the the court of the
patients unconscious has been invaded by the grandmothers court
and this has been in operation for the entirety of the patients life.
This has important technical considerations for this interview, as the
grandmother comes into the picture whenever the therapist attempts
to get close to the patient and have direct access to the pathogenic core
of her unconscious. This manifests as unconscious anxiety. This inter-
view was very powerful. The verbal content is written above. But the
degree of pain that the patient experienced is difficult to accurately
58 U n d e r s ta n d i n g Dava n l o o s IS - TD P

capture in words. This illustrates the necessity of video technology in


the process, as the quality and intensity of pain are impossible to fully
capture with audiotaping or process notes alone.
Metapsychologically, we must formulate an explanation for this
degree of pain. As the therapist attempts to get close to the patient and
help her evacuate the enormous amount of guilt she has in relation to
the mother, the court of the grandmother repeatedly comes into oper-
ation. As the process progresses, the grandmother is in the court of the
patients unconscious, asking How dare you get close to your mother?
Each time the patient said I love you, mom, the grandmother prover-
bially tightened the rope around her neck. The grandmother comes into
the picture because she has a fear of being left out. But the therapist
relentlessly pursues this, realising that the goal is to allow the patient to
get in touch with the loving feelings she has for the mother.
At a young age, the patient was trained not to get close to her mother.
When the patient sought help in the form of her prior course of treat-
ment she was further damaged.The transference neurosis from that
prior course of therapy serves to reinforce the destructive nature of
allowing the court of the grandmothers unconscious to invade the
patients own unconscious. Davanloo formulates that that therapist
himself established his own court in the patients unconscious.
The goal of Davanloos psychotherapeutic techniques is for the
patient to establish her/his own personal court in the unconscious.
In the case of this patient, her grandmother demanded that her court
take the upper hand. The grandmothers court won this battle and the
patient suffered her entire life because of this. The therapist is deal-
ing with the patient as an autonomous individual. But, if a patient has
a transference neurosis, then she/he has agents/courts behind the
system in front of the therapist and this makes the process far different.
It is useful to imagine these courts as collaborating or even battling to
put victory flags in the patients unconscious to mark their victory and
territory.
As above, the patient has two courts in her unconscious. One court
is the Queen Bee; the other is the therapists court. But they go hand
in hand. The unconscious of the grandmother has allowed the previous
therapist to put his flag into the patients unconscious. One must then ask
if this grandmother had psychopathic character traits. Or was she sim-
ply blinded by her own psychoneurosis and unable to see the damaging
effects of her actions? It is important not to speculate at this point but to
follow the trail of the unconscious as it leads to further truths.
t r a n s f e r e n c e n e u r o s i s : pa r t i i 59

In this patient, then, there are three courts in her unconscious (includ-
ing her own). Handling these three courts is not easy. The patient is
operating as if she is a three-year-old child. As a three year old, her only
goal in life is to get close to her mother. But these two courts (one that
is the grandmother and the other that is completely iatrogenic) dictate
that she must never get close to her mother.
The presence of the court of the grandmother comes and goes in the
above interview. When this court comes, the patient either has projec-
tive anxiety or is in much pain. The grandmother never wanted to give
autonomy to the mother or the patient. As a result, the two figures of
the mother and grandmother are fused in the patients unconscious.
The mother, grandmother and patient are then fused and united in tor-
turing each other for the rest of eternity. The above intricate psychody-
namics explain why the interview is so tough and painful for the patient.
As she gets close to her mother, she experiences the full neurobiological
pathways of murderous rage and guilt. This allows her to fully experi-
ence her love towards the mother. Metapsychologically, this causes the
grandmother and previous therapist to suffocate. Given their tremen-
dous hold on the patient, the process is rockier than it should be.

Fusion
Fusion was introduced in Chapter Three. The age that the fusion occurs
is especially important. The earlier it occurs, the more damaged the
patient is and the more complicated the entry into the pathogenic core
of the unconscious will be. In order to proceed with a major mobilisa-
tion, the fusion must be removed so that the distinct columns of uncon-
scious emotions are fully experienced.
At what age did fusion occur for this patient? It is clear that the
patient had a bond with her mother as a baby and that the grandmother
tried to destroy this bond because of her own unconscious issues. The
age of fusion of murderous rage and guilt in the unconscious is the
age at which the grandmother tries to destroy the patients bond
to the mother. Since this comes from the previous generation, and is
largely the result of the grandmothers character issues, we know that
fusion occurred in the early phase. It is unlikely that the grandmother
would let the patient have a loving relationship with the mother and
then interfere at age five or six.
The patient has more fusion with her grandmother than her mother.
She has tremendous feeling that the grandmother actively invaded in
60 U n d e r s ta n d i n g Dava n l o o s IS - TD P

her own life with her mother. The patients toughest battle is the trans-
ference neurosis with her previous therapist because that therapist (in
her unconscious) is her grandmother. The issue is how best to create a
strategy for dealing with this transference neurosis.

Transference neurosis
As we get a better sense of the grandmothers life orbit, more light is
shed on the exact nature of the transference neurosis in this patients
life. It must be stressed that the patient is not being treated for her
transference neurosis. More information has been gathered by the
above process. If anything, a foundation is being laid for possible treat-
ment in the future should the patient and therapist agree to it. Under-
standing and removing transference neurosis is a pervasive theme in
this book.
The lack of autonomy is central to this patients transference neurosis.
The patient is, metaphorically speaking, not the captain of her own
ship. It is necessary for parents to be commanders of the lives of their
children. But a healthy childhood, which is relatively free of psychoneu-
rotic illness, manifests an autonomous adult. This is the cycle of human
life, but a transference neurosis aborts such a healthy transformation.
One of the many degrading aspects of the transference neurosis is that
it introduces another parent into the patients unconscious in the form
of the therapist. We must question why Freud regarded it as such an
important part of the psychoanalytic process and why dependence on
the therapist was almost universally encountered in psychoanalysis
(Freud, 1933a; Reed, 1990).
The head-on collision is an intervention that communicates that
freedom is a fundamental human right (Gottwik & Orbes, 2001). It is
collaborative in nature and highlights the right of the human being to
be captain of their own destiny. The therapist accepts no responsibility
for the patients choices and fate in life. Davanloo argues that psycho-
therapy should promote adult autonomy and freedom. It should not
promote childlike dependence and regression.
As a result of this patients transference neurosis with her previous
therapist, her original neurosis remained unexamined for many years.
Her previous therapy focused on her father and not the mother and
grandmother. While this interview was bumpier than it should have
been, the patient was still able to drain a massive reservoir of guilt for
t r a n s f e r e n c e n e u r o s i s : pa r t i i 61

the mother. With this came a degree of fluidity in the unconscious such
that the patient became more receptive to the MUSC that the therapist
began to apply. It is important to note that the patient revealed the
information about her grandmothers sister (Josephine) following such
a breakthrough. This was enormous data with no contamination of
resistance, as the UTA was in dominance at that time.
Further questions arise. Exactly what part of her sadistic murderous
rage belongs to her and what part belongs to her previous therapist?
At this stage, it cannot technically be divided. But, ultimately, the result-
ing guilt belongs to the patient. She is acting on behalf of the previous
therapist. Davanloo likens the situation to the patient being employed
by this previous therapist who is now commanding her life. Uncon-
sciously, he tells the patient that she is doing his criminal work and
that he has given her murderous material to destroy under her name.
Clearly, this is a massively disastrous interaction.
Davanloo has repeatedly referred to the ethical issues involved in the
formation of transference neurosis. The patient does have a responsibil-
ity in this situation. She went to a destructive therapist and went along
with a therapy that she questioned. She repeatedly informed the thera-
pist of her transference neurosis and, on some level, was aware that the
situation was not getting better. On an unconscious level, she knows
that she was responsible in complying with the therapist. In this case,
the therapist transferred his own neurosis (and his own tremendous
sadism towards his genetic figures) onto the patient.

The destructive competitive form of the transference neurosis


This particular breakthrough is more extensive than the previous ones.
It is very heavy and the patient described that she felt exhausted after it.
From a metapsychological perspective it is clear why it is heavier.
This patient is heavily damaged by a destructive competitive form
of transference neurosis with her own mother. This process is very
complex and very guilt-producing and will be explored in detail in
Chapter Ten of this book.
One must ask: what exactly is a destructive competitive form of trans-
ference neurosis? Essentially, this is an intra-psychic phenomenon that
involves the need to destroy other members of the family. Often there
is an intergenerational component and an element of rivalry at play.
This phenomenon contains heavy murderous rage with intense guilt.
62 U n d e r s ta n d i n g Dava n l o o s IS - TD P

The grandmother starts to destroy her daughter because she is the


target of this destructive competitive form of the transference neurosis.
Destroying the daughter (the patients mother) builds more guilt in
the unconscious. As murderous rage increases, so does guilt. The two
remain in a fused state in the unconscious.
The patient loves her grandmother but the grandmother also had
a destructive competitive form of transference neurosis with her own
mother and/or father. It turns out that the grandmothers father was
explosive. At this stage, it is not clear if the grandmothers original
neurosis centred on him or her mother. At any rate, the grandmother
transferred it onto her daughter (the patients mother), who is also a
carrier of this destructive competitive form of transference neurosis.
It is clear, then, that the grandmother has an intra-psychic system that
constantly generates a massive guilt. Destroying her own daughter calls
for a heavy pernicious guilt that is very destructive. What complicates
the picture is that the grandmother aligns with her own granddaughter
(the patient) to destroy her own daughter. In doing so, she abuses the
grandmother/granddaughter love and bond. When she uses her grand-
daughter against her own daughter, the grandmother becomes a master
of destruction. In this sense, the grandmother has adopted the profes-
sion of generating guilt. The patient has incorporated this into her own
unconscious.
This pernicious guilt is massively fused in the unconscious of the
grandmother, the mother, and the patient. In the patients example, she
kept building on this guilt by seeking out the destructive relationship
with her previous therapist. The grandmother had the patient in her
own camp to destroy the innocent mother. In this sense we must ques-
tion: did the grandmother have a psychopathic form of the destructive
competitive form of the transference neurosis? This would explain why
the patient went to such a destructive therapist.
These concepts are very disturbing and many participants in the
closed circuit training programme find themselves resistant to consider-
ing them. It is particularly disturbing, for example, to consider that var-
ious genetic figures have psychopathic tendencies. Indeed, Davanloo
does not use the term psychopath in the same sense as the DSM 5
(American Psychiatric Association, 2013). Rather, he uses it to shock
the unconscious and to refer to those tendencies of family members to
act in an extremely destructive fashion.
Davanloo has discussed the concept of the patient becoming the
victim of the generation before. There is intergenerational transmission
t r a n s f e r e n c e n e u r o s i s : pa r t i i 63

of psychopathology (the focus of Chapter Fourteen) to the innocent


members of the next generation. In this case, the patient is being sacri-
ficed for the great-grandmother or great-grandfather (or both). Or pos-
sibly, she is being sacrificed for her great-aunt. Davanloo has referred
to the novel Crime and Punishment by Dostoevsky. An innocent person
is meant to suffer for a crime that she/he did not commit. In this sense,
the patient is being tortured in this system for an unconscious crime
that she did not commit. This phenomenon is at the heart of intergen-
erational transmission of psychopathology.

Unconscious defensive organisation


It is important to note that many therapists who have had previous ther-
apy arrive at the closed circuit training programme with an impaired
unconscious defensive organisation. This is because many therapists
outside of this programme confuse defences with major resistance. For
example, a patient may have a healthy defence in an interview session,
but the therapist might mistake this as major resistance and label it as
such. Doing so damages the unconscious defensive organisation of the
patient. The patient suffered this kind of damage to her defensive struc-
ture in her previous therapy. But her unconscious defensive organisa-
tion (the focus of Chapter Twelve) is not yet destroyed.
This is a very high quality passage for a number of reasons. The
patient is experiencing the most painful human emotion. There are no
malignant character defences in operation. She must protect and pre-
serve the integrity of her character. While the transference neurosis has
damaged her unconscious, it has not damaged her integrity. It is highly
admirable that the patient can get in touch with this feeling for her
mother. She experiences the most painful human emotionsintense
guilt combined with intense love. With this experience of love, we see
the dialogue between the mother and the daughter. It is important to
note the vulnerability of the patient at this moment. For this (amongst
other reasons), the interviews must be audiovisually recorded. This is
because the vulnerability of the patient is very high and it is vital not
to distort or misinterpret the exact passage of emotion and communica-
tion from the unconscious.
Intra-psychically, what is needed is for this patient to align not
with her grandmother but with her mother. Her transference neuro-
sis with the previous therapist served only to reinforce this misalliance
with the grandmother. Intellectually, the patient knows that this is the
64 U n d e r s ta n d i n g Dava n l o o s IS - TD P

royal road to her freedom and her mothers freedom. Experiencing this
depth of emotion (both positive and negative) shows that she has the
highest respect for both herself and her mother. In fact, during the pas-
sage of guilt, Davanloo has sometimes said do it for her and for you
acknowledging the unique benefit not only to the patient but to her
mother as well.
This is the beginning of what Davanloo refers to as unconscious
structural changes. These changes are largely in the realm of her uncon-
scious defensive organisation. The patient begins to have a different
view of the reality and potential of her relationship with her mother.
At the nuclear centre of the patients unconscious is a powerful alliance
and relationship with her mother. This is, indeed, the foundation of her
relatively well put together, albeit destructive, character. She begins to
respect herself and her mother. The patient has a tremendous depth of
communication towards her mother when she utters the words I love
you so much. The tone of her voice cannot accurately be captured by
text alone. This moment offers one of the best foundations to establish
what went wrong in the relationship with the mother. But first, the
patient must allow herself to experience the depth of her love for her
mother. By experiencing this love, she is restructuring her current rela-
tionship with her mother as well.

The protective role of the high TCR


It is important to note the contagious quality of the transference neu-
rosis. Many therapists say that they are correctly applying Davanloos
technique but they have inadequate training to do so. In addition, many
of these therapists are blind to their weaknesses and limitations. Some
have psychopathic elements in their characters. The transference neu-
rosis, then, can involve multiple psychopathic therapists and, in this
sense, can have something akin to satellite operations.
The high TCR is needed to access the mountains of guilt in this
patients unconscious. The patient sees her mother and has tremendous
feeling about it. She has the highest respect for her mother and her-
self. During this interview, she fully realises that the royal road to her
freedom lies in re-establishing a loving relationship with her mother.
The grandmother was very much part of the intra-psychic problem and
played a key role in destroying that relationship. With this, we begin
to see a different patient. She becomes more highly sophisticated.
t r a n s f e r e n c e n e u r o s i s : pa r t i i 65

She realises that she has lost her relationship with her mother, father,
and grandmother. There is tremendously high guilt associated with
thisthe optimum rise in the TCR not only protects the process but
allows and encourages it, as well.

Conclusion
To summarise, this was a very important interview for this patient
for many reasons. One is that she got in touch with her core neuro-
sis. This patient has a deep love and attachment to her mother. With
this, she has painful guilt-laden feelings because she betrayed this
love and attachment by aligning with her grandmother to torture her
mother. Prior to this, these feelings lay buried as a massive abscess in
the patients unconscious. This abscess demanded that the patient be
destructive in life and suffer. The formation of a transference neurosis
was a by-product of this need to suffer. A further goal would be to have
serial breakthroughs into the patients unconscious and to remind her
that she does not need to accept destructiveness in life. This interview
was extensively discussed by Davanloo and his group participants in
multiple settings. It highlights many of his newer techniques and con-
cepts. For this reason, this brief summary will serve as a foundation for
the more detailed chapters that follow.
C hapter seven

Multidimensional unconscious structural


changes: Part I*

W
e continue to focus on our case. The first interview focused
on the major mobilisation of the patients unconscious
and the total removal of the resistance. The next two inter-
views focused on the patients transference neurosis with her previous
therapist. A number of important concepts were reviewed in the last
chapter. These included the following:

1. The role of the grandmothers sister in her original neurosis.


2. The grandmothers early life orbit and how this impacted the family.
3. The role of projective anxiety and the court of the grandmothers
unconscious.
4. Fusion.
5. Transference neurosis.
6. Destructive competitive form of the transference neurosis.

*Originally published in 2015 as Multi-dimensional unconscious structural changes


in Davanloos Intensive Short-Term Dynamic Psychotherapy: Part I (pp. 4551) and
Multidimensional unconscious structural changes in Davanloos Intensive Short-Term
Dynamic Psychotherapy. Part II (pp. 5357) in Archives of Psychiatry and Psychotherapy (1).
Reproduced with permission.
67
68 U n d e r s ta n d i n g Dava n l o o s IS - TD P

7. Unconscious defensive organisation.


8. The protective role of the high TCR.

What follows is the fourth interview in the series, which was previously
published as two articles (Hickey, 2015a, 2015f). However, the evaluations
and commentaries have been updated since these two publications. There
will be a special focus on the use of MUSC as a means of solidifying the
therapeutic task, acquainting the patient with her resistance, and high-
lighting the possibility for change. Simply put, MUSC are any interven-
tions used by the therapist to change various unconscious structuresfor
example, unconscious defensive organisation, unconscious resistance,
unconscious anxiety, and/or unconscious emotion. In doing so, the thera-
pist attempts to help the patient make conscious sense of the unconscious
material that comes to the forefront during the interview process.

Vignette I: the therapeutic task and the phase of dynamic enquiry


TH: Ok, thanks for coming. In spite of that we have a lot of data. But some
of the things need to be more explicit. How do you feel now?
PT: I feel anxious. Before you came in I felt anxiety.
TH: How do you account for that anxiety?
PT: I feel there is a rage building in me.
TH: So you feel the rage?
PT: I do.
TH: You are still on the principle of honesty?
PT: I am.
TH: Complete honesty? Lets see how you experience the rage.

Evaluation of vignette I
The patient has gained a degree of familiarity with the experience of
the neurobiological pathways of anxiety, rage, and guilt. She presents
with anxiety about meeting the therapist again. On brief exploration,
she acknowledges that the anxiety is explained by the murderous rage
she feels towards the therapist. In this case, the therapist does not pur-
sue the steps of the central dynamic sequence in a sequential manner,
as there is no need to. The patient has far less resistance than what was
present in the first interview. Fewer interventions are therefore needed
to mobilise the TCR. The therapist simply puts pressure on the patient
to experience the neurobiological pathway of the murderous rage in the
transference and the impulse to murder the therapist.
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 69

Vignette II: the experience of the neurobiological pathway


of murderous rage in the transference and the passage of guilt
PT: I have a knife. And I go in your nose. Pound your head. Pound it.
Pound your head. Into the ground. I smash your head into the
ground. I put my foot in your face.
TH: And then? And then? What do you see there? Who do you see
there?
PT: My father.
TH: Father? Let it go.
PT: I love you.
TH: Let it go.
PT: I love you. I love you.
TH: Let it go.
PT: I love you. I love you.
TH: Let it go.
PT: I love you. I love you. I love you, Dad. Im sorry, I love you and Im
sorry.
TH: What do you see there?
PT: I see my father.
TH: What colour are the eyes?
PT: Very light blue.
TH: You see those blue eyes. Let it go, you have a lot of feeling.
PT: I love you. I love you. I love you, Dad. I love you, Dad. Im sorry.
I love you, Dad. Im sorry. You know how much I love you, Im
sorry. Dont leave me. Dont leave me. Dont let her drive a wedge
between us. Dont let her do it. Dont let her do it. Im sorry.
Im sorry.
TH: How old is he? In this?
PT: He has darker hair so I think he would be in his forties.
TH: Hair is dark.
PT: But there is some grey.
TH: How do you look at him?
PT: Hes peaceful and happy and content and relaxed. He loves me.

Evaluation of vignette II
The murderous rage and guilt towards the patients father are of
supreme importance. The patient is able to comfortably and com-
pletely experience her guilt in relation to this important genetic figure.
70 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Chapters Five and Six focused on the patients previous transference


neurosis. As a result of the transference neurosis, the patient did not
have an appropriate focus in that therapy. In a misguided effort to
directly access the unconscious, that therapist pursued multiple major
unlockings focused on the father. Subsequent closed circuit evaluations
showed that this was the wrong focus.
At the heart of the patients pathogenic organisation of her uncon-
scious was the conflictual but loving relationship with her mother. When
the patient was a young adolescent, the mother turned her against her
father with whom she previously had a loving and affectionate relation-
ship. This resulted in murderous rage and guilt towards her mother. But
because of the past therapy and transference neurosis, the patient has
an even more massive build-up of guilt. The guilt towards her mother
was largely unexamined in that course of therapy. The guilt towards
her father, while present, was in many senses exaggerated and embel-
lished. The patient colluded with the previous therapist in creating an
avalanche in the unconscious. The true core neurotic structure lay
unexamined like a treasure chest covered in an avalanche of snow. This
added to the massive reservoir of guilt in the unconscious and fuelled,
rather than treated, the patients ongoing symptom and character
disturbances.
We must examine the conditions that create the atmosphere for such
a smooth passage of murderous rage and guilt in the above vignette.
Many patients can present at this moment of therapy with projective
anxiety. In this case, the therapist may currently be assuming the role
of a past genetic figure. The patient may see the therapist as her grand-
mother, the Queen Bee, who constantly hovers in the background of
all of her human relationships and interactions.
In this vignette, the therapist employs the technique of total removal
of projective anxiety. Because of the highly mobilised milieu of the
closed circuit training programme, very few interventions are needed.
Throughout the programme, participants are exposed to a number
of therapeutic interventions (by means of live interviews, review of
audiovisual recordings) that mobilise the unconscious. Head-on col-
lision is employed on and on. Participants come to understand that
there is no room for malignant character defences. There is no sense
of omnipotence. If one wants to learn this technique and engage in the
total removal of resistance and major mobilisation of ones own uncon-
scious, then the responsibility lies with the individual. In this sense,
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 71

projective anxiety is removed as a result of both group and individual


processes and interactions.As a result, direct access to the unconscious
and complete experience of the neurobiological pathways of murder-
ous rage and guilt becomes not only possible but comfortable.

Vignette III: the phase of psychic integration and


the incorporation of MUSC
TH: How big was the knife?
PT: Was there a knife? I cant remember.
TH: What do you think?
PT: There was a knife in your nose.
TH: What do you remember?
PT: I just remember pounding.
TH: What do you remember?
PT: My memory was that there was a knife in your nose and I pounded.
It was very powerful and I took you and pounded you in the floor.
TH: What do you do with the knife?
PT: What comes to mind is that it goes up the rectum. Because he was
penetrated in life. He was a subordinate to my mother and grand-
mother. They called the shots.
TH: So both of them dominated your father? Who else besides the two?
PT: I added to it. I aligned with my mother and grandmother. But less so
than my other sisters.
TH: All throughout your life?
PT: Mostly since my early teens.
TH: Do you have a memory?
PT: Yeah, I had an affectionate relationship with him when I was four,
five, six years old and then I gradually grew apart from him. We had
less hugs and kisses when I was eleven, twelve, thirteen years old.
I am sure it was under the influence of my mother.
TH: Why are you not sure? Y oure not 100% sure about being in align-
ment to torture your father? Why are you vague in your memory
about it?
PT: I didnt realise I was being vague about that.
TH: This torture of your father and alignment with your mother and
grandmother is very important. You say your father was basically a
passive person. What did your father do for a living?
PT: He was a fireman and then an electrician and then a fireman.
72 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: So his last job was a fireman. He did physical work.


PT: He worked at the airport. There werent a lot of fires. It was not that
strenuous.
TH: You said that, in a sense, you have a memory that your mother and
grandmother run him around. He was used and abused by your
grandmother.
PT: If you consider neglect abuse, then he was certainly abused.
TH: You have memories? How would you say his relationship is like with
your mother?
PT: Its very bad. Ive never seen them be affectionate.
TH: How was he with your mother? Was he critical of her or would they
clash with each other?
PT: My memory is that my mother was critical of him.
TH: Could you tell me about your memory of him being scolded?
PT: Once he tried to do some cleaning after he had had a few drinks. She
would yell at him and be explosive. She was never like that with us.
TH: Could you describe an instant where she was explosive?
PT: She said: What are you doing? Why are you using that? Youve
made a mess.
TH: You have a specific memory? That she was openly critical that he was
no good. Do you have a specific memory? You take a sigh whenever
I say specific memory.
PT: I do have a memory.

Evaluation of vignette III


In the above vignette, we see the therapist engaging in the process of
MUSC. Junior therapists often focus heavily on MUSC during the phase
of psychic integration following the unlocking of the unconscious and
the breakthrough of murderous rage and guilt. Ideally, however, MUSC
should be incorporated throughout the interview regardless of which
phase of the central dynamic sequence the therapist is employing.
Incorporating MUSC into the interview is important in patients who
have had transference neuroses like this patient. The consequences of an
untreated transference neurosis are widespread. If it is not removed, the
patient will continue to be destructive and pass this on to her children.
It is clear that this patient has a massive reservoir of guilt in relation to
her father. While he was the focus of her prior therapy, he was not at the
nucleus of her core neurotic structure. Ironically, the guilt towards her
father was intensified because it was not fully and accurately evacuated
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 73

in her prior course of therapy. Just as the father assumed the pene-
trated position in life, he also assumed the penetrated position in her
prior course of therapy. This guilt is the engine to many of her distur-
bances and manifests as a massive inhibitory force in her life. She per-
ceives herself as less intelligent than other therapists around her. She has
difficulty with her husband and feels sexually inhibited in this relation-
ship. She repeats the patterns of her mother, father, and grandmother,
who, because of their own neuroses, were part of a lost generation. This
is a very painful reality for the patient.
At some point in this patients development she was turned against
her father by her mother and grandmother. The father was subse-
quently deprived of a loving and affectionate relationship with his four
children. This highly destructive pattern is not immediately obvious to
the patient, despite her mobilised unconscious. Unless these destruc-
tive forces are highlighted repeatedly, the patient will continue to be
destructive. In order to change, she needs to be made aware of what
needs to change. Otherwise, without this emphasis, the destructiveness
will continue and be passed on to the next generation in an intergenera-
tional transmission of psychopathology.
The above vignette demonstrates the inverse relationship between
guilt and memory. The patient cannot remember some of the details of
the passage of murderous rage. She cannot remember that she attacked
the therapist with a knife. In general, the larger the reservoir of uncon-
scious guilt, the more impaired is the patients memory for the histori-
cal details of her early life. The sooner the guilt is removed, the sooner
the patient will get her full memory back.

Vignette IV: the second major unlocking of the unconscious


TH: And what was your reaction?
PT: If I felt anything, I never stood up for him. But as you say that, Im
sure I feel angry. But I never stood up.
TH: But how you feel?
PT: I feel a rage building. Towards her.
TH: Right now, you take a sigh.
PT: Its building again.
TH: So you want to experience it? Is it rage? Youre talking about the
rage?
PT: Its a violent, murderous rage towards my mother. I stab you in the
eye. I would choke you repeatedly. I see your legs dangling mid-air.
74 U n d e r s ta n d i n g Dava n l o o s IS - TD P

And I squeeze tight, as tight as I can. And I bang you against the floor.
Pound the floor. Why? Why do you have to do this? Why?
TH: And still you have rage towards your mother?
PT: Why? [Massive passage of guilt.]
TH: How do you feel right now?
PT: I love you. I love you, Mom.
TH: What do you see? Could you describe the body of your mother?
PT: I see my mother as a very young girl and she just lost her father and
she is so alone.
TH: When she was nine, he died?
PT: She would do anything to get him back. I tortured her in life.
TH: She talked to you about her father?
PT: Now?
TH: Any time?
PT: She has.
TH: There have been times that you talk? What did she say?
PT: She loved her father. He was very kind and warm and loving.
TH: You mean the grandfather was kind. The grandfather who died was
kind. Could you describe the way she portrayed her own father?
PT: He was the life of the party. He was a loving man. He was kind and
warm and loving and affectionate and a wonderful person.
TH: And when you say thisyou mean your mother really then turned
against men because her father died on her? And she has a lot of
feeling about that.
PT: Her recollection is that he was a very loving man.
TH: She destroyed her own relationship with your father?
PT: Yes. Under the power of my grandmother. Thats what comes to
mind. My grandmother wanted it destroyed.
TH: When you do this, you murder your father. Y ou murder your mother.
Do you see the dead body?
PT: I see it as a flash and then it comes to life again like a living body. They
go from being dead to being living.
TH: Out of here also?
PT: Im not sure what you mean.
TH: Your mother has an affectionate bond for her dead father but she
destroyed it with your father. What do you make of that? That she
destroyed but she was craving an affectionate relationship with her
own father.
PT: It goes to show you how destructive she is.
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 75

Evaluation of vignette IV
The patients mother lost her father, who was an affectionate and loving
man. The patients grandmother subsequently went on to struggle with
poverty as a single mother to two young children. Given the economic
reality of this situation, she became dependent on her own mother and
father to help her raise these children. To some degree she is loaded
with murderous rage and guilt towards her first husband about this
fateful event in her life. The only way she can deal with this traumatic
event is to become even more massively controlling; hence, the persona
of the Queen Bee. She exerts massive control on the people in her life
and this serves only to drive people further away. She cannot tolerate
a close bond with another affectionate and loving man, so she married
her second husband (Grappy), who was explosive.
The patient, through the mechanism of intergenerational transmis-
sion of psychopathology, has been raised by a damaged system. To
remedy her guilt, she seeks out more guilt by developing a transfer-
ence neurosis with her previous therapist. MUSC are needed so that
she can be fully acquainted with these destructive forces. In this phase
of her therapy, there are repeated breakthroughs in the transference
with repeated passages of guilt. This must occur until such a time that
there are sufficient unconscious structural changes. In actuality, the
patients resistance has undergone some structural changes and there
is an emergence of an early UTA. However, the resistance still domi-
nates the UTA. For the process to proceed, the UTA needs to build and
dominate the resistance. Dr Davanloo has referred to this early UTA as
a young, dynamic system (Davanloo, 2013b). Given that she travels
from Europe, it would be ideal for her to have block therapy sessions at
least once per month. Otherwise, this young, dynamic UTA will die and
further attempts at therapy will be analogous to starting from scratch.

Vignette V: further MUSC: focusing on the patients current life


orbitthe C in the Triangle of Person (Menninger, 1958)
TH: So that was your mothers attitude towards men and your grandfather.
What is the way you are with men?
PT: My relationships with men are easier than my relationships with
women.
TH: Right now, how about in your current life. How is your marriage?
76 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: I think that its a good marriage. But Im a bit domineering and I dont
like it and I am constantly aware of it.
TH: What way are you domineering?
PT: I say to my husband, lets go here, lets do that.
TH: Whats he like? You are the decision maker like your mother. Does he
want to follow you or he gets upset about it?
PT: For the most part, he does want to follow.
TH: So, in the daily life situation, you are the one who is the power in the
marriage?
PT: Yes.
TH: And he follows. Do you like it?
PT: No, I dont like it.
TH: Why?
PT: I know what its like to live with a woman like that.
TH: I know, but that is what you know.
PT: I dont want my husband to be penetrated.
TH: If we dont use symbolic communication, in what way do you control
your husband?
PT: I convinced him to move to my home town when he didnt want to.
I dont want to be the Queen Bee in this relationship. I know I have
that tendency.
TH: Does he go along with you or bottle up his feelings?
PT: Thats a good question.
TH: You mean you dont have thoughts?
PT: My thought is that he doesnt want me to go explosive.
TH: Do you have an example?
PT: Before we got married, I was upset about some minor details about
the wedding. I had a tantrum on our living room floor. I was curled
up in a ball on the floor.
TH: Could you describe in more detail what you were feeling?
PT: Rage.
TH: Towards who?
PT: The situation.
TH: That means you have rage towards him but you displaced it.
PT: I must have, there is no reason to take it out on the floor.
TH: Did you experience rage?
PT: I dont know.
TH: Is there a time you get enraged with him?
PT: Sometimes.
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 77

TH: Are you talking to me about your husband in a real, honest way?
PT: I think so.
TH: You have a major problem with your mother and your grandmother.
The issue is cover upcover up means misery is going to be there.
PT: I dont want to cover up.
TH: My questionis there any time you get enraged with him and put it
out or cover up?
PT: Sometimes, when he doesnt help out with the kids or the cleaning.
TH: Any time you were physical with him?
PT: No, never.
TH: How do you describe him?
PT: He is tall, about six foot one. And 180 pounds. Athletic.
TH: What does he do for a living?
PT: Hes an engineer.
TH: Any problems in the marriage?
PT: I think that I am sexually inhibited. Id like to be less. I dont like him
initiating sex.
TH: Where does he work?
PT: In an office building. He does contract work.
TH: You have a lot of difficultymoving with your past. Grandmother,
mother, all both damaged very badly. The marriage has potentialities.
But also has a lot of difficulties. Could be much better. Is that your
agenda, to make it better?
PT: My feeling is that I dont deserve a close, loving, sexual relationship
in a marriage.
TH: But do you want to change?

Evaluation of vignette V
Here the therapist is focusing on the patients relationship with her
husband. The emphasis is on achieving a balanced human relationship.
The patient struggles with this because she inherited a destructive com-
petitiveness from her mother and grandmother. This destructiveness
led to the patient seeking out an unhealthy therapeutic relationship
with a past therapist. This relationship resulted in the formation of a
malignant transference neurosis.
During the MUSC highlighted above, the therapist is attempt-
ing to block the passage of the destructive transference neurosis from
the previous generation to the marriage. Sadly, nothing can be done
78 U n d e r s ta n d i n g Dava n l o o s IS - TD P

for the patients father, who was the victim of the controlling Queen
Bee that was the grandmother and the mother to some extent. At this
point, the only hope is that the husband can be protected from this
malignant force.
There is a definite danger of the transference neurosis moving
in the direction of the patients husband. The question is how much
has the transference neurosis damaged the marriage up until this point?
The patient senses the potential for further damage and the potential for
change. She understands the need for structural changes. Otherwise,
she might do what her mother did and allow the destructiveness of the
previous generation to sabotage her potential in life.

Conclusion
The above is the fourth in our series of interviews. We can see that
the patient, as a result of her participation in the closed circuit train-
ing programme, arrives at the interview in a mobilised state. Very few
interventions are needed for her to fully experience the neurobiological
pathways of murderous rage and guilt. What is needed, however, is a
careful application of the process of MUSC. The phase of MUSC runs
parallel to the central dynamic sequence.
Some clinicians have argued that the only goal of IS-TDP is to gain
direct access to the patients unconscious and evacuate the reservoir of
guilt. Such a reductionist approach is short-sighted and does not reflect
the richness of the current day theories and techniques of Davanloo.
Without the thoughtful application of MUSC throughout all phases
of the interview, the patient cannot achieve an understanding of their
resistance, their destructiveness, and their capacity for change in life.
The next chapter in this series will continue to highlight the importance
of MUSC and will focus on the neurobiological pathways of murderous
rage and guilt.
C hapter eight

The neurobiological pathways


of murderous rage and guilt

T
he first interview focused on the major mobilisation of the
patients unconscious and the total removal of the resistance.
The next two interviews focused on the patients transference
neurosis with a previous therapist and the metapsychological and
treatment considerations of this. The fourth interview in the series
focused on the use of MUSC throughout the interview process and how
MUSC are the building blocks for change in the patients defensive and
character structure. This next interview will focus specifically on the
neurobiological pathways of murderous rage and guilt.

Vignette I: the phase of enquiry and the therapeutic task


TH: So we are meeting again.
PT: Yes.
TH: And you look forward to it?
PT: Yes.
TH: And again we move to this principle of honesty.
TH: To explore the most painful issues and honesty is the principle.
How do you feel right now?
PT: I was anxious in the room.
79
80 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: How do you feel right now?


PT: I dont feel that anxiety right now. I feel pretty calm. I feel ready to
do this. I feel motivated and ready to explore my feelings.
TH: Motivated to do what?
PT: Explore my feelings.
TH: How do you feel right now?
PT: I felt anxious when I said feeling.
TH: How do you feel right now? Youre anxious.
PT: I feel the rage building again.
TH: It immediately comes up.

Evaluation of vignette I
The therapist begins the interview in the same fashion that the other
interviews were conducted. There is a focus on honesty. By agreeing
to focus on the most painful issues the patient is agreeing to complete
honesty and transparency in the session. This immediately increases her
feelings in the transference and the TCR. On one hand, the patient wants
to clean up her unconscious. But on the other hand, she would prefer
to let sleeping dogs lie. The therapists emphasis on her ambivalence
increases her transference feelings. She is deeply appreciative that the
therapist will have no tolerance for anything but the truth. But his
dogged and relentless pursuit of the truth will immediately stir up her
feelings and her resistance.
Throughout the interview process, the therapist is constantly evalu-
ating various parameters of the patients unconscious. In this sense, the
therapist is scanning the unconscious and is constantly searching for
the resistance of the patient. Outlining the therapeutic task and the need
for honesty sets the stage.
Given that this is the fifth interview in the closed circuit setting, the
patient has some familiarity with the process. She feels rage more quickly
than in previous sessions. The therapist, therefore, casts his attention to
the neurobiological pathway of murderous rage. Overall, this pathway
is in operation and the process is in the early stages. But the therapist
must monitor the process to ensure that it reaches its maximum level.
When the patient takes a sigh, it signals to the therapist that she has
unconscious anxiety. At this time, she has projective anxiety. On one
hand, she sees the therapist as an important figure from her pastmost
probably her grandmother. On the other hand, she is afraid that she is
t h e n e u r o b i o l o g i ca l pat h way s o f m u r d e r o u s r ag e a n d g u i lt 81

actually going to murder the therapist. The therapist formulates that


the patient has been travelling with her grandmothera domineering
womanthroughout her entire life. This is important, because she will
perceive the therapist (as an authority figure) as her grandmother.

Vignette II: the experience of the neurobiological pathway


of murderous rage in the transference
TH: How do you feel towards me?
PT: Now there is a power in my abdomen.
TH: Where do you feel it?
PT: Now I feel it coming up out my arms and it wants to launch again.
In your right eye.
TH: Decrease number but increase power.
PT: In your right eye.
PT: Carving down your face. I feel your neck. Your neck is big.
TH: And if you continue. Full intensity. Full intensity. How far would
you go?
PT: And I pound on your chest and your dead body. Dead. Dead. Dead.
And I pound on the abdomen. And I take the knife and I slash
the uterus.
TH: And then? And then? And then?
TH: How do you feel right now? Its a major wave in you. Its a major wave
in you. Its a major wave in you.
PT: I love you. I love you. I love you. I love you. [Passage of guilt-laden
feeling.]

Evaluation of vignette II
There is a significant passage of murderous rage in the transference.
In order for this to occur, the TCR must reach a critical threshold. To
fully maximise the neurobiological pathway of murderous rage, how-
ever, the TCR needs to be further maximised. While the patient has
some familiarity with the physical experience of the murderous rage,
she needs structural changes.
Like many patients with obsessional character defences, the patient
has had a lifelong tendency to mistake the neurobiological pathway of
anxiety with the neurobiological pathway of murderous rage. These
patients confuse the sensation of anxiety with the feeling of rage.
82 U n d e r s ta n d i n g Dava n l o o s IS - TD P

This confusion relates to the age of the patient when the attachment and
bond to the important genetic figures was disrupted. In this case, the
patient was likely between the age of two and three years old. At that
age, the patients neurobiological system was not fully developed. In this
sense, she must begin to learn how to fully experience the physical and
emotional concomitants of rage.
To fully experience the rage, the patient should decrease the fre-
quency of the movement (repeated gestures of carving the face) but
give more power to the intensity of the passage. Increasing the intensity
of the passage of the rage not only acquaints the patient to the true
neurobiological pathway of this emotion but it also removes the projec-
tive anxiety. By experiencing the physical sensation of this impulse
some patients describe it as a building volcano or an exploding
fireballthe patient learns that there will be no actual murder despite
her unconscious anxiety about one actually occurring.
With each breakthrough into the unconscious, the intensity of the
passage increases and the neurobiological pathway of murderous rage
undergoes structural change. As it undergoes structural change, the
passage of guilt becomes heavier. The extensive evacuation of guilt,
along with the careful application of MUSC throughout the interview,
lies at the heart of therapeutic change. Had the patient been older when
the attachment and bond was ruptured, the neurobiological pathway
of murderous rage would have been more fully developed and there
would be less need for structural change.
The disrupted attachment, which lies at the core of the pathogenic
structure of the unconscious, need not be overt or violent to cause long-
term psychological damage to the patient. The neurobiological pathway
develops as a result of a multitude of experiences in childhood. In this
case, the nature of the trauma to the bond was subtle and a result of
the patients mothers own characterological disturbances. The mother
was very affectionate with her children but not with her husband.
The patient had conflict about this, as she was close to her father. In a
sense, she was like a sibling with her father, competing with him for the
mothers love and affection, a competition that he would surely lose
over and over again. The patient developed tremendous unconscious
guilt, as the father was deprived of a loving and close relationship with
his wife because of her preferential treatment of the children.
There has been an optimum passage of murderous rage but, as
mentioned above, there needs to be further restructuring of the
t h e n e u r o b i o l o g i ca l pat h way s o f m u r d e r o u s r ag e a n d g u i lt 83

neurobiological pathway. Further restructuring would create change


in the patients capacity to tolerate these painful emotions. It would
also increase the efficiency of the therapeutic process itself. In one three-
hour block therapy session, the patient could have five breakthroughs
into the unconscious rather than three. This would result in completion
of the therapy in less time, and the expenditure of less psychic energy.
To summarise, there is a high TCR at present. There is a major mobil-
isation of murderous rage in the transference. The patient initiates a
primitive murder of the therapist. The murder continues until the visual
imagery becomes clear, as illustrated in the vignette below. We expect
the mobilisation of the neurobiological pathway of guilt and the actual
experience of guilt. When the guilt comes into operation, we say that
the resistance of the guilt is gone for a moment. This creates a solid
foundation for structural change.

Vignette III: the experience of the neurobiological


pathway of guilt
TH: Go on, its a major wave in you. Its a major wave in you. Keep in touch
with this. There is a major wave. You have murdered. Who do you
see there?
PT: I see my grandmother and in the uterus was my mother.
TH: The uterus is open. Inside was your mother. How badly slashed is
the uterus?

Evaluation of vignette III


The passage of guilt in the above vignette is very powerful. Throughout
the course of researching IS-TDP, the primitive, torturous destruction
of the uterus of a genetic figure has come up time and time again. It will
be the focus of Chapter Seventeen of this book. The ramifications of
destruction of the uterus are multifaceted. In this case, destruction of
the grandmothers uterus puts an end to the patients mother and the
patient as well. This is indeed a triple murder and it is associated with
a massive amount of guilt.
Dr Davanloo refers to a particular type of guilt called pernicious
guilt, which this patient has. This refers to an especially insidious
and malignant form of guilt that has been cemented in the uncon-
scious for decades. Its associated tenacious degree of cementation has
84 U n d e r s ta n d i n g Dava n l o o s IS - TD P

led to a structural issue. In a sense, the guilt has become a part of the
unconscious. It is not an alien part and in some ways is ego-syntonic for
the patient. One could argue that this guilt is inherited and a result of
the intergenerational transmission of psychopathology.
Davanloo theorises that guilt is not just a psychological phenomenon;
it is a neurobiological entity that is felt and experienced physically. This
physiological sensation is particularly heavy when the murder involves
the uterus and any potential foetuses.

Vignette IV: the phase of psychic integration


and the incorporation of MUSC
PT: Its like a red, muscular organ.
TH: You see it? You see a muscular organ?
PT: Yes.
TH: You see it, hmmm? Could you describe the uterus?
PT: Its shaped like that. Its red, its muscular. Its slashed open.
TH: At what level is it open?
PT: The front is opencarved out.
TH: You see the inside?
PT: The infant is there.
TH: Your mother?
PT: Yes.
TH: Could you describe it?
PT: Its a baby and its maybe twenty-four weeks and so happy to be
there. And I have destroyed it. I have destroyed it. I have destroyed
it. I have destroyed it.
TH: You have a lot of feeling about your mother.
PT: Yes.
TH: Even the birth of your mother.
PT: They love each other so much and I want to destroy them both.
I want to destroy them. They are two innocent people and I want to
destroy it.
TH: Yeah, but on the other side, you want to destroy your mother at the
uterus level. Even that early. Y ou want to destroy her at this level.
TH: So this means you have a tremendous negative feeling for the birth of
your mother. If your mother was destroyed in the uterus, you would
not be here. The years of your upbringing were so painful, you wish
you could terminate it.
t h e n e u r o b i o l o g i ca l pat h way s o f m u r d e r o u s r ag e a n d g u i lt 85

PT: I wish it could have been different.


TH: The life between you and your grandmother has been Hell.
PT: Yes.
TH: Your grandmother, your mother.
PT: Its destructive.
TH: Its all destructive and nothing else, so far we see nothing positive.
PT: Theres love.
TH: Love for destruction. But in a sense, its very clear. Y esterday we saw
that. To love your mother paralysed you.
PT: I could not have positive feelings.
TH: For your mother. The way she treated your fatherlike garbage.
PT: She dismissed him.
TH: This is with you. She was turned against your father and you. This is
a very dark phase of life. A young little girl. Every day you are turned
against your mother and your father. He was dead in a sense.
PT: This is true and it got worse.
TH: Yesterday was showing it was very clear.
PT: Hmmm.
TH: You have to look to this. This is not something one wants to look at
its very dreadful. Y
our grandmother turning you against your mother
and father. Destructive against your motherturns you against your
mother, father.

Evaluation of vignette IV
In the above vignette we see the importance of the patient destroying her
mother in the uterus. While this is an act of intense, primitive, torturous,
murderous rage, it is also an act of love. In death, the patients mother
can have peace. The mother has had a tremendous amount of suffering
in her own lifefrom losing her father at the age of nine to living a
life of destructive competitiveness with her own mother and children.
In this sense, living is torture for the mother and death offers peace,
even if her death is at the hands of her own daughter.
The power of the resistance of the guilt is extremely high and cannot
be underscored. It leads to the destructiveness inherent in the patients
character. This tendency towards destructivenesswhich has been
fuelled by the intra-psychic murder of the mother and grandmother
has been in operation for many years. However, at this time, the resis-
tance of the guilt is out and is no longer operating in the patients
86 U n d e r s ta n d i n g Dava n l o o s IS - TD P

unconscious. There is an intra-psychic change such that the therapist


can do a psychoanalytic investigation of the unconscious. The patient
does acknowledge her mothers one saving gracewhich is the love of
her mother. Later in this interview, in a portion that was not transcribed,
she states, Thats the one thing that saved her and the one thing I want
to destroy.
This focus on the physical experience of emotion is unique in
Davanloos work, and is one of the key features that differentiates it
from other brief dynamic therapies. This neurobiological aspect of his
theory needs further research in order to be fully delineated, under-
stood, and operationalised.

Conclusion
The above interview was the fifth in a series exploring a single
patient. We have highlighted the importance of establishing that the
neurobiological pathway is in maximum operation. Often this involves
the process of restructuring the unconscious, as many patients have
been traumatised (either covertly or overtly) at a young age. Devel-
opmentally, structural changes are needed, as trauma at a young age
damages the neurobiological pathway and prevents patients from the
full physical experience of the emotions of rage and guilt in the future.
C hapter nine

The transference neurosis: Part III

W
e begin with the patients sixth interview in the closed
circuit setting. The focus of this chapter (like the second and
third) is the recognition and management of the transfer-
ence neurosis in IS-TDP. As a result of the syndrome of the mother
turning the daughter against the father (see Chapter Fifteen), the
patient became more distant and detached from her father as a young
adolescent. What emerges is that the entire family system was under
the controlling influence of the grandmother, who is revealed as the
Queen Bee of the family. The grandmother, due to her own upbringing
and neurosis, could not tolerate anyone in the family getting close to
anyone else. This destructive competitiveness was kept alive through
means of intergenerational transmission of psychopathology and trans-
mitted to the daughter and then the patient herself. We now focus on
how this unconscious system was in operation when the patient sought
out therapy with an individual with whom she developed a transfer-
ence neurosis.

87
88 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Vignette I: recapitulation of the task and the phase


of dynamic enquiry
TH: How do you find yourself?
PT: I feel pretty good. I have the tiniest headache there. Its a very mild
discomfort.
TH: Do you get them often?
PT: Yes.
TH: Left or right?
PT: Left or right, but more right. Other than that, I feel pretty good.
TH: Can you tell me what year you started therapy with Dr X?
PT: 2004.
TH: Could you describe one of your sessions?
PT: I sure could.
TH: How many sessions did you have?
PT: Fifty-five hours. Each session was three hours. I am wondering if
I should describe a session in the beginning or the end. I dont know
what would be most helpful.
TH: You choose.
PT: I guess I will go with the end because it was clearly destructive at
that time.
TH: Go ahead.

Evaluation of vignette I
The therapist begins the session by focusing on how the patient is feel-
ing. He then shifts to the patients past experience in therapy with the
therapist who will henceforth be referred to as Dr X. The patient her-
self is a well-respected professional therapist. She has both a technical
and an emotional understanding of the devastating impact of the trans-
ference neurosis on her own life and the lives of others. The focus on
this past therapist, then, creates a tremendous feeling in the patient. She
has murderous feelings towards this past therapist. She also has feeling
towards the current therapist for bringing all of this material to the fore-
front. Already, the stage has been set for a high rise in the TCR.

Vignette II: the experience of the neurobiological pathway


of murderous rage in the transference
PT: During one of my last sessions, I put myself back on my migraine
medications. I said, Look, I went back on meds.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i i i 89

TH: You went back on the medications. W hat was the medication?
PT: Topiramate. I told him that and that was not what he wanted to
hear. We had a session and at that point, I had destroyed, I believe,
my mother. Her uterus was empty. He said, Look further repeat-
edly. I said, No, theres nothing in it. At that point I was very angry
withhim.
TH: What was the way you experience the anger?
PT: I decided Im going to zone out and Im not coming back. I felt angry.
I can feel that building.
TH: You notice you do that.
PT: I dont want to feel it.
TH: If you direct it at me, whats the intensity? If you put the whole rage
out? If you go totally vicious?
PT: I have claws.
TH: If you had a weapon.
PT: I go with a knife.
TH: Go with the full intensity. Full intensity. Full intensity. What happened?
What do you see?
PT: Its Dr X. But its you.
TH: Could you look at me? Its him and I there. Could you look to
my eyes?
PT: I see your dark brown eyes.

Evaluation of vignette II
In the above vignette we see a variety of interventions come into play.
The patient developed a malignant transference neurosis in the course
of her prior therapy, as described above. The therapist is aware of this.
The patient has murderous rage towards this prior therapist for many
reasons. The transference neurosis has seriously sabotaged her poten-
tial in life. She is enraged that the prior course of therapy did not help
but greatly hindered her in many respects.
The therapist knows that focusing on this C or the Current in
the Triangle of Person (Menninger, 1958) will nicely activate the neu-
robiological pathway of murderous rage. But he is also aware that it is
very early in the course of this patients mobilisation. She has not fully
engaged in or agreed to treatment at this point (but does later). As
such, it is important to attempt as many unlockings via the transfer-
ence as possible, for the time being. Once therapy is firmly established,
unlockings can occur outside of the transference. For this reason, when
90 U n d e r s ta n d i n g Dava n l o o s IS - TD P

the patient appears to be in touch with the neurobiological pathway of


murderous rage towards the prior therapist, the therapist changes the
focus, saying, If you direct it at me, whats the intensity? Allowing
the breakthrough to occur in the transference ensures the safety of the
process and widens the scope of view into the pathogenic core of the
patients unconscious.

Vignette III: the experience of the neurobiological


pathway of guilt
TH: What colour? What else do you see? You have a lot of feeling right
now.
PT: What comes is the blue eyes of my father. The blue eyes and crippled
body.
TH: You have a lot of feeling. Your life is at stake, dont minimise your
feelings. Lets face with your feeling. Face with your feeling. Face with
your feeling. Face with your feeling. Face with your feeling. Theres
more feeling in it. Theres more feeling in it. Dont fight it. Face with
the feeling.
PT: I love you Dad. I love you Dad.
TH: How would you say it?
PT: I love you, Dad. I love you, Dad. I dont want you to live a crippled
life. Im sorry I was part of this. I love you.
TH: Still you have feelings about it. Y
ou see the blue eyes still?
PT: Yes.
TH: Could you describe his face? When you say you can see the blue
eyes
PT: He has dark hair. Hes wearing something from the seventies.
TH: How old was he then?
PT: Forty-one or forty-two.
TH: How old you were then?
PT: Three or four.
TH: You have memory of him?
PT: I remember him reading me a story with my sister before we
went to bed. My Dad stuttered in life and he did that when he was
anxiousor angry. But at this moment hes reading a book and hes
happy to be with ushes enjoying this. Its nice to be close with
my Dad.
TH: You were close to him.
PT: Yes. In this image I was.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i i i 91

Evaluation of vignette III


It is important to clearly understand the role the father plays in the
nucleus of the pathogenic zone of the patients unconscious. This is
especially true given the avalanche that was created by the transfer-
ence neurosis from the previous course of therapy.
The patient has a deep-seated and lifelong problem. While her grand-
mother was the Queen Bee in the system and the mother was com-
pliant to her, the father struggled with the highest degree of catatonic
compliance in the family. He was subordinate to both the mother and
grandmother and they both mistreated him. When both of these figures
attempted to turn his daughters away from him, he accepted his fate in
life in a penetrated position. He resorted to excessive alcohol intake as a
way of dealing with this tremendous pain. In this sense, the father was
highly masochistic and went for disaster after disaster in life. His mis-
sion in life was to seek out and accept the penetrated position.
The patient has had a lifelong tendency to let sleeping dogs lie. She
does not want to admit to the above family dynamic. Nor does she want
to admit to the reality of her prior course of treatment. Davanloo argues
that her transference neurosis is analogous to being brainwashed. In a
sense, it is much worse than the catatonic compliance that her mother
and father displayed towards the grandmother.
The patients parents and grandmother had far less opportunity in
lifenone of them had the chance to study at a university. The patient,
however, has two university degrees and the independence and auton-
omy that come with professional life. Despite this, she has the deeply
embedded and highly masochistic character traits of her mother, father,
and grandmother. She has not yet met her potential to succeed in life.
Her masochistic character traits, manifested as a lifelong destructive
need to suffer (in many ways, an addiction to suffering), have led to
this fate. This addiction to suffering, albeit an unconscious addiction,
led to the development of this very tough transference neurosis from
her prior course of therapy.

Vignette IV: the phase of psychic integration, psychoanalytic


investigation into the unconscious, and the
ongoing creation of MUSC
TH: What was his hobby? What things did you do together?
PT: He had a garden. He had a piece of land close to the ocean. We used
to go together. My sisters would go. We would plant potatoes and
92 U n d e r s ta n d i n g Dava n l o o s IS - TD P

carrots. His mother lived close by. We had a lot of family there and
we had cousins there. He spent a lot of time with us.
TH: What sister comes to mind?
PT: What comes to mind is Sandy. Leah and Janie were older than me.
TH: What comes to mind? Most of the time you were together your
mother was there or just him?
PT: We went to his mothers. It was with him. He used to take us because
my mother would want a break.
TH: How do you feel right now?
PT: I feel very good. I feel that that was a good feeling to get the
guiltout.
TH: You feel relaxed?
PT: I feel relaxed. I feel good.
TH: Hows the headache?
PT: At this moment, its gone.
TH: At this moment.
PT: Yes.
TH: You said the headaches got worse with Dr X.
PT: The severity improved but not the frequency.
TH: Why?
PT: I thought it was because the guilt towards my mother and grand-
mother was not experienced. But there were other things as well.

Evaluation of vignette IV
In the above vignette, the patient discusses her relationship with her
father as a young child. The therapist engages in psychic integration
and MUSC. An attempt is made to acquaint the patient with her past
memories. Some of these have likely been restored following the drain-
ing of a massive volume of guilt towards the father.
The therapist then moves on to focus on the patients main symptom
disturbance, which has been a lifelong history of near daily migraine
headaches. He then ties this into the role the transference neurosis plays
in her symptom and character disturbances. What then follows is a
vignette outlining even further MUSC. The patient describes two inci-
dents in her life where she felt walked all over. One was in her previ-
ous course of therapy, when the therapist asked if he could show her
tape in a group supervision setting. The patient initially was hesitant
but later called the therapist to express her consent for this. She later
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i i i 93

found out that he did not review her tape in supervision and her entire
course of therapy was, therefore, unsupervised. The second incident
is an ongoing situation in her work life. She does not speak up when
she does not agree with the decisions of the senior nurses with whom
she works. This vignette will be edited and contains the most salient
passages only.

Vignette V: further psychoanalytic investigation


into the unconscious and ongoing MUSC
TH: What happened that you didnt walk out?
PT: I guess he knows what he is talking about. But on one hand, I knew
thats not right.
TH: He didnt want to see you if you put up conditions.
PT: This would have been fall, 2004. In hindsight, he asked about showing
my tapehe didnt show it. All kinds of little problems.
TH: You mean you complied?
PT: I either didnt see it or I complied.
[The patient then relays the incident with the senior nurses and how
they make decisions that the patient does not supportthis section
is edited for the sake of brevity.]
TH: They run your life.
PT: In other ways, Ive been more direct. Ive caused an uproar.
TH: You let them to run your life, like with Dr X you let him run your life.
PT: There have been times when I disagree. There are other times, when
Im tired or not feeling well, and I say, Fine.
TH: Why do you alternate?
PT: Im afraid of them. I am afraid to confront them. They are two senior
nurses.
TH: Letting them run your life. Who is that person?
PT: Its my grandmother. I became compliant with Dr X just like my
mother was compliant with my grandmother.
TH: But you keep doing it.
PT: Im changing but Im slow to change.
TH: Why slow?
PT: Theres a slowness in me thats been very destructive but Im slow
to change it.
TH: Youre a double person, number one is your mother and number two
is your grandmother. Y ou shift. Either you comply
94 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: Im more grandmother than mother, but mother is there.


TH: You are a commander of destructiveness.
PT: I was more mother with Dr X. I should have walked out after session
number five.
TH: You always say should. This is in operation.
PT: I struggle with it.
TH: What do you do with it here?
PT: I dont want my double personality to destroy it. This is a once in a
lifetime opportunity.
TH: Both striking, you go to treatmentyou chose your mother or your
grandmother.
PT: I dont want to choose either.
TH: You say you dont but tomorrow you do it. You are made of this
destructive system.
PT: Well, I dont want to be destructive anymore.
TH: Well then what can you be? When you went to that therapy it was
destructive.
PT: That was extremely destructive. It made me worse. The headaches
were worse.
TH: I dont think that its just headaches.Theres a scar in your unconscious.
You need structural changes to clean up that scar. It has a negative
effect. Y
ou are the victim of his reputation. He is telling everyone that
he is the expertthat he is treating you. He is elevating himself but
who pays the price.
PT: I do.
TH: But you are going to do it. But you say in April you wanted to be nice
to him. This is your grandmother.
PT: I feel angry as we talk about it.
TH: But this is reallyyou see it as a lamb when it is a wolf.

Evaluation of vignette V
The above vignette highlights the phase of MUSC. The therapist knows
that following the above breakthrough the patients unconscious is in a
highly mobilised state. This is a perfect time to enquire into the nature of the
transference neurosis, the events that took place before it crystallised in her
unconscious, and the malignant character defences that not only allowed
for the development of the transference neurosis but perpetuated it.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i i i 95

The patient comes from a family where members allowed themselves


to be walked over on a regular basis. This sad reality is very painful
for her and she does not wish to admit it. But the development of her
own transference neurosis was much deeper than allowing herself to be
walked over. The patient is a qualified therapist and is respected in her
community as a good clinician and teacher. She does not wish to admit
the obvious truth; that many of her character defences are syntonic and
cemented and she cannot tell whats what. This is especially true in
the development of her transference neurosis but applies to other areas
of her life as well.

Conclusion
The above vignette illustrates many important technical aspects of the
major mobilisation of the unconscious and the total removal of resis-
tance. In this particular interview, we see the timely and accurate appli-
cation of MUSC throughout the various stages of the central dynamic
sequence. The patient presents in a highly mobilised state, having ben-
efited from numerous live interviews and audiovisual presentations
throughout the week of this programme.
It is important to acknowledge that the patient has not yet entered
treatment. But this interview does lay the foundation for treatment.
The early UTA that has developed will die if patient and therapist do
not meet for frequent (at least monthly) sessions. At the current time,
we are only seeing the tip of the iceberg. This phrase, as used by
Dr Davanloo, refers to the emergence of a small portion of the reservoir
of feelings that lie beneath the surface in this patients unconscious.
More intense feelings will emerge if and when a course of therapy is
put in place.
The presence of the transference neurosis in many therapeutic rela-
tionships is deeply disturbing. Patients present for help and deserve
to see trained professionals. Dr Davanloos techniques are extremely
powerful and require lifelong training. However, many clinicians are
practising the powerful techniques of IS-TDP and major mobilisation
of the unconscious with entirely insufficient training. It is important to
be mindful of this situation and to be vigilant (but not accusatory) in
questioning the credentials and ethics of all who claim to practise this
technique.
C hapter Ten

The destructive competitive form of the


transference neurosis

W
e continue with our case. We have reviewed several
important new concepts in Davanloos work. These include:

1. The role of transference neurosis and how it must be avoided at all


costs.
2. The use of MUSC throughout the interview process.
3. The neurobiological pathways of murderous rage, guilt, and grief.

Now we will review another new feature of Davanloos work.


Davanloo has identified an important metapsychological concept
called the destructive competitive form of transference neurosis.
This concept must be carefully understood. While it will be reviewed
in detail in the case below, it must be briefly defined before we con-
tinue on with the case.
Most families contain individual members who have varying
degrees of psychopathology. Transference neurosis can develop amongst
these family members. The intra-psychic issues of one family member
are transferred to another family memberwho is often in the next gen-
eration and suffers as a result of this transmission. Theindividual who
transfers this material usually does it unconsciouslybut the net result
97
98 U n d e r s ta n d i n g Dava n l o o s IS - TD P

is that that the individual who receives the material suffers because
of it. In this sense, the entire system is morbid in nature and results
in major destructiveness in the family. There is competition for being
destructive, rather than competition for being successful. We return to
the seventh interview to show this dynamic in operation. Clinical mate-
rial will make some of these more abstract concepts more tangible.

Vignette I: the experience of the neurobiological pathway


of murderous rage in the transference
TH: OK, Dr, we are here again. So first, on behalf of the science of the
metapsychology of the unconscious, I want to thank you for your
eagerness and willingness to make a contribution to those they suffer.
Because you know that the intergenerational transmission of psy-
chopathology has a lot of victims. So any contribution we can make
would be the future of those who suffer. OK, so I remind you of the
principle of the truth of honesty. The truth of the unconscious. You
are willing?
PT: Yes I am.
TH: You are always. How do you feel towards me right now?
PT: How do I feel towards you?
TH: Yeah. Right now.You took a sigh.
PT: So, all week I have been in rage. It has not been towards you but
towards other people.
TH: But how do you feel towards me? But if you honestly examine your-
self, how do you feel towards me?
PT: I have positive feelings towards you but I feel the rage building up.
TH: So there is rage in you.
PT: Theres rage.
TH: You move around. So there is rage. So you have rage towards me.
PT: I do.
TH: You do.
PT: I feel it building.
TH: You took a sigh.
PT: Because there is some anxiety but theres rage there for sure.
TH: So this is building? You took a sigh.
PT: Because it is building.
TH: Lets to see about your rage towards me. Lets see how you experi-
ence this rage towards me without any censorship.
t h e d e s t r u c t i v e c o m p e t i t i v e f o r m o f t h e t r a n s f e r e n c e 99

PT: What comes to mind is that I have an axethe blade is this bigand
somehow I just chop your head off and I slash.
TH: Lets go. Lets go. Lets go. Lets go. Go on. Go on. Go on. Go on.
Go on. The maximum you can do. Go on. Go on. Go on.
PT: And I pound your head but your head is decapitated so I take what
I can at your chin and I pound it further against the wall.
TH: Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on.
Go on.
PT: I take whats left and I pound the wall. And I smash whats left.
I pound with one and then the other fist.
TH: Go on. Go on. Go on.
PT: And youre flattened.
TH: Could you look at the totally destroyed body of mine? Could you
look at it and my eyes? What colour are the eyes?
PT: Theyre green/blue. Theyre the eyes of my grandmother.
TH: Your grandmother. Y ou have a major wave of feeling for her.You have
a major wave of feeling for her. Let it out. Let it out of you.
PT: I love you.
TH: Let it out.
[There is a massive passage of guilt and the patient is sobbing
profusely.]
TH: Let it out.
PT: I love you.
TH: Let it out. How is she dressed up?
PT: She has a sweatshirt and an apron on.
TH: She has an apron?
PT: Yes.
TH: Lets see how you feel further. Dont hold on the feeling. Your life
depends on this feeling which has destroyed your life. This guilt is
a destructive force in you. This guilt is a destructive force in you,
Dr, lets go. Let all the feeling out. This guilt has been destructive. This
guilt has been destructive. Let it out. Y ou have a lot of feeling for your
grandmother. You have more feeling if you carefully examine it. You
have more feeling.
PT: Im sorry and I loved you. Im sorry [patient whispers].
TH: There is a lot of feeling.
PT: There is.
TH: You said she has an apron on. What colour?
PT: White or yellow. Off-white.
100 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Is it familiar to you?


PT: Not really. I remember her in an apron a lot.
TH: Did she use them a lot? What was the favourite colour of your
grandmother?
PT: I dont know.
TH: You dont know.

Evaluation of vignette I
This interview occurred as part of private treatment after a five day
closed circuit training programme. As a result, the patient has seen a
number of interviews in the preceding daysboth live and recorded.
It is in this context that the UTA went to a peak position very rapidly. The
TCR, which had already been mobilised from the weeks events, rapidly
moved to a vertical position. As a result of the high TCR and the domi-
nance of the UTA over the resistance, the fusion between the murderous
rage and the guilt for the grandmother was removed. Consequently, we
see a massive passage of murderous rage in the transference.
The therapist works in a vertical fashion, as demonstrated in previ-
ous chapters, and the neurobiological system goes rapidly into opera-
tion. The situation is analogous to a pilot rapidly reaching a flying
altitude. As in the case of a smooth flight, there is no stagnation in the
process whatsoever. The primitive murderous rage passes rapidly and
the patient rapidly moves to the experience of guilt. The guilt is very
heavy and is fully experienced. Interestingly, we see the murder of the
grandmother, who is wearing an apron. This is an important communi-
cation from the unconscious.
This guilt is very extensive, not only because of the manner in which
the therapist was murdered, but because of the quality of the grand-
mothers character. The patients grandmother was a hard-working
person in a variety of different contexts throughout her life. At one
point, she worked in a hotel to bring money to the family. This was not
easy work and the therapist is cognisant of this and the resulting posi-
tive feelings the patient has towards her grandmother.
The grandmother, while very controlling and domineering, added
warmth to the home life of the family. The image of her wearing an apron
is a direct reminder of this. The patient had previously struggled with posi-
tive feelings for and memories of her grandmother. The image of the grand-
mother in the apron is an unconscious symbol of the love and affection she
had for the family. We begin to see the human side of the grandmother.
t h e d e s t r u c t i v e c o m p e t i t i v e f o r m o f t h e t r a n s f e r e n c e 101

This indicates that there is some loosening of the core neurotic centre in
the unconscious. This is fundamental for structural change.
This passage of murderous rage was extremely primitive. The patient
herself is puzzled and shocked that she wants to go at the therapist with
an axe. Her grandmother was not a psychopath and does not deserve this
degree of primitive rage. One must again ask: where is this primitiveness
coming from? Is this truly the unconscious of the patient? The patient
is a well put together professional therapist and this degree of sadism
does not fit with her make-up metapsychologically. Could this possibly
be the result of her transference neurosis with the previous therapist? Is
there another potentially psychopathic agent in her unconscious?
In the situation of a transference neurosis that resulted from a course
of treatment, much of the therapists unconscious has been transferred
onto the patient. So the patient potentially struggles with the guilt of
someone elsesomeone with a more primitive unconscious. As a result,
the guilt is very heavy and intense. The patient experiences the guilt for
an unconscious murder of a woman whom she loved. That she acquired
this degree of primitiveness from her previous therapeutic relationship
adds to the heavy burden of guilt.
Despite the presence of a transference neurosis, the patients uncon-
scious defensive organisation is still operating fairly well. However, the
presence of the transference neurosis creates a phenomenon of rusting
in the unconscious. The longer it goes untreated, the more likely it is to
cause insidious and long-lasting damage in the unconscious.
The therapist uses the technique of echo in this vignette. By repeat-
edly stating, This guilt has been destructive, the therapist is setting the
stage for the ongoing reverberation of this phrase in the patients inner
psychic world. Long after this interview is over, the patient will hear
these words of the therapist, not as a hallucination, but as an unspoken
truth. The technique of echo is a powerful means of restructuring the
unconscious and was first described by Davanloo using the Case of the
Cement Mixer (Davanloo, 2000).

Vignette II: the phase of psychic integration,


psychoanalytic investigation of the unconscious,
and the ongoing creation of MUSC
TH: But she used to use apron.
PT: Yeah.
TH: What she used to do with the apron?
102 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: She used to cook a lot. There was a time she used to cook a lot.
TH: She used to cook a lot?
PT: Yeah. I remembered this week. She used to cook at the priests
residence. She used to do that. And she worked as a maid in a hotel.
And she was promoted.
TH: I see, she was a maid. And she used to cook at the hotel?
PT: No she was a maid and promoted to housekeeper.
TH: She used to cook at home?
PT: Yeah. She was a good cook.
TH: Do you remember what dishes she would cook? That you like.
PT: Just, like, chicken. Meat. Potatoes.
TH: Potato what?
PT: I dont know, like mashed potatoes. Gravy. French fries. She was
fond of that.
TH: What else? In terms of cooking?
PT: She would make cakes and pies. Lemon meringue pies I remember
specifically.
TH: So she would give warmth to the family?
PT: Yes.
TH: If you were going to choose one of the things she would cook, what
would stand very strongly?
PT: I dont know.
TH: What else. What would you pick?
PT: Where she comes from, they would make fried bread dough. Its not
very healthy. T hats what I would pick.
TH: In the country, they used to do that.
PT: Umm hmm. Its not very healthy.
TH: How do you feel right now?
PT: I feel good. I was filled with rage all week. So it feels good to get it out.
TH: Do you feel good now?
PT: Pretty good.
TH: One thing is this. Grandmother is the power. On one hand, food is
the power system.
PT: It is difficult to get upset with someone when they are feeding you so
well.
TH: Your grandmother must have had dishes. Fried bread. Old days in
thecountry life they used to do it. Farmers.They work hard and they
can burn it. You probably have dishes. You remember it as you go.
You see, she must have had major issues with her past, her father or
t h e d e s t r u c t i v e c o m p e t i t i v e f o r m o f t h e t r a n s f e r e n c e 103

mother, but resulted in a neurosis of that generation which trans-


ferred to your mother and yourself.
PT: I asked my mother about this. My great-grandmother was kind and
gentle. But her father was explosive and she was one of ten or twelve
children so who knows what that was like.
TH: That should be kept. Because that was the most common. Should be
recordedthat is very important for the transference neurosis. So
was explosive and how that affects your mother and grandmother.
Your grandmother was explosive?

Evaluation of vignette II
We see that the grandmother was explosive but loving. This impacted
the developing children in the family in a specific way. On one hand, the
grandmother provided warmth and good cooking. She was a dedicated
and devoted woman who worked hard as a maid in a hotel to provide
for her family. This is why the attachment to the grandmother is strong.
But on the other hand, the children learned to be on guard and to fear
the explosiveness of the grandmother. We must ask: what is the impact
of the grandmothers explosiveness on the neurobiological pathways of
her grandchildren?
When a genetic figure such as the grandmother is explosive, the
family lives in constant fear of upsetting this individual. In this sense,
the family lives in the constant fear of waking the beast. As a result,
there is increased projective anxiety in the children and grandchildren.
This is a grandmother who wants everyone around her to be calm, cool
and collected and tries to rule the family with an iron fist. She wants
everyone to be under her control. The grandchildren want the goody
goodies that come with the warmth of the grandmother. But in an
atmosphere of ongoing projective anxiety, the children learn to become
compliant.
This is why the therapist questions the patient about the types of
food her grandmother cooked. This application of MUSC neutralises
the projective anxiety. It also acquaints the patient with memories of
her grandmothermemories that may possibly be restored following
this massive passage of guilt. But at this particular point in the process
the degree of resistance is still high; most likely because of the presence
of transference neurosis. If the resistance was lower, there would be an
intense flood of memories about the grandmother. Like Dr Davanloos
104 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Case of the Machine Gun Woman (Davanloo, 2000), the patient might
start to smell the dishes of the grandmother as her memory returns.
But it is too early in the process to expect this. This projective anxi-
ety is further complicated by the presence of the destructive competi-
tive form of the transference neurosis, which will be reviewed in more
depth below.
Patients have original neuroses towards important genetic figures.
A transference neurosis occurs when the patient develops a neurosis
with another figure (perhaps a child, spouse, other family member, col-
league, or therapist). This new neurosis serves as a means of displacing
the painful feelings associated with the original neurosis. The destruc-
tive competitive form of the transference neurosis is a specific type of
transference neurosis in which the feelings associated with the original
neurosis are targeted on other individuals in the family. What results is
an extremely destructive family dynamic that often involves turning one
family member against another. The projective anxiety creates the foun-
dation for the destructive competitive form of the transference neurosis.
The term intergenerational transmission of psychopathology (the
focus of Chapter Fourteen) refers to the transfer of unconscious conflicts
from one generation to the next. In many cases, the structure of the patho-
genic core of the unconscious can be extremely similar between parents,
grandparents, and children. One intervention, often employed during
the application of the head-on collision, is to remind the patient that their
own psychopathology has likely been passed on to their children. Such
a reminder serves to increase transference feelingsthe patient becomes
angry that the therapist points out an obvious, yet painful, truth. This
intervention also increases the TCR. Often the destructive competitive
form of the transference neurosis is tied in with the intergenerational
transmission of psychopathology. When the destructive competitive
form of the transference neurosis is transmitted to children and grand-
children, suffering lives on in the family for generations to come.

Vignette III: continued psychic integration, psychoanalytic


investigation of the unconscious, and the application of MUSC
TH: She was explosive. So like her father.
PT: Yeah, but you know we were so anxious of her we would do any-
thing to avoid it.
TH: This is important. Y
our grandmother was explosive but you would do
anything to avoid it.
t h e d e s t r u c t i v e c o m p e t i t i v e f o r m o f t h e t r a n s f e r e n c e 105

PT: One thing is that she was very dismissive. She would put an end to it.
And this is coming out this week. When people dismiss me I get very
explosive.
TH: You need to write this down.
TH: Great-grandfather, what was his name?
PT: Elias.
TH: He was explosive. And then your grandmother was also explosive.
But she had something more. Namely, dismissing. If you disagreed
she would have explosiveness or would dismiss you. This should
be documented that your grandmother was dismissive. Was your
mother dismissive?
PT: No.
TH: Was she compliant?
PT: She was compliant with my grandmother, but she didnt dismiss me.
TH: This is very important. Explosive and dismissive.Your grandmother is
not like Queen Bee. More like Queen Victoria. Dismissive.
PT: She wasnt going around in tantrums all day.
TH: Did your mother avoid your grandmother?
PT: No. They spent a lot of time together. She wouldnt say anything
because she would avoid her mother getting explosive. And so there
wasnt a lot of explosiveness with her because it would never get
to that.
TH: Have you read much about Buckingham Palace?
PT: No. I did see a documentary about it on television a few weeks ago.
TH: Because Queen Victoria was like that and you see the impact on her
children. Dismissing.

Evaluation of vignette III


We see the evolution of the patients mothers character. As a young
child, the mother learned to go dead in the face of the grandmothers
explosiveness. She learned that in order to enjoy the warmth of the
grandmothers cooking, she needed to be a compliant child. One
must examine the impact of this type of environment on the develop-
ing child.
Dr Davanloo has written about the Case of the German Architect
(Davanloo, 1990). This patients father was a Calvinistic priest. He
believed that children should be physically disciplined. The grand-
mother in our case does not engage in such physical brutality. When
it comes to character development, including the development of
106 U n d e r s ta n d i n g Dava n l o o s IS - TD P

defences, one must question which type of discipline causes more


pervasive damage to the childs character.
The members of the closed circuit training programme begin to feel
closer to the grandmother as the patient reveals her as a human being
who is flawed but devoted. This is the beginning of structural change
in the unconscious. The above vignettes depict the patients experience
of intensely painful feelings towards her grandmother. The patient had
a tremendous positive feeling towards her grandmother. This woman
worked hard to give life to the family. But at the same time, because
of the grandmothers destructive competitive form of the transference
neurosis, she turned the patient against her own mother. As a result, the
relationship with the grandmother was very conflictual for her.

Conclusion
The patients unconscious is in a highly mobilised state. Her communi-
cations are more spontaneous and fluid than before. The early chapters
of this book reviewed interviews that were early in the process. While
the patient was responsive to the technique early on, her unconscious
was more cemented. Fusion of the murderous rage and guilt towards
multiple genetic figures was more clearly in place.
The core of this patients neurosis is simple yet painful. She wants the
love of her mother but she is competing with her grandmother for that
love. She also wants the love of her grandmother, but competes with her
mother for that love. Both women can be controlling (the grandmother
more so than the mother), and both turned her against her fathera
passive man who remains relatively innocent in the conflict.
The patient has major guilt in two directions. We reviewed the con-
cept of the destructive competitive form of the transference neurosis in
this chapter. This is in operation in this patients unconscious because
of the above dynamics. Destruction is part of the intergenerational
transmission of psychopathology in her family. The patient has had a
lifelong, albeit unconscious, search for major destruction. In her pre-
vious course of treatment, the TCR was too low to get to the original
neurosis, which centres around the mother and grandmother. In this
transference neurosis, that therapist became fused with the patients
grandmother. That previous therapist, for unknown reasons, did not
want the patient to heal the core neurosis and become close with her
own mother. Because of this fusion and the presence of the destructive
t h e d e s t r u c t i v e c o m p e t i t i v e f o r m o f t h e t r a n s f e r e n c e 107

competitive form of the transference neurosis, the therapeutic process


is very complicated.
This chapter details a dynamic exploration into the patients uncon-
scious. This interview begins to richly unravel the story of the patients
grandmothers life. Previously, she was seen as the controlling and
domineering Queen Bee. But we now begin to see the warm and
human side of her. We see her as a woman who in the cold winter went
to work as a maid in a hotel. We see her as a grandmother who strug-
gled with poverty and made fried bread for her family. She was singu-
larly devoted to her children and grandchildren. Her dedication to hard
work and her family adds to the patients guilt.
The application of MUSC by the therapist has a twofold purpose.
Seeing the humanity of the grandmother (both good and bad) adds to
the patients guilt. It also adds to her understanding of the grandmother
and why she made her choices in life. This is why the therapist does this.
It results in the beginning of structural change in the patients uncon-
scious. The patient begins to accept that she owes it to her grandmother
to get her freedom from the original neurosis and the transference neu-
rosis. She also begins to realise how proud the grandmother would be
of her throughout this journey.
C hapter ELEVEN

The transference neurosis: Part IV

W
e continue with our case and will review the eighth interview.
The subject of this interview will once again be the transfer-
ence neurosis and how it leads to destructiveness.

Vignette I: the experience of the neurobiological


pathways of murderous rage and guilt
TH: So we are here again.Again I put underline on the principle of honesty
but the second issue we have to keep in mind is the destructiveness
inherent in the difficulties. So if we keep the destructiveness on one
side then honestly we can proceed. Because you are here to remove
the destructiveness and be autonomous in your life. This is your own
right in this universe. How do you feel towards me? You took a sigh.
PT: I wasnt aware of anxiety until you asked how do you feel
towards me?
TH: So there is a rage?
PT: I wasnt aware there is a rage.
TH: How do you feel towards me? If honestly
PT: The axe comes back.

109
110 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on.
Go on. Go on. No interruption. Go on. Go on. Go on. Go on. Go on.
Go on.
PT: Im chopping your neck.
TH: Go on.
PT: I hold you. Im so powerful I can use the axe with one hand.
TH: And then. And then. And then. Go on. Go on. Go on. Go on.
PT: And I pound your body. But youre dead now. How could you
do this?
TH: Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. Right now,
there is a major wave of feeling in you. Look to my murdered body.
What colour are the eyes?
PT: Green/blue. Its my grandmother.
TH: Its grandmother, huh? Go on. Let it out as best as you can. Y ou have
the full capacity to experience it. Go on. Go on. Go on. Let the feel-
ing out. Its a major wave. Its a major wave. Its a major wave. Its a
heavy wave and you have the capacity to experience this major heavy
wave. Let it out. Let it out. Go on with it rather than fighting it. Let it
go. You need to experience this. Waves after waves. There are waves.
Go with the waves. It comes like a wave. It comes like a wave. It
comes like a wave.

Evaluation of vignette I
As in the previous chapter, the patient has attended a five day closed
circuit training programme prior to the depicted treatment interview.
As a result, her unconscious is mobilised. But it should be remem-
bered that the whole system is still under the power of the trans-
ference neurosis. In this sense, the unconscious is still in the state
of an avalanche. The neurobiological pathway rapidly comes into
operation. The TCR rapidly shoots up and she accesses her primitive
murderous rage with relatively few interventions. Every therapist
should remember the economic concept of action, since it is best to
do the minimal number of interventions necessary to rapidly mobilise
the TCR and neurobiological pathway of murderous rage as quickly
as possible.
As in the previous chapter, we see that the passage of the rage is
extremely primitive and this is not in keeping with how well put
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i v 111

together the patient is. Once again, this degree of primitiveness is not
typical of the original neurosis. The murderous organisation involving
the brutal attack with the axe is unusual. As in the previous chapter,
one must question if the unconscious of the previous therapist has been
transferred onto this patient. The presence of another unconscious with
no biological connection to the patient adds to the complexity of the
process and the passage. The neurobiological pathway of guilt is also
in an optimum position, but the experience of guilt has not undergone
structural changes. Repeated serial breakthroughs would create uncon-
scious structural changes. The spacing of the sessions in time is impor-
tant. If there is an interval of more than one month between sessions
(which is the case here), then the resistance comes back. In this con-
text, the guilt is currently heavy and painful. Its passage does not yet
have a rhythm. With repeated, frequent breakthroughs over time, the
passage of guilt will become more fluid and comfortable for the patient
to experience.

Vignette II: the phase of psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
TH: Go on. Let it out. Theres a major wave. It comes like a wave.
Enormous feelings. Y ou say you see the eyes. Do you see the eyes?
PT: I just see all of these pictures of her when she was a young woman
before I was alive and she is with my mother as a baby. She is such a
loving mother to my mother. She did her best.
TH: Let the waves out.
PT: She worked so hard. I was so destructive but she worked so hard.
TH: Let the waves out first and then you can talk. There is more waves
in you. What is the colour of the eyes now?
PT: I see these black and white photos.
TH: I know, but if you look to my murdered body.
PT: Green/blue.
TH: Green/blue eyes. Is it looking at you?
PT: Yes.
TH: Keep in touch with the green/blue eyes of your grandmother. Could
you look to this greenish blue?
PT: When I look to the floor I see her green eyes, but I see a laceration.
112 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Is the laceration horizontal or vertical?


PT: Vertical.
TH: What colour is the hair?
PT: Brownish/grey.
TH: Skull is open? You see the brain?
PT: Yes.
TH: Do you see the brain?
PT: Yeah.
TH: Shes badly wounded, hmm? Totally destroyed, hmm?
PT: She says: I only wanted you to love me.

Evaluation of vignette II
We see the patient experience a massive passage of guilt towards her
grandmother. In this vignette, we see the portrait of the grandmother
as a young woman, loving the patients mother. While the patient
was not alive during this phase of her mothers and grandmothers
lives, she sees the black and white pictures that have likely domi-
nated her memory. The patient had loving and affectionate bonds
towards both her mother and grandmother and this triangular rela-
tionship remains at the pathogenic core of her unconscious. The dis-
ruption of these bonds was not due to any particular event or trauma.
The bonds were disrupted simply because of the grandmothers
own character pathology and her desire to turn the mother against
the daughter.
After the primitive and brutal murder of the therapist, the therapist
asks for extensive detail of the visual image of the therapists body. The
visual image of the murdered body of the therapist quickly transforms
into the black and white photos of the grandmother with the mother.
By asking for extensive detailfor example whether the laceration was
vertical or horizontalthe therapist is asking the patient to paint as rich
a visual image as possible. The reasons for this are twofold. Seeing an
extremely rich visual image of the grandmother allows the patient to
fully experience and drain the massive column of guilt towards her.
Second, focusing on the rich and detailed portrait of the grandmothers
murdered body may activate further memories associated with the
grandmother. These memories may be de-repressed following the pas-
sage of guilt and may serve as rich communications about the nature of
the grandmothers relationship with the patient.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i v 113

Vignette III: continued psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
TH: How is her chest? Because that lethal equipment will cut it open.
How is the chest?
PT: I dont remember how but it is splayed open, there is skin and bones,
but I dont see bones. Theres flesh and blood.
TH: What do you see now? Do you see the blood?
PT: I see her shoes because I remembered those shoes this week. Maybe
they were the only shoes she had because she didnt have a lot
of money.
TH: She has physical resemblance to you mother?
PT: She doesnt really. I saw rapid imagery of my grandmother with my
mother as a child.
TH: What was their relationship?
PT: They were very close. She was a very loving mother to my mother.
TH: And then you were born. Do you have memory of your mother and
grandmother?
PT: Yes, but it was always with my mother. I have three sisters so a lot
of those memories would include them.
TH: When you say sisters. Your mother had three daughters. You were
the fourth. So your mother had three daughters but you were born.
What were your memories of your mother and grandmother?
PT: I know we used to go shopping and have lunch. That was the best time
of my life. My mother gave in to the demands of my grandmother.
My mother never made plans.
TH: Your mom was like a sister to you?
PT: I wouldnt use the word sister. My mom took care of me.
TH: This shows a primitive passage towards your mother.

Evaluation of vignette III


As the therapist continues to probe for more detail of the visual imagery
of the grandmother, we see more important communications from the
unconscious. The therapist asks the patient if she sees the brutal impact
of the axe on the grandmothers chest. One might expect this to further
increase the guilt. Since the resistance is now removed, the patient spon-
taneously brings up that she sees the grandmothers shoespossibly
114 U n d e r s ta n d i n g Dava n l o o s IS - TD P

the only shoes that she owned. The patient reveals that the grandmother
may have had only one pair of shoes because she did not have much
money. As in the previous chapter, we begin to see the warm and human
side of the grandmothera woman who worked tirelessly to bring food
to her family and to ease the burden of poverty.
The therapist then begins to explore further the nature of the family
dynamics. The patient was one of four daughters. The grandmother
was a domineering and controlling woman and was threatened by
the possible closeness her daughter might feel towards any one of her
own four daughters. The therapist is unsure if the patients mother was
more like a sister towards the children and enquires further into this.
The resistance is removed at this point and the process becomes a fact-
finding mission. The therapist and patient collaborate together to dis-
cover the truth of the patients unconscious. There has been a six-week
interim between this session and the last. In the interim, it is clear that
the position of the resistance is different. The patient has much better
access to the pathway of rage and guilt. But the volume of her guilt has
greatly increased.
There is a fundamental question that must be asked: is the transfer-
ence neurosis always associated with such a high degree of destructive-
ness? If this is the case, then the patients level of destructiveness might
lower her motivation to change. What can be done, then, to enhance the
motivation for change in this situation? Davanloo has repeatedly noted
that patients with transference neuroses have a need to procrastinate.
Such a need to procrastinate will prolong the process and unnecessarily
prolong the patients destructive tendencies.
The situation would improve if the patient were to have repeated
breakthroughs at a more frequent interval. With the repeated and
frequent passage of guilt there must also be a timely and accurate
application of MUSC. With this, and with further psychoanalyti-
cal investigation into the unconscious, there will be more structural
changes. But the reality is that she is not available for weekly sessions
because of her geographical distance. While the progress is good, the
process is prolonged.

Conclusion
This is the patients eighth interview with Dr Davanloo. The posi-
tion of her resistance is different now compared to the first interview.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t i v 115

Thepatient has much better access to the neurobiological pathways of


rage and guilt. However, the presence of the transference neurosis is
associated with a high degree of destructiveness and the therapist is
constantly monitoring for how the transference neurosis is impacting
the moment-to-moment functioning of the unconscious. The presence
of the transference neurosis also results in a need to procrastinate, which
in itself is highly destructive. The progress with this patient is good but
it is prolonged. The therapists task is to be mindful of many factors; one
of which is the destructive tendency in the patient with a transference
neurosis and his/her need to procrastinate over the therapeutic task.
C hapter t w elve

Unconscious defensive organisation


and brainwashing

W
e continue with the ninth interview in the case. At this point,
several chapters of this book have been dedicated to exam-
ining the transference neurosis. It has been highlighted as a
morbid entity that is to be avoided at all costs. But there remain many
unanswered questions about the transference neurosis. For example:

1. Why do some patients develop transference neuroses when others


do not?
2. Why are some therapists blind to their propensity towards inflicting
transference neuroses on their patients?
3. What are the ethical ramifications for therapists once they have
established that a transference neurosis exists in a therapeutic
relationship?
4. Is there an element of brainwashing in the development of the trans-
ference neurosis?

This chapter will focus very specifically on the effect of the transfer-
ence neurosis on a patients unconscious defensive organisation. This
chapter will also focus on the link between impairment of the uncon-
scious defensive organisation and brainwashing.
117
118 U n d e r s ta n d i n g Dava n l o o s IS - TD P

In the closed circuit training programme workshops (Davanloo,


2015), Davanloo has spoken about how similar the development of
the transference neurosis is to brainwashing. Before this is explored in
detail, one must examine the more formal literature surrounding brain-
washing at McGill University in the last century.
During the 1950s and 1960s, McGill Universitys chair of the
department of psychiatry was a Scottish-born psychiatrist named
Ewen Cameron. Cameron later became involved in what has been
known as the MKUltra mind control programme, which was covertly
sponsored by the Central Intelligence Agency (CIA) (Ross, 2006).
Cameron had been hoping to treat schizophrenic patients by erasing
existing memories and reprogramming the psyche. He carried out
MKUltra experiments at McGill that consisted of using LSD, para-
lytic drugs, and electroconvulsive therapy (or ECT) at significantly
higher doses than usual. His driving experiments consisted of put-
ting subjects into a drug-induced coma for weeks at a time (up to
three months in one case) while playing tape loops of noise or simple
statements. These experiments were also carried out on patients who
had entered hospital for minor problems such as anxiety or mood dis-
orders. Many suffered permanent debilitation after these treatments
(Marks, 1979). Such consequences included amnesia and language
disturbance (Turbide, 1997). His work was inspired and paralleled
by the British psychiatrist William Sargant, who was also involved
with the Intelligence Services. Sargant experimented extensively on
his patients without their consent, causing similar long-term damage
(Collins, 1998).
Many have questioned Camerons motives. Under the guise of
psychiatric research he was instrumental in developing methods
of torture that could be used by the CIA as a means of extracting
information from resistant sources (Klein, 2007). While it is hard to
fathom that such research occurred in recent times, it is important
to remember the mission of the powerful organisation that funded it.
The influence and legacy of Cameron cannot be easily dismissed. Few
Canadian psychiatry training programmes have specific courses or
teaching about the devastating effects of his research. Many Canadian
psychiatry residents graduate from training programmes without ever
having heard his name. However, he was a powerful and influential
figure for decades and his unique approach to research has been
u n c o n s c i o u s d e f e n s i v e o r g a n i s at i o n a n d b r a i n wa s h i n g 119

imprinted on his students and colleagues alike. So it is in this context


and atmosphere that many Canadian trainees have learned dynamic
psychotherapy.
Rather than engaging in cover-up, Davanloo is interested in explor-
ing the history of brainwashing in the psychiatric profession. There
are many aspects of brainwashing one could focus on. These include
ethical considerations, motivation of brainwashing researchers, and
research funding sources. Davanloo has asked specific questions about
the possible interplay of brainwashing and transference neurosis. He
has questioned the impact of brainwashing on a patients unconscious
defensive organisation. With brainwashing, a patients unconscious
defensive organisation becomes damaged. While this statement is an
intuitive one, it cannot be overemphasised. An individual who is brain-
washing a patient (or a subject) has no respect for the patients uncon-
scious defensive organisation. Often, the individual in question labels
a normal defence as resistance. As such, the patient becomes systemati-
cally desensitised as to what is normal and abnormal. The individual
who is brainwashing the patient assumes complete control.
Many therapists who do not have adequate training in this technique
treat patients using inappropriate methods. They do not understand
how to recognise and optimally mobilise the TCR. They use too much
challenge, which is often premature in nature. They avoid the proper
and timely application of head-on collision. They do not use MUSC.
The patient often feels criticised, inadequate, and misunderstood.
It is in this scenario, then, that brainwashing occurs. It is also in this
scenario that the unconscious defensive organisation becomes impaired.
Since the two concepts are so closely linked with each other and with
the concept of transference neurosis, they will be explored together.

Transference neurosis

Brainwashing Impairment in unconscious


defensive organisation

Figure 3. Triangle of Impairment (Hickey, 2015g).


120 U n d e r s ta n d i n g Dava n l o o s IS - TD P

In this ninth interview, these important concepts will be reviewed in


greater detail. See Figure 3 for the Triangle of Impairment, which sum-
marises the interplay between these elements.

Vignette I: the experience of the neurobiological pathway


of murderous rage in the transference
TH: So, Dr, we are here again.
PT: Yeah.
TH: Again, the principle that governs the process is honesty and integ-
rity and you have both of them. Can we adhere to that principle
and go?
PT: Yes.
TH: So can we see how you feel towards me?
PT: So I had anxiety and I know that anxiety is still there.
TH: So lets see how you feel.You took a sigh.
PT: My rage is building.
TH: So lets to see how you feel to examine the most painful issues.
[Patient has experience of murderous impulse.]
TH: Go on. Go on. Go on. Go on.
PT: Theres a rage and it goespounding. I hold your neck and I pound
further. All on your head. I hold your head and youre on the floor.
How could you do this?
TH: Go on. Go on. Go on. Go on at the highest you can. Go on at the
highest you can. Go on at the highest you can. How do I look there?
Look at my eyes.
[Patient has passage of intense guilt.]
TH: Very painful. Very painful. Very painful.
PT: I love you. My mom.
TH: Who do you see?
PT: My mom.
TH: Your father?
PT: My mother.
TH: What colour are the eyes?
PT: Brown.
TH: Brown. How old is she?
PT: Thirty-eight or thirty-nine.
TH: The colour of the hair?
PT: Brown.
TH: Brown?
u n c o n s c i o u s d e f e n s i v e o r g a n i s at i o n a n d b r a i n wa s h i n g 121

PT: I love you. I love you mom. I love you mom. I love you mom. I love
you mom.
TH: What communication do you get from your father?

Evaluation of vignette I
As in the previous interview, the patient is now well acquainted with the
process. As expected, there is a rapid mobilisation of the neurobiological
pathway of murderous rage in response to minimal therapist intervention.
Her perception at this point in the therapy is different compared to her
perception during the first interview. In the beginning, her unconscious
defensive organisation was somewhat impaired. Right now, it is better.
In the previous eight interviews, she has not only had repeated break-
throughs that resulted in evacuation of extensive columns of murderous
rage and guilt, she has also had MUSC. With this has come a gradual
but progressive restructuring of her unconscious defensive organisation.
What has resulted is a better defensive system. Structural changes in other
dimensions also have to be taken into consideration. The neurobiological
pathway of murderous rage has also changed. During the first interview,
the neurobiological pathway was not solid. The patient was very weak
and clumsy in that she did not know how to hold a knife. Currently, the
neurobiological pathway is much stronger. As a result of this, there is
structural change in the neurobiological pathway of guilt as well. The
column of guilt that is drained is much heavier. The patient has a higher
adaptive capacity to experience and tolerate painful feelings, which are
very heavy because of the intense loving feelings she has for her mother.
How did she make this progress throughout the course of interviews
we have seen? One reason is the optimal position of the TCR. The opti-
mal position of the TCR allows for the optimal mobilisation of the neu-
robiological pathways of murderous rage and guilt. As a result, fusion
of guilt and rage is removed. The guilt comes pouring out. Intra-psychic
changes are rapid and clear. The principle of honesty, as initially out-
lined in the interview, sets the stage for all of this.

Vignette II: the phase of psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
PT: Its my mother.
TH: Your mother.
122 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: She loves me.


TH: What communication she makes?
PT: She didnt mean to drive me away from my father. She didnt mean
to do it.
TH: How is she dressed up in this portrait?
PT: She has on a white turtleneck, and like a red jacket and navy-blue
pants.
TH: Its familiar to you?
PT: Slightly, but not 100%.
TH: Its familiar to you, the way she looks.
PT: Yeah.
TH: When was the last time you saw your mother? In reality? In person?
PT: Uh, Monday.
TH: Monday, hmm? So its a week ago. What was the occasion?
PT: I go to her house quite a bit. Two to three times per week.
TH: You visit?
PT: Yes.
TH: How did it go?
PT: It was a good visit.
TH: Hmm?
PT: It was a good visit.
[Patient proceeds to describe the nature of the visit, including a dis-
cussion she had about her parents intention to visit her sister who
lives far away. Passage will be edited for simplicity.]
TH: When you meet your mother, how does it go?
PT: I give her a hug and I kiss her on the cheek but I know theres still a
wall between us.
TH: Shes not comfortable with you?
PT: She is but I sometimes go dead.
TH: So theres a dynamic force that moves in between you and your
mother and she senses it.
PT: I am sure she does.
TH: When you visit, your father was there? How did you feel towards
him?
PT: I had a good visit. At the end, all three of us hugged. I said I hope they
have a good visit.
TH: Was there a flashback from the past? In your mind?
PT: Flashback? Not really.
TH: But there is some wall.
PT: Yes.
u n c o n s c i o u s d e f e n s i v e o r g a n i s at i o n a n d b r a i n wa s h i n g 123

TH: This is less with your father?


PT: My mother is more affectionate than my father. I feel like Ive done
my best with my father but I could do better with my mother.
I am the problem in the relationship with my mother because she
gives back.
TH: Your dilemma has to do with your mother and father. The fusion
you have there is mixed up with the other fusion with the ther-
apist you had a transference neurosis with. How do you feel
towards that?

Evaluation of vignette II
The patient very clearly describes a wall between herself and her mother.
This wall is synonymous with resistance against emotional closeness.
On an unconscious level, the patient sees herself as responsible for the
transference neurosis. Unconsciously, she let a stranger come between
her and her mother and grandmother. She has a tremendous feeling
about this. In the following vignette, the patient discusses her feeling
upon discovering that some of her colleagues also had a transference
neurosis towards her previous therapist.

Vignette III: continued psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
PT: Yesterday, when we discovered their transference neurosis towards
him, I was filled with rage towards him. I want to deal with it con-
structively both here with you and in the outside world.
TH: So it mobilised rage in you. That was quite something to discover
their unconscious is under the power.
PT: Its scary really. Its frightening.
TH: Its a mixture of unconscious and neurobiological structures.You said
you were in rage with that doctor. Is that gone?
PT: I could have just as easily felt it towards you.
TH: Is it gone?
PT: I could summon it up again.
TH: If again, you follow the principle of honesty and integrity, it has to do
with integrity. Your integrity was invadedinvaded to the level you
wrote a letterworld class therapist if you put this rage out and
put it on me.
124 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Evaluation of vignette III


While there have been some structural changes, the pre-existing
structural problems are not completely removed. The patient has not
completely worked through her transference neurosis. She still has
impairment in her unconscious defensive organisation. She has leftover
feelings, so to speak, in every dimensiontowards her mother, grand-
mother, and father. She begins the interview as though she is a two-
year-old infant and projective anxiety comes into play, as she sees the
therapist as her grandmother or mother. The neurobiological pathways
of murderous rage and guilt come fully into operation.
Lets revisit the dynamics of her transference neurosis once again to
fully understand these concepts. In her previous treatment, her grand-
mother became fused with that therapist. There were two commanders-
in-chief. These were two powerful, colonialistic people who resided
in her unconscious. That said, while the grandmother had a destruc-
tive impact on the patient, she also had a loving impact. She had an
affectionate and deeply caring side to her character. She worked very
hard, in difficult times, to give warmth and love to the family. This is
in strong contrast to the previous therapist, who had no such altruistic
intention with the patient. In the previous course of therapy, that thera-
pist often labelled normal defences as resistance. The patient was told
that she was cold and unexpressive by her previous therapist. Because
of the avalanche the transference neurosis created in her unconscious,
she was unable to see the truth of her own defensive structure. She
internalised the therapists labelling of her, despite it being completely
inaccurate. This resulted in impairment in her unconscious defensive
organisation.
It is important to understand the impact of this system on the patients
unconscious. Essentially, the transference neurosis has demanded that
the patient keep murdering her mother unconsciously. This would
destroy any chance the patient has for establishing a truly loving and
affectionate bond with her mother, who is still living. This system would
also like to destroy the patients children as well. On reviewing this ses-
sion, Dr Davanloo likened the situation to falling from a 10,000 foot
cliff. Psychoanalytic investigation of the unconscious like this high-
lights the sadistic organisation of the patients guilt.
When engaging in psychoanalytic investigation of the unconscious at
this stage of the therapy, it is necessary for the therapist to be as objective
u n c o n s c i o u s d e f e n s i v e o r g a n i s at i o n a n d b r a i n wa s h i n g 125

and accurate as possible. The patients grandmother lived as a single


mother during the Great Depression. One has to respect the reality of the
time and the circumstances she was faced with. Otherwise, the therapist
is accusing her. The grandmother lived in hard times and she worked
hard for this family. It may well be that the grandmothers life was such
that she had valid interpersonal conflicts that became intra-psychic in
nature. In this sense, conscious murderous rage and guilt resulting from
an intra-psychic conflict may have generated an unconscious conflict.
This could have fed into an intergenerational transmission of psychopa-
thology. It is possible, then, that the grandmother is a carrier of intergen-
erational psychopathology rather than the instigator of it.

Vignette III: continued psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
PT: Now theres a knife. Before there wasnt.
TH: Put it out.
PT: Maybe its not a knife. Its an axe.
TH: Its more intense than that. Go on. Go on. Go on.
PT: Its a knife, it slices in your eye.
TH: So I have two.
PT: I think thats it.
TH: What do you see there?
PT: I see more Dr X. His glasses are off and he is choking. The life is
leaving him.
TH: Who the eyes are?
PT: I thought at first it was my father but its my grandmother.
TH: Eyes of your grandmother? What colour?
PT: Green/blue.
TH: Could you look to the eyes?
[Patient has a massive passage of guilt.]
TH: Still you see the green eyes? She looks at you, the grandmother?
PT: Yeah.
TH: Let it out. Let it out. Dont fight it. Let it out. You have a major wave
of painful feeling. Y ou have a major wave of painful feeling. Y
ou have a
major wave of painful feeling. What communication do you get from
your grandmother?
126 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: Communication? She just holds me close to her.


TH: Holds you? Close to her?
PT: On the chest.
TH: You have a lot of feeling.
PT: She loves me and she worked so hard.
TH: You have a lot of painful feelings in relation to your grandmother.
You see you have a lot of painful feeling towards your grandmother
because she is replaced by Dr X.
PT: A misguided soul. A misguided soul in life. Misguided and damaged
like Dr X.
TH: Do you have any memories?
PT: Were in her house and shes holding me close under the blanket she
made and shes making bread. Its very safe.
TH: Holding you close? How old you were and she?
PT: I must be three or four and she would be in her sixties in this
picture.
TH: You see this is going to be a lot of issues you have. Because you see
this relationship you have with your grandmother has been disrupted
and Dr X has moved into the place of your grandmother. You had a
nest with your grandmother and he disrupted this. And theres going
to be a lot of feeling as you go on. And your task is to sort out all of
this feeling. The unconscious you have lost. You have to conquer it.
We call this structural change.

Evaluation of vignette III


The patients second breakthrough is as powerful as her first. If the
patient was having block therapy, the course of the session would be
different. The therapist would be mindful of the need to avoid psy-
chic exhaustion. For this reason, there would ideally be a short break
and then the therapist would go for a third breakthrough. With a
fairly robust patient who has no character pathology, there could be
up to seven breakthroughs in one day. Over the course of one to two
days, then, the position of the unconscious could dramatically change.
There will be a shift from the dominance of the resistance to the domi-
nance of UTA.
If years pass without this type of intervention, then the patients
defensive structure will become further impaired and she will have
ongoing impairment in her unconscious defensive organisation. In such
u n c o n s c i o u s d e f e n s i v e o r g a n i s at i o n a n d b r a i n wa s h i n g 127

a state, the patient will remain unable to examine her original neurosis
and experience the unconscious feelings associated with it.

Conclusion
The above interview demonstrates important considerations in how
one works with a patient who has an impaired unconscious defensive
organisation. In this context, the impairment came from the transference
neurosis the patient had with her previous therapist. But impairment
in the unconscious defensive organisation can come from a variety of
other situations as well. One could argue that the culture of psychiatry
has been shaped by individuals, such as Cameron, who have created an
atmosphere of disrespect for the very trainees they hope to shape. Such
a culture creates fertile ground for damaging the unconscious defensive
organisations of these young trainees; it is a historical truth that the
psychiatric profession, at least in Canada, has failed to recognise and
address.
C hapter thirteen

Pathological mourning and the mobilised


unconscious

W
e continue with the tenth interview in the series. The focus
of this interview will be pathological mourning. Specifi-
cally, Davanloos approach to working with and removing
pathological mourning will be illustrated through further vignettes. But
before we can explore this further, there must be a brief review of the
history of pathological mourning.
Freud first explored this concept in Mourning and Melancholia
(Freud, 1917e). He noted that the deep feelings a patient experienced
with the loss of a loved one were very similar to the feelings that a
patient with melancholia experienced. Individuals suffering from mel-
ancholia shared the same loss of interest in the outside world and were
absorbed in their own intra-psychic worlds. However, mourning was
seen as a normal phenomenon whereas melancholia was viewed as
a medical condition that required active intervention and treatment.
Mourning occurred after an actual and apparent loss and was experi-
enced as a conscious emotion. Melancholia did not occur after an actual
death and the loss was seen as an unconscious one.
Erich Lindemann went on to further refine Freuds conceptualisa-
tion (Fleck, 1975). Lindemann was a psychiatrist who studied grief at
Massachusetts General Hospital in the 1940s and 1950s. He studied
129
130 U n d e r s ta n d i n g Dava n l o o s IS - TD P

the effect of trauma on the survivors (and their family members) who
were involved in the Coconut Grove Nightclub fire in 1942. He was
specifically interested in understanding how grief presented symp-
tomatically. He established some common symptoms of grief, which
included somatic distress, preoccupation with images of the deceased,
guilt, hostility, and functional impairment. He also spoke of situations
in which the bereaving individual would take on traits of the deceased
individual.
Lindemann believed that grief could have a normal or abnormal
trajectory and that a mental health professional could help a patient suf-
fering with an abnormal trajectory get back on a normal one. Lindemanns
work had a profound impact on how the psychiatric community viewed
and diagnosed normal and abnormal grief. It also had a profound impact
on Davanloo, who was a resident under Lindemanns supervision at
Massachusetts General Hospital many decades ago.
In the last several decades, there has been a shift in focus on how grief
has been conceptualised. As psychodynamic theory and practice have
become less popular, grief has become more medical in nature. This is
reflected in the current nomenclature and terminology associated with
The Diagnostic and Statistical Manual of Mental Disordersor the DSM.
The previous edition of the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV) (American Psychiatric Association,
2000), had a specific classification system that many clinicians used.
Bereavement was categorised as a V Code. This simply meant that
bereavement was one of the other conditions that may be a focus of
clinical attention. In this sense, bereavement was not seen as an illness
but as a distressing problem that was normal. This was in contrast to a
major depressive episode, which was only diagnosed in the context of
grief if several specific features were present; for example, if there were
symptoms of profound worthlessness, guilt, or suicidal ideation, or if
the functional impairment associated with the loss was prolongedthe
suggestive cut-off was two months at which point major depression
was diagnosed.
With the more recent publication of the Diagnostic and Statistical
Manual of Mental Disorders, fifth edition (DSM-5) (American Psychiatric
Association, 2013), there has been a change in how grief is categorised
and diagnosed. Prior to its publication, some authors argued for the cre-
ation of a distinct new disorder representing abnormal grief (Prigerson,
Vanderwerker, & Maciejewski, 2008). This Prolonged Grief Disorder
pat h o l o g i ca l m o u r n i n g a n d t h e m o b i l i s e d u n c o n s c i o u s 131

would characterise individuals who have intense and prolonged


symptoms, and functional impairment following a loss. However, this
disorder was not included in the final version of DSM-5. Instead, DSM-5
suggests that any individual who meets the criteria for a major depres-
sive disorder should now be diagnosed with that disorder, regardless
of whether or not the symptoms coincide with an acute and recent loss.
This is a very controversial change, as many clinicians feel that normal
grief has now been medicalised and that many patients who would
otherwise improve with time will now be started on pharmacotherapy.
Davanloos approach to grief is, naturally, a psychodynamic one.
He differs from Freud and Lindemann in that he has a more active
approach in both understanding and working with mourning and
pathological mourning. Specifically, Davanloo works with individuals
in the Montreal closed circuit training programme who often have a
high degree of mobilisation. This is in stark contrast to patients who
might present at community mental health centres or private practices
with a highly cemented unconscious. While many of these patients are
in various states of normal and abnormal grief, such grief is often pres-
ent in a fused rather than in a mobilised state in the unconscious. This
means that the affect-laden experience of grief is often extremely diffi-
cult for the patient to experience. This is in stark contrast with individu-
als in the closed circuit training programme. These individuals often
have deep experiences of such grief. When this is combined with the
phase of MUSC, there can be meaningful and dramatic changes in a
patients intra-psychic and interpersonal life. These concepts will, once
again, be best illustrated with our case.

Vignette I: the experience of the neurobiological pathway


of murderous rage in the transference
TH: OK, Dr, we are on the issue of destructiveness, and honesty is the
best formula. Do you agree with it?
PT: Yes.
TH: That honesty is the best formula to remove destructiveness. You
adhere to this principle?
PT: I do.
TH: When you watch that, no question, you have a lot of feeling that you
have reduced yourself.
PT: Yes, I do.
132 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: You have a lot of feeling. W


hat is the feeling?
PT: I have rage about the situation.
TH: Rage or murderous rage?
PT: Well, its very murderous rage.
TH: If you transfer that rage to me, very tightly control it. How would
it go?
PT: I have an axe and I slice on your head. Slice on your head. Slice on
your head.
TH: Go on. Go on. Go on. Go on to this primitive system. Go on to this
primitive system. Lets go. Lets go. Lets go. Go on.
PT: I have a knife and two knives.
TH: And then. And then. And then.
PT: Pounding with my fists. Crushing your head. Your head is sliced
open.
TH: And then. And then. And then. And then.
PT: Pounding your chest. Then its all spurting.
TH: Then? Then? Then? Now if you look to my eyes. Carefully look to my
eyes. Carefully look to my eyes. What is the colour?
PT: At first, I thought it was green/brown but now it is green/blue.
TH: What?
PT: Green/blueits the eyes of my grandmother.

Evaluation of vignette I
This session occurred after some discussion with the patient and the
entire closed circuit training group. These discussions are not videotaped
but they often contain rich communications from the unconscious of the
participant(s). It is during one of these discussions that data emerged
from the patients unconscious. Specifically, the patient acknowledged
that while her grandmother had died about fifteen years earlier, she
had not grieved her in any way. In this sense, Dr Davanloo questioned if
the patient had a degree of pathological mourning over the death of her
grandmother. This is to be expected because the patients relationship
with the grandmother was complicated. Metaphorically, her uncon-
scious is shrouded in a heavy layer of fog. Structural change is needed to
remove this overcast state in her unconscious. If this cloud of pathologi-
cal mourning is not removedby means of the patient actively experi-
encing the actual grief for her grandmothers deaththen she cannot
pat h o l o g i ca l m o u r n i n g a n d t h e m o b i l i s e d u n c o n s c i o u s 133

achieve full structural changes. Structural changes would be possible


for this patient and would make her worldboth intra-psychically and
interpersonallyquite different.
When the murderous rage in the transference passes, the therapist
rapidly goes to the image of the murdered body and asks the patient
to look at the eyes. This is because the resistance of the guilt operates
extremely quickly. By rapidly focusing on the eyes, the patients own
psychosomatic pathway of the eyes very speedily comes into operation.
The teaching point from this vignette is that the resistance of the guilt
travels like the speed of light. The therapist needs to be faster than the
speed of guilt. If the interventions can be done in this wayin a fashion
that is precise and economicalthen the resistance has little chance to
come into operation.

Vignette II: the phase of psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
TH: Loaded with feeling. Loaded with feeling.
[Patient has intense passage of guilt.]
PT: How could I do this to her?
TH: Let the feeling out. Its heavy, heavy. Its very heavy. V
ery heavy. Still
you have more feeling in yourself. More feeling in you. More feeling in
you. More feeling in you.
PT: She did the best she could.
TH: Still there are feelings in you. Still what do you see now?
PT: I see her body viciously attacked. Splattered. Blood. Organs.
TH: How old is she? How old is she?
PT: In this image, she must be in her early sixties.
TH: What?
PT: Shes in her early sixties.
TH: How is she dressed up?
PT: She has a reddish/brown jacket, navy blue pants and she has a leather
purse and I cant see her shoes as clearly, but
TH: It is familiar to you?
PT: Yes.
TH: Its familiar to you.
PT: Yes.
134 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Do you remember the last time you saw her with the jacket?
PT: What is coming is theres a picture and shes wearing that jacket.
Were at a hill. Theres a picture. Shes there. My mother and three
sisters are there.

Evaluation of vignette II
The therapist started by focusing on the transference. Just prior to this
session, she had been watching a DVD that pertained to her own trans-
ference neurosis. While watching that DVD, she had massive murder-
ous rage towards her previous therapist. It must be stressed that while
she had massive feelings towards that individual, she also had uncon-
scious feelings in the transference, towards the therapist who is asking
her to honestly examine a situation that was extremely destructive in
her life. When she transfers the rage onto the therapist, she then experi-
ences a massive guilt. The therapist is then ready to engage in psycho-
analytic investigation of the unconscious.
Following this session, while the group was critically appraising it by
means of DVD, Dr Davanloo engaged in further psychoanalytic inves-
tigation into the unconscious. This is a practice that is commonplace
in the closed circuit training programme. It is unfortunate that these
group discussions are not audiovisually recorded, because they often
offer rich dialogue and multiple learning opportunities. In this instance,
he asked the patient if she could remember her last Christmas with her
grandmother. The patient could not remember any details surrounding
this time, indicating that the neurobiological pathway of memory had
not been sufficiently mobilised. However, upon exploring the grand-
mothers death, memory does emerge.
The patient was unable to be present when her grandmother died
because she was working in another area of the country. She did recall
that her sister was at the bedside of the grandmother when she died.
She had a very painful feeling when she admitted that she should have
been there, too. She stated, I wish I had done that. The unconscious is
restructuring, as evidenced by her desire to have a loving relationship
with her grandmother and to be present at her deathbed. Previously,
she would not have been able to acknowledge this.
We also see restructuring in how she experiences guilt and how she
experiences love. Not only does she experience true love and mourning
for the grandmother, but she also expresses regret for the way life
pat h o l o g i ca l m o u r n i n g a n d t h e m o b i l i s e d u n c o n s c i o u s 135

happened. She expresses the wish that she and her mother could unite
and go to the grave of the grandmother. Her transference neurosis had
been holding her back from unification with both her mother and grand-
mother. She goes through the process of mourning in an active and
experiential way, so that there is less residual pathological mourning in
her unconscious.
This psychoanalytic investigation of the unconscious occurs in many
dimensions. The goal of this phase is to create structural changes in the
unconscious. When the patient experiences the visual imagery of her
grandmother, mother, and sisters, it is like she opens up a photo album.
She sees the family as they appeared decades ago and with this comes a
massive feeling that had previously been buried beneath the surface for
many years. With this, destructiveness becomes less.
With these structural changes, the patient makes different choices
in her life. She chooses to stand at her grandmothers grave with her
mother in order to pay respect to the grandmother and experience her
love for her. By removing the resistance in a multidimensional fashion,
the patient is able to experience an extensive column of guilt. She also
experiences the massive column of grief that had been sitting in her
unconscious for years.
Experiencing this previously unconscious pocket of mourning
reduces the resistance of the guilt. Indeed, every unconscious feeling in
any dimension has to be experienced in order to reduce the resistance
of the guilt. In effect, this experience reduces the satellite operation
of the guilt. Since these are very painful feelings, the patient represses
them. But they manifested in another way which is in the destructive-
ness she has had in her life. This destructiveness was/is in service of
the guilt.
While viewing this album of her grandmother, and with the help of
ongoing MUSC, other feelings come to the surface. The patient begins
to experience peace with her grandmother. In order to experience this
peace, she has to work through not only her pathological mourning, but
also the transference neurosis with her previous therapist.
Repetition of this process is essential. The therapist and the patient
jointly agree on the task of removing the resistance of the guilt and
engaging in MUSC throughout the process. This is how structural
changes are created. By experiencing the neurobiological pathway
of memory, the patient decreases the column of guilt associated with
that memory. If this is done a number of times over multiple sessions,
136 U n d e r s ta n d i n g Dava n l o o s IS - TD P

we begin to see a new structure in the unconscious. When the feeling


comes up, it is more than grief and guilt. When she sees the jacket of
her grandmotherwho could not afford luxurious clothesshe experi-
ences other feelings besides guilt. She experiences love for her grand-
mother, who worked extremely hard in life to provide for her family.
At this point, though, there are many unanswered questions. Why
does the patient and her sisters have a need to destroy themselves?
If the grandmother was so loving, then why are they all destructive?
We cannot yet fully explain why the grandmother is linked with the psy-
chopathic character elements of the therapist for whom the patient had a
transference neurosis. Did the grandmother get psychopathic elements
in her unconscious from the husband in her second marriage? This
would be speculative at this time and there has been no evidence from
the patients unconscious to support this yet. There is much about her
attachments and early life history (specifically with her grandmothers
second husband Grappy) that we still do not know.

Vignette III: the phase of psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
TH: How far back is that?
PT: I am about two or three. Over fifty years ago.
TH: You have that picture?
PT: I do.
TH: In your house?
PT: Yes, I do.
TH: When was the last time you saw that picture?
PT: Six months ago. Maybe since then, but I know for sure I saw it six
months ago.
TH: Did you use to hug your grandmother with that jacket?
PT: When I was young I am sure I did.
TH: But do you have memories?
PT: I do. I have memories of hugging her. Not with the jacket but with
other clothes on.
TH: You have memory of hugging her? As far back to when?
PT: I remember hugging her when I was ten or eleven years old. I feel
happy that I can connect with her and I feel loving with her.
pat h o l o g i ca l m o u r n i n g a n d t h e m o b i l i s e d u n c o n s c i o u s 137

Evaluation of vignette III


With each investigation another feeling is triggered. The therapist rec-
ommends that the patient, when she goes home from this session, open
the family photo albums of the past. The more memory that emerges,
the more feeling the patient will experience. With the concomitant
structural changes there will be a global reduction of the power of
guilt in her unconscious. The therapist recommends that she visit the
grandmothers grave and then take some private time afterwards.
He advises that she ask her mother how life was between her and her
mother before the patient was born. The degree of restructuring that
could occur with this is endless.
By recommending this, the therapist is intending to move globally
in the unconscious. He likened the situation to a D-Day in the uncon-
scious. The goal is to clean up all of the destructive forces in the patients
unconscious as rapidly as possible.

Vignette IV: the phase of psychic integration, psychoanalytic


investigation of the unconscious, and the ongoing
creation of MUSC
TH: There is a portrait of love.
PT: Umm hmm.
TH: That you hug her?
PT: Umm hmm. She had many good qualities. She was a loving woman.
I want to be close to her.
TH: You have a good feeling towards your grandmother? Do you have
memory of the last part of her life?

Evaluation of vignette IV
The patient and therapist are starting to see good, albeit early, structural
changes. They are jointly working together and doing so activates the
pathological mourning in the unconscious. There is the beginning of a
chain reaction in the unconscious that leads to the experience of every
dimension of her affect-laden unconscious feelings and memory. While
she is doing well with experiencing the columns of affect-laden feeling,
she needs to improve more on the dimension of experiencing memory.
138 U n d e r s ta n d i n g Dava n l o o s IS - TD P

It helps to stand back and attempt an aetiological formulation of the


psychodynamics of her family. This will greatly aid in understanding
both the style and content of the therapists manoeuvers. The grand-
mother had a destructive competitive form of transference neurosis
with some important genetic figure(s) in her own life. Specifically which
figure(s) remains unknown. Most likely it was towards her mother or
father, but her sister (whom she named her daughter after) is also a pos-
sibility. The grandmother then transferred this destructive competitive
transference neurosis onto the patients mother, who transferred it onto
the patient. The end result is that the patient feels that she cannot love
both her mother and grandmother at the same time.
The grandmother has destroyed the mother in a sense. The patient
has destroyed her mother, too. It is very painful for the patient
to fully admit this and take responsibility for it. In her life, she was
faced with an impossible task. She had to find some way to live with
this inherited destructive competitive form of transference neurosis
from the past generation. She was constantly and unconsciously torn
between her mother and grandmother. In order to love one, she had to
torture the other. This Catch 22 causes massive guilt in the patients
unconscious.
The patients mother, too, had been faced with an impossible task
in life. In an unconscious sense, she was forced to pick between her
mother and her dead father in life. The guilt that comes with picking
her mother over her father is enormous. She uses compartmentalisation
in life, but the task is tough.
The role of the transference neurosis in this system must also be
understood. The transference neurosis has further damaged the whole
system of the original neurosis. The unconscious feelings towards the
grandmother do not want to let the resistance of the guilt go. The actual
memories of the grandmother will be the killer of the resistance of
the guilt. Metapsychologically, because of the transference neurosis, the
murdered body of the grandmother lies in a million pieces under the
avalanche that is the transference neurosis. Metaphorically, the patient
needs every piece of the grandmother out.

Conclusion
Accessing unconscious pathological mourning is not easy. How one
actively deals with pathological mourning has not been previously
pat h o l o g i ca l m o u r n i n g a n d t h e m o b i l i s e d u n c o n s c i o u s 139

described in the brief dynamic therapy literature. Nor has it been


previously captured so well with the use of audiovisual recording.
In this sense, the Montreal closed circuit training programme is at the
cutting edge of psychodynamic training and teaching.
The patient needs to protect herself, because otherwise her defen-
sive structure will continue to be impaired. The resistance of the guilt
has a massive power over her. It will easily come back because the
patients entire unconscious is taken up by these feelings towards her
grandmother. Davanloo has suggested that pathological mourning can
become a major resistance of the guilt itself. The patient destroyed the
women that she loved most in life. The grief for her grandmother, a
woman whom she both loved and wanted to murder, is so painful that
it lies in a pocket in her unconscious. This fuelled an engine of destruc-
tiveness in her life. We will explore this and other concepts as we con-
tinue with the next session in this series.
C hapter FOURTEEN

Intergenerational transmission
ofpsychopathology

F
ollowing the tenth interview, there was another interview in
the closed circuit training programme that was audiovisually
recorded. While the visual component of the recording was intact,
there was no audio component. As such, the transcript of this interview
is not available. For this reason, our next chapter will focus on the twelfth
interview in the series. The topic of this chapter will be Davanloos con-
cept of the intergenerational transmission of psychopathology.
The notion that psychopathology is or can be transmitted or trans-
ferred from one generation to the next is not new. Over forty years
ago, Guze, 1973 spoke about how the presence of psychiatric illness in
one generation often increases the risk of that same illness occurring
in members of the next generation. While there are some clear genetic
associations for some psychiatric diseases (Alzheimers and other
types of dementia, for example), many would view these illnesses as
neurological or brain diseases. Davanloo has formulated that psycho
neurotic illness can be directly transmitted from one generation to the
next. Davanloo does not see this transmission as a biological one, but
rather a psychodynamic one. Children of destructive parents tend to
become destructive themselves. Poor attachments in one generation

141
142 U n d e r s ta n d i n g Dava n l o o s IS - TD P

often result in poor attachments in the next. The same relationship and
family dynamics tend to be propagated through the generations.
Once again, Davanloos aetiological formulation of the patient is
essential in understanding the exact psychopathology that is present.
At the heart of much of this psychopathology (at the pathogenic core
of the unconscious) is the nature of the patients attachments and the
degree to which those attachments were disrupted. The age at which the
attachment was disrupted also refers to the age that fusion occurred in the
unconscious. The case will best illustrate some of these abstract principles.
This chapter will focus on the extent to which this patients transference
neurosis fulfilled her need for destructiveness; specifically as it related to
her own familial system of intergenerational psychopathology.

Vignette I: the experience of the neurobiological pathway


of murderous rage in the transference
TH: Ok, listen. If you I mean you have the ability to move yourself inter
nationally, and the feeling that you have I mean this is an enormous
issue.
PT: The transference neurosis?
TH: Yeah, I mean this is not the ordinary issue. Its a loss of ones self.
PT: Right.
TH: To another system. First it starts with some social interaction and
this and that and leads to this. And you are familiar with [the univer-
sity she trained atomitted for privacy issues]?
PT: I am.
TH: On the surface is charming but underneath is psychopathic criminals.
PT: Its true.
TH: So this instantly mobilises feelings in you. And you are very honest,
am I right?
PT: I am honest.
TH: And are you going to follow the principle of honesty and see how
you feel towards Dr X and the satellite operation4 or 5 therapists?
You have a lot of feeling.
PT: I do. I feel it building up.
TH: If you transfer it all onto me.
PT: There are two figuresDr X and Dr Y. I put it onto you. I shake
your neck and you are gasping for breath and I pound on your head.
I pound. I pound. I pound. I pound. I pound.
i n t e r g e n e r at i o n a l t r a n s m i s s i o n o f p s y c h o pat h o l o g y 143

TH: Go on. Go on. Go on. Go on. Go on. Go on.


PT: Youre on the floor and I shake you. I go on the floor.
TH: Go on. Go on. Go on. Go on. Go on. Go on.
PT: I take a knife. And its in the abdomen and then the uterus.
TH: Go on. Go on. Go on. And then. And then. And then. If you look now
to my eyes, what do you see in my eyes?
PT: I see the green/blue eyes of my grandmother.
TH: And you have massive feeling.
[Intense passage of guilt.]

Evaluation of vignette I
As in previous interviews, the therapist begins by focusing on the
patients transference neurosis with the previous therapist. Again,
it might seem to some that he is focusing not on the transference but
on an affect-laden zone towards another figure in her unconscious.
Using the Triangle of Person (Menninger, 1958), this might seem like
the therapist is working in the C and not in the T. But by focusing
on this highly charged, affect-laden zone, the therapist is working quite
definitively in the transference. The patient does not want to focus on
the destructive nature of the transference neurosis. She does not want
to focus on her role in maintaining a destructive therapeutic relation-
ship with her previous therapist. She has tremendous feelings not only
towards that previous therapist, but also towards the therapist who
asks her to honestly examine her destructiveness.
But what is interesting in this vignette, is that the therapist is focus-
ing not only on the previous therapist but on the satellite transference
neuroses in operation in her unconscious. The patient trained at a uni-
versity and had supervisors of questionable characterone of whom
faced criminal charges. While the exact criminal activities of these
individuals are beyond the scope of this book, it was well known that
the training programme was subjected to these psychopathic elements.
We must ask: what is the effect of this on the patients own uncon-
scious? While she is a flawed and destructive human being on one
hand, she is also a remarkably robust and motivated individual on the
other. What happens to an individual like this when they are exposed
to such psychopaths in a training programme? The effect of train-
ing programmes on the unconscious of trainees will be reviewed in
Chapter Twenty One.
144 U n d e r s ta n d i n g Dava n l o o s IS - TD P

The answer is not yet clearly obvious. While she may not have
been exposed to any frankly criminal activities, the presence of these
domineering and influential psychopathic figures likely left a mark on
her unconscious; or as Davanloo would say a scar in the unconscious.
What might result? She could have impairment in her unconscious
defensive organisation. She could have rusted or cemented defences.
She may not know her own unconscious and may not be able to distin-
guish between normal defences and major resistance. In this last regard,
she may have been brainwashed in her former training programme.
Davanloo continues to question the interface between transference
neurosis and brainwashing (the subject of Chapter Twelve). While the
exact relationship is not entirely clear, these questions are worth further
exploration.

Vignette II: the experience of guilt and the phase


of psychoanalytic investigation into the relationship
with the mother and grandmother: exploring the role
of the destruction of the uterus
TH: You have major waves. Major waves. Major waves. Major waves. Major
waves. Major waves. Who else is [there] besides your grandmother?
PT: My mother was in the uterus. But she is a child. But an older child.
TH: How old is she?
PT: Two. Two years old.
TH: Its young.
PT: Yes.
TH: How old?
PT: Two.
TH: Who else is, besides her?
PT: Its just my grandmothers dead body.
TH: Where is her husband? Your step-grandfather?
PT: He wouldnt be here.
TH: No? Where is he?
PT: Hes not in the picture yet because my mother was only two.
TH: Could you describe the body as clearly as you can?
PT: I see my grandmother as she would have been.
TH: How is she dressed?
PT: She is wearing an apron. A white apron. It flashes back to when she
was a young woman and her hair is dark.
i n t e r g e n e r at i o n a l t r a n s m i s s i o n o f p s y c h o pat h o l o g y 145

TH: You have a lot feeling for this woman.


PT: Shes doing her best.
TH: Is she looking at you if you keep eye contact?
PT: Shes in pain. Shes got to work hard and shes doing her best.
TH: Could you describe your mother?
PT: Shes two. I dont understand.
TH: Do you visually see your mother? How would you describe her?
PT: She has big chubby cheeks and curly hair.
TH: Is she attractive?
PT: Yes.
TH: If you were mother to your mother how would you approach her?
PT: I love you. Everything will be ok.
TH: Could you do this?
PT: Yes.

Evaluation of vignette II
This was a very powerful vignette for several reasons. She has often been
asked by Dr Davanloo who the central figure is in her neurosis. While
Dr Davanloo has formulated that it is her mother, the patient has reported
that if this is the case, she is often hand in hand with the patients grand-
mother. In this particular vignette, the patient clearly demonstrates this.
She violently destroyed the abdomen and uterus of the therapist (who
then becomes the grandmother). Following this, she sees the dead body
of the grandmother, and the mother as a young two-year-old child.
One might ask: why does she see the mother as a two-year-old child
rather than the murdered foetus from the grandmothers uterus? There
is no clear and obvious answer to this question. In many cases, with an
optimal rise in the TCR, the patient sees the murdered body of only one
genetic figure. However, it is possible that a patient will see two figures
as a result of a very high TCR. It is also possible that she sees the mother
as a two-year-old child rather than a foetus because seeing the young
child results in a greater experience of guilt. At any rate, the destruction
of her mother in the uterus of her grandmother has profound implica-
tions. This unconscious murder would result in the destruction of the
patient herself, who would not have been born had her mother been
murdered as a young child.
In one way, this unconscious destruction of the uterus of the
grandmother would put an end to the intergenerational transmission
146 U n d e r s ta n d i n g Dava n l o o s IS - TD P

of psychopathology in a very final and definitive way. It is difficult to


fully comprehend the ramifications of this. It would result in the patient
herself never being born. Perhaps putting an end to the lives of all three
people (patient, mother, and grandmother) would be the only solution
to ending the intergenerational transmission of psychopathology in
this family. Is this act an expression of the resistancea self-destructive
desire to end the problem rather than work through it? Or is this act an
expression of the UTA? Does the UTA want peace and reunion for the
family and does it see the triple murder as the only way of achieving
this? Perhaps, in this vein, the UTA sees that in death there is love. But
at this point, these are only questions. The patient and therapist both
know that they must follow the trail of the unconscious in order to get
answers to any of these questions.

Vignette III: further psychoanalytic investigation


into the unconscious: the patient becoming
a mother to her own mother
TH:Have you ever had thoughts [on] how life would be like if you were
mother to your mother?
PT: Yes.
TH: Could you describe you and your thoughts of being mother to your
mother?
PT: I would push her to be the best that she could be. Because my mother
has a lot of potential and she didnt meet it. But I would want her to
meet her potential.
TH: You see you have climbed the academic life. At any time, do you have
thoughts if your mother climbedwhat she would be like?
PT: My mother could have done anything she wanted to. At one point
she told me she wanted to be a social worker. She is very good at
math. She reads all the time.
TH: What do you think happened?
PT: Last time, you asked why I did medicine. Maybe that was my grand-
mother. My grandmother influenced us but not my mother.
TH: Why?
PT: My grandmother was very big on educationmore for financial free-
dom. My sisters and I all have two degrees and I am working on my
third. My mother didnt get the same push.
TH: Your mother didnt get the same push? Why?
i n t e r g e n e r at i o n a l t r a n s m i s s i o n o f p s y c h o pat h o l o g y 147

PT: I ask myself that question. I didnt think that there was a university in
her area back then. My grandmother swayed her to be a secretary.
TH: Its very important. Your three sisters and you have had much better
opportunity. You and your sister went to medical school but your
mother remains on the bottom. Is this the by-product of something
between your mother and grandmother? The intergenerational
issues with your grandmother and her pasttransferred to your
mother?
PT: Im very suspicious of that. I thought it was far less expensive to send
my mother to secretarial school. I dont know if that was true.
TH: Your grandmother didnt want her to move up. Im questioning is this
neurosis between her and her own mother? She named your mother
after her sister. But she was destructive to both.
PT: I think its very possible if not probable.
TH: Im talking about your thoughts.
PT: I think its very possible.
TH: Is there any other way to explain it? You have to examine it.
PT: My mother told me that my grandmother saved up $500 for my
mother to go to secretarial school. Looking backtuition to univer-
sity was not that much higher. Unless my grandmother didnt want
her to succeed academically. She had potential.
TH: Was your grandmother negative towards your mother? It is impor-
tant that its your ideation.You dont want to look at these feelings.
PT: Through my entire life I wouldve said: a) there was no university and
b) it was too expensive. Now it doesnt make sense that it would be
that much more expensive. My mother got different treatment than
my sisters and I did.
TH: You had a better deal.
PT: I did.
TH: Your grandmother did not do that for your mother. In the eyes of
your grandmother you were more important than your mother.
PT: Umm hmmm. But we all were. Three of my sisterswe all had the
same treatment.

Evaluation of vignette III


The above vignette nicely demonstrates the intergenerational trans-
mission of psychopathology in this patients family. It is clear that the
patients mother had tremendous academic potential. As a young child,
148 U n d e r s ta n d i n g Dava n l o o s IS - TD P

she excelled academically. However, she lived in poverty and academic


opportunities were limited.
What comes out in the above vignette is that the grandmother
had saved $500 (back then, a large amount of money) to further her
daughters education. The patient had always thought that a univer-
sity education would not have been available. However, during this
interview (and during the unrecorded group dialogue that ensued), it
is clear that a university education would have been possible for her
mother had her grandmother promoted it.
So why would the grandmother want her daughter to be a secretary
rather than a university-educated individual? If this was the choice
and preference of the mother, then there is no unconscious crime and
there is no transmission of psychopathology from the grandmother to
her daughter. However, if this was not clearly the choice of the patients
mother and if her own potential clearly exceeded that of a secretary,
then the situation is worthy of further exploration.
There are obvious questions that must be asked. Did the grand-
mother want her daughter to be employed but not fully educated to
her potential? Did she want her to have a stable life but not a richly
academic one? Did she not want the patients mother to have the edu-
cated life that she herself was deprived of? Did the grandmother also
have the potential (but not the opportunity) to study at university? Was
her decision to promote secretarial school for her daughter a means of
fulfilling her own destructive competitiveness? Was the grandmothers
destructive competitiveness transmitted from members of the previous
generation?
These are important questions. Once again, by following the trail of
the unconscious, we hope to get more answers to these in the future.
But previous to this interview, the patient had resistance to looking into
the idea that her grandmother wanted her granddaughters to have uni-
versity educations but not her own daughter. After this interview, the
patient is more open to exploring this idea.

Vignette IV: the relationship of the transference neurosis to the


intergenerational transmission of psychopathology
TH: My question is this: do you plan to get out of the transference neuro-
sis with Dr X or remain in it? As slave to the master?
PT: I will do everything in my power to get out of it.
i n t e r g e n e r at i o n a l t r a n s m i s s i o n o f p s y c h o pat h o l o g y 149

TH: All of this, taken together, you have not much autonomy to give your
views and do things on your own. You want to talk to you mother.
Good. But does your mother talk to you about her life?
PT: We went to the graveyard and I took my scrapbook and we went to
lunch. I kept asking lots of question about each picture.
TH: And you have it at the site of the grave? Could you portray one of the
pictures of your grandmother?
PT: Theres a picture of her and her two parents and 12 siblings at
work. Its summer.
TH: How is she dressed?
PT: She has a bandana on her head. She has dark hair and is in her
teens.
TH: Shes attractive?
PT: Yes. Shes smilingtheir arms are around each other. She looks very
happy.
TH: If she were here how would you relate to her?
PT: My grandmother? Last night I was looking at pictures from
the 1990s2000s. She was a happy, jolly soul. I couldnt rem
ember this.
TH: You have feeling and you want to run away from the feeling.
PT: I give you a hug. Its great to see you being happy.
TH: You have the opportunity to get in touch with her. Dont fight your
feeling. Be honest with yourself. Shes looking at you?
PT: Shes smiling. Shes wearing a blue hat and a blue coat.
TH: Shes loving?
PT: Yes.
TH: If she was hugging you how it would be?
PT: I feel the coatits winter.
TH: How she hugs you?
PT: She hugs back.
TH: There is feeling in you?
PT: Yeah. Last night I started to remember the happy, jolly grandmother
and its wonderful.
TH: Why you hold on to your feeling?
PT: Im notits there. And youre right, you said that the transference
neurosis was a betrayal of my grandmother and it was a betrayal of
my happy, jolly grandmother, who I can remember now.
TH: You see you have strong memories of your grandmother.
PT: Yes.
150 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: But then always the transference neurosis puts a blanket on top of it.
You must have been a feeling person. But when you become unfeel-
ing, the transference neurosis comes into operation. Because it is the
memory that brings back feeling. To what extent you are governed
by the transference neurosis and to what extent you need to get out
of the iron wall of the transference neurosis?
PT: Im piecing together the events of my life. My grandmother died in
2001. My previous therapy was in 2004.
TH: We have met several times. You have not described the content of
your treatment.
PT: I wrote my previous therapist and got my notes. You couldnt read
it. It was a disastera complete mess. It doesnt follow the metapsy-
chology of the unconscious.
TH: What was it?
PT: It felt like confabulation and I accept my responsibility. Thats what
my treatment was. Thats what it reads like and I went along with it,
which is very disturbing.
TH: You went along with it.You were compliant.

Evaluation of vignette IV
This vignette highlights the potential relationship between the trans-
ference neurosis figure and the intergenerational transmission of psy-
chopathology. The transference neurosis has been the subject of several
chapters of this book. It has been explored in great detail.
In this vignette we see how the patients development of a transfer-
ence neurosis was the reflection of an unconscious need. In this case,
the patient had an unconscious need to maintain the homeostasis asso-
ciated with the intergenerational transmission of psychopathology.
Specifically, she had an unconscious need to maintain and propagate
the destructive competitiveness she inherited from her grandmother.
When her grandmother died in 2001, she did not adequately grieve
and she suffered from pathological mourning. This was the focus of
the previous chapter. She was unable to experience the depth and
breadth of all of her feelings towards this complex character in her life
when she died. On some level, she was unconsciously looking for a
replacement for her grandmother following her death. She was seek-
ing out an individual who, while appearing benevolent on the surface,
i n t e r g e n e r at i o n a l t r a n s m i s s i o n o f p s y c h o pat h o l o g y 151

was profoundly destructive underneath. She found this in her previ-


ous therapist and this allowed her to meet her own need to maintain
destructiveness in her life.

Conclusion
At this point in the sessions, the patient has developed a UTA with the
therapist. In this particular session, the therapist was able to rapidly
mobilise the TCR very quickly by focusing not only on the transference
neurosis with her previous therapist, but on the satellite operation
of the other four to five therapists. The patient is well aware that there
was a psychopathic element in her residency training programme. She
is well aware that her previous therapist was influenced by psycho-
pathic individuals. Rather than cover it up, the therapist is asking the
patient to look at it more closely. The patient, at least unconsciously,
does not want to. When she does examine it, she has a massive rage
and experiences a massive impulse to murder the therapist in the trans-
ference. But what we see is that this is not an impulse to murder her
previous therapist or members of the satellite operation. Nor is it
an impulse to murder her therapist. It is truly an unconscious impulse
to murder her grandmothera destructive woman whom she deeply
loved. Following the experience of guilt, the therapist then engages in
psychoanalytic investigation of the unconscious, to better understand
the role her grandmother played in propagating the intergenerational
transmission of psychopathology in her life. This will be explored in
greater detail with further clinical vignettes.
C hapter fifteen

The turning away syndrome

T
he next two interviews in the series (interviews 13 and 14) were
not available for transcription. So what follows is the fifteenth
interview in the series. The focus in this particular chapter is
a topic that Davanloo has begun to explore only relatively recently
(Davanloo, 2015). Specifically, there has been a focus on family members
turning other family members against each other. Any member of the
family can turn another member away from a third member. We call
this the turning away syndrome.
Again, while this would intuitively cause major intra-psychic dam-
age to a developing child, no other brief dynamic therapist has focused
on it or published on it to date. When one searches the literature on this
theme, some information arises from biblical quotes. For example, in
Matthew 10:35 (King James Bible) we see the following scripture:

For I am come to set a man at variance against his father, and the
daughter against her mother, and the daughter in law against her
mother in law.

As with many concepts in dynamic therapy, the truth of the uncon-


scious tends to materialise more in literature than it does in research.
153
154 U n d e r s ta n d i n g Dava n l o o s IS - TD P

The medical and psychiatric communities have neglected this field of


focus for decades. And while Freud clearly understood the importance
of unconscious emotions towards parents, in no way did he work to
understand the importance of subtle psychodynamics such as these.
One of Davanloos goals is to better understand the nuances
of the complex nature of interpersonal human interactions. Many
families have members who form alliances with each other. Many of
these formed alliances have specific family members as targets. Because
of the destructive competitiveness of the various family members, indi-
viduals are turned against one another. As one might imagine, under-
standing the nature of these alliances and dynamics can be very difficult.
However, they have become essential in Davanloos work. A solid com-
prehension of who is turning family members against each other greatly
aids in the aetiological formulation of the patient. Often Dr Davanloo
formulates the patient and targets interventions accordingly. Following
these interventions in the live interviews, the formulation is explored
and discussed in depth.
We return to the case and the fifteenth interview to demonstrate
these dynamics. The case will show the turning away syndrome with
greater clarity and will also show how this syndrome interfaces with
the destructive competitive form of the transference neurosis and the
concept of intergenerational transmission of psychopathology.

Vignette I: the experience of the neurobiological pathway


of murderous rage in the transference
TH: You go through a difficult time with your grandmother. From 2005,
your letter indicates you were in massive idealisation. With idealisa-
tion you were wiping out the feelings you had. What were the feel-
ings you had?
PT: Towards the transference neurosis therapist?
TH: Yes.
PT: Back then or now?
TH: Back then and now.
PT: How wonderful the therapist was. But I also had rage towards him.
He wouldnt return his phone calls.
TH: So lets look at this. Y
ou had massive rage. If you transfer it to me and
honestly experience it. Y ou are an honest person.
t h e t u r n i n g away s y n d r o m e 155

PT: Id stand on the table. Id lean over. I would grab your head and
pound both of your eyes. I would flatten your skull. Im holding you
by the neck and pounding your head.
TH: Go on. Go on. Go on.
PT: Im squeezing the neck. Youre looking up at me but it is Dr X and
Im happy to see him suffer, you suffer and that was a knife.
TH: What colour are the eyes?
PT: I see the blue eyes of my father.
TH: Right now you have a massive feeling. Let it out. This is toxic. Let it
out. Y
ou owe it to yourself. Y
ou owe it to your life. Y
ou owe it to the
next generation.
PT: I betrayed you with this therapy. I love you. I love you.

Evaluation of vignette I
As in previous interviews, there is a very quick activation of the neu-
robiological pathway of murderous rage. Again, while it might look
like this murderous rage is towards the former therapist (the C in
the Triangle of Person (Menninger, 1958)), it is actually very much
in the transference. As in previous sessions, the patient has a sadis-
tic impulse to murder the therapist. Upon unleashing this, she has
a brief image that it is her former therapist. She sadistically admits
that she is glad that he suffered. Very quickly, however, the eyes of
the murdered body become the eyes of her father. Upon seeing him,
she makes a very important communication. She states: I betrayed
you with this therapy. This sentiment, in her mobilised state, is not
contaminated by resistance. In addition, she announces what had
previously only been an unconscious awareness about her previous
therapy. She now becomes consciously aware that this therapy
characterised by the very destructive transference neurosiswas a
betrayal of her father.
As reviewed in previous chapters, at the centre of the pathogenic
core of her unconscious is a conflictual but extremely loving relation-
ship with her mother. Her grandmother also plays a key role in this
conflictual relationship. Davanloo has formulated that her grand-
mother turned the patient against her own mother. The patient sought
out therapy with her previous therapist for a variety of reasons. One
is that she was seeking a domineering, omnipotent figure who could
156 U n d e r s ta n d i n g Dava n l o o s IS - TD P

continue to allow her to be destructive in life. In this sense, her previous


therapist became her grandmother. Just like her grandmother, the pre-
vious therapist had a mission to turn her against various members of
her own family. The grandmother wanted to be a mother to the patient
and wanted to turn the patient against her mother for this reason. But
in addition, both the grandmother and the patients mother wished to
turn her against her father.
In this particular breakthrough, the patient sees her father as rela-
tively innocent in the whole process. While he was not perfect and
had his flaws as a human being, he did not warrant the degree of mur-
derous rage and guilt directed towards him in the previous therapy.
The patient has a tremendous guilt towards the fact that she allowed
this to happen. One must ask: why did she comply with the previ-
ous therapist in making her father the main (and erroneous) target of
her therapy? Again, this has to do with the destructive transference
neurosis towards him and her unconscious desire to maintain suffering
in all ways possible.

Vignette II: the experience of guilt and the application of MUSC


during the psychoanalytic investigation of the unconscious
TH: Go on, you have a lot of feeling. Still you see the eyes?
PT: Yes.
TH: Is it the same colour? What do you see?
PT: Pain in his blue eyes.
TH: How old is he?
PT: He was older. But he looked younger when you asked.
TH: How is he dressed up?
PT: Two things come. First, he is in a plaid shirt. Then a magenta/pink
shirt that was the style in the 1970s. A pink-magenta shirt with a
wide collar and a purple tie. It sounds very strange but that was
the style.
TH: You have memories?
PT: I think it is summer and were at a family members house.
TH: Whatever you see. The importance is what you see. You say it is
summer. Where are you having this?
PT: Its summer. Were at a festival. My dad is very happy. I am very
happy.
t h e t u r n i n g away s y n d r o m e 157

TH: How old you were? When you talk about the 1970s?
PT: Age three.
TH: You remember yourself at age three?
PT: I remember him reading us stories. This memory of age three at the
festival, that is not entirely clear. What comes very clear is that I have
betrayed my father back then and in that terrible therapy. My sense
is that I betrayed him by siding with my mother and grandmother
against him. Its very painful but true. And he took the penetrated
position in life and I went along with that.
TH: Are you saying that you were turned against your father?
PT: Many times.
TH: How old were you?
PT: Three.
TH: Is it possible you examine your memory?
PT: Well what comes to mind is that were at this festival. Its not 100%
clear. But he is at the beer tent and they are critical of him. We went
on vacation, once, and my father bought alcohol.

Evaluation of vignette II
The patient has a heavy experience of guilt towards her father. The
therapist tries to maximise this experience of guilt. He asks for as much
vivid detail as possible. By rehearsing the details of the portrait of the
dead body he is draining as much guilt as possible for this particular
breakthrough. He is also laying the foundation for any memories that
the patients unconscious may introduce.
We see the two visual memories of the father wearing two different
outfits. While she initially sees the father as being happy, this quickly
changes. Her unconscious introduces the notion that she betrayed him
by siding with her mother and grandmother against him. She becomes
consciously aware of the deep-seated alliance she formed with her
mother and grandmother against her father. She also acknowledges
the penetrated position he took towards these family members. They
were critical of him and he did little to stand up for himself or change
the family dynamic more generally. This has placed a heavy burden
of guilt upon the patient for her entire life. She acknowledges the pain
associated with the reality of having turned against her father under the
power of the mother and grandmother.
158 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Vignette III: the further application of MUSC during the


psychoanalytic investigation of the unconscious
TH: Even back then they were critical? Could you look at what way they
were critical with him?
PT: I have more memories of my mother. But my dad says my grand-
mother did it, too. They were explosive and would be critical of you.
TH: Your mother and grandmother were critical of your father?
PT: And Grappy. My mother was very critical to my father. She was
more silent and withdrawn from Grappy.
TH: Umm Hmm. How do you feel right now?
PT: I feel very relaxed. Its very easy to discuss these matters with you.
TH: Its easy for you?
PT: Yeah.
TH: You see your father often?
PT: I see him probably two to three times per week.
TH: How do you approach each other?
PT: Hes cut off from his feeling. He doesnt like to hug. I try to hug him.
Hes resistant. He doesnt hug back but he pats my arm.
TH: How do you feel?
PT: Its upsetting.
TH: That doesnt say how you feel.
PT: Theres a rage that he wont accept my hug.
TH: You feel rage?
PT: Not now. There is a wish I could have been close to him. And what
comes is that it all went downhill at age two or three. I love my dad
so much.

Evaluation of vignette III


It is important to understand how the patient and therapist came to this
type of communication. As in all other breakthroughs, this type of com-
munication is not contaminated by resistance. In general, the greater
the column of guilt that is evacuated in the breakthrough, the lower
the likelihood that the following communication will be influenced or
tainted by resistance.
In this session, the therapist focused on her feelings towards her pre-
vious therapist and then shifted that feeling towards the transference.
In the previous session, the therapist focused not only on her previous
t h e t u r n i n g away s y n d r o m e 159

therapist but on the satellite organisation of other therapists around


him. Clearly, the patient was exposed to destructiveness in her former
therapy. But she was also exposed to extreme destructiveness in her
training programme.
One could formulate that she allowed herself to be used and abused
by these individuals because she was searching for extreme destructive-
ness to replace the omnipotent figure of her grandmother, who died
early in her training. This has been the formulation of the therapist
throughout the last several sessions. By aligning with the previous ther-
apist she was able to replicate the relationship with the grandmother,
who sought to inflict extreme suffering in her life. One of the ways she
did this was by turning against those individuals whom she loved most:
her mother and father.

Conclusion
This concludes the fifteenth interview for this patient in the Montreal
closed circuit training programme. The above vignettes highlight the
importance of the turning away syndrome. This phenomenon is
closely related to the concepts of intergenerational transmission of
psychopathology and the destructive competitive form of the trans-
ference neurosis. Indeed, all three of these may be in operation in the
same patient. We will further discuss these abstract concepts and how
they materialise and are clinically understood in operation in the closed
circuit training programme.
C hapter Sixteen

Following the trail of the unconscious

W
e continue with the sixteenth interview of the series. By
now, the patient is quite familiar with the process. She has
been interviewed in the Montreal closed circuit training pro-
gramme multiple times. She has had multiple breakthroughs of murder-
ous rage and intense guilt. The therapist has applied MUSC throughout
the entire process. At this point in the journey we are beginning to see
the start of structural change in her unconscious. Simply put, the various
components of her unconsciousher defensive organisation, her anxi-
ety, her resistance, and her emotionare beginning to change.
For example, earlier on in the course of the therapy, she often had
projection in relation to the therapist. She had unconscious anxiety in
relating to him and this was for a variety of reasons, as reviewed. To
summarise, she had unconscious anxiety generated by her murderous
impulse. In addition, she had projective anxiety simply because she saw
him as her grandmother; and this omnipotent, authoritative, and some-
times explosive figure frequently induced anxiety in her as a small child.
However, in the last several sessions, we see that the patient pres-
ents with less unconscious anxiety in the early phases of the interview.
While there is still resistance in place, there is less compared to earlier
interviews. We begin to see more fluidity in her unconscious. She is
161
162 U n d e r s ta n d i n g Dava n l o o s IS - TD P

more spontaneous and dynamic in her communication. These are the


hallmarks of early structural changes. The next interview will continue
to focus on the application of MUSC. Specifically, the therapists spon-
taneous and attuned approach to the unconscious will be more clearly
highlighted. This approach will be referred to as following the trail of
the unconscious.

Vignette I: the experience of the neurobiological pathways


of positive feelings and murderous rage in the transference
TH: Josephine is a French name. Josephine and Bonaparte.
PT: I hadnt realised that.
TH: You had a dream?
PT: I hadnt realised it was a French name.
TH: How do you feel right now?
PT: I feel positive feelings right now.
TH: But how do you feel right now with me? If you honestly examine your
feelings? How do you feel towards me? How do you feel towards me?
PT: I feel it. But there might be positive feelings.
TH: Lets to see how you feel towards me. Y ou say positive but you took a
sigh. Are you declaring to say how you feel? Y ou follow the principle.
How do you feel?
PT: The rage is building.
TH: The rage is building. But that is a sentence. It doesnt say how you feel
towards me. If you go at maximum level. How do you feel towards
me? If you let the rage out.
PT: Im powerful.
TH: If you go further. Let the viciousness out.
PT: I squeeze your neck.
TH: Lets go. How do you finally destroy me?
PT: What comes is that youre on the floor. Your head is open. Theres
brain. Youre gurgling blood.
TH: What do you see?
PT: I see the green/blue eyes of my grandmother.

Evaluation of vignette I
Prior to this videotaped interview, the patients great-aunt Josephine
had been discussed in the group format. As the session opens, the
therapist brings her up once again. This was the sister of her maternal
f o l l o w i n g t h e t r a i l o f t h e u n c o n s c i o u s 163

grandmother, and while her exact psychodynamic significance in the


family is still largely unknown, we begin to find out more about her
during this session.
The therapist then explores how the patient feels towards him. The
patient spontaneously reports that she has positive feelings towards
thetherapist and the therapist simply put pressure on whatever feelings
she does have. This is when the rage appears. In the past, Davanloos
critics objected that the technique focuses exclusively on the rage that a
patient may or may not have in the transference. However, those who do
notparticipate in the Montreal closed circuit training programme would
not have the opportunity to witness vignettes such as the above. The
therapist is in no way fishing for rage. He is simply putting pressure on
the patient to experience whatever feelings she has in the transference.
While it is not recorded in the vignette, the patient did describe the
neurobiological pathway of her positive feelings outside of the session.
Like many other patients, she experienced her positive feelings as a
lightness in the chest and abdomen, which wanted to express itself
through the arms, ending with a hug of the therapist. As the phase of
pressure to feelings in the transference continued, the patient herself
spontaneously introduced the feeling of rage. This was not because
the therapist suggested it but because the patients unconscious intro-
duced it. Fishing for rage would be unethical. Applying pressure for the
patient to experience her feelingswhatever they areis in keeping
with following her unconscious.

Vignette II: the experience of the neurobiological


pathways of murderous rage and guilt
TH: Lets to see how you feel.
[Patient is sobbing.]
TH: Let it out. Let the feeling out. Let the feeling out. Let the feeling out.
Let the feeling out. Let the feeling out.
PT: I want to rip them apart from each other.
TH: Let the feeling out. How old is your grandmother?
PT: What?
TH: How old is she?
PT: Its almost like she is in her fifties. But what comes is that my mother
is a child and I want to take her from her own mother. I want her for
myself. I want to destroy my grandmother. I want to have my mother
for myself.
164 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Stay with your thoughts.


PT: I want to protect my mother from my grandmother. I want my
mother to myself.
TH: That is very important because you want to protect your mother.
PT: I want to destroy my grandmother so that my mother is healthy.
I want her all to myself.
TH: You want to protect your mother. She is how old?
PT: My grandmother?
TH: What she is dressed up?
PT: She is wearing an apron.
TH: Its familiar to you?
PT: A ratty, threadbare apron.
TH: You must have seen it somewhere?
PT: I just see my grandmother whos struggling and not doing well in life.
I want to keep my mother away from it.
TH: But theres a major change. Y ou want to protect your mother.
PT: But to do that, I have to destroy my grandmother. To do that, I have
to be destructive.

Evaluation of vignette II
Many important issues are raised by this vignette. But before there is a
discussion on MUSC and how we follow the trail of the unconscious,
we must first review what has metapsychologically transpired in the
session. The following concepts were reviewed in the group session
with Dr Davanloo after the session had transpired.
First: what is the nature of the passage that we see above? At the
heart or the nucleus of this pathogenic core we see the patient, her
mother, and the grandmother. Her father plays a more peripheral role.
Because she had such intensely loving relationships with all of these
genetic figures, she has a powerful centre of guilt in her unconscious.
This has been an engine to her destructiveness in life. It has been an
engine to her character resistance, which includes an idealisation of
destructiveness.
Second, is this her original neurosis? Or has her unconscious under-
gone manipulation of some sort such that we are still seeing ongoing
effects of the transference neurosis? The transference neurosis has been
a heavy focus of this book. While she is beginning to work through
this transference neurosis and to understand its implications in her life,
f o l l o w i n g t h e t r a i l o f t h e u n c o n s c i o u s 165

it is much too early to speculate on whether or not it has been removed


from her unconscious. In addition, we must also question if there was
some degree of brainwashing in her previous therapy. Most likely, the
patient is still intensely under the power of guilt. Davanloo formulates
that she is under the power of idealisation of destructiveness.
Third, why is there such a massive murder? What did these genetic
figures do such that they deserve this level of sadism? Her grand-
mother was controlling and explosive but this does not justify this
degree of sadism. There is a court of law in the unconscious, metaphori-
cally speaking, which demands justice. Davanloo, the patient, and the
entire group reflected on several issues. One is: where does this degree
of sadism come from? Could it be the transference neurosis with her
previous therapist? Or could it be from someone in that individuals
past? Or could it be from the patients step-grandfather? We still know
very little about him, the make-up of his unconscious, and the impact
he had on the family.
While the answers to these questions are not immediately obvious, it
is important to be mindful of them. Asking the patient these questions
while her resistance is intact will accomplish nothing. When resistance
is in operation, there is the potential that speculation will be intro-
duced into the process. When this occurs, the speculation may be con-
taminated by projection, blame, and accusation. This is to be avoided
at all costs.
At this juncture, Davanloo emphasised the need to stay attuned with
the communications from the unconscious following the breakthrough
of guilt. These are no longer contaminated by resistance. To summarise:
this first breakthrough centres on the patients grandmother. In the por-
trait, the patient identifies that she would like to take her mother away
from the grandmother. As the patient says, I want to rip them apart
from each other. Her mother is close by and she wants to protect her
mother against her grandmother.
In the above vignette we see a degree of sadism towards the grand-
mother that seems out of keeping with what the law of the unconscious
might determine she deserves. We do not see clearly the grandmother
as a wholly psychopathic womanindeed, at the core of her character
is a loving, albeit controlling and demanding, centre. It is not clear why
there is such a large volume of sadism towards this woman. But it is
vital not to prematurely judge. It is far more important to go where the
patients unconscious leads us.
166 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Vignette III: MUSC during the phase of psychoanalytic


investigation into the unconscious
TH: Do you have any memories? Its important to see if you have any
memories of Josephine and your grandmother. As far back as you can
remember, any memories of Josephine with your grandmother?
PT: So, were at my house. Josephine is home. Shes in her fifties or six-
ties. She likes to eat fish. Shes had too much to drink. Shes singing
songs and my sister is on the piano. And my grandmother hates it.
TH: Your grandmother was intolerant if Josephine was drunk.
PT: Not drunk, just two to three drinks.
TH: How old were you?
PT: Six or seven.
TH: Josephine has a good time. If Josephine had totally gone berserk and
lost her thoughts, how would she go at your grandmother? Without
censorship, how would she attack your grandmother?
PT: She would pound her. She would pound her. Strangle her. Pound her.
TH: If it was in the kitchen and she had hold of a butchery knife?
PT: Its a blade and it goes like this. Left, right, left eye.
TH: Go on and your grandmother makes what noise?
PT: She falls to the floor.
TH: Go on. So she would murder your grandmother? Could you describe
the murdered body of your grandmother?
PT: She has an apron on. And a sweatshirt on.
[Patient has a massive passage of guilt.]
TH: Josephine has murdered the grandmother. Josephine has murdered
the grandmother. Josephine has murdered the grandmother.
PT: I can smell the fish.
TH: Josephine has murdered the grandmother. Y ou have a lot of feeling.
PT: Yes. Because its me.
TH: You are the murderer?
PT: Yes.
TH: Why you say that youre the murderer?
PT: Because its very clear I was the one who murdered my grand
mother.
TH: Now let me to ask you this. You said your grandmother was given
a drink. Your mother was at your home. What if your mother lost
control? How would she go on the body of your grandmother?
How would she terminate your grandmother? If you may, your
f o l l o w i n g t h e t r a i l o f t h e u n c o n s c i o u s 167

mother had lost control and went berserk on the body of your
grandmother?
PT: She would take her head and tilt it back and slash her throat.
TH: What kind of knife?
PT: Butchery knife.
TH: How would she do it?
PT: Head back
TH: What noise would she make?
PT: Shed gurgle.

Evaluation of vignette III


Prior to the session beginning, the patient, Dr Davanloo, and the group
had been discussing the patients grandmother and speculating about
the exact nature of her unconscious. Again, these discussions do not get
videotaped, which is unfortunate because some of the richest commu-
nication, exchanges, and emotional experiences occur in this context. At
any rate, these discussions often lay the groundwork for the videotaped
sessions that follow them. In particular, they set the stage for the appli-
cation of MUSC in the interviews themselves.
At this point, clarification of some terminology is in order. The term
MUSC or multidimensional unconscious structural changes is not
exactly synonymous with structural changes but the two terms are
closely related. The former refers to the therapists series of interven-
tions designed to create the latter. The application of MUSC was the
focus of Chapter Seven in this book. It has been a neglected area of
focus. In order to present IS-TDP as a simplified (and easily applicable)
technique, some authors have focused only on the concepts of break-
throughs to murderous rage and guilt. In doing so, they have lost sight
of the importance of MUSC. Simply stated, breakthroughs of rage and
guilt will be beneficial to a patient and many participants report that
they feel better after having had breakthroughs in this programme.
However, in order to achieve long-lasting changebe it in symptoms
or structural changes in anxiety, defences, and resistancethere needs
to be an ongoing application of MUSC.
Patients (and participants in this programme) do not respond to a
formulaic agenda in this therapy. Some have criticised IS-TDP as being
mechanical and indeed some therapists have been criticised for having
an agenda in the therapy room. However, in the Montreal closed circuit
168 U n d e r s ta n d i n g Dava n l o o s IS - TD P

training programme, participants are encouraged to follow the trail of


the unconscious. There is an element of spontaneity. Participants do
not know if they will interview, be interviewed, or simply watch the
process. Sometimes participants are told to go into the therapy room
with a specific plan to follow one of the steps in the central dynamic
sequence. But this is usually not the case. The spontaneity of the process
is essential in encouraging participants to follow the cues of the patient
and to apply MUSC when possible.
The therapist then does something different from what has occurred
in previous interviews. He asks how Josephine would murder the
grandmother. This is an interesting intervention for several reasons. For
one, it has obvious transference implications. When the patient describes
the sadistic murder of the grandmother by Josephine, she then spon-
taneously announces that she herself was the murderer. The therapist
then asks her how the patients mother would terminate the life of the
grandmother, but the transcribed interview was limited and does not
include the full interview. Again, this is not a third person murder
and the transference implications are obvious.
In the patients unconscious, both the mother and great-aunt murder
the grandmother, and she wishes to ally with them and also murder the
grandmother. When the patient is asked how her mother would murder
the grandmother, she states that she would slash her throat. This would
result in a more painless and quick death and is devoid of some of the
sadism we have seen in the previous breakthroughs. While the entire
transcribed interview is not available, it is important to stress that the
patient later stated: It is for your own good. The good of the family.
In this sense, there is a loving communication that in this murder the
greater good of the family would be achieved.
Another reason for this intervention is that it allows the therapist
to create MUSC in the unconscious. With Josephines murder of the
grandmother, the patient announces that she can smell the fish. This
is the neurobiological pathway of memory coming into operation. The
patient is having an olfactory experience, which is related to the actual
event that had taken place decades ago.

Conclusion
In this instance, the therapist has lifted up the neurosis. What this
means is that he has temporarily removed the resistance to the degree
f o l l o w i n g t h e t r a i l o f t h e u n c o n s c i o u s 169

that the patient can spontaneously communicate what is in her uncon


scious. In this case, she is able to communicate with a good degree of
accuracy and detail the nature of the relationships between several of
the important females in her family. It is important to note that this
degree of fluidity in the unconscious is temporary in nature and occurs
after the patient has an excellent breakthrough with a major evacuation
of guilt.
When the neurosis is lifted up, both patient and therapist have the
ability to go precisely where the unconscious wants to take them. This
can create a chain reaction in the unconscious. A chain reaction means
that important material is revealed in a serial fashion. Often it is com-
municated in a short period of time. However, a chain reaction can con-
tinue for two to three days. Following such a chain reaction (and the trail
of the unconscious more generally) can be invigorating for both patient
and therapist. A therapist who is willing to let the patients unconscious
take charge of the process often finds it uniquely simpleas the chal-
lenges associated with searching for and crystallising the resistance in
the transference are absent. These concepts will be reviewed in future
chapters so as to make them less abstract.
C hapter seventeen

The neurobiological destruction


of the uterus

W
e move on with the seventeenth interview of the series. By
now, many of Davanloos newer concepts should be familiar
to the reader. One concept that has been touched on in previ-
ous chapters (albeit in less detail than what is covered in this chapter) is
the neurobiological destruction of the uterus.
In some of the patients previous breakthroughs, she has violently
destroyed the uterus of the therapist. The visual image of the murdered
body of the therapist and the destroyed uterus transferred to the visual
image of the murdered body of an important genetic figureusually
the grandmother. The destruction of the uterus has dramatic psycho-
dynamic implications. In this case, the patient is caught in a destruc-
tive competitiveness that triangulates her between her mother and
grandmother. She wishes to destroy the grandmother to achieve close-
ness with the mother and vice versa. So destroying the uterus of the
grandmother has extreme significance for her. It accomplishes her intra-
psychic goal of achieving the undivided love of her grandmother (in the
absence of her mother). But it also creates a tremendous volume of guilt
towards the mother and grandmother as well.

171
172 U n d e r s ta n d i n g Dava n l o o s IS - TD P

In this act of destruction, she is obviously inflicting tremendous pain


on the grandmother, who physically suffers because of this brutal act.
But it is not only the physical suffering that she endures; she is also
deprived of a loving bond with the foetus that the uterus is carrying
which is the patients mother. In addition, the destruction of the uterus
causes clear pain to the foetus (the mother) and also deprives the mother
of a loving bond with her own mother. The end result is tremendous
physical and emotional pain to both mother and grandmother. The
patient also suffers a complete absence of closeness towards these two
important female genetic figures in her life. The fact that the patient has
reported that she has more difficulty getting close to the females in her
life compared to the males is not insignificant or coincidental. Its roots
lie firmly planted in her unconscious and in the destructive competi-
tiveness that she inherited from the previous generations. We continue
to focus on this theme with the following interview.

Vignette I: the neurobiological pathway of murderous rage


and the impulse to murder the therapist
TH: Dr, listen. The whole issue of idealisation and the character resis-
tance of idealisation of destructionthis is very strong, hmm? You
have been, in a sense, promoting these people. In that way you are a
promoter of these people, arent you?
PT: Well, when you say that, I feel angry because I did not mean to pro-
mote anyone.
TH: In reality, it was promoting. Calling them he was called world class
therapist. Its not promotion, then? He was promoted to that. Y ou
promoted him to world class. There is promotion.
PT: On one hand, people walk all over me. But on the other hand people
respect me and respect my opinion. I feel very trapped by that.
TH: You have a lot of feeling.
PT: I need to be used and abused.
TH: You have a lot of feeling about that. If you took all the feeling, the net
result of all the feeling you havepositive and negative, if you direct
it to me, what would it be?
PT: Its a knife in your eye and I am holding your neck. Its two knives.
TH: How powerful?
PT: I dont even know one of them but theyre both there.
TH: What do you see? Look to my eyes in front of you.
t h e n e u r o b i o l o g i ca l d e s t r u c t i o n o f t h e u t e r u s 173

PT: So, I see Dr X. And then I just vaguely see the other Dr X who
I didnt know. But its like theyre lying together. Theyre holding
each other.
[Patient has a passage of guilt.]
TH: A lot of painful feeling. Who do you see?
PT: I see my mother in the arms of my grandmother. But I see my mother
most clearly. So, I see my mother in the arms of my grandmother,
but its a cold winters night.

Evaluation of vignette I
The data indicates that there is no need for a head-on collision at the
opening of the session because the patient is already enraged. When the
therapist uses the phrase promoting these people he is actually exam-
ining the state of the patients neurobiological pathway. He knows this
patient well by now and knows that the neurobiological pathway is likely
in a state of either anxiety or murderous rage. In this vignette, he clearly
sees that she is experiencing the neurobiological pathway of murderous
rage. If he saw evidence that the neurobiological pathway of anxiety was
high, he would have chosen to use a head-on collision instead.
The neurobiological pathways of murderous rage and guilt quickly
come into optimal position. Those who watched this videotape were
able to see the blasting power associated with the patients experience
of the impulse to murder the therapist.Tremendous sadism clearly
persists towards the grandmother.
The patients unconscious defensive organisation has the potentiality
to operate on a high level. But she knows that she has a tendency to let
people walk all over her. On an unconscious level, she knows that she
has identified with her mothers catatonic compliance and obedience.
This is very ego-dystonic for her. She has tremendous feeling about the
therapist exploring this painful chapter of her life. While she had not
previously realised she had been promoting her previous therapist,
this now comes to light. She has tremendous feelings about this. At the
time of her previous therapy, she had idealised the therapist as being
world class. She now realises that this was a destructive idealisation.
Dr Davanloo has called this phenomenon the character resistance of
the idealisation of destructiveness and this will be the focus of the next
chapter (Chapter Eighteen). The net result is a massive amount of feel-
ing towards the therapist.
174 U n d e r s ta n d i n g Dava n l o o s IS - TD P

The therapist is the first individual to expose this situation to her.


Earlier on, in previous interviews, she committed to the principles of
honesty and integrity. She cannot, therefore, deny the reality of this
situation. But at the same time, she has tremendous feelings towards
the therapist for exposing this reality. She declares that she feels angry
towards the therapist. But there is more than just rage. She is grate-
ful that she is seeing the reality of the situation and that the therapist
has pointed out her idealisation of destructiveness. She knows that she
must move away from this idealisation of destructiveness. The above
system of transference feelings leads to massive resistance and an opti-
mum rise in the TCR.

Vignette II: the neurobiological pathway of guilt, the


experience of guilt, and the phase of psychoanalytic
investigation into the unconscious
PT: It is dark and windy. They are trying to survive and be safe and warm.
And they are all that they have. Thats all that they haveis each
other. And I wanted to destroy them both.
TH: But they love each other.
PT: Yes they do. They love each other very much.
TH: Dr, it is very important. Here your mother and grandmother they
are moving towards each other and your grandmother loves her
daughter. Then, in the previous one, your grandmother wants to get
rid of her. What do you make of this? This is very important. This
raises the issue of the constant need to idealise destructiveness.
Here the two are loving each other. Even the portrait is surviving.
They are struggling to stay together.
PT: Life was very hard back then.
TH: I know. What I am looking at is this: this is way different from other
breakthroughs. Your mother and grandmother wanted to do away
with each other. Here they seem to love each other.
PT: They love each other very much.

Evaluation of vignette II
The transference neurosis has been partially lifted up. The mother and
grandmother are currently close and are now moving towards each
other. Both patient and therapist are successfully applying MUSC.
t h e n e u r o b i o l o g i ca l d e s t r u c t i o n o f t h e u t e r u s 175

There is good psychoanalytic investigation of the unconscious. Here


the therapist continues to work on the character resistance of the ide-
alisation of destructiveness. Following this session, the DVD recording
of this interview was reviewed in detail many times in the group set-
ting. One question (reviewed in other interviews/chapters) was raised
again. How much of what we see is the result of the transference neu-
rosis in the unconscious? And how much is the actual original neurosis
of the patient? The patient has had many previous interviews with the
therapist. She has been part of the closed circuit training programme for
years. Very few therapist interventions are required for an optimum rise
in the TCRwhich happens relatively quickly.
For these reasons, the reader may conclude that because of this
high level of operation we are seeing the truth of what is in the uncon-
scious and what lies at the nucleus of the pathogenic core of the
unconscious. But both therapist and patient must always be vigilant
that the transference neurosis could contaminate the communications
from the unconscious. In her previous therapy, the patient also thought
that she was seeing the truth of her unconscious. However, this was a
different truth contaminated by resistance, most notably the idealisa-
tion of destructiveness.

Vignette III: further psychoanalytic investigation


of the unconscious
TH: But the reality is that they love each other.
PT: Yes.
TH: But this is the ultimate reality.
PT: I do believe they loved each other deeply. My grandmother was very
destructive and passed it on to her daughter. When my grandfather
died, my grandmother clung to my mother because that was her only
support. She had a son but he was a year old when my grandfather
died. My mother was there for much longer and my mother was her
favourite.
TH: This is something new, isnt it?
PT: It might be new in my breakthroughs.
TH: The love between your mother and grandmother was very deep.
You didnt talk of it.
PT: I didnt?
TH: Im questioning.
176 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: I wanted to destroy my grandmother to be close to my mother.


Now I dont have to destroy one to be close to the other.
TH: We have to look. We know that you were brainwashed in that
therapy. You think this was influenced by your previous treatment?
PT: No doubt. My grandmother didnt come up once. Im sure this was
because she was aligned with that therapist.
TH: What came up?
PT: My father, sister, and mother. I overlooked the role of my mother.
I am sure this is because he was aligned with my grandmother, which
was obviously a major problem.
TH: What was the major problem?
PT: That she never came up. And my grandmother came up repeatedly
last year.
TH: That therapist you were brainwashed they did not focus on your
grandmother or mother. Y ou went along with it?
PT: I didnt know what was in my unconscious. There were things I was
aware of. Things I should have addressed but I cant say I knew she
was there. Recently, I was at my grandmothers grave and I had to
grieve my grandmother. How can you go through therapy for three
years and it doesnt come up?
TH: How do you feel?
PT: I feel really angry.
TH: Anger or rage?
PT: Rage.

Evaluation of vignette III


We see that the patient allied with her grandmother to torture her
mother. Effectively, she was communicating to her own mother: I dont
want you as a mother. Ill take you as a sister. At the centre of this
system is a major pocket of guilt. The unconscious of the patient con-
tinues to introduce the loving side of the grandmother. The therapist
examines the loving relationship between the mother and grandmother
in this visual image. In previous breakthroughs, the patient murdered
either the mother or grandmother or both, but we have not seen this
degree of love between the two. We continue to see early structural
changes in the unconscious.
The therapist questions the patient to see if previous breakthroughs
were characterised by this degree of love and affection between the
mother and grandmother. The patient is not certain. The therapist
t h e n e u r o b i o l o g i ca l d e s t r u c t i o n o f t h e u t e r u s 177

then goes on to enquire about her previous treatment and why the
mother and grandmother were not a focus. The therapist makes the
comment: they did not focus on your grandmother or mother. You
went along with it? It is important to note that he ends with a question.
He is not accusing or blaming the patient or the previous therapist. He
is simply enquiring if the patient complied with the therapist. On some
level, he is questioning her unconscious about whether idealisation of
destructiveness (by means of compliance) was in operation with the
previous therapist.This comment is a subtle but powerful intervention
and results in a massive rise in the TCR. The patient begins to experi-
ence the neurobiological pathway of murderous rage in the transfer-
ence once more.

Vignette IV: the experience of the neurobiological pathway


of murderous rage in the transference
TH: If you move all of that rage towards that therapist and transfer it to
me? If you dont censor it.
PT: I would stab you in the abdomen with a knife. I would stab you in the
abdomen with a knife. Your body is slashed from before. And I slash
your abdomen with two knives. And then the uterus.
TH: If you look, what do you see?
PT: It almost looks like my step-grandfather. Its not as clear as before.
I see the uterus and one to two babies.
TH: Two babies? One?
PT: Its not as clear.
TH: But you have feeling. Lets to see how you feel about it.
PT: I think this is my mother. [Massive wave of painful feeling.]
TH: You see your mother?
PT: What comes is that my grandmother is jealous of my mother for
having children. Shes jealous. And Ive destroyed my mother and
sister. My grandmother is jealous of my mother. I want to destroy
my mother to make my grandmother happy.
TH: Let the feeling out first. Let the feeling out.
PT: I dont know how I never thought of this before, but my grandmother
was jealous of my mother because she had four children and a
husband who didnt die. And they didnt live in poverty. I wanted
to destroy my mother to make my grandmother happy and not feel
jealous. I wanted to be my grandmothers daughter like my mother
was her daughter.
178 U n d e r s ta n d i n g Dava n l o o s IS - TD P

TH: Let the feeling out. T


ry to experience your feeling as deeply as possible.
PT: This is what comes. I want to destroy my mother and three sisters
so I can be the golden child.

Evaluation of vignette IV
Multiple serial breakthroughs are not only possible but achievable for
many patients. In a patient such as thiswho is very robust and has had
previous sessions, as we have seenwe often see two or more break-
throughs in a single morning or afternoon. These breakthroughs do
not necessarily occur only in the videotaped interviews but during the
group discussion and outside of the programme as well. In this sense,
such patients are said to have a sufficient degree of unconscious fluid-
ity to allow for multiple breakthroughs to happen. In this particular
breakthrough, the murdered body of the therapist is transferred to the
murdered body of an important genetic figure who is not immediately
clear. Initially, the patient thinks that the figure is her step-grandfather,
who was previously referred to as Grappy. But as the image intensi-
fies, she sees the destroyed uterus of the murdered body and one to
two babies.
Interestingly, she does not identify the murdered body as her grand-
mother, but, rather, simply reports the visual image of the uterus and
one to two babies. While she does not say it in the session, she later
reports in the group environment that Grappy had a very round
abdomen and she and her sisters would often joke with him that he was
pregnant. In this sense, she may have had a visual flash to him before
we see what this image truly represented in her unconscious. Nonethe-
less, the unconscious is sufficiently mobilised to allow for the image of
the uterus and murdered babies to emerge.

Vignette V: further psychoanalytic investigation


of the unconscious
TH: You have three sisters?
PT: I have three older sisters.
TH: You said you were preferred to the three.
PT: I was the youngest. I had the most attention. I wanted to be for my
grandmother what my mother was to her.
TH: These three are doing well?
t h e n e u r o b i o l o g i ca l d e s t r u c t i o n o f t h e u t e r u s 179

PT: One is doing well. The other two arent doing as well.
[The next passage will be edited for brevity. The patient tells of her
two sisters, who struggle with anxiety. One struggles quite severely
and was recently admitted to hospital. Her oldest sister is doing the
best of the three.]
TH: The middle one is hospitalised. So shes lost.
PT: Shes a lost soul. She struggled. The third one is a doctor. She has
anxiety.
TH: They all have neurosis but the second one struggles the most. You
had the idea that you were preferred?
PT: I wanted to be. I wanted to be my grandmothers favourite but
I never lived up.

Evaluation of vignette V
To summarise, the patient has a massive passage of sadism towards her
previous therapist. As this huge pocket in the unconscious approaches,
the rage towards this individual comes. When this unconscious sadism
moves towards the mainstream, it is either experienced in its entirety, or
some fragment of it remains in the unconscious. When some fragment
remains in the unconscious, the patient often becomes symptomatic in
either a few days or a few weeks. This is so that the perpetrator of
the unconscious can maintain a homeostatic system of suffering in the
patients life.
This patient is one of four daughters. One of her sisters has struggled
intensely in life and has been admitted to an inpatient psychiatry unit.
If the patient does not deal with her unconscious, then there is the risk
that she will become extremely destructive like her sister. The patient has
stripped her mother of all human rights. This mother had lost her father
to tuberculosis and was a very damaged child. It produces tremendous
guilt for the patient to face the truth of her unconscious and the pain of
the guilt associated with this. In addition to this, she aligned with her
grandmother and unconsciously viewed the mother as her sister. In this
sense, she terminated all of her mothers rights as a mother. This, too,
results in a massive reservoir of guilt in the patients unconscious.
One of the issues illustrated by this vignette is that the patients
unconscious belongs to her grandmother and motherat least these
are the two very important and loved figures at the core of her original
neurosis. Reunification is this patients true desire. With her intense
180 U n d e r s ta n d i n g Dava n l o o s IS - TD P

passage of guilt, she wishes to be close to her mother and grandmother.


In addition, she wishes for them to have a close and loving relation-
ship based not on destructiveness but on the love they shared for
each other.

Conclusion
This seventeenth interview in the series nicely highlights an impor-
tant theme in Davanloos IS-TDP and that is the destruction of the
uterus. Usually, this type of breakthrough does not occur unless there
has been optimum mobilisation of the TCR and complete removal of
the resistance. The destruction of the uterus has been seen in multiple
other patients and in multiple other interviews in the Montreal closed
circuit training programme. It is significant and usually reflects a pro-
found communication from the unconscious. In this particular case, it
announces the patients real and disturbing wish to destroy her mother
whilst she is in utero with her grandmother. Such a vicious and sadis-
tic destruction would result in profound pain and suffering for both of
these genetic figures. It would end the patients mothers life. Indeed,
it would end the patients life as well. The grandmother would be left
alone with the ultimate experience of loss, pain, and suffering. On some
unconscious level, this is what the patient wished for.
But given the loving nature of her relationships with both her mother
and grandmother, this sadism results in tremendous guilta guilt that
fuels the perpetrator of her unconscious and demands that she exact tre-
mendous suffering in her own life. By removing this reservoir of guilt,
she is enabling herself to be free from the suffering and destructiveness
she previously experienced. However, such an experience is only the
tip of the proverbial iceberg. Further breakthroughs of this intensity are
needed on an ongoing and frequent basis before permanent structural
changes can be made.
Dr Davanloo highlighted that the patients unconscious should be a
sacred place for her, her mother, and her grandmother. The transference
neurosis has left the patient with structural impairment. The task for
both therapist and patient is to restructure this impairment.
C hapter eighteen

The character resistance of the


idealisation of destructiveness

W
e now move on to the eighteenth interview in the series. By
now, the reader should have basic familiarity with the for-
mat of the Montreal closed circuit training programme and
just how refined the technique has become over the last several years.
It is only through live, experiential interviews that Dr Davanloo and
the group participants can see some of these newer concepts and inter-
ventions in action. But the group has been met with some controversy
in the national and international psychodynamic communities at large.
Many psychodynamic psychotherapists reject this model of training.
The training is unconventional, immersive, and uniquely experiential.
Some therapists have critiqued it as being invasive and as crossing
boundaries (Frederickson, 2016).
However, each and every participant gives written, informed consent
to engage in this training. No one is coerced to partake by any means.
In fact, many therapists seek it out because it is unique. No other train-
ing programme offers participants the opportunities to both interview
and be interviewed. No other programme allows group members to
repeatedly view, dissect and understand this very complicated and pre-
cise technique. And few other training programmes (in any modality)
allow the founder to teach it precisely using modern day technology.
181
182 U n d e r s ta n d i n g Dava n l o o s IS - TD P

An insightful and prudent reader might ask: is the critique of this pro-
gramme legitimate? Readers are asked to be mindful of this question
throughout the remaining text. We will revisit the question in the last
section of the book.
The purpose of this current chapter is to outline and understand
in further detail Davanloos new term the character resistance of
the idealisation of destruction. Davanloos use of language can be
fluid. Some terms are extremely abstract and can be difficult to fully
comprehend when first heard or read. This term refers to a type of
resistance in which an individual is not only destructive, and identi-
fies with destructive individuals, but also idealises them. It is often
present in individuals who have suffered from transference neurosis
or brainwashing. We return to the interviews to understand this term
in action.

Vignette I: the rapid mobilisation of the neurobiological


pathways of murderous rage and guilt
TH: May I suggest we use the brainwasher term for the transference
neurosis? Not to use the name? You see, right now you have a lot
of feeling mobilised in you that has to do with the brainwasher. But
there you decapitated your grandmother with brutality, that you
disastrously destroyed your grandmother with brutality. Extreme
sadism at its highest level and this is not the way you destroy this
mother, that you do this to that woman.
PT: No.
TH: The question is: is it your doing or are you under the power of the
character resistance of idealisation? That you are idealising destruc-
tion and that you are under the power of the character resistance
of the idealisation of destruction. So my question is that: is that
destructiveness still in you? That destructiveness, namely the charac-
ter resistance of a brainwasher in you, is transferred to you? In the
form of this idealisation of destructiveness? Because you are very
destructive.
PT: I have murderous organisation towards my mother and grandmother
but there are also psychopaths in my unconscious and do I have
idealisation?
TH: How do you feel? I feel you are choked up in the feeling.
PT: I have a lot of rage.
t h e c h a r ac t e r r e s i s ta n c e o f t h e i d e a l i s at i o n 183

TH: OK, so lets to see. Y


ou have a lot of rage.
PT: I do.
TH: You have a lot of rage and you have a lot of other feelingsto do
that to your grandmother, the old lady, mobilises a lot of feelings.
You have a lot of feeling there. If you put all the rage, and all the other
feelings together, and lump it together, how would you go at me?
PT: Its your right eye.
TH: On intensity. Go on. Go on. Go on. And could you look to the eyes?
My eyes? The murdered body and the eyes? What colour?
PT: Theyre light brown and its my mother.
TH: Your mother, huh?
[Patient sobs and has massive passage of feeling.]
TH: You go through the feeling. Theres a lot of painful feeling. Youre
loaded with the pain. Y oure loaded with the pain. Y ou are loaded
with feeling. Loaded with feeling. Loaded with feeling.
PT: I love my mother. I love you. What comes to mind is that these psy-
chopaths say, How dare you have this closeness with your mother?
How dare you? I feel very close to my mother. I love my mother
and these peoplethese psychopathsare shaking their heads and
saying, How dare you? I want them gone. Ive had enough of them.
I love my mother.

Evaluation of vignette I
The therapist begins the interview by referring to the brutal murder
of the grandmother by means of decapitation in a previous interview
that had just been watched by the group. The group has witnessed the
extent and depth of this violent and brutal sadism. Once again, they are
left wondering: does the grandmother deserve this? If not, then where
is this sadism coming from?
He then goes on to question the patient directly. To paraphrase, he
questions her as to whether she commits this violent, sadistic murder
on her own, or whether she does so under the character resistance of
the idealisation of destruction. In doing so, he is aware that bring-
ing this issue up alone will stir up painful unconscious emotion in
thepatient.
She will have to acknowledge that her former therapy was
unsuccessful. It was not simply an enormous waste of time. It was
an extremely destructive endeavour in her life, one that not only
184 U n d e r s ta n d i n g Dava n l o o s IS - TD P

maintained her suffering but idealised it. Acknowledging this will


not only stir up feeling towards her previous therapist, but it will
also stir up intense murderous rage in the transference. The patient
has committed to the principles of honesty and integrity. She can-
not deny that she allowed herself to be brainwashed in her former
therapy. This causes a tremendous rage in the transference, as the
therapist will not partake in what the patient has done for decades
let sleeping dogs lie.
The therapist is using the patients own character resistance to cre-
ate an optimum mobilisation in the TCR. By simply labelling a system
that he sees in operation in the patients characterthe resistance of the
idealisation of her former therapisthe quickly achieves an optimum
rise in the TCR.
We can see why those who are not involved in the Montreal closed
circuit training programme might choose to criticise this programme
and this intervention. The national and international community of
psychotherapists may be a large one. But the community of those who
are interested in this technique is still a very small one. These individu-
als know each other. Some have friendships. Many have viewed each
others workand this has not been commonplace in other dynamic
psychotherapy training programmes. For this reason, some therapists
might be resistant to hearing that their colleagues (or themselves) have
had very poor training in this technique. They may be resistant to hear-
ing that they are using this powerful and precise technique in an inap-
propriate and unsupervised fashion. With this may come a massive
cover-up and denial of the truth.
However, Dr Davanloo refuses to comply with such a cover-up. This
is a technique that he singularly created and developed. This might
seem like a ludicrously obvious statement. However, he has been criti-
cised by some as not practising IS-TDP (Frederickson, 2016).
All these dynamics may seem petty. Indeed, they are difficult to
understand on many levels. But it is important to note the vulnerability
of individuals who have had training in these environments. Residents
and other students are often in positions where they do not have the
power to stand up for themselves. Trainees are supervised by individu-
als who are often in a position of authority over them. That said, some
residents idealise destructive supervisors and therapists. While there is
vulnerability, there is also responsibility. Pointing this out to the patient,
in the context of mutually agreed upon honesty and integrity, causes
a massive rise in the TCR. With this massive rise in the TCR, there is
t h e c h a r ac t e r r e s i s ta n c e o f t h e i d e a l i s at i o n 185

optimum activation of the neurobiological pathway of murderous rage.


The guilt passes well.

Vignette II: the passage of guilt and the portrait


of love for the mother
TH: You have a lot of feeling that You said the eyes is what colour?
PT: Light brown.
TH: Huh?
PT: Light brown.
TH: How old is she?
PT: I think I saw images earlier on of her in her late thirties and I would
be three or four.
TH: Late thirties? How was she dressed up?
PT: She has a red jacket on. And she is wearing jeans. And it is just the
two of us.
TH: Do you remember the last time you saw her in her red jacket? Could
you describe it?
PT: She has dark hair and it is a zip up jacket and it is just the two of us.
TH: Let it out. Y
ou have a lot of feeling towards your mother. Y ou have
a lot of feeling towards your mother. You said you were age four
or five.
PT: Three or four.
TH: Do you remember one incident?

Evaluation of vignette II
There are several therapeutic tasks at this stage of the interview. One is
to have maximum activation of the neurobiological pathways including
the neurobiological pathway of memory. When the therapist asks the
patient how old the mother is in this image, the neurobiological pathway
of memory comes into maximum operation. The patient reports a very
powerful memory and sees her mother wearing a red jacket and jeans.
There are several reasons for the therapists search for important
related memories at this stage of the breakthrough. One is that a specific
memory (such as the one of the mother above) tends to speed up the
entire process. Another reason is that a specific memory can set about
a chain reaction in the unconscious. In this context, a single memory
can trigger multiple other memories. Patients sometimes report events
that had been previously forgotten, or repressed, for years. With this
186 U n d e r s ta n d i n g Dava n l o o s IS - TD P

experience, the unconscious can become rapidly and dramatically


fluid. Important communications from the unconscious are introduced
and processed as they surface. The psychoanalytic investigation into
the unconscious becomes more robust and the dialogue that ensues is
devoid of contamination by the resistance.

Commentary and group discussion


While the interview was longer than what appears in this chapter, it
unfortunately was not available in its entirety for transcription. What
follows are important themes reviewed in the group discussion.
The therapist is aware that the patients mother was only nine years
old when her father died of tuberculosis. He is aware of the multifac-
eted ramifications of this loss and trauma. The patients grandfather
likely carried a risk of infecting the entire family with his tuberculosis
and it is quite possible that everyone in the family was asked to keep
their distance and stay away from him. In this context, the trauma is
very heavy. At this point, the therapist and the group are beginning
to wonder about the mothers home life following this very significant
and traumatic loss of her father.
The grandmother got remarried to Grappy. We do not yet know
what motivated the grandmother to remarry. There could have been
a significant emotional attachment to this man. The grandmother was
left to raise two children, in economic hardship, as a single mother. So
there may have been financial considerations. In the group discussion,
the therapist questioned: what did Grappy bring to the family life? Was
he a benign individual? Or did he have a criminal psychopathic back-
ground? Was Grappy sadistic and controlling of the patients grand-
mother and mother? Could he have brought a special form of neurosis
to the family? The patients mothers trauma could possibly be twofold:
she lost her kind and warm biological father and could have gained a
destructive stepfather in the exchange.
The impact of this on the patients mother (and the transmission of
this to the next generation) cannot be overemphasised. There may be
a familial idealisation of destructiveness that can only be described as
a love for destructiveness. For these reasons, the therapist is careful to
deliberately and repeatedly spell out the patients character resistance
of the idealisation of destruction as he opens the interview. He knows
that, without this repetition, the process of applying MUSC will not
have the same powerful effect.
t h e c h a r ac t e r r e s i s ta n c e o f t h e i d e a l i s at i o n 187

In the group discussion, the patient has an important memory of a


very positive time in her life. She states that her fondest memories are
from when she was four years old. All of her older sisters were in school
at that time. She stayed at home with her mother who was a homemaker.
Her father worked shifts and was often home during the day. The mem-
ory of her mother wearing a red jacket and jeans comes from a time she
was shopping with her mother. It was just the two of them together. Her
mother did not usually give in to her demands whilst out shopping. But
the patient had requested a Barbie doll in a department store and her
mother bought it for her. This was an unusual and isolated episode from
her childhood, as the family was not wealthy and she rarely received
new toys, except for Christmas. This one act of the mother buying the
Barbie doll was seen as generous and experienced as joyous by the
patient. She reported it as an extremely happy memory that character-
ised the warmth and love of her relationship with her mother.
The introduction of this memory indicates that the patient has
achieved some structural changes in her unconscious. There has been
some removal of destructiveness; however, a large reservoir still persists.
She does not yet have a full return of all of her memory. Should she
achieve further, more extensive structural changes, then there will likely
emerge sharper, more salient memories. This will lead to a fuller activa-
tion of the neurobiological pathway of guilt. In this interview, the thera-
pist went straight to the sadistic organisation of the unconscious. Both he
and the patient saw themselves as partners in a journey with the goal of
removing and permanently ending the intergenerational cycle of abuse.

Conclusion
Suffice to say, this interview (and the subsequent group discussion) had
a meaningful impact on the patient. The therapist was able to create an
optimum rise in the TCR by simply focusing on the patients character
resistance of the idealisation of destruction. This was manifest in her
previous therapy and in her previous training. While the patient has
agreed to honestly examine what is in her unconscious, she has both
deep murderous rage and deep appreciation for the therapist, who
exposes this element of her character. This causes the optimum rise in
the TCR, the full activation of the neurobiological pathways of murder-
ous rage and guilt, and the return of loving memories of her time with
her mother as a child. These concepts will be reviewed again in the
remaining chapters of this book.
C hapter Nineteen

Being a mother to ones own mother

W
e continue with the nineteenth interview in the series. The
focus of this particular chapter is on a psychodynamic con-
cept that Davanloo has explored in the past. He continues to
explore it in the Montreal closed circuit training programme. For the
sake of simplicity, it will be referred to as being a mother to ones own
mother in this chapter.
By now, it should be clear that there is a certain rhythm to the uncon-
scious and how it works in this setting. Resistance comes and goes. If it
is not present at the beginning of the interview, then it is the therapists
job to search for it, to maximise it, and to remove it. The goal should
always be complete removal of the resistance and total mobilisation of
the unconscious. When resistance is removed, important unconscious
emotions are experienced and important communications emerge from
the unconscious. It is the therapists job to then listen carefully and to be
empathically attuned to the patient. As seen in other areas of the inter-
view process, this demands a high level of therapist empathy, precision,
and understanding.
When resistance is removed, the therapist begins to understand
exactly what is at the heart of the pathogenic core of the unconscious.
Usually, this is a loving bond and attachment to an important genetic
189
190 U n d e r s ta n d i n g Dava n l o o s IS - TD P

figure such as the mother, father, or grandparent. As this becomes


clearer, and as the patient shares important communications about
that genetic figure, a skilled therapist may choose to ask the patient:
What would life have been like if you had been a mother to your own
mother? These words are a paraphrase and other wording has been
used in the past. These terms are gender-neutral and do not necessar-
ily refer to a patients mother, or to a female patient. The therapist, for
example, could ask a male patient what it would have been like to be a
mother to his father.
In any of these scenarios, the results can be quite powerful. The ther-
apist often chooses to focus on the genetic figure that the patient has
just had a breakthrough towards. By asking what life would have been
like had the patient been a loving parent to the genetic figure, the thera-
pist is able to focus on a number of important aspects of the patients
(and the genetic figures) life. First, the therapist is able to focus on the
concept that the genetic figure was damaged in life. Often, this genetic
figure has been badly damaged. Second, the therapist is able to focus on
the intergenerational transmission of psychopathology to the patient
and to other members of the family. This often results in some degree
of rage in the patientusually because he or she was innocent and did
not deserve this psychopathology. Third, the therapist is able to focus
on the love, attachment and bond to the genetic figure and the empa-
thy the patient feels in acknowledging the genetic figures suffering
in life. Fourth, the therapist is able to maximise the entire column of
guilt towards the genetic figure, because focusing on the love, attach-
ment and bond to the genetic figure, as well as the brutal murder of that
beloved figure, greatly maximises the affective experience of guilt. So
the intervention, albeit subtle in nature, has a profound impact on the
unconscious of the patient. We turn to the case to see the intervention in
operation during a clinical interview.

Vignette I: the rapid mobilisation of the neurobiological


pathways of murderous rage and guilt
TH: Audio is on? Lets to look. We have to understand because you have
a major destructiveness. And then, in the interview you had with
the other doctor, we see this idealisation of destructiveness and
the therapy you had was loaded with idealisation of destructiveness.
Nothing in it but destructiveness. Youve gotten yourself to destroy
the fabric of your being.
b e i n g a m ot h e r to o n e s o w n m ot h e r 191

PT: Um Hmm.
TH: Your grandmother fought for the life of the family, hmm?
PT: She did.
TH: She did.
TH: And your background is that your family, they have been fighting
under the difficult times. So you must have a lot of feelings.
PT: I do.
TH: But you see, I do is not enough. If you command all of this positive
and negative feeling, whatever it is. And as optimal and honestly you
can, if you put it together and direct it to me.
PT: So its towards my former transference neurosis figure.
TH: Everything you have, if you pool it together and put it on me. What is it?
PT: Its a knife and now I hold on to your neck and I slash into your
right eye.
TH: What do you see right now in the front of you?
PT: I see Dr X and his face.
TH: OK, what else besides Dr X?
PT: I see a murdered body.
TH: You see a murdered body. Could you look to the face and eyes?
PT: Its coming. I see both my mother and grandmother.
TH: Lets to see. What do you see? What do you see? What do you see?
You have a massive load of feeling.
PT: I see my mother.

Evaluation of vignette I
The therapist begins the interview by focusing on the patients idealisa-
tion of destructiveness. He states: Youve gotten yourself to destroy
the fabric of your being and is aware that this communication is
loaded with intensity. He points out that the patient has not only been
destructive but has idealised others who have been destructive. He
then directly links this to the grandmother. The grandmother was also
destructive, but she was a fighter in life. She worked hard, as a single
mother, to fight for the well-being of her two children. She also worked
hard to provide love and warmth for her grandchildren. However, we
have come to see that she is not a simple character. On some level, she
wanted to replace the patients mother and become a mother to her.
This stirs up tremendous feeling in the patient.
These feelings are not just towards the grandmother. They are also
deeply rooted in the transference. The therapist is not directly focusing
192 U n d e r s ta n d i n g Dava n l o o s IS - TD P

on the phase of pressure to feelings in the transference by repeatedly


asking: How do you feel towards me? At this stage, there is no need
for such a formulaic application of the phase of pressure to feelings in
the transference. The therapist knows the patient well enough to have
a firm grasp on her unconscious defensive organisation. He knows that
this has been badly damaged from her previous transference neurosis.
He knows that there has been an element of brainwashing in that
therapy. By simply commenting on what he sees and pointing out that
the patient has agreed to honesty, he is creating an optimum rise in the
TCR. Doing so causes the patient to have the rapid mobilisation of the
neurobiological pathways of murderous rage and guilt, as we have seen
in previous interviews. With this communication, which is global in its
depth and breadth, the therapist succeeds in mobilising the neurobio-
logical pathway of murderous rage with optimum intensity. However,
on reviewing the DVD of the session later, Dr Davanloo did comment
that the passage of the impulse to murder the therapist (repeated slash-
ings of the eye) needed more power and less frequency. This should
come with further unconscious structural changes.

Vignette II: the passage of guilt and the application of MUSC


during the phase of psychoanalytic investigation into the
unconscious
TH: There is waves coming. More waves. More waves. Let it out. Expe-
riencing waves. Waves coming. Waves. Waves of feeling you have for
your mother. How old is your mother?
PT: In this picture?
TH: Yeah, in this.
PT: Shes a little girl and what comes is what it would be like to be a
mother to my mother and what it would be like to help her when
her father died. I wish I could help her.
TH: How old is your grandmother?
PT: In this? I guess shed be forty. Less than forty. Thirty-five.
TH: So shes younger.
PT: I dont see her as clearly. Now its like shes gone.
TH: So could you look at it to see her clearly? You could if you look at it.
PT: See my grandmother?
TH: What is she dressed like?
PT: She has an apron on, its like a white apron. White shirt.
TH: What else?
b e i n g a m ot h e r to o n e s o w n m ot h e r 193

Evaluation of vignette II
Thus far, we have seen a high level of the TCR plus an optimum mobil-
isation of the neurobiological pathways of murderous rage and guilt
and the actual experience of sadism and guilt. The therapist allows the
patient to completely experience and finish the passage of guilt. Early
unconscious structural changes are taking place.
Here Davanloo is engaging in the technique of psychoanalytic inves-
tigation of the unconscious. This consists of the phases of consolidation,
application of MUSC, and analysis of the transference. For the patient,
there has been an optimum mobilisation of sadism but it has not yet
been completely removed. Dr Davanloo used the analogy of wisdom
teeth that have been mobilised but have not been completely removed.
This needs to be addressed.
Davanloo hypothesises that when there is a transference neurosis
there is a mixture of two systems. There is the patients original neuro-
sis, which consists of murderous rage and guilt. But with the transfer-
ence neurosis with the former therapist, we see purely sadism with no
guilt. Indeed, this sadism is transposed from the therapist to the patient.
Having the therapists sadism (with no associated guilt) leads to a tre-
mendous amount of anxiety in the patient. This is why anxiety is higher
in patients with transference neuroses compared to those who do not
have them. It is because the sadistic impulse (with no accompanying
guilt) is terrifying to the patient. It is as though she is momentarily act-
ing directly on behalf of a psychopath. This phenomenon is contribu-
tory to the patients degree of pernicious guilt as well.

Vignette III: the application of MUSC and the phase of


psychoanalytic investigation into the unconscious
PT: Shes young. I cant quite see her as young as she would have been in
this picture.
TH: Concentrate on it, hmmm?
PT: Shes wearing glasses. Her hair is dark, its short. She has her hair
clipped back.
TH: What is the colour of the hair?
PT: Dark. Dark brown.
TH: What else do you see?
PT: Its more my mother. Its more just my mother as a small child.
TH: You have a lot of feeling when you say a small child.
194 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: Yes.
TH: When you say a small child. How old?
PT: Seven, eight, nine.
TH: Eight years old, hmm?
PT: Around that age. Yeah.
TH: Have you ever had thoughts what it would have been like if you
were the mother to your own mother?
PT: I might have had thoughts but this would be the first time I had feel-
ings about that.
TH: Could we look at that?
PT: Yes.
TH: You see there is a wish in you that you could be a mother to your
mother.
PT: Yes. Right now there is.

Evaluation of vignette III


The patient states that she had previously had thoughts about being
a mother to her mother. But this is the first time she has the affective
experienceladen with feelingsabout being a mother to her own
mother. The patients grandmother was a complicated individual.
The previous chapters have shown her to be a very loving woman
who worked hard to bring warmth to her family. But she could also
be extremely destructive and there were times when she related to the
patients mother in a cold, brutal, and destructive way. On some level,
the patient knows that she was involved in this and unconsciously
aligned with the grandmother. She wished to destroy the mother so
that she could be the golden child of the grandmother. This has a major
impact on her unconscious.
Here, in this vignette, we see a different side of the patients uncon-
scious. We see a deeply emotional side of the patient that wants to help
her mother after her father died. On some level, the patient is aware
that her grandmother failed her mother when her first husband died.
The grandmother did not allow the patients mother to fully experience
her grief and mourning towards the father who died tragically. This
impacted the mother severely and caused her to have long-standing
characterological effects. She became resistant against emotional close-
ness and unable to tolerate a loving bond with a male (her husband)
thereafter. The patient is declaring that she wishes she could have been
b e i n g a m ot h e r to o n e s o w n m ot h e r 195

a mother to her mother during the time of her fathers death. This
would have created a major change in the mother. She would have
grieved her father properly as a child, and would have had the poten-
tial to love and receive affection as an adult. The patient has profound
feelings about this, that she could have helped steer her mother on a
different course in life.
The therapist is aware of this and was searching to see if a major
empathy towards the mother was emerging. Davanloo has shown in his
outcome research (Davanloo, 2005) that a total removal of all murder-
ous rage, sadism and fusion results in the return of a patients empathic
capacity. Dr Davanloo later commented that the day the patient masters
her own unconscious is the day that she will have a deep-seated empa-
thy for her mother. She will also wish to have the true mother/daughter
relationship that had hitherto gone with the wind. The empathic
capacity we see here has developed as a result of the patients tenacious
effort and her work in the transference.

Vignette IV: further application of MUSC and the phase


of psychoanalytic investigation into the unconscious
TH: How do you think about this issue about being a mother to your
mother? This would have definite impact on your mothers upbring-
ing. There is something between your mother and grandmother that
impacted the relationship negatively.
PT: She was blind. My grandmother was blind about how destructive she
could be. She was destructive about how she thought it was best not
to face the grief towards her husband. She thought it was best to
sweep the grief under the carpet. My mother needed to face it. She
still needs to face it.
TH: In that sense your grandmother was destructive because she had
blindness, hmmm?
PT: This is it. Blind stubbornness and this is what I saw in Dr X and
I latched on to it. Because this was my grandmother.
TH: You say you latched on to this blind stubbornness which is very
destructive.
PT: Yes.
TH: What you say is this: this quality of your grandmother was very
destructive with your mother. And you could have been a better
mother to your mother.
196 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Evaluation of vignette IV
The patient is aware that her grandmother was destructive in life.
The grandmother was devoted to her daughter (the patients mother)
but she committed the most destructive act of all. She dismissed the
patients mother as a mother. She was seen as the almighty and power-
ful force in the family. The patient was an infant when this happened but
still, intra-psychically, she sees herself as involved in this crime. Indeed,
in the patients unconscious she has committed a massive crime.
The passage of murderous rage involves both the mother and grand-
mother. But a portion of it also involves the transference neurosis. After
she experiences the impulse to murder the therapist, she then sees the
image of her former therapist. Only after the therapist asks What else
besides Dr X does she see the portrait of the murdered bodies of the
mother and grandmother. One must strive to understand the true meta-
psychological aetiology for the patients destructiveness. At this time,
the patient, Dr Davanloo and the group have an inability to differenti-
ate the destructiveness from the patients own character and original
neurosis from the destructiveness that resulted from the development
of her transference neurosis.

Vignette V: further application of MUSC and the phase


of psychoanalytic investigation into the unconscious
PT: To be honest, that was the only quality. In other ways, she was
wonderfulloving, prioritised the children.
TH: That is blind destructiveness.
PT: Yes, thats the exact quality. I was looking for it in a therapist. And
I found it in spades. But he had a lot more besides thatpsychopathic
elements. I dont see that with my grandmother like I did with Dr X.
TH: Um hmm. Now this idea, that you wish you could have been a mother
to your motherhow long that comes?
PT: How long? Intellectually, a few years. But as a feeling, I cant remem-
ber it. I might have. But I dont have that memory right now.
TH: You were questioning the subject of when you got pregnant. You
know before that you had questionsyou couldnt get pregnant
because of emotional and psychological factors. What do you think
now? How old are your children? When you spend time with them
do you think this comes to mind?
b e i n g a m ot h e r to o n e s o w n m ot h e r 197

PT: I know that comes to play but there is guilt associated with it. Because
the last generation didnt have that.
TH: Do you think that this was two murders? Murder of your mother and
murder of your grandmother?
PT: Seems like that.
TH: This is within your unconscious?
PT: Theyre both there.
TH: Umm.
PT: Theyre both hand in hand with each other. Im not surprised that
theres murder of both.

Evaluation of vignette V
There is further psychoanalytic investigation into the unconscious. Like
pilot and co-pilot, the therapist and patient explore the clinical phenom-
enon of destructiveness. The therapist is aware that the patient has a
destructive competitive form of the transference neurosis. She has had
intergenerational trauma from a very early phase. The grandmother
had positive features in that she was loving, devoted to her children and
grandchildren, and created a tremendous sense of warmth in the family.
But she also had negative features. She was considered the Almighty
in the family. With this perception of her as the ultimate power and
authority, the family members became blind and obedient to her. This
had an extremely destructive impact on them all. The patient requires
repeated removal of the fusion of the murderous rage and guilt at close
intervals. When this occurs, the fusion will lose its power and we will
see evidence of more permanent unconscious structural changes.
In a previous chapter we explored in depth the neurobiological
destruction of the uterus. Dr Davanloo revisited this concept after
reviewing this interview. The centre of the patients destruction is the
uterus. The patient has repeatedly and sadistically destroyed the very
organ of motherhood. This is the core of her neurosis.

Conclusion
In this nineteenth interview in the series, we have continued to explore
important concepts in the major mobilisation of the unconscious. We
explored in more detail a concept that is not entirely new. In many past
symposia, Dr Davanloo has shown video vignettes of patients he has
198 U n d e r s ta n d i n g Dava n l o o s IS - TD P

treated where the concept of being a mother to ones own mother has
come up. Here we have added to and expanded on this concept. The
issue of empathic capacity was also reviewed. When a patient gets to
the point in therapy where they have loving feelings about being a par-
ent to their own parent, the ideas of empathy, love and forgiveness must
be investigated. The patient begins to see the parent in a more objective
light and wishes that life could have been different for both the parent
and themselves. When the patient comes to have loving feelings and a
desire to forgive the genetic figure, there is a sense of reunification with
that figure. At this point, there is an indirect reference to the issue of ter-
mination. The patient and therapist sense that the disrupted attachment
and all of the resulting unconscious emotions are being worked through
and an end to treatment is in sight. This concept will be reviewed in
more detail in the subsequent chapters.
C hapter TWENT Y

Multidimensional unconscious structural


changes: Part II

B
y now the reader should be familiar with many of the newer
concepts of Davanloos work. Also, by now, the reader should
have a sense that some of these concepts are not entirely easy to
grasp and define. Just like the unconscious itself, these terms can be
dynamic in nature. Often there is a large degree of commonality and
overlap present. For example, the intergenerational transmission of
psychopathology, the transference neurosis and the destructive com-
petitive form of the transference neurosis all share common features.
But the previous chapters in this book outlined how they are all subtly
different from one another. Similarly, the terms MUSC (multidimen-
sional unconscious structural changes) and unconscious structural
changes are closely related to one another. However, the former phrase
(MUSC) refers to an active phase of therapist intervention and was first
reviewed in Chapter Seven of this book. The latter phrase refers to the
end result of that therapist intervention.
This chapter will be a continuation of Chapter Seven. That chapter
explored in detail the application of MUSC during the patients fourth
interview with Dr Davanloo. This chapter, highlighting vignettes from
the patients twentieth interview in this format, will continue to focus
on this important therapist intervention.
199
200 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Vignette I: the experience of the neurobiological pathway


of murderous rage
TH: So obviously this volume of mixed feelings. Some are not really mixed.
Its very clear you have a lot of feelings. If you keep looking at the
transference neurosis that you developed, obviously you must have a
lot of issues there.
PT: I do.
TH: That an intelligent person like yourself has undergone that process.
PT: Umm hmm.
TH: Now if you lump all that feeling, as much as you can, and direct it on
to me.
PT: Its about eighty per cent. I have to think about situations with him
to feel it fully.
TH: Lets see. What do you have?
PT: A knife in my right hand.
TH: Go on. Go on. W hat is the intensity of it? What do you see there?
PT: I see my mother and her brown eyes. [Massive passage of guilt.]

Evaluation of vignette I
As in the previous interviews, there is little therapist intervention
needed at this point to rapidly mobilise the neurobiological pathway
of murderous rage. The therapist simply points out that the patient
underwent involvement in a very destructive transference neurosis.
He points out that the patient has a lot of feelings and some are not
really mixed. This is an interesting communication for several reasons.
For one, it is simple yet honest and accurate. The patient has mixed
feelings for certain, but there are also other feelings that are not mixed.
Some might criticise this intervention and suggest that the therapist is
fishing for rage. But this is not an entirely fair criticism. He has not
ruled out that the patient may have positive feelings that are not mixed.
He realises that this is unlikely but he in no way leads the patient
towards feelings she does not have. He is simply asking her to examine
her own unconscious and be as truthful as possible about the nature of
her feelings. He suspects that there are both mixed and pure feelings
and does not underestimate their intensity in any dimension.
Even with this simple and brief intervention, there is the application
of MUSC. The therapist is labelling what is in the unconsciousboth
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 201

mixed and pure feelingsand the patient knows that her task is to
honestly experience these feelings with her greatest determination. With
this comes an activation of the neurobiological pathway of murderous
rage. The patient estimates that it is about an eighty per cent rise. She
offers that she will have more of an activation if she focuses on specific
situations with the transference neurosis figure. She then actively mur-
ders the therapist in the transference. The image of his murdered body
then transforms into the image of the mother and her brown eyes.

Vignette II: the neurobiological pathway of guilt and the actual


experience of guilt towards the mother
TH: How is the eyes? There is a lot of feeling in you. There is a lot of
feeling in you. A lot of feeling. Y
ou owe it to yourself. You owe it to
yourself to express it. Let it out. Let it out. Let it out. How old is she
your mother?
PT: I see my mother as a young child. About seven, eight, nine. But then
I flash to her when she is about thirty-five or thirty-six. So it comes
and goes.
TH: Thirty-five years old? What is she dressed up?
PT: It goes from being an orange shirt to a red jacket. It comes and goes.
TH: Its familiar to you?
PT: Yes.
TH: You have major waves. Major waves. Major waves. Major waves.
Major waves in you. Still you see your mother?
PT: No. Im at lunch with my mother and grandmother. I can see it.
I must be three years old and three of us are together. I can see the
red plastic tray. And I was very happy to be with them both.
TH: Who else is in there?
PT: Me and my grandmother. Nobody else. Its a very strong visual
image.
TH: Strong visual memory of who?
PT: Memory of my grandmother and I spending time together. Three of
us together.

Evaluation of vignette II
The therapist knows that it is his job to maximise the patients experi-
ence of guilt as fully as possible. As in other breakthroughs, he focuses
202 U n d e r s ta n d i n g Dava n l o o s IS - TD P

on the age of the mother in the portrait of her murdered body. Ini-
tially, the patient reports that she sees the mother as a child but then
reports that she sees the mother at age thirty-five or thirty-six. This
would make the patient age two or three in this vignette. Next, the
therapist asks the patient to focus on how the mother was dressed. She
reports that it varies from being an orange shirt to a red jacket. When
this image comes clearly, she experiences major waves of guilt towards
the mother.
While it might not appear obvious, the therapist is applying the
phase of MUSC even during the phase of the breakthrough of guilt.
By focusing on the rich and vivid details of the portrait of the murdered
body, he is laying the foundation for the unconscious to offer the deepest
communication possible. This occurs in conjunction with the activation
of the neurobiological pathway of memory. The introduction of hitherto
repressed memories is especially important, as these memories can
dramatically restructure the patients emotions, defensive organisation,
and anxiety.

Vignette III: the experience of guilt and the further


application of MUSC
TH: Where is your father?
PT: Hes not therewe were very close at that time.
TH: Your father?
PT: My mother, and grandmother and I.
TH: How about your father?
PT: Hes there, too, but hes at work in this image. My three sisters are
at school.
TH: You are close to your mother and grandmother?
PT: In this image.

Evaluation of vignette III


The therapist is aware that the patient now has very little (if any) resis-
tance. In the absence of overwhelming resistance, he knows that the
communications brought forth from the unconscious are likely to be
extremely rich in meaning and importance. The therapist does not
want to contaminate these communications with speculation or by
introducing his own theories or ideas into the discussion. Indeed, such
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 203

methodologies would be unethical, dangerous, and counter-intuitive.


They would be the antithesis of the stated goal and would lead to ripe
and fertile grounds for a transference neurosis.
In the past, critics have objected to what they would call fishing
in the unconscious. It is true that some therapists, without adequate
supervision and training, have indeed been fishing for various elements
in the unconscious. Commonly, critics have voiced concerns that
therapists are looking for or fishing for rage. The above vignette
shows that there is no fishing in this situation. The therapist simply
scans the unconscious to see if the father is present in this vivid image
that resulted from the activation of the neurobiological pathway of
memory. The therapist enquires about the father because if he is present
in this image then the patients resistance is sufficiently low to introduce
an important communication about him. In this case, the father is not
present. The therapist simply repeatedly enquired about him and when
the patient reports that he is not there, the therapist does not pursue the
matter any further. Repeated enquiry, with no preconceived goals or
agendas, lies at the heart of MUSC. As expected, this cannot easily be
taught in a reductionist or rote fashion. Rather, the mastery of this skill
comes only with years of practice and timely supervision.

Vignette IV: the experience of guilt and the further


application of MUSC
TH: Its different from the one when you destroy your grandmother?
PT: Theres a closeness. Before, I would destroy one to be with the other.
TH: In real life, when did you move apart?
PT: I would have gone to school so I wouldnt have been as close. I spent
a lot of time with them together from age three to five.
TH: Where is this, your grandmother was hostile towards your mother?
In the other one your grandmother is turning you against your mother.
But here you have a very close bond. What do you make of that?
PT: What comes is that my grandmother was hostile with that blind
stubbornness when she was a mother. But as a grandmother, she
would want to start fresh. Shes not a psychopath. She would want a
second chance.
TH: What year you were born? When did Grappy come to the picture?
PT: They married in 1955. I was born years afterwards.
TH: They were married how long?
204 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: Forty years.


TH: So you were not born when they were married? When you were
born, your grandmother had ten years of marriage already. Have you
had thoughts about Grappy?
PT: Definitely. We all had negative feelings. Usually he was very jovial but
sometimes he would drink.

Evaluation of vignette IV
In this process of MUSC, the therapist is constantly scanning the uncon-
scious to determine the status of any structural changes. With this, he is
looking to the nature of the relationship between the patients mother
and grandmother. If there is healing of this disrupted triangular rela-
tionship then their relationship within the patients unconscious will
eventually change. There should be the gradual emergence of love,
forgiveness and reunification between these two figures. Again, it
is important to note that the therapist is not fishing for change. He is
simply asking about the status of the mother and grandmother in the
patients unconscious.
Davanloo has discussed an inverse relationship between the level
of destructiveness in the patients unconscious and the activation of
the neurobiological pathway of memory. As the patient has repeated
breakthroughs into the unconscious, the columns of murderous rage
and sadism decrease. As this occurs, the patient drains larger and larger
columns of guilt, and becomes less destructive. Simultaneously, the
patient reports more and more memories that had been repressed. In this
case, the patient later disclosed that the memory that returned was of
herself, her mother and her grandmother having lunch at a department
store caf. The memory was a loving one of sharing food together as
a family. In this image, the grandmother is not dead but is very much
alive and a loving member of the family.

Conclusion
In this twentieth interview, the patient continues to explore her uncon-
scious. She has another breakthrough to her mother and has the return
of a very positive memory of having lunch with her mother and
grandmother. As the therapist continues to apply MUSC, we see the
m u lt i d i m e n s i o n a l u n c o n s c i o u s s t r u c t u r a l c h a n g e s 205

emergence of a loving and tender relationship between the mother and


grandmother. With this, we begin to see the themes of love, forgiveness
and reunification with the genetic figures. Forgiveness is especially
important for this patient because on a conscious and unconscious
level she wants desperately to heal and forgive. Forgiveness will be
the subject of Chapter Twenty Two and will be reviewed in greater
detail there.
C hapter t w ent y one

The transference neurosis: Part V

B
y now, we have discussed many of the numerous recent principles
and technical interventions of Dr Davanloo. The reader is, by now,
familiar with how he has refined his technique to work with very
destructive and resistant patients. Embedded in this work is a repeated
focus on the concept of the transference neurosis. Chapters Five, Six,
Nine and Eleven have reviewed the concept of transference neurosis in
detail. This chapter will also focus on the transference neurosis; specifi-
cally, the most recent classification system of the transference neurosis,
as reviewed by Dr Davanloo. Specifically, we must define and under-
stand three different types of transference neuroses.

1. The transference neurosis resulting from treatment


This patient has had a transference neurosis towards her former
therapist. This type of transference neurosis resulting from a therapeu-
tic relationship would be referred to as a treatment transference neu-
rosis. In this system, the therapist (the previous therapist in this case)
transferred much of the psychopathology of his unconscious onto the
patient. What exactly was transferred is still open to reflection, debate,
and some speculation. It varies from case to case. Truly understanding
207
208 U n d e r s ta n d i n g Dava n l o o s IS - TD P

what has been transferred in the transference neurosis only comes


when the patient has repeated breakthroughs into the unconscious and
the unconscious introduces the nature of the damage.

2. The transference neurosis resulting from the training


programme
This transference neurosis comes from the training programmes them-
selves. There is a widespread pattern of attending supervisors assigning
the most complex patients to young trainees (often mislabelling them as
excellent learning cases). What results is that these residents in psy-
chiatry (or trainees in other disciplines) develop an inherent sense that
they must treat and be responsible for the most complex and challeng-
ing patients. These patients often have extreme destructiveness in the
unconscious. Often the supervision from such supervisors is woefully
inadequate. Many of the patients are not amenable to treatment, despite
being labelled excellent learning cases. Clearly this system is unethi-
cal and inappropriate. Often, such supervisor therapists have some
degree of psychopathy in their unconscious. Such psychopathic forces
can often be transferred to the trainees, as there is often a degree of coer-
cion present in the supervision itself.
Hence, many participants arrive at the Montreal closed circuit training
programme with such a transference neurosis in full force. Dr Davanloo
advises young trainees to protect their unconscious against such
damage and warns them not to accept too many challenging patients
(with inadequate supervision) early in their training.

3. The transference neurosis resulting from professional practice


In this last type of transference neurosis, an individual develops a trans-
ference neurosis with ones own patients or colleagues. For example,
therapists have often had difficult experiences in training (See 2/above).
As a result of this, despite being in autonomous practice, they choose
to work with extremely complex and damaged patients. They often
develop a cementation or rusting of their own character defences
and/or unconscious defensive organisation. As a result, with time, their
colleagues and/or patients tend to transfer their own psychopathol-
ogy onto them. This system is very destructive but all too common in
mental health centres throughout the world.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t v 209

These three types of transference neuroses may not occur in a single


form. There is often overlap and patients may show features of two or
three of these types of transference neuroses. Many participants in the
Montreal closed circuit training programme arrive with such a constel-
lation of transference neuroses firmly in operation. We explore both the
transference neurosis due to treatment and the transference neurosis
due to training in this twenty-first interview with the patient.

Vignette I: the activation of the neurobiological pathway of


murderous rage via focus on the transference neurosis
TH: Look. I hope that you are not believing that you have to agree with
me. We are here on the premise that you have to examine phenom-
enon. We have to face with the reality.
PT: My goal is to make the most of this time.
TH: You went to this disastrous experience. You lost your intellectual
function. Prior to this, you had a residency programme. All of this has
to do with the issues of your mother and grandmother. Y ou were
damaged, hmm? But you did not defend yourself.
PT: I did defend myself but not with some people.
TH: But this residency programme. This reflects the problem you have
with your mother and grandmother. The murder of your grand-
mother and in the uterus you murder your mother. This is a
morbid guilt.
PT: I didnt know this residency programme was like that. I should have
switched. I tried. I should have switched.
TH: Destruction was in residency.
PT: Everywhere. Every day.
TH: Where this rage goes? That you go to this destructiveness totally
paralysed?
PT: It just stayed in me. I had increased anxiety and headaches. But the
rage stayed in.
TH: Are you saying its dead?
PT: No, its built up inside me.
TH: How do you experience it in a neurobiological way?
PT: Im here to experience it.
TH: If you put it to him and experience it?
PT: Its not just him. Its the other doctor, too.
TH: If you took those doctors and put it in relation to me.
210 U n d e r s ta n d i n g Dava n l o o s IS - TD P

PT: Its a knife. Its more than that.


TH: Go on. Go on. Go on. What do you see there? Look to my tortured,
murdered body. Look to my eyes and face. What do you see?
PT: I see my grandmother holding my mother.
TH: You have a lot of feeling. You have a lot of feeling. Your grandmother
is holding your mother. Y ou have a lot of feeling.

Evaluation of vignette I
The therapist begins with the focus on the principle that the patient
should not agree with him. He knows that, as a resident, her train-
ing programme was highly destructive. He knows this because of his
own experience with other individuals who acted as supervisors for
the patient. He is concerned that some of these supervisors may have
had psychopathic elements in their unconscious. In this context, he
knows that the patient may have had a tendency to agree blindly with
them in the past. He wants to call attention to this tendency to agree
and to remove any possibility of it coming into operation with him.
He also knows that she may have projected a sense of authority and
omnipotence onto the therapist himself, just like she did with her previ-
ous therapists. He wants to undo any projected omnipotence that may
have resulted.
The therapist then segues into the disastrous nature of the treat-
ment transference neurosis in which the patient lost her intellectual
function. There is then a rapid shift to the residency programme. The
therapist applies MUSC and directly links the destructive position
the patient took in relation to her former therapist and training pro-
gramme to the destructive position she took in the situation with her
mother and grandmother. This creates an optimum mobilisation in
the TCR for a number of reasons. The patient had intellectual knowl-
edge that her residency programme was destructive in nature. Many
of her co-residents completed their training but disengaged from the
destructive supervisors whenever possible. The patient is aware that
she chose not to do this. Rather, she engaged with the destructive and
psychopathic supervisors on a regular basis. Intellectually, at the time,
she would have labelled the process of engaging with teachers and
supervisors as a reflection of a desire to learn more. But at this point
in her life, she knows that that was an extremely destructive decision.
She has tremendous feelings towards the therapist for pointing this
out to her.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t v 211

In addition, the therapist points out that the patient accepted this
destructiveness in a paralysed fashion. The patient is aware of her char-
acter defence of going obedient, dead, catatonic and compliant in rela-
tion to destructive and authoritative figures in her life. But she very
much wants to dismiss these defences and sweep them under the
carpet. The therapist knows that this destructive character resistance
allowed for fertile ground in the development of the transference neu-
rosis with the previous therapist. Indeed, Dr Davanloo has used the
analogy of the transference neurosis being very similar to crabgrass,
which is a pest weed, frustrating for many gardeners. It is like the trans-
ference neurosis in that it is very insidious in nature and tends to crop
up most when the patient feels that it has been completely eradicated.
He also knows that pointing out this destructive major character resis-
tance of the patient, and the transference neurosis in general, will stir up
unconscious emotion and create a massive rise in the TCR.
After viewing this particular video vignette, Dr Davanloo also com-
mented on the clinical manifestation of guilt. The patient became sub-
ject to the power of guilt when she was a resident. He also commented
that we continue to see the early emergence of structural changes in
the unconscious. The grandmother is holding the mother. The degree
of destructiveness between them is less. After having had repeated
breakthroughs of guilt in the unconscious, the level of residual guilt has
gone down.

Vignette II: the experience of guilt and the application of MUSC


TH: You have a lot of feeling. Grandmother is holding your mother. You
have a lot of feeling. Because it is totally different from the other one
where your mother is murdered. You have a lot of feeling. Let the
feeling out. Y
ou have a lot of feeling.
PT: I love you. I love you both. I love you.
TH: How do you feel right now?
PT: I feel very good at the current time. Calm. But I could have lots of
waves at any minute. What comes is that the psychopaths saw the
good in mewhich is my mother and grandmotherand wanted to
destroy me.
TH: You were the target of a situation where you were abused.
PT: Yes.
TH: Why you become destructive? That is the fundamental issue
idealisation of destructivenessand accepting destructiveness.
212 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Evaluation of vignette II
The patient has had yet another massive passage of guilt. One of the
therapists tasks is to maximise this experience of guilt. Another task is
to engage the unconscious in conversation. Again, this is because the
conversation supplied by the unconscious is not currently contaminated
by resistance. As such, it will offer significant insight into the pathogenic
core of the patients unconscious. Also, if the therapist is able to satisfac-
torily apply MUSC, there will be a greater chance that the patient will
have more long-lasting and robust unconscious structural changes.

Commentary and group discussion


Unfortunately, the transcript of the complete session was not available
for discussion. However, Davanloo made some conclusions following
the viewing of these two vignettes. Before the patient entered therapy
(with her first therapist), her training had impaired both her cognition
and unconscious defensive functioning. Dr Davanloo asserts that there
was an element of brainwashing in her residency training programme
such that her unconscious defensive organisation underwent impair-
ment. Her residency training occurred at a critical time in her life.
It coincided with the death of her grandmother. The relationship with
the grandmother and the grandmothers exact place in the pathogenic
core of her unconscious has been a prominent theme of this book. The
patients own pathological mourning towards this complicated person
was the subject of Chapter Thirteen.
The situation the patient found herself in during the residency was
a difficult one. The cumulative forces of the destructive training pro-
gramme and the death of her grandmother left her further damaged.
In her unconscious, she was looking for a replacement for her grand-
mother. While she was seeking out a warm individual, her previous
therapist was only warm on the surface. Underneath this he was a
destructive and authoritative figure whom the patient perceived as a
god. Davanloo likened the situation to the patient floundering in the
middle of the Atlantic Ocean with sharks. She simply collapsed.
The above psychodynamics are disturbing to the patient. We might
see why she would want to sweep such dynamics under the proverbial
carpet. However, she has pledged to adhere to the principles of honesty
and integrity. With this, she has agreed not to avoid this complex system
but to face it head-on.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t v 213

Conclusion
In this twenty-first chapter, we focused on the multifaceted nature of
the transference neurosis. We highlighted how the patient, because of
the death of her grandmother and the resulting pathological mourn-
ing that transpired, was vulnerable to both a training and a treatment
transference neurosis. Because of this vulnerability, she remained in a
very destructive residency training programme. This programme fur-
ther weakened her unconscious defensive organisation, and resulted in
her seeking out a very destructive course of private therapy.
The ethics of such situations come into discussion. What responsibil-
ity did the patient have herself in leaving these disastrous situations?
Do young and vulnerable trainees have an obligation to report destruc-
tive supervisors in their training? Does the power differential implicit
in the trainee relationship prevent such reporting? Who is present and
able to help these trainees?
The answers to these questions are not immediately obvious. The
dynamics are complicated. However, it is important in this age of
resident (and trainee, in general) wellness to at least ask these ques-
tions. Since the Montreal closed circuit training programme has no
agenda or rigid rules, such discussions frequently arise and are often
uniquely invigorating and stimulating. These discussions address com-
mon themes, recognisable to all the participants, which are seldom
reviewed in any other forum. We will continue with the twenty-second
interview to explore these concepts further.
C hapter t WEnt y t wo

The metapsychology of forgiveness

W
e are approaching the end of this series of interviews. As we
review the twenty-second interview, it is clear that a number
of principles have been recently discovered by Dr Davanloo.
He has gone on to expand his metapsychology to include a number of
sophisticated new elements in his approach to the unconscious.
With this more sophisticated understanding of the unconscious
come numerous questions. As we approach the end of the interviews,
the reader will undoubtedly be asking questions in an attempt to
gain greater understanding and familiarity with the unconscious and
how it works. Some of these questions may (or may not) include the
following:

1. How do I begin to operationalise these concepts in my work with


patients?
2. How do I begin to appreciate the subtlety and nuance of this work,
both theoretically (from an academic perspective) and clinically
(from a patient perspective)?
3. How do I know if I am applying this technique correctly? What can
I do to ensure my competency in providing this technique?

215
216 U n d e r s ta n d i n g Dava n l o o s IS - TD P

4. When is a patient done with therapy? What are the criteria for
termination in this technique?
5. What role does forgiveness play in this technique?

In the remaining chapters of this book, we will explore some of these


questions in further detail. But in this chapter we will focus mostly
on this last question and the concept of forgiveness. Specifically,
this chapter will focus on the metapsychology of forgiveness. In this
case, we will review the twenty-second interview in further detail
to understand why and how the unconscious forgives. We will also
look to the timing of forgiveness and how it is an integral part of the
process of working through. Specifically, we will see how the rhythm
of the unconscious works, and how, after multiple breakthroughs and
extensive evacuations of guilt, the unconscious begins to work towards
forgiveness, reunification, and love.
The process (or phase) of working through tends to occur in the latter
part of the course of a patients therapy. Essentially, this phase occurs
after the patient has had repeated breakthroughs into the unconscious
and has drained extensive columns of guilt. While MUSC are applied
throughout the entire interview, and the entire series of interviews,
they are especially important in the phase of working through.
As previously discussed, the therapist applies MUSC so that the
patient can begin to make conscious sense of the unconscious work
that has been done. One of the key factors necessary for the successful
application of MUSC is repetition. The therapist must repeatedly apply
the Triangles of Conflict and Person (Ezriel, 1952; Menninger, 1958) to
restructure the patients unconscious anxiety, defence, and feelings.
Another key factor necessary for the successful application of MUSC
is timing. While applied throughout the entire interview process, they
have an especially important meaning when they are applied after the
resistance has been removed and the communication from the uncon-
scious is no longer contaminated by it.
At this point in the patients course, she is beginning the phase of
working through. She has had repeated breakthroughs of guilt. She has
had repeated experiences of seeing the murdered body of the therapist
transform into her mother and grandmother. As the process approaches
the possibility of termination, she begins to see some reparation of the
relationship between the mother and grandmother. In the interview
below we will see once again the loving relationship between the
t h e m e ta p s y c h o l o g y o f f o r g i v e n e s s 217

grandmother and mother. As the patient begins to see more of the lov-
ing dimension of this relationship, she sees these two figures as more
human and develops more empathy for them. With this we see the
beginning of forgiveness and reunification with these women.

Vignette I: the early mobilisation of the TCR


TH: You know you have a very complex unconscious. You have original
neurosis with your mother and grandmother.
PT: Umm hmm.
TH: That is clearly intergenerational. Your mother to your mother. And
you have a very heavy fusion very clearly. You know that but this
has been complicated by a series of transference neuroses. A very
complicated form of transference neuroseseach of them has left a
large amount of the feelings in you. And the format of this, you have
had it in therapy, the transference neurosis, hmm?
PT: Yes, I have.
TH: In the therapy, and then you ended up having a major idealisation.
PT: Very early on.
TH: Very early on. This goes back to 2005.
PT: Yes.
TH: That you had this massive idealisation.
PT: I did.
TH: Which, in a sense, is part of that transference neurosis. So then
you have this large amount of the feeling in every situation. At the
present time you are struggling with all these complex feelings.

Evaluation of vignette I
The signalling system of the patient shows that she has considerably
less anxiety than what she presented with during many of the earlier
interviews. Her unconscious anxiety has undergone structural changes.
Here there is no indication for the therapist to proceed with total block-
ade, because anxiety is not the presenting issue. For this reason, the
therapist chooses not to use the phase of pressure or head-on collision.
Each of these interventions has a specific indication and we do not see
indications for these interventions here.
The patient begins to achieve mastery of her own unconsciousand
this is a foreign concept for her, as she has been obedient and compliant
218 U n d e r s ta n d i n g Dava n l o o s IS - TD P

to the authority figures that had hitherto dominated her life and her
transference neurosis. In this light, we are also beginning to see restruc-
turing of the patients defensive organisation, which again points to
early mastery of her own unconscious.

Vignette II: further mobilisation of the TCR and


the experience of the murderous rage in the transference
TH: Now, if you could lump out all this feelingnot an easy job. If you put
all the feeling you have, all the feeling of the way he used and abused
you in the transference neurosis, on top of the original neurosis. If you
put all of this positive and negative complex feeling you have and
direct it to me with the highest power and intensitywhat would
the feeling be like?
PT: There is a knife in your right eye. Eye. Right eye.
TH: Go on. Go on. Intensity. Intensity. Highest. Go on. Highest. Highest.
PT: I slash down your abdomen.
TH: Higher. The highest. The highest that you can experience. Now if
you look to my body and my eyes. Do you see the colour of the eyes?
PT: Yes I see the green eyes of my grandmother holding my mother as a
baby.
TH: Holding your mother? Your grandmother is holding your mother?
PT: Yes.
TH: How old is your grandmother in this vision?
PT: Twenties. She is in her twenties.
TH: Shes young?
PT: Yes.
TH: How is she dressed up?
PT: She has on a white shirt and a white skirt and her hair is dark and
curly and she wears glasses.
TH: She has glasses.
PT: Yes.
TH: Dark hair?
PT: Yes. I love you.
TH: And when you look at your grandmother, age twenties, and then
what is the colour of her eyes?
PT: Green. Green/blue but a little more green than blue.
TH: You see the eyes very clearly?
PT: Yes.
t h e m e ta p s y c h o l o g y o f f o r g i v e n e s s 219

TH: How old is your mother that she is holding?


PT: About six months. She can sit.
TH: Could you look to the eyes of your mother? Could you look to the
eyes of your mother? What do you see?
PT: Big chubby cheeks. Light brown eyes. Curly brown hair.
TH: Curly hair?
PT: Yes.
TH: So then it is your grandmother and mother in a loving relationship?
PT: Yes.
TH: And this must mobilise a lot of feeling, hmm?
PT: Yes.
TH: Your mother and your grandmother.

Evaluation of vignette II
There are still many unanswered questions about the structure of this
womans unconscious. On reviewing this clinical vignette, Dr Davanloo
still questioned if there was a psychopathic element transferred
from her previous therapist and supervisors. We still see a degree
of sadism in the passage of the impulse that seems out of keeping
with the nature and extent of her original neurosis. The therapist
might not immediately have an answer to this question, so it is
important not to introduce speculation and conjecture. Rather, he
must continue to follow the trail of the patients unconscious on an
ongoing basis.
The patient has the impulse to murder the therapist by attacking the
right eye with a knife and slashing the abdomen. One of her symptom
disturbances is chronic migraine headaches. We can see that her uncon-
scious may play a role in the aetiology of these headaches, as she has an
unconscious desire to murder her mother by means of a sadistic attack
on the right eye with a knife. One could formulate that when she has
conflict with others in her daily life (the C of the Triangle of Person),
this activates her unconscious desire to murder her mother. In order
to deal with this, she inflicts her own rage, guilt and suffering on her-
self and develops migraine headaches in the exact area she wishes to
attack her mother. Davanloo refers to this phenomenon as projective
identification and symptom formation. This elegant theory illustrates
the economy of the unconscious and its need to discharge emotion and
anxiety in a fluid and timely fashion.
220 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Following the impulse to murder the therapist, she sees the visual
image of the grandmother as a young woman holding her own mother,
who is a young childa six month old, the patient estimates. As previ-
ously discussed, the appearance of two visual images (representing two
genetic figures) only occurs when the TCR is extremely high.
This visual image of the mother and grandmother is especially
meaningful. Obviously, the patient was not alive to witness her mother
at this very early age. She had not yet been born. What she is seeing in
this image is based on an actual black and white photo that had been
in a family album for years. In this photo, the grandmother and mother
had been sitting outside on a blanket. However, the unconscious has
allowed the image to metamorphose. The patient sees the two figures
not only together, but the grandmother is holding the mother. This is
not what the original photograph displayed.
We could disregard this as an insignificant detail that is simply
incidental. Or we could examine it further. It is possible that this
changethe grandmother holding the mother rather than just sitting
with heris reflective of a change in their relationship. It is possible that
the relationship between the two is healing in some way. Perhaps the
unconscious is furthering the notion of them having a loving relation-
ship. This is at the heart of a potential reunification between the two.
In this sense, it is possible that the unconscious is undergoing structural
changes and is focusing on a loving reunification of the two genetic
figures that are at the pathogenic core of the unconscious. Seeing them
as two loving, but imperfect, human beings is the beginning of the
phase of forgiveness.

Vignette III: the ongoing application of MUSC


and the phase of working through
PT: What mobilises feeling is that they love me despite my murder and
torture of them.
TH: How is she lying there after the murder? Could you describe the
murdered body?
PT: I saw them alive until you asked that and then its hard to look at.
But its almost like I see my grandmother dead and her abdomen
is splayed open. But it is like my mother is alive and trying to wake
her up.
TH: You have a lot of feeling, hmmm?
t h e m e ta p s y c h o l o g y o f f o r g i v e n e s s 221

PT: I see that my grandmother is dead and my mother is a young baby,


alive.
TH: Your grandmother is dead but your mother is a young baby, alive.
That is very important that your mother is alive.
PT: Yes.
TH: But they were in a loving relationship?
PT: At this time, they are very much in love. Very much in love with each
other.
TH: But in other portraits they were not in a loving relationship, am I
right?
PT: Maybe early on, a couple of years ago they were not in love, not like
this; not here in my work with you.
TH: Do you have memories of your mother and grandmother in life?

Evaluation of vignette III


In this vignette, the theme of forgiveness is multifaceted. Here we
see that the patient has profound guilt about having murdered these
two loving figures. The mother and grandmother love not only each
other but the patient as well. Despite having tortured them both, the
two figures have a deep love for the patient. They are willing to forgive
her for her sadistic impulses towards them. They also have a loving
relationship with each other in this vignette and we see that this is the
basis of forgiveness between them both. In this sense, these three figures
(patient, mother, and grandmother) are beginning to love one another,
despite their incessant torture of each other. They all begin to see the
reality of the human conditionthat they are damaged, flawed, and
imperfect. But the love, attachment, and bond that they have with one
another is enough to sustain them. They forgive one another for the
sadism and are able to reunify as a loving family. This is the essence of
the metapsychology of forgiveness. The therapist introduces the idea
of memories at the end of the vignette so as to solidify these concepts
even further.
Once again, more questions are raised than are clearly answered.
For example, to what extent is the unconscious dominated by the
pathology of the original neurosis? And to what extent do we have
the global psychopathology of the transference neurosis still in
operation? In previous chapters we discussed the satellite opera-
tion of the transference neurosis. In this light, there is not only the
222 U n d e r s ta n d i n g Dava n l o o s IS - TD P

psychopathology of one therapist being transferred. There are five sets


of psychopathologysome of these sets belong to her previous super-
visors. The task is therefore extraordinarily complex. One must ask:
what belongs to the patient and what belongs to the other five indi-
viduals? It is not clear at this time. Because of the complexity of the
material of the transference neurosis, we do not yet have full clarity
about what is occurring.

Vignette III: the phase of MUSC and the


process of working through
PT: Yes.
TH: In life; in living memory. Do you have living memory?
PT: So very early on, my grandparents would come down on Sundays.
We would have a family dinner together. Sometimes she was in a
very good mood and would play cards. Other times, she would not
be in a good mood and she would be colder and detached. This I
remember very early on.
TH: In the past six months, do you have more memories of your mother
and grandmother or your father?
PT: I do.
TH: Do you have more memories or the same?
PT: I have snapshots of memories. So I can remember her facial expres-
sions. I can remember the smell of her apartment. I have memories
of my grandfather. Actual events I dont haveclear memories of
actual events. I see a picture of who they were.
TH: Your memory has not become too much stronger.
PT: Its going up but not at the top where I want it to be.
TH: Not lifted up?
PT: Not one hundred per cent, no.
TH: How is it in actuality with your mother?
PT: How is what?
TH: Do you visit her?
PT: I see her two to three times a week. Saturday, Sunday and Monday
afternoons. Sometimes I talk with her or read a book.
TH: What do you do?
PT: Sometimes we have supper together or have coffee together or have
a talk.
TH: Could you recall a positive memory? A pleasant time?
t h e m e ta p s y c h o l o g y o f f o r g i v e n e s s 223

PT: Pleasant? A week before I came on this trip, I told her about the
struggles of my life and she is always very supportive. She was very
supportive of me.
TH: You have feeling?
PT: Yes.
TH: When you play with your children, you must have a memory of your
mother also?
PT: Yes, when I play with my children, I see my mother and the love I
have with them and with my mother. Im very lucky.
TH: So why you dont want to face with the feeling?
PT: I do. Im very lucky. Im very lucky. Im very lucky. I have a very loving
mother. I really do. And she had to be this way because of her own
mother. I know she was very destructive but she was also a very lov-
ing mother to my own mother. Very loving. But I wanted to destroy
their love. This is the guiltI wanted to destroy their love. And this
is what comeshow dare I have this love for my children when I
wanted to destroy their love? This is what comes.
TH: How do you feel right now?
PT: I feel that this is the core of what is driving my symptoms. It is the
guilt I have for the love I have for my children and the guilt I have for
wanting to destroy their love.

Evaluation of vignette III


The focus of MUSC is the state of the patients memory. The neuro-
biological pathway of memory should be more fluid now that there
has been an optimum mobilisation of the neurobiological pathways of
murderous rage and guilt. These neurobiological pathways are all inter-
connected and optimum mobilisation of one should result in optimum
mobilisation of the other.
The therapist is scanning the patient to see which memories (if any)
have been activated in her daily life. Since her mother is still alive, he
probes for further details on the actual relationship with her mother
and the status of this. The therapist then introduces the patients chil-
dren. This has a powerful effect for two reasons; first, it introduces
the possibility of the intergenerational transmission of psychopathol-
ogy and the patients intense feelings about that. Second, it focuses on
the importance of motherhood in both the patients current life and in
her family of origin as well. This causes the patient to spontaneously
224 U n d e r s ta n d i n g Dava n l o o s IS - TD P

declare that her grandmother had indeed been a good mother to her
mother; as, otherwise, neither she nor her mother could be the loving
people that they are. This causes the patient to have an enormous wave
of positive feelings towards both of these figures. With this, the uncon-
scious spontaneously offers an explanation for the patients own symp-
toms. Specifically, the perpetrator of her unconscious demands that she
suffer in life in order to diffuse the guilt that she has in relation to her
mother and her grandmother. In addition, she feels an intense love for
her children and this causes tremendous guilt in relation to the murder-
ous sadism she has felt/feels towards her mother and grandmother.
These tremendously conflictual feelings, she announces, are driving her
disturbances in life.
This communication could not occur unless the patients uncon-
scious was highly mobilised. A highly resistant patient could not spon-
taneously piece together the aetiology of her/his disturbances in life,
unless she/he has had repeated breakthroughs into the unconscious.
These must be accompanied by repeated evacuations of extensive col-
umns of murderous rage (or sadism) and guilt, and appropriately timed
and targeted MUSC. We can see that when this has occurred, as in this
patient, the UTA will spontaneously declare the truth of the pathogenic
core. If the therapist simply follows the trail of the unconscious, then
this truth will emerge.

Vignette IV: the continued phase of MUSC


and the process of working through
TH: You wish your life with your mother and grandmother would have
been like with your children? There is a good relationship with your
children and this mobilises a wish your grandmother
PT: I wish my grandmother wasnt so rigid. I wish I didnt have a need to
destroy my mother. I wish I could have destroyed her in an honest
way and a healthy way.
TH: And you feel the transference neurosis has had a negative impact on
this process?
PT: I think that the transference neurosis was a means for me to seal
this off and to not go there and to not feel the guilt I have about
this destruction of love. To pretend it never happened. But Im
responsible.
t h e m e ta p s y c h o l o g y o f f o r g i v e n e s s 225

TH: How would you say is your level of destructiveness? Because when
you had the transference neurosis you were very destructive.
Massive idealisation is destructive. Do you have vivid memories of
this destructiveness when the transference neurosis took over?
PT: I do have vivid memories. The things I dismissed. I would never put
up with it now. Sometimes I have relationships crop up profession-
ally and I sense that they are controlling and I try to disengage. If I
cant, I try to stand up.
TH: Do you see your father?
PT: I saw him yesterday and a couple of days before. It is mostly grief.
TH: How do you find your relationship with your father?
PT: Im doing the best I can. He is a very walled-off man. He doesnt like to
hug. He is anxious. I feel the sadness that I wasnt as close to him. Its
more of a grief. I have a lot of guilt that he suffered and I didnt stand
up for him. I didnt stand up for him. I let them walk all over him.
TH: Who?
PT: My mother and grandmother. He was very penetrated in life.
TH: Do you feel that if there is more lifting up of the transference neu-
rosis there would be more ample opportunity to work with your
unconscious better? You see the original neurosis is under the power
of the transference neurosis.

Evaluation of vignette IV
Following the viewing of this vignette, a number of comments were
made by Dr Davanloo and the group participants. The neurobiological
pathway of murderous rage is far stronger now than it was earlier in
the course of these interviews. The same goes for the neurobiological
pathway of guilt. There is now a much shorter interval between the pas-
sages of murderous rage and guilt compared to the earlier interviews
in the series. The neurobiological pathway of anxiety is much lower.
As the patient continues in the phase of working through, she makes
statements that reflect a strong understanding that her mother was
deprived of being a mother. Again, having a true understanding of why
the mother and grandmother were this way lays a strong foundation for
forgiveness of these two figures.
Also, even though the patient maintains a high degree of fluidity in
her unconscious, the therapist is still vigilant in searching for resistance.
226 U n d e r s ta n d i n g Dava n l o o s IS - TD P

He knows that identifying and working with this resistance will


uncover further truths in the unconscious and that this will expedite
the phase of working through.

Conclusion
This twenty-second interview was reviewed and the salient points
surrounding the theme of forgiveness were highlighted. As the evalu-
ation of the vignettes suggested, the rhythm of the unconscious is such
that forgiveness must occur only when the unconscious introduces it.
It is of no use for the patient to consciously declare that she/he forgives
past genetic figures for their unjust treatment. Rather, Davanloo focuses
on the repeated experience of murderous rage (or sadism) and guilt
towards these figures. It is only on having these repeated experiences
(with appropriate MUSC) that the patient begins to have the affec-
tive experience of forgiveness. It is important to note that this patient,
while highly mobilised, is only beginning to experience the forgiveness
towards these two figures. There is much work to be done. The next
interview will review this concept further.
C hapter t w ent y three

The transference neurosis: Part VI

W
e now come to the patients last interview that will be
reviewed in this book. Hopefully, the reader will have a good
understanding of how the patient arrived at this point. She
is a highly resistant therapist who chose to participate in the Montreal
closed circuit training programme of her own will. While she is highly
resistant, the therapist was able to clearly establish this resistance early
on in her first interview. He was able to totally remove this resistance by
achieving an optimum mobilisation of the TCR and an optimum mobil-
isation of the neurobiological pathways of murderous rage and guilt.
With this came repeated evacuations of large columns of guilt. As the
therapist applied MUSC, the patient began to achieve early unconscious
structural changes. These structural changes, while profound, are early
and partial.
Central to this work has been a focus on the patients transference
neurosis. This is not only towards her previous therapistalthough
this individual bears a prominent role in her transference neurosis. Also
involved is her former training programme and the individuals she
was exposed to therein. Some of these individuals had access to psy-
chopathic elements in their character. Indeed, we must question if some
of these individuals were frankly psychopathic.
227
228 U n d e r s ta n d i n g Dava n l o o s IS - TD P

By focusing on the patients feelings towards the individuals involved


in her transference neurosis, the therapist has been able to mobilise the
patients unconsciousextensively. However, at this stage in the course
of therapy, the job is not done. The patient is not ready to say that she has
cleaned up her unconscious. Part of the reason for this is the ongoing
influence of the transference neurosis. So this last chapter (documenting
the clinical interviews) unfortunately does not detail the termination of
this therapy. Indeed, the patient is not ready for termination. Rather it
focuses on transference neurosis once more. The patient is aware that
she has not cleaned up her unconscious. She is aware that her trans-
ference neurosis still lingers and, to some extent, obscures the original
neurosis. It must be lifted up in order for us to better understand the
original neurosis. We return to the interview to understand this better.

Vignette I: the optimum mobilisation of the TCR


TH: OK, you know. First may I ask you not to use names? A, B, C? Some-
thing like that. You were talking about destructiveness like that and
you know that there is an element of destructiveness and that we
talked about idealisation of destructiveness. Often we talk of the ide-
alisation of destructiveness towards your mother and grandmother.
You were talking about a specific incident with your mother. What
was the incident?
PT: Are you talking about the phone call I had?
TH: Yes
[Patient tells of an incident where her mother told her about an
important piece of mail from the therapist.]
PT: I asked her to open and read it to see if it was important. It was
a letter from you saying that projective anxiety was in me previ-
ously since birth. You talked to me about my pathology. In this letter
you referenced projective anxiety present since birth. She felt very
badly and said, It must be my fault. I said, I dont think Im that
bad. Do you think Im that bad? She said, No, I dont think youre
that bad.
TH: You see, you have a lot of mixed feeling about many things. You
are also interested to learn that destructiveness doesnt come from
nowhere. There must be a centre in your psyche that calls for
destructiveness. Is this something you want to look at?
PT: Yes.
t h e t r a n s f e r e n c e n e u r o s i s : pa r t v i 229

TH: You want to see why you have this destructiveness? We have labelled
it idealisation of destructiveness, but it is a baseline destructiveness.
You yourself in interviews tells to the patient, you say: why are you so
destructive? What do you think about your destructiveness?
PT: There is a destructiveness that comes from me and there is a destruc-
tiveness I seem to have sought out in my residency. Truthfully, I could
have gone my whole residency with no exposure to psychotherapy.
But instead, I gravitated towards psychopathic supervisors.
TH: Was there an element of destructiveness in your training?
PT: Yes.
TH: Towards you?
PT: Yes.
TH: Then you have had an experience that mobilises feeling. Your train-
ing. So you have a lot of mixed feelings. You were in therapy from
19992004?
PT: I went to treatment in 2004 in my last year of residency.
TH: Ok, so you have a lot of long-term built-up feeling in you. They dont
die unless you experience them. Is it possible you lump out all this
destructiveness, this way we see, and put all the positive and negative
feelings and put them, all of them, in my direction? And put this
built-up system out more? What are you doing?
PT: Knife in your eyes.
TH: Lets see how it goes. Could we look to see how it goes further if you
have this primitive system?
PT: Comes out on your abdomen.
TH: Could you put this primitive system out? And then. And then. And
then. And then. What do you see there? Could you look to my eyes
there? What do you see?
PT: I see my mother and grandmother but I see most clearly my grand
mother.

Evaluation of vignette I
The patient has had an optimum mobilisation of the murderous rage.
However, she needs to mobilise her neurobiological system to a much
higher degree than this. This is in order to remove the transference neu-
rosis. While the neurobiological pathway of murderous rage is high,
it is not as high as it needs to be to completely remove the resistance.
The neurobiological pathway is not as strongly active as the degree of
230 U n d e r s ta n d i n g Dava n l o o s IS - TD P

sadism suggests it needs to be. Because of this, the extensive, sadistic


organisation in the patients unconscious is not completely experienced
and removed.
On viewing this vignette, Dr Davanloo commented that there is a
massive station of sadism in this patients unconscious. However, with
this massive station of sadism is a massive station of love. This presence
of both sadism and love in the unconscious is reflective of being human
and is common with many patients who have original neuroses. Having
an original neurosis is common to humanity. But patients with just an
original neurosis in the unconscious present far differently from those
with co-morbid transference neuroses. The complexity of the uncon-
scious in patients with both original neurosis and transference neuroses
cannot be emphasised strongly enough.

Vignette II: the phase of psychic integration and the


ongoing application of MUSC
TH: Your grandmother and your mother. Let the feeling out. Let the
feeling out. Let the feeling out. Let the feeling out. You must have a
massive feeling within yourself. Your mother and grandmother. Let
the feeling out. Let the feeling out. Let the feeling out. What is the
colour of the eyes of your mother?
PT: Brown.
TH: And your grandmother?
PT: Green/blue.
TH: They look at you?
PT: Yes.
TH: Could you look at the eyes of both of them? Who do you see
more?
PT: When you ask that I see my mother.
TH: Your mother. What do you see in her eyes?
PT: Shes confused and shes lost.
TH: You have a lot of feeling. Let the feeling out. Let the feeling out.
Let the feeling out. You have a lot of feeling. How your mother is
dressed up?
PT: It is winter and she has a knitted hat and a snowsuit on and its very
cold.
TH: What else do you see? What else do you see?
t h e t r a n s f e r e n c e n e u r o s i s : pa r t v i 231

PT: And I see my grandmother is very worried about her. But this all
happened before I was born and this was when my mother was a
young child. And thats what I see.
TH: What do you see right now?
PT: Just the same thing. I just see my mother. Shes outside in the winter
and its very cold. Shes lost.
TH: In this portrait that you saw your mother and grandmother, how old
was your grandmother in that portrait?
PT: Early thirties.
TH: So young. How about your mother?
PT: Four or five years old.

Evaluation of vignette II
Once again, we see not just one genetic figure in the breakthrough
but two. This is evidence that the TCR is quite high. But as above, it
is not high enough to mobilise and evacuate the complete columns of
sadism in the patients unconscious. In his aetiological formulation
of the patient, Davanloo has offered that her original neurosis centres
largely on the mother. But the grandmother is very close by, and the
patient had previously commented that the two are hand in hand in
her unconscious.
At any rate, the therapist uses a common technical intervention
and asks the patient Who do you see more? This forces the patients
unconscious to pick the figure for whom the sadism (and resulting guilt)
is higher. The patients unconscious answers that the clearer figure is
the mother. This is very similar to previous breakthroughs in earlier
chapters. One might ask: why does the original neurosis centre around
the mother? Why not the grandmother? At this point, the trail of the
unconscious has not entirely answered this question. However, several
irrefutable facts have emerged:

1. The patients mother was damaged in life.


2. Much of this damage related to the loss of her father early in life.
3. Some of this damage related to how the mother dealt with the loss of
the father.
4. The relationship between mother and grandmother was loving but
conflictual.
232 U n d e r s ta n d i n g Dava n l o o s IS - TD P

5. As a result of this loving but conflictual relationship, the patients


mother developed a neurosis.
6. The patient, through means of intergenerational transmission of psy-
chopathology, inherited this neurosis.
7. The patient sought out a transference neurosis as a means of deal-
ing with this painful, but relatively more straightforward, original
neurosis.

Metapsychologically, then, it would make sense that the patients


mother is relatively innocent compared to the grandmother. As such, the
mothers innocence in the conflict greatly increases the patients guilt in
relationship to her. It is this intense love for the innocent mother, com-
bined with the intense guilt for sadistically torturing her, that drives the
patients original neurosis and her disturbances in life. Seeing the two
in a loving relationship, which is a continuation of the theme from ear-
lier chapters, is reflective of the reunification and forgiveness that the
patients unconscious is introducing.

Vignette III: the continued phase of psychic integration


and the ongoing application of MUSC
TH: How do you feel right now?
PT: I feel very calm. I dont understand why the rage towards those psy-
chopaths yields the image of my mother and grandmother. Its not
obviously clear just yet why this is related. You know I looked for
my grandmother in my previous therapist. I see him and my grand-
mother as a clear association. But here, its very clear that its both
of them. And its a loving mother. This is a loving association.
TH: The memory is winter.
PT: She is loving and just doing her best to take care of her young child
who is very cold and lost and afraid. Its a very loving grandmother.
Its a very maternal grandmother.
TH: This contains a lot of very positive feeling.
PT: The guilt is not for murdering the psychopaths; its for murdering the
loving grandmother.
TH: Because this memory is your grandmother in the cold winter.
PT: Yeah.
TH: You see, Dr, this is a very profound positive feeling that your grand-
mother loved her daughter and in the cold winter the mother is struggling
t h e t r a n s f e r e n c e n e u r o s i s : pa r t v i 233

to give her daughter the warmth. As a result of that therapy, your


mother and grandmother
PT: My mother was cheated because she didnt get the attention she
deserved in that therapy. But my grandmother didnt deserve to be
aligned with a psychopath.
TH: Its very important. The transference neurosis

Evaluation of vignette III


The above vignette is not complete, as the entire video transcript was
not available. Here the patients unconscious is introducing important
themes. She acknowledges that there was rage towards the psycho-
pathic figures of her transference neurosis of the past. She has made
the link (with the help of the repeated MUSC) that this transference
neurosis was a means of seeking out the destructiveness that she had
in the relationship with her grandmother. With the grandmother she
was blind, obedient, and submissive. With her previous therapist,
she also displayed those same character traits. In this sense, she sees
why she murdered those figures and why she had such sadistic rage
towards them.
At this time, what she is currently trying to make sense of is the loving
relationship between mother and grandmother. While previously she
did not see the mother and grandmother in this type of loving bond,
her more recent breakthroughs have shown it to a greater degree. She
does not connect her transference neurosis figures with this degree of
love. Metapsychologically, it is difficult to understand what this means.
The following could explain her perplexity.

1. While the psychopathic figures may have been associated with the
rage and the negative qualities associated with the grandmother,
they are very foreign and appear disconnected when the patient
attempts to reconcile them with the loving and positive qualities of
her genetic figures.
2. Perhaps the patient is introducing the notion that the psychopathic
figures did not actually have loving relationships in their early lives.
3. Perhaps the lack of loving bonds explains their sadistic nature and
their absence of guilt.
4. Perhaps there are other aspects at play but the unconscious has not
yet revealed them.
234 U n d e r s ta n d i n g Dava n l o o s IS - TD P

At any rate, the patient and therapist continue to work on forgiveness


and reunification with the mother and grandmother. While the psy-
chopathic figures associated with the transference neurosis fit with the
degree of rage she feels, their association with love and forgiveness is
not clear.

Conclusion
This concludes the series of interviews for this patient. It must be noted
that she has not officially terminated therapy and there is more work
to be done. At the time of writing, she has not had further interviews.
There are several important realities as to why the therapy has not yet
finished.
The patient and therapist both agreed that the frequency of sessions
(every four to eight weeks) was not intense enough to promote more
robust unconscious structural changes. They both agreed that a fre-
quency of four to five weekly sessions per month would be ideal. But
the patient lives far away from Montreal and cannot feasibly arrange
for weekly sessions without moving to that city. For these realities, the
patient decided not to engage in any further sessions until she could
realistically commit to a frequency that would promote more robust
structural changes.
Importantly, these interviews summarise the newest discoveries
and technologies that allow Davanloo to work with highly resistant
patients in the twenty-first century. It is the authors hope that the pre-
ceding twenty-three interviews show the dynamic nature of Davanloo;
a dynamic nature that has fuelled his intellectual curiosity and his tena-
cious work ethic. While some have perceived him as rigid and confron-
tational, these interviews show him as neither. Indeed, his students and
mentees have described him as a deliberate, nuanced and creative inter-
viewer. He does not accept the status quo. Nor does he dismiss patients.
He simply dismisses their resistance. This is done with the utmost
of empathy and with the skilled precision of a surgeon. Many of his
students have described a deep and abiding sense of gratitude towards
him. The next section will focus on future directions in the teaching and
research of Davanloos work.
Part III
Future directions
C hapter t w ent y four

Competency-based psychotherapy
education and research: an introduction

T
he twenty-three interviews in this book reflect the newest
discoveries and techniques of Davanloo. They also reflect
his most up to date understanding of the metapsychology of
the unconscious. Interwoven in this book are several themes. First,
Davanloos technique is one of great precision. It is hoped that the
nuanced approach of following the trail of the unconscious has been
highlighted in the preceding interviews. This is a highly attuned and
empathic approach without any rote agenda. The use of challenge, if
present at all, is momentary and occurs only when the resistance is
firmly crystallised in the transference and the breakthrough into the
unconscious is imminent.

The state of the field


This approachone of great flexibility and creativityis not present
with all practitioners of IS-TDP. Many have promoted the technique
without actually having had extensive training from Davanloo. Since
this technique is not currently manualised, the need for ongoing,
livesupervision is essential.

237
238 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Not everyone who claims to be practising IS-TDP is actually


practising IS-TDP. Indeed, the age of video technology has allowed
us to review and dissect the tapes of many practitioners. Some use
extensive premature challenge. Some fish for rage. Some have
completely disconnected from their patients in what can only be
described as a woeful state of ongoing misalliance. While the stu-
dents of Davanloo are not infallible, their attempts at achieving a
high TCR have been viewed and supervised by him. Live, formative
feedback occurs often.
Some of these same individuals who have inadequate training in the
technique also attempt to research it. Indeed, much attention has been
focused on such research in the last decade. But one must ask: what
psychotherapeutic technique is being used in these research studies?
Given the heterogeneity of techniques used, it is difficult to draw any
conclusions on the validity of such research. I recommend that the pru-
dent reader ask the following four questions when reading any of the
latest research in the field. This research could include case reports,
meta-analyses, and randomised controlled trials.

1. What modality (or modalities) of psychotherapy was/were used?


Often, umbrella terms such as short-term dynamic therapies or
brief psychotherapies or psychodynamic therapies are used.
These terms often encompass a variety of different modalities, none
of which have any real similarities to one another other than being
dynamic in nature.
2. If more than one type of modality was used, is this listed? What
information is supplied (if any) on the modality of therapy used?
3. If the particular modality in the study was IS-TDP, what training and
experience did the therapists conducting the studies have? Is this
clearly stated?
4. If there is insufficient information about the training and experience
of the therapists involved, can it be said that the therapists are using
Davanloos Intensive Short-Term Dynamic Psychotherapy? What
information (specific and concrete) do the authors include about the
fidelity and adherence to the method of IS-TDP itself?

Since the modality of IS-TDP does not have a specific manual or a spe-
cific rating scale, it can be difficult to know what is transpiring in the
therapy of the subjects. It is, therefore, difficult to make any conclusions
c o m p e t e n c y- ba s e d p s y c h ot h e r a p y e d u cat i o n a n d r e s e a r c h 239

about such studies. The state of the research is, therefore, precarious.
Let us now move on to the assessment of competency.

Competence-based education and assessment


Various regulating and training bodies (ACGME, 2007), (RCPSC, 2013)
have changed the direction of psychotherapy education and assess-
ment. Previously, the apprenticeship model was considered enough
in residency training. Now, there is a focus on the actual and accurate
assessment of whether or not a trainee is competent to do what she/he
is trained to do. While great care and attention goes into the assessment
of competency in residents and other trainees, less attention goes into
the assessment of competency in the licensed and practising psycho-
therapist. This needs to change.
So how does a patient know if her/his therapist is competent in pro-
viding IS-TDP? What measures are available to ensure competency in the
students of this technique? There is a clear need, then, to have more spe-
cific and concrete measures to determine if the following are possible:

1. A more manualised approach to Davanloos IS-TDP.


2. At least one rating scale to determine adherence to Davanloos
technique.

While there is the central dynamic sequence, Davanloo in no way


encourages his trainees to approach the patient in a rote and mechanical
fashion. Indeed, he encourages a great deal of flexibility in the approach
to the patient in the therapy session. This is where the art and science of
psychotherapy intersect. Many (including trainees of Davanloo) would
argue that such a flexible approach to the unconscious cannot be easily
manualised.
One could argue that abstract entities such as resistance, the TCR
and various sequences of the central dynamic sequence could be mea-
sured. Since the assessment and quantification of such entities would
undoubtedly be open to some degree of interpretation, it might make
sense to use a consensus approach. For example, a group of experienced
therapists who are still in active training with Davanloo (and familiar
with his latest discoveries) could meet to devise such a rating scale.
With the use of videotaped vignettes, the therapists could come up
with their own opinions as to which video vignettes met the various
240 U n d e r s ta n d i n g Dava n l o o s IS - TD P

parameters above and to what degree. A rating scale could be devised


using various parameters, for example, the TCR, the UTA, the neurobio-
logical pathway of murderous rage, and so on. Each parameter could be
rated anywhere from 010 where 0 represents not at all adherent and
10 represents extremely adherent to Davanloos technique. Follow-
ing the presentation of a segment of video, each therapist could assign
various vignettes a score. Such data could then be compiled. Therapists
could be compared to one another, and those with a high degree of
inter-rater reliability could be included in a consensus group. This con-
sensus group could meet and review standard IS-TDP teaching tapes.
The group could then rate the various parameters at various points in
the vignette and make this information available to trainees who are
attempting to learn the technique.
There is, then, some optimism that an IS-TDP adherence rating scale
could be formalised. This could determine the degree to which a ther-
apist adheres to Davanloos precise technique. As such, a measure of
treatment fidelity could be developed. As of the present, there is no
such measure. The above could not be accomplished without patient
consent. Preferably, these teaching tapes would only be viewed live in
an annual meeting venue. There are a wide variety of concerns about the
privacy and security of disseminating such information over the inter-
net using online teaching modules. Patient privacy cannot be secured
in such online modules. For this reason, it is vital that the patient give
consent for this work to be preserved and never jeopardised through
means of online modules.
The next chapter concludes this book by focusing on one of the most
promising future directions in psychotherapy research: neuroimaging.
While in its infancy, neuroimaging research offers some of the most
promising information on just how powerfully psychotherapy can
impact the brain. This information, while early and preliminary, can
offer a foundation to best understand and operationalise just how intri-
cately the unconscious influences, and changes, the brain.
C hapter TWENT Y FIVE

Neuroimaging and Intensive Short-Term


Dynamic Psychotherapy: psychotherapy
and the brain
Dr Robert Tarzwell

S
kilful IS-TDP appears to yield lasting changes in both distressing
symptoms and maladaptive character traits, observable by the
therapist, reported by the patient, and detectable in outcome
studies. How these changes correlate with brain function is unknown.
IS-TDP itself has not been studied with functional brain scanning
methods. This is no slight against IS-TDP; the entire field of psycho-
therapeutic imaging is young, and most psychotherapy methods have
not been investigated with neuroimaging. The fields birth was only in
1992, when L. R. Baxter compared brain metabolism changes in patients
with OCD treated with either behaviour therapy or the antidepressant
fluoxetine and found that both treatments, when successful, corre-
lated with similar changes in the caudate nucleus (Baxter et al., 1992).
A stunning result at the time, Baxter and colleagues trailblazing paper
has been cited over 1,500 times.
The excitement generated by Baxters finding seems unusual now,
given the retrospective knowledge that the brain is constantly chang-
ing due to experience. However, this was once extremely controversial.
Starting in 1952, a raging debate began about whether psychother-
apy (particularly psychoanalysis) had any effect at all, sparked by
Hans Eysencks negative evaluation and fierce critique. He reported
241
242 U n d e r s ta n d i n g Dava n l o o s IS - TD P

that, while only 44% of neurotic patients in analysis improved, 72%


improved who were merely receiving encouragement from their GP
(Eysenck, 1952), and a 1965 follow-up study appeared to show similar
results (Eysenck, 1965). This challenge was taken up by Hans Strupp,
and so began the field of outcome studies in psychotherapy, of which
functional brain imaging could be considered the technologically facili-
tated branch that directly probes neurobiology (Strupp, 1963).
At present, the mere fact that a brain is detectably changing in
response to a stimulus is no longer interesting. We want to know how
and where it is changing, and why the observed changes are occurring.
We want to know what those changes mean in the context of what is
now a much larger body of knowledge about brain function. Current
neuroscience has a much more sophisticated understanding of how the
brain functionsas a vast series of networksand this new theoretical
approach has opened a rich, busy, and fruitful agenda of exploration
(Sporns, 2010). As researchers get better at determining how brain
networks operate, they get better at detecting the changes that correlate
with psychiatric disorders. They also get better at determining the ways
in which various psychiatric treatments affect the brain.
The longer answer to the question about how IS-TDP changes the
brain will involve investigating three separate questions. First, based on
current knowledge, how might IS-TDPs psycho-diagnostic constructs,
specifically low, moderate and high resistance, and fragile character
structure, correlate with abnormalities of large-scale brain network
function, and what experiments could we conduct to examine this?
Second, and much more challenging, can we demonstrate what specific
IS-TDP techniques from the central dynamic sequence are doing to brain
networks in real time during the therapeutic hour? Third, does IS-TDP
operate in a neurobiologically unique way, unduplicated in other thera-
peutic modalities?
To approach these questions, we will review the history of brain
science, survey the main methods used to determine activity in the
living brain, and see how those activity patterns were used to deter-
mine that the brain functions like a network. Current ideas about
brain network function will be explored, including in psychiatrically
healthy and disordered states, and Menons triple network model of
psychopathology will be introduced. Next, the current literature on
brain changes measured during psychodynamic psychotherapy will be
reviewed. Finally, a testable theory and research agenda will be sketched
N e u r o i m ag i n g a n d IS - TD P 243

out that explores, using the latest research, the interaction between the
psycho-diagnostic constructs and central dynamic sequence of IS-TDP,
and the triple network model of psychopathology.

Functional brain imaging


The past: a brief history of brain function
For centuries, the main debate within brain function studies was
whether it operates in a holistic way or whether functions are localised
to specific brain regions. The experimental results of Pierre Flourens
in the nineteenth century seemed to show that the entire brain partici-
pated in behaviour. He removed cortical tissue from animals and fre-
quently observed complete functional recovery, suggesting to him that,
because healthy parts of the brain can take over the function of damaged
ones, specialisation could not be true (Pearce, 2009). By contrast, stroke
studies in human patients seemed to indicate that with the loss of par-
ticular areas there could be specific functional losses that never recover.
Pierre Broca reported a case of a man who, after a small stroke, under-
stood speech perfectly but could only say the word tan. Later, Carl
Wernicke presented a case where, after a small stroke in a nearby but
distinct region, the patient did not understand speech, and although he
could speak fluently, his speech made no sense (Kaitaro, 2001).
The debate between holism and localism went back and forth, up to
the turn of the twenty-first century, when scientists discovered that both
views were right and wrong. A new synthesis of brain function arose
from combining twenty-first-century functional brain imaging results
with an obscure branch of mathematicsgraph theoryinvented in
1736 by Leonhard Euler (Sporns, Tononi, & Edelman, 2002). From this
was born brain connectivity science, which seeks to understand how the
brain is anatomically and functionally connected by applying network
concepts and graph theory to results from functional brain scans, espe-
cially fMRI. But, this grand synthesis could not have occurred without a
key discovery upon which functional brain imaging depends.
Neurons, the basic computational cells of the brain, are unable to
store energy. Therefore, they are completely dependent on blood
supply. How are they always steadily supplied with the right amount
of energy, regardless of their state of dormancy or activity? In the 1880s,
Roy and Sherrington discovered that the brain of a dog would expand
244 U n d e r s ta n d i n g Dava n l o o s IS - TD P

from the inflow of blood within seconds of sensory nerves being


stimulated and just as reliably shrink after stimulation stopped (Roy &
Sherrington, 1890). How this tight coupling between neuronal activity
and circulatory changes operated remained a mystery until 1948, when
Seymour Kety and Carl Schmidt deduced that regional blood flow in
the brain is directed by the brain itself (Kety & Schmidt, 1948). Breath-
ing in CO2 caused the arteries in the brains of young men to dilate.
It was already known that metabolically active neurons consume more
oxygen and produce more CO2 from metabolising glucose. So, increas-
ing CO2 concentrations from a population of active neurons causes
localised dilation of blood vessels, which leads to increased delivery of
glucose and oxygen. By this elegant mechanism, the brain completely
regulates its own blood supply.

The present: imaging methods currently used


to determine brain function
Where blood flow is increasing or decreasing, changing neuronal
activity is the driver. Therefore, blood flow is a reliable indicator of brain
metabolism. The first images of brain function based on this principle
were captured in 1961, using radioactive xenon (Ingvar, 1997). The
individual would inhale a small amount of the gas, which would pass
into the bloodstream. As brain functions changed under experimental
conditions of sensory stimulation or motor activation, scientists could
detect the radiation from the xenon to see which parts of the brain had
more or less blood flowing through them.
By the late 1960s, early versions of all brain imaging methods were
being developed. These break down into two main types. Structural
imaging, as demonstrated by CT and MRI, reveals the brains anatomy.
Functional imaging, such as PET, SPECT, and fMRI, reveals what the
brain is doing by demonstrating which parts show high activity in
comparison to other parts showing relatively low activity. Since we
are primarily interested in how IS-TDP changes brain function, we will
focus on the methods most commonly used in studying psychotherapy:
PET, SPECT, and fMRI.

PETpositron emission tomography


PET scanners detect the energy that escapes when an electron collides
with a positron, a tiny particle of antimatter that has the mass of an
N e u r o i m ag i n g a n d IS - TD P 245

electron but with a positive charge, whereas electrons carry negative


charge. Positrons are emitted by specially labelled molecules, created
in a medical cyclotron by bombarding stable atoms with high energy
protons travelling at close to the speed of light. The matter and anti-
matter annihilate after colliding and are converted into two gamma
photons. These fly away in opposite directions and strike a ring of detec-
tors. Computers are able to determine the point of origin of the photons,
and millions upon millions of photons originating from different parts
of the brain produce the image.
The most common positron-labelled atoms are carbon, nitrogen,
oxygen, and fluorine. Because these are basic components in biomol-
ecules, it is possible to make positron-emitting sugar, water, and simple
biomolecules. Therefore, PET is particularly well suited to studying
molecular processes in the body. The most commonly used PeT tracer
is FDG, fluorodeoxyglucose. It is the result of removing an oxygen
atom from glucose and replacing it with positron-emitting fluorine.
Since glucose is the brains main energy source, FDG is used to directly
measure brain metabolism. Neurons that are working hard have a high
metabolic demand, and therefore they will take up more FDG mol-
ecules. By contrast, neurons with impaired metabolism take up less
FDG, and on brain images those regions look less active. FDG creates
a map of brain activity over a thirty to sixty minute period after injec-
tion. Because of this long time-window, FDG is well suited for studying
processes such as dementia, where neurons themselves are damaged
(Alavi & Hirsch, 1991).

SPECTsingle photon emission computed tomography


SPECT scanners also detect gamma photons, but these lower energy
gamma emissions come directly from radioactive atoms, not annihila-
tion reactions; usually the metal technetium. Radioactive technetium
comes from molybdenum decay, itself produced from the controlled
fission of uranium in medical nuclear reactors. Technetium is joined
to a specially designed molecule that is specifically attracted to a cer-
tain organ or physiological process in the body, and this radio-atom
plus molecule complex is known as a radiotracer. Once the radiotracer
is in the body, the technetium atom releases its gamma photon, and
detectors outside the body capture the photon. Computers generate
images using millions of detected gamma photons from the organ or
process of interest.
246 U n d e r s ta n d i n g Dava n l o o s IS - TD P

SPECT can be used to detect large radiolabelled molecules, such as


proteins, antibodies, or specially designed molecules that are highly
attracted to certain organs. The most common molecules for brain
imaging measure blood flow. Where blood flow is high, large numbers
of tracer molecules are delivered. These pass into neurons, where they
become locked inside the cell, generating a snapshot of brain activity
during a brief time-window; about ninety seconds. Other SPECT
radiotracers are able to bind with serotonin and dopamine receptors
or transporters, located on the axonal and dendritic surfaces inside the
synapse (Devous, 2013; Santra & Kumar, 2014).

FMRIfunctional magnetic resonance imaging


MRI uses radio waves in a magnetic field to excite small atoms by
changing their direction of spin. When the radio pulse switches off,
the atoms relax, and they give off tiny radio waves of their own. These
tiny radio waves get detected, and computers generate images. MRI
has the flexibility of generating both structural and functional images
of the brain, which allows researchers to precisely localise the origin
of activity within the brain. The main form of functional imaging
with MRI is based on the fact that blood uses a large protein called
haemoglobin to carry oxygen. Haemoglobin carrying oxygen gives
off a slightly different MRI radio wave than haemoglobin that has
unloaded its oxygen. In areas of the brain that are working hard, more
haemoglobin is giving up its oxygen, and fMRI is able to detect this
change on a second by second basis, and this is the basis of BOLD
(blood-oxygen-level dependent) imaging (Kameyama, Murakami, &
Jinzaki, 2016). Therefore, MRI is well suited to exploring brain activity
changes in real time.

Functional brain imaging in psychodynamic psychotherapy


Within the vast world of functional brain imaging research, with over
187,000 searchable publications on the PubMed database as of the pub-
lication of this volume, there have been a small number of studies spe-
cifically examining brain changes after psychodynamic psychotherapy.
These have been summarised in a systematic review that found that a
total of 116 patients in eleven studies with depression, hypomania, panic
disorder, somatoform disorders, and borderline personality disorder
N e u r o i m ag i n g a n d IS - TD P 247

had received functional brain imaging before and after a course of psy-
chodynamic psychotherapy (Abbass, Nowoweiski, Bernier, Tarzwell, &
Beutel, 2014).
To qualify as psychodynamic therapy for purposes of the review, the
treatment approach needed to be defined by a manualised treatment
protocol with established efficacy, with a focus on the emergence of
unconscious conflict in the transference relationship. In eight studies,
therapy was conducted in outpatient settings, while the other three
occurred in the context of inpatient treatment. Overall, investigators
in the eleven reviewed studies reported a trend towards normalisa-
tion in brain imaging findings after clinically successful therapy and a
lack of normalisation in unsuccessful treatments. Research participant
scans came to look more like control scans in studies using PET, SPECT,
and fMRI, which examined glucose metabolism, brain blood flow, and
changes in dopamine and serotonin neurotransmitter, receptor and
transporter activity. To date, there have been no brain imaging studies
in IS-TDP.
These results suggest first that individuals with psychiatric disor-
ders have detectable differences in their brain function when compared
with asymptomatic controls. Second, symptom improvement brought
about by psychodynamic treatment correlates with changes in brain
activity in the direction of healthy controls. These results, unfortunately,
cannot tell us, from a neurobiological standpoint, how psychodynamic
treatment brings about these results, or if it has unique therapeutic
ingredients that lead to results not seen via other psychological or phar-
macological therapies.
IS-TDP has a psychological theory of changethe unlocking of
the unconscious in the transference relationship with the therapist
built from the minute study of video-recorded sessions. While the
main thrust of psychotherapy outcome research has been to explore
whether a given therapy works compared with a reasonable control,
and how therapies perform against other active treatments, direct
research into mechanisms of change is very difficult. Ultimately,
the video itself cannot tell us what defences are being deployed,
or whether resistance is crystallised in the transference. These con-
cepts, critical though they are, are theoretically informed inferences
from the tape, not direct data. A brain-based theory of psychopathol-
ogy potentially opens a new window to the problem, since brain
changes can be detected and demonstrated in a more direct fashion.
248 U n d e r s ta n d i n g Dava n l o o s IS - TD P

Because of technological advances, determining whether the amygdala


is activated is a much more straightforward matter than determining
if the transference is activated, particularly when attempting to
demonstrate the activation to independent observers who may not
understand or accept IS-TDP constructs. To sketch out a brain net-
work-based theory of psychopathology, let us begin with a theory of
normal psychological function.

How the brain functions under normal conditions:


large-scale networks
Functional brain imaging has helped us solve the mystery of why the
brain sometimes appears to be quite localised in its functions and yet
at other times quite generalised and distributed. The most exciting
discovery of the last twenty years is that it does both: the brain uses
networks (Sporns, 2010). In this way, brain activity is quite similar to
flight paths that connect large and small airports, or the way information
gets routed through computers on the internet. Airports are localised
and fixed in location, as are the jet routes between them, yet there are
vast differences in activity patterns in a given network of airports. One
example would be air traffic at night vs. early morning. In the same way,
the brain has structural connectivity, which is its anatomy, and func-
tional connectivity, which are the various patterns of activation within
the neurons.
Importantly, brain activity is not a formless, constantly shifting free-
for-all, neither is it completely specialised in a one structure for one
function way. Instead, there are particular regions of the brain that
become active under particular circumstances, in quite a reliable way.
These activated regions, or modules, all perform some small compo-
nent of a larger task in isolation from one another, and they then com-
municate their results with each other via hubs, which integrate these
separate signals (Bressler & Menon, 2010). Fourteen large-scale func-
tional networks have been discovered (Menon, 2015a). Scientists try to
determine what parts of the brain become more or less active during
particular tasks, performed over and over again by research volunteers.
From the psychotherapy and psychiatric disorder point of view, three of
the fourteen large-scale networks seem to be especially important: the
central executive network, the salience network, and the default mode
network (Menon, 2011).
N e u r o i m ag i n g a n d IS - TD P 249

CENthe central executive network


The CEN involves the dorsolateral prefrontal cortex (dlPFC) and the lat-
eral posterior parietal cortex (PPC) in both left and right hemispheres.
There are other nodes, discovered in other research studies, but these
two appear to be the most important. The CENs most important job
appears to be maintaining and manipulating information in short-term
memory, also known as working memory, which resides in the dlPFC.
The CEN is also activated by tasks that require rule-based problem-
solving, and in making decisions when attempting to accomplish a
goal. It has been proposed as the network of action (Agnati, Guidolin,
Battistin, Pagnoni, & Fuxe, 2013). CEN abnormalities have been
described in ADHD, depression, PTSD, schizophrenia, and borderline
personality disorder (Doll, Sorg, & Manoliu, 2013; Menon, 2011).

DMNthe default mode network


The DMN is deactivated during cognitive tasks. It was discovered
when investigators noticed that particular brain regions would reliably
activate when their research subjects were between tasks, laying
in the scanner during restful wakefulness. Like the CEN, it has two

Dorsolateral prefrontal Posterior parietal


cortex (dIPFC) cortex (PPC)

Central executive network (CEN)


Figure 4. Nodes of the central executive network.
Only the left hemisphere nodes are shown here, but the CEN is a bilateral
network, and it also includes the right dlPFC and PPC. Image modified
from Kenhub.com. Permission gratefully acknowledged.
250 U n d e r s ta n d i n g Dava n l o o s IS - TD P

principal, bilateral nodes: the posterior cingulate cortex (PCC) and


the medial prefrontal cortex (mPFC). These are midline structures,
where the hemispheres meet. It was the first large-scale brain network
to be discovered. It is activated in self-referential tasks, such as recall-
ing autobiographical memories, emotion regulation, applying semantic
meaning to internal states, and making decisions based on values. It has
been proposed as the seat of imagination (Agnati, Guidolin, Battistin,
Pagnoni, & Fuxe, 2013). The DMN has been found to be overactive in
depression and schizophrenia (Whitfield-Gabrieli & Ford, 2012), and
it shows reduced internal connectivity in Alzheimers disease (Jones,
Machulda, & Vemuri, 2011).

SNthe salience network


The SN, like the CEN and DMN, involves multiple nodes bilater-
ally, but two appear as the most important: the dorsal anterior cingu-
late cortex (dACC) and the anterior insula (AI) (Menon, 2015b). The
SN constantly samples data from the exterior world and the interior
world, and its main role appears to be choosing relevant stimuli and
filtering out the irrelevant. Information about the bodys internal state

Posterior cingulate
Medial prefrontal
cortex (PCC)
cortex (mPFC)

Default mode network (DMN)


Figure 5. Nodes of the default mode network.
These nodes are found in both left and right hemispheres in the midline,
on the brains medial surface, where the hemispheres meet. Image modi-
fied from Kenhub.com. Permission gratefully acknowledged.
N e u r o i m ag i n g a n d IS - TD P 251

comes from the posterior insula. Information about emotional salience


arises from the amygdala, while reward relevance information flows
from the ventral tegmental area (VTA), itself part of the reward circuit.
One critical role of the AI is, after assigning salience, deactivation of the
DMN and activation of the CEN. Essentially, the SN functions as a con-
troller, by detecting relevant stimuli and bringing cognitive resources
online, while also reducing internal distraction. The SN has been found
to be overactive in anxiety disorders and underactive in depression,
particularly the right AI (rAI). The SN also appears to be hyperactive in
individuals who demonstrate painful hyperresponsiveness to innocu-
ous stimuli, and it is hyperactive in addiction, especially in the experi-
ence of cravingthe conscious urge to seek drugs or alcohol.

Brain regions linked to emotion


Of critical interest to IS-TDP theory and practice is helping patients
directlyexperience their own true feelings about the past and present.
The study of emotional experiencing as a branch of neuroscience and
functional brain imaging in its own right appears to involve brain
regions that heavily overlap with large-scale intrinsic brain networks,
particularly the SN and the DMN. A large analysis of over hundreds of
studies of brain regions activated during emotional experiencing has
yielded that frequently activated areas include the amygdala, theanterior

Anterior Dorsal anterior


insula (AI) cingulate cortex
(dACC)
Salience network (SN)

Figure 6. Nodes of the salience network.


Note that the insula, meaning hidden, is tucked inside the lateral fissure,
the boundary between the frontal and temporal lobes. The dACC, like the
mPFC and the PCC, is midline. Image demonstrating the insula modified
from Kenhub.com. Permission gratefully acknowledged.
252 U n d e r s ta n d i n g Dava n l o o s IS - TD P

hippocampus, the AI, and the cingulate gyrusa remarkable overlap


with SN nodes (Satpute, Wilson-Mendenhall, Kleckner, & Barret, 2015).
Activation has also been demonstrated in the medial prefrontal cortex, the
posterior cingulate cortex, and the precuneusall nodes of the DMN.
Current models of emotional experience have not robustly integrated
large-scale network theory, so it is premature to make specific claims,
though the overlap of involved nodes is striking and certainly bears fur-
ther investigation. It is reasonable to at least hypothesise that large-scale
networks, at least the SN and DMN, simultaneously incorporate affec-
tive and cognitive nodes; more likely affect in the case of the SN and
affect regulation in the case of the DMN. So far, there do not appear
to be unique networks or specific modules linked to specific emotions.
Activity in the insula and amygdala, for instance, has been demonstrated
in experimental paradigms that activated sadness, anger, fear, and dis-
gust (Lindquist, Wager, Kober, Bliss-Moreau, & Barrett, 2012). It seems
reasonable to propose that one way the SN makes a stimulus salient is
via the activation of an emotion in relation to that stimulus, to encourage
approach or avoidance, and this could, in part, explain the strong over-
lap of affective and SN network nodes. From the IS-TDP standpoint,
the outcome of so-called locationist vs. constructivist debates about
emotion, although scientifically interesting, has little practical or theo-
retical bearing. IS-TDP is not dependent on any particular neuroscien-
tific theory of emotion and thus has the luxury of remaining agnostic.

The triple network model of normal psychology


and psychopathology
Under normal circumstances, the SN, particularly the rAI, detects salient
internal or external stimuli and activates the cognitive resources of the
CEN, such as working memory and attention, to initiate appropriate
behavioural responses. Activation of the CEN by the SN is simultaneously
accompanied by the deactivation of the DMN. You may be daydreaming
about retirement (DMN) when suddenly you notice you are hungry (SN),
so you go to the fridge and get a snack (CEN). The SN accomplishes its
function by deactivation of the DMN and activation of the CEN.
When not actively engaged, the brain is in its resting state, and the
default mode network is activated. The salience network is constantly
sampling internal stimuli from the body, including emotions and
physiological cues, and external stimuli, the data from the five senses.
N e u r o i m ag i n g a n d IS - TD P 253

Default mode Central executive


network network
+

Salience
network

Internal External
stimulus stimulus

Figure 7. Normal operation of the triple network.

Whenever it flags a stimulus as salient, it activates the central execu-


tive network and deactivates the default mode network. This orients
the mind away from the self and toward the stimulus. The DMN could
be considered the realm of self-referential or imaginative thought. The
CEN is the realm of stimulus-oriented, goal-directed thought, which
leads to action.
Abnormalities in this pattern of response can lead to difficulty, and
the seemingly universal involvement of abnormal SN, DMN or CEN
function in all fMRI studies of psychiatric disorders to date led to the
proposal of a triple network model of psychopathology (Menon, 2011).
If there are internal functional problems in the SN, it may assign inap-
propriate salience. For instance, an individual with a spider phobia will,
due to hyperactivation of the SN, assign extreme salience to seeing a
spider in the living room. A depressed person, with underactivation of
the SN, may not assign salience to hunger signals from the body, leading
to the commonly reported symptom of loss of appetite. Then, because
of insufficient salience, the SN may fail to activate the CEN, leading to
inappropriate behavioural responses, such as when a depressed person
stops eating, despite significant weight loss. Essentially, the SN may
suffer from internal dysregulation, leading to the misassignment of
salience, or external dysregulation, leading to a failure in control signal-
ling of the DMN or CEN, leading to dysfunction in multiple networks
(Menon, 2015b). This is the essence of the triple network model of
psychopathology.
The initial impetus for the model was to try and understand why
these three networks in particular always seemed implicated in such
symptomatically diverse psychiatric disorders as anxiety, depression,
autism, schizophrenia, and dementia. The model emerged as an
attempted synthesis of diverse research findings. Investigators have
254 U n d e r s ta n d i n g Dava n l o o s IS - TD P

since discovered that certain activation patterns within the SN or


the DMN may predict treatment response in depression. Brockmann
used SPECT imaging to predict treatment response to antidepressants
based on what, retrospectively, appear to be nodes of the DMN and
SN (Brockmann, 2009). McGrath, using FDG PET research to study
brain metabolism and depression, has reported that underactivation
in the rAI, a node of the SN, predicts treatment response to escitalo-
pram or CBT (McGrath, Kelley, & Holtzheime, 2013). Her research
also suggests that overactivation of the subgenual ACC, a node of
the DMN, predicts treatment resistance to those same interventions
(McGrath et al., 2014).

IS-TDP through a triple network lens


1. Possible fMRI findings in various psycho-diagnostic categories
One of the first tasks in IS-TDP is assessing the patients capacity to
withstand the impact of their own unconscious feelings, and Dr Davanloo
has proposed a spectrum of resistance from low to high, or fragile
described more comprehensively in Chapter Onederived from the
clinical observation of how patients respond to therapeutic interven-
tions. Individuals from these specific psycho-diagnostic categories
might be expected to show similarities in large-scale and affective
network function. This would deepen our understanding of both the
neurophysiological basis of IS-TDP psycho-diagnosis and allow us to
extend the application of the triple network model. The model allows
for speculation in a principled manner based on current knowledge, but
ultimately only by directly investigating can we come to understand
if there are specific neurobiologies attached to specific neurotic char-
acter structures. With this caveat in mind, here is a sketch of what we
might find.

Low resistance in the fMRI


Patients with low resistance can rapidly ally with the therapist and
become psychologically vulnerable enough to experience and share
their true thoughts and feelings with a stranger they have just met.
They understand and accept the therapeutic situation and intent.
The patient is able to understand the goal of the therapy and communicate
N e u r o i m ag i n g a n d IS - TD P 255

in a self-referential way while experiencing whatever emotions arise.


This suggests good activation of the DMN to access the traumatising
autobiographical memory, and the SN to recognise salient aspects of
activated emotion from recall of the trauma, which in turn activates
the CEN to direct cognitive resources and attention towards the goal of
experiencing blocked pockets of emotion related to the trauma.
We can hypothesise that individuals who qualify as having low
resistance would therefore demonstrate normal triple network func-
tion during fMRI studies while carrying out cognitive and emotion-
related tasks. A sufficiently capable therapist should be able to arrive
at the appropriate psycho-diagnosis without knowledge of the MRI
findings, and blinded assessors of the MRI researchers might be able
to categorise the patient as low resistance from knowledge of triple
network function alone.

Moderate resistance in the fMRI


The larger group of moderately resistant patients have difficulty
forming an alliance with the therapist. They often have some level of
difficulty describing their symptomatic and characterological difficulties,
and the therapists moves toward intimacy lead to unconscious resis-
tance from the patient. We might therefore expect some members of
this group, particularly those who deploy hysterical defences, to exhibit
overactivation of the SN, particularly the rAI, but without deactiva-
tion of the DMN, and with insufficient activation of the CEN. These
patients are quite anxious, and they are unable, initially, to participate
with the therapist via the transference, although they may appear
clinically to be quite engaged. They cannot direct sufficient attentional
resources to the therapeutic task, cannot set a therapeutic goal, and
often their traumatic memories are too salient. Thus, they cannot eas-
ily withstand emotional activation without first learning to attribute
appropriate salience, which necessitates activation and retraining of the
CEN to engage in therapeutic goal-setting, with the therapist acting as
a surrogate CEN.
Some in this category, who are able to deploy obsessive, intellectual-
ising defences, would be expected to demonstrate overactivation of the
CEN and SN, but without DMN deactivation, as cognitive resources
are misdirected away from traumatic memory and towards reducing
the salience of intimacy-related anxiety. The initial task is undoing
256 U n d e r s ta n d i n g Dava n l o o s IS - TD P

intellectualising defences, helping the patient modify the CEN towards


more adaptive focusing of attention, and cognitive effort on the direct
experience of transference anxiety and trauma-related emotions
activated in the transference.

High resistance in the fMRI


Highly resistant patients often have difficulty even recognising that
they have characterological difficulties or symptom disturbances,
and they are highly identified with their own resistance. There is little
ability or desire to look inwards, and the therapist often faces massive
detachment. Alexithymia is clinically common in this population. From
a triple network perspective, significant underactivation of the SN
might be expected, particularly in relation to affect. These patients often
require the therapist to act as a surrogate SN, and the therapeutic task
frequently involves helping the patient to name and identify detachment
and emotion by relentlessly directing attention towards even the tiniest
somatic expressions of affect in the transference. Underactivation of the
SN might be expected in fMRI emotional activation paradigms, with
normal performance in cognitive paradigms, except in the depressed
segment of highly resistant patients, who would show poor perfor-
mance relating to hyperactivation of the DMN, underactivation of the
SN, and subsequent inability to recruit the CEN.

Fragile character structure in the fMRI


Patients with fragile character structure often appear flooded by
anxiety. They have no capacity to tolerate their anxiety, and they are
often cognitively disrupted as well, unable to engage in even basic
conversation with the therapist, let alone undertake emotionally chal-
lenging work. Somatic symptoms are frequently present, often to
a significant enough degree that the patient has misinterpreted the
symptom as a manifestation of disease and has sought out medical
consultation. The SN might be expected to be extremely overactive in
these patients, with salience attributed to the entire interoceptive milieu.
However, the rAI is simply unable to activate the CEN, clinically mani-
fested as cognitive disruption, and the patient is unable to direct atten-
tion or cognitive resources towards internal stimuli.
The therapist is often quite intellectually active with these patients,
teaching them to activate the CEN by example, helping the patient to
N e u r o i m ag i n g a n d IS - TD P 257

name and gradually tame the constant flood of distressing experience.


This may be an extensive portion of the therapy and lead to substan-
tial symptomatic benefit, even before the patient can withstand their
unconscious affects and address the traumatic memories maintaining
overactivation of the DMN. These patients might be expected to perform
poorly in experimental paradigms in which emotional activation pre-
cedes cognitive tasks, with an fMRI-observable hyperactivation of the
rAI without subsequent CEN activation.

2. The neurobiology of the central dynamic sequence


While fMRI might be the modality of choice to study the specifics of
network function in the various psycho-diagnostic populations, it is
highly impractical in the clinic. The patient lies on their back in the
scanner, with their head held perfectly still by a special coil to enhance
detection of brain activity. It is difficult to imagine how a therapeutic
alliance could be formed, with activation of the transference, under
such intrusive circumstances. As well, the time-course of many IS-TDP
interventions occurs in a time frame shorter than the thirty minutes
needed to achieve adequate brain equilibrium of FDG for a PET study.
Brain perfusion SPECT, with a time-window of about ninety seconds,
and the ability to delay image acquisition for several hours, may be
close to ideal.
An experimental design would predetermine the particular inter-
vention to be examined: enquiry, pressure, challenge, head-on collision,
partial unlocking, full unlocking, or multiple unlockings with analysis
of the transference. The patient would be pre-prepared with an IV
connected to a pump that would deliver the tracer dose via remote
signal from the therapist or an observer. The therapy session is other-
wise conducted as per usual. When the intervention of interest is occur-
ring, the tracer is remotely injected, and even though brain activity over
the next ninety seconds is what is captured, the images themselves can
be acquired up to six hours after injection, because the tracer remains
stably locked, allowing as much time as needed for naturalistically con-
cluding the therapy session.
Regardless of what occurs after tracer distribution, it will show
brain activity as it was during the narrow window of the injection and
uptake phase, analogous to a Polaroid snapshot. Images of the reaction
to various interventions could be statistically pooled and compared.
Research of this nature would be an exciting development in therapeutic
258 U n d e r s ta n d i n g Dava n l o o s IS - TD P

imaging, which currently only happens outside of therapeutic sessions.


The potential exists not only to document normalisation but to under-
stand the specific large-scale and affective network responses to specific
interventions. The path to the destination could be revealed, rather than
simply the points of origin and arrival.

3. Discovery of unique therapeutic potential in IS-TDP


Following in the footsteps of investigators like Brockmann and
McGrath, a third critical aspect of an IS-TDP neuroimaging research
programme would seek out functional imaging predictors of response
or non-response to a course of therapy. It would be especially interest-
ing to discover not just general predictors of response, which might be
found in any therapeutic intervention, such as McGraths suggestion
about low metabolism in the rAI predicting a positive response to either
CBT or medication, but if there are specific markers suggesting IS-TDP
might be uniquely efficacious when other interventions are predicted
to be ineffective. This would help situate IS-TDP within the therapeutic
universe and allow for rapid identification and referral of patients either
at initial presentation, or after the demonstration of treatment resistance
to other psychotherapies and medications.
This could not replace an initial psycho-diagnostic assessment and
trial of therapy, but it could help decide who would benefit from a
referral. Ideally, predictive treatment markers would help reduce the
rate of non-response and treatment dropout, significant issues in any
mental health clinic. Also, as our understanding of large-scale networks
deepens, it might be possible to begin correlating unique predictors
of response to deeper, more complex psychological constructs in
IS-TDP, such as resistance against emotional closeness, unconscious
self-sabotage, and the destructive organisation of the defences.

Summary and conclusion


What we can say with confidence, on the strength of the current state of
psychiatric neuroimaging, is that psychodynamic psychotherapy leads
to demonstrable normalisation of brain activity in mood, anxiety, soma-
toform, and personality disorders, in the direction of healthy controls.
Normalisation of brain blood flow, glucose metabolism and synaptic
activity have all been demonstrated. We can also say that three of the
N e u r o i m ag i n g a n d IS - TD P 259

brains large-scale networks, the SN, the CEN and the DMN have
been implicated in every psychiatric disorder studied so far, primarily
problems in the SNs internal ability to assign salience and its external
ability to appropriately activate the CEN and deactivate the DMN.
Evidence is accumulating that triple network abnormalities corre-
spond reasonably with the symptom profiles of the particular psychi-
atric syndromes, such as underactivation of the rAI in depression, or
overactivation in anxiety. We can also state that there is strong overlap
between networks involved in emotional experiencing and the brains
large-scale networks. With these building blocks, a testable model to
study the effect of IS-TDP on the brain can be proposed to explore the
neurobiology of psycho-diagnostic categories and of the central dynamic
sequence, and to determine the unique place of this therapeutic format
within the psychiatric armamentarium.
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Abbass, A., 13, 247 psychoanalytic investigation of


abstract entities, 239 unconscious, 193197
adherence rating scale, 240 rage and guilt, 190192
aetiological formulation of patient, 138, sadistic impulse, 193
142, 154, 196, 224, 231 therapists sadism, 193
Agnati, L., 249, 250 transference neurosis, 193
Alavi, A., 245 bereavement, 130 see also: pathological
Alazraki, A., 241 mourning
anterior insula (AI), 249251 Bernier, D., 247
anxiety, projective, 23, 49, 68, 7071, Beutel, M., 247
8082, 103104, 124, 193, 228 Bliss-Moreau, E., 252
see also unconscious anxiety Blyett, M., 15
role of, 5759 BOLD (blood-oxygen-level dependent),
Augsburger, T., 5, 10 246
Bowlby, J., 17
Barrett, L., 252 brain see also: Intensive Short-Term
Battistin, L., 249, 250 Dynamic Psychotherapy;
Baxter, L., 241 neuroimaging
Beeber, A., 34 activity, 248
being a mother to ones own mother, -based theory of psychopathology,
189 247
guilt and MUSC, 192193 and emotion, 251252
intergenerational trauma, 197 function, 243244, 248

269
270 index

functional imaging, 243244, intergenerational transmission


246248 of neurosis, 2021
network function, 242 MUSC, 21
regions linked to emotion, 251252 neurobiological pathway
brainwashing in psychiatric profession, of memory, 2122
119 projective anxiety, 23
Bressler, S., 248 transference neurosis, 1920
Brockmann, H., 254 default mode network (DMN), 249250
see also: neuroimaging
Cameron, E., 118 destructive competitive transference
Case of the Machine Gun Woman, 104 neurosis, 97, 106107, 199
central dynamic sequence, 910 Case of Machine Gun Woman,
central executive network (CEN), 249 104
see also: neuroimaging psychoanalytic investigation of
Central Intelligence Agency (CIA), 118 unconscious, 101, 104
chain reaction in unconscious, 137, rage, 98101
169 rusting, 101
character resistance of idealisation of structural change in unconscious,
destructiveness, 181 106
chain reaction, 185 technique of echo, 101
discussion on, 186187 destructive tendency, 85
guilt and portrait of love, 185186 idealisation of destructiveness,
love for destructiveness, 186 164
rage and guilt, 182185 love for destructiveness, 186
structural changes in unconscious, Devous, M., 246
187 Diagnostic and Statistical Manual of
childhood, healthy, 60 Mental Disorders, fifth edition
closed circuit training programme, 22 (DSM-5), 14, 62, 130, 131
Collins, A., 118 discharge pattern of unconscious
competency-based psychotherapy anxiety, 1011
education and research, 237 disrupted attachment, 82 see also:
abstract entities, 239 neurobiological pathways of
competence-based education and rage and guilt
assessment, 239240 Doll, A., 249
regulating and training bodies, 239 dorsal anterior cingulate cortex
state of the field, 237239 (dACC), 250251
Craighead, W., 254 dorsolateral prefrontal cortex (dlPFC),
249
Davanloo, H., 3, 5, 10, 14 Dunlop, B., 254
aetiological formulation of patient dynamic enquiry phases, 3031
by, 142
approach to grief by, 131 echo see technique of echo
goal of psychotherapeutic Edelman, G. M., 243
techniques of, 58 electroconvulsive therapy (ECT), 118
Davanloos discoveries, 17 emotional experience models, 252
fusion, 1719 enquiry and therapeutic task, 7981
i n d e x 271

Euler, L., 243 haemoglobin, 246


Eysenck, H., 242 head-on collision, 60 see also:
Ezriel, H., 216 transference neurosis
Hickey, C., 21, 29, 37, 68
Fleck, S., 129 Hirsch, L., 245
Ford, J., 250 holism vs. localism, 243
forgiveness, 205, 215 see also: Holtzheimer, P., 254
transference neurosis
metapsychology of, 216 imaging methods, 244 see also:
process of working through, 220, neuroimaging
222, 224 Ingvar, D., 244
projective identification and initial evaluative interview, 27
symptom formation, 219 case presentation, 2729
TCR mobilisation, 217220 dynamic enquiry, 3031
visual images, 220 mobilisation of unconscious, 3335
Frederickson, J., 181, 184 rise in TCR, 3133
Freud, S., 19, 60, 129 Intensive Short-Term Dynamic
functional brain imaging, 243244 Psychotherapy (IS-TDP), 34,
see also: neuroimaging 237, 241, 258259 see also:
history of brain function, 243244 neuroimaging
holism vs. localism, 243 adherence rating scale, 240
in psychodynamic psychotherapy, brain and emotion, 251252
246248 central dynamic sequence,
functional magnetic resonance 257258
imaging (FMRI), 246 see character structure in fMRI,
also: Intensive Short-Term 256257
Dynamic Psychotherapy; fMRI findings in psycho-diagnostic
neuroimaging categories, 254
fusion, 17, 5960 see also: transference modality of, 238
neurosis practising, 95, 184, 238
genetic figures, 18 research, 238
Fuxe, K., 249, 250 resistance in fMRI, 254, 256
therapeutic potential in, 258
Gottwik, G., 9, 10, 60 through triple network lens, 254,
grief, 130 see also: pathological 258259
mourning treatment fidelity, measure of, 240
Guidolin, D., 249, 250 triple network model, 252254
guilt see also: rage intergenerational transmission of
towards mother, 201202 neurosis, 2021
and MUSC, 156157 intergenerational transmission of
portrait of love for mother, psychopathology, 6263, 104,
185186 141, 199 see also: transference
and psychoanalytic investigation, neurosis
5354, 144146 Davanloos aetiological formulation
Guze, B., 241 of patient, 142
Guze, S., 141 expression of resistance, 146
272 index

guilt and psychoanalytic multidimensional unconscious


investigation, 144, 146 structural changes (MUSC),
rage, 142144 10, 21, 48, 67, 75, 78, 199 see
satellite operation, 151 also: neurobiological pathway
scar in unconscious, 144 of guilt; neurobiological
transference neurosis to, pathway of rage;
148151 neurobiological pathways
Triangle of Person, 143 of rage and guilt
interview see initial evaluative forgiveness, 205
interview guilt and, 190, 201, 202, 203, 211
inverse relationship, 204
Jinzaki, M., 246 and psychic integration, 7173,
Jones, D., 250 8486, 166168, 230, 234
in psychoanalytic investigation
Kaitaro, T., 243 of unconscious, 158159,
Kameyama, M., 246 193195, 197
Kelley, M., 254 rage, 6971, 190192, 200201
Kety, S., 244 and structural changes, 167
Kleckner, I., 252 therapeutic task and dynamic
Klein, N., 118 enquiry, 68
Kober, H., 252 unlocking of unconscious, 7375
Kumar, R., 246 UTA, 75
Murakami, K., 246
Legett, A., 15
Lindemann, E., 129130 neurobiological destruction of uterus,
Lindquist, K., 252 171
love see also: guilt perpetrator of unconscious, 179
for destructiveness, 186 psychoanalytic investigation
for mother portrait, 185186 of unconscious, 174175,
175177, 178180
Machulda, M., 250 rage pathway, 172174, 177178
Maciejewski, P., 130 unconscious defensive
Manoliu, A., 249 organisation, 173
Marks, J., 118 neurobiological pathway of guilt, 50,
Mayberg, H., 254 174, 187, 201, 225
Mazziotta, J., 241 guilt towards mother, 201202
McGrath, C., 254 neurobiological pathway of rage,
medial prefrontal cortex (mPFC), 250 6971, 8890, 98101, 131133,
memory, neurobiological pathway of, 142144, 154156, 177178,
2122 200201
Menninger, K., 75, 89, 143, 155, 216 activation of, 209211
Menon, V., 248, 249, 250, 253 and impulse to murder therapist,
MKUltra mind control programme, 118 172174
Montreal closed circuit training positive feelings and, 162163
programme, 1315, 56 in transference, 8183, 120121
i n d e x 273

neurobiological pathways of rage and chain reaction in unconscious, 137


guilt, 79, 109111, 163165, Davanloos approach to grief, 131
182185, 190192 grief, 130
disrupted attachment, 82 Prolonged Grief Disorder, 130131
guilt pathway, 8384 psychoanalytic investigation of
pernicious guilt, 83 unconscious, 133, 135, 136, 137
psychic integration and MUSC, rage pathway, 131133
8486 transference neurosis role, 138
rage in transference, 8183 Pearce, J., 243
tendency towards destructiveness, pernicious guilt, 83 see also:
85 neurobiological pathways
therapeutic task, 7981 of rage and guilt
neuroimaging, 241, 258259 positron emission tomography (PET),
see also: Intensive Short-Term 244245 see also: neuroimaging
Dynamic Psychotherapy posterior cingulate cortex (PCC), 250
blood flow, 244 posterior insula, 251
brain functioning, 248 posterior parietal cortex (PPC), 249
central dynamic sequence, 257258 Prajapati, A., xv
central executive network, 249 Prigerson, H., 130
default mode network, 249250 projective anxiety, 23
functional brain imaging, 243244, projective identification, 219 see also:
246248 forgiveness
functional magnetic resonance Prolonged Grief Disorder, 130131
imaging, 246 see also: pathological mourning
imaging methods currently used, 244 psychic integration and MUSC, 71, 84,
positron emission tomography, 230
244245 psychoanalysis, 8
salience network, 250251 psychoanalytic investigation into
single photon emission computed unconscious, 54, 135, 146, 175,
tomography, 245246 193, 197
neurons, 243 guilt and phase of, 144146
neurosis rage and guilt, 190192
intergenerational transmission of, psychoneurotic disorders, 7, 141
2021 psychopathology
lifting up, 168169 intergenerational transmission of,
transference, 1920, 193, 221 104
Nowoweiski, S., 247 triple network model of normal,
252254
Orbes, I., 9, 10, 60
Ostertag, I., 9 Queen Bee,
grandmother as, 2830, 41, 49,
Pagnoni, G., 249, 250 5455, 57, 58, 70, 75, 87, 91,
Parker, S., 15 105, 107
pathological mourning, 129, 138139 mother as, 40, 42
bereavement, 130 patient as, 76, 78
274 index

radiotracer, 245246 transference see also: resistance;


rage, 88, 98, 142, 154, 200 see also: guilt unconscious
and guilt, 109, 163, 182, 190 rage in, 8183, 120121
positive feelings and, 162163 twin factors of, 6
in transference, 120121 transference component of resistance
Reed, G., 20, 60 (TCR), 7, 1415, 50
resistance see also: unconscious early mobilisation of, 217218
expression of, 146 mobilisation of, 228230
transference component of, 7 and rage in transference, 218220
twin factors of, 6 rise in, 3133, 3943
right AI (rAI), 251 protective role, 6465
Ross, C., 118 transference neurosis, 19, 37, 60, 65, 87,
Roy, C., 243244 97, 114, 138, 193, 199, 207, 213,
rusting, 101 227, 234 see also: transference
component of resistance
sadism, 165 conflictual relationship, 5657
vs. love, 230 court of grandmothers
therapists, 193 unconscious, 5759
sadistic impulse, 193 destructive competitive form of,
salience network (SN), 250251 6163
see also: neuroimaging discussion on, 45, 56, 212
Santra, A., 246 fusion, 5960
satellite operation, 151 see also: goal of Davanloos
forgiveness psychotherapeutic
of transference neurosis, 221 techniques, 58
Satpute, A., 252 guilt, 5354, 9091, 211212
Schmidt, C., 244 head-on collision, 60
Schwartz, J., Jr., 241 healthy childhood, 60
self-referential tasks, 250 intergenerational transmission of
Selin, C., 241 psychopathology, 6263
Sherrington, C., 243244 love and forgiveness, 233234
short-term memory, 249 mobilisation of TCR, 228230
single photon emission computed mobilisation of unconscious, 4344,
tomography (SPECT), 245246 50, 5153
see also: neuroimaging Montreal closed circuit training
Sorg, C., 249 programme, 56
Sporder, U., 9 mother turning daughter against
Sporns, O., 242, 243, 248 father, 87
Strupp, H., 242 from professional practice,
Szuba, M., 241 208209
psychic integration and MUSC,
Tarzwell, R., 241, 247 230, 232
technique of echo, 101 psychoanalytic investigation into
therapists sadism, 193 unconscious, 54, 91, 93, 111,
Tononi, G., 243 113, 123, 125
i n d e x 275

rage activation via, 209211 defensive organisation, 57, 63, 173


rage and guilt, 109111 direct access to, 8
rage pathway, 8890 emotions towards parents,
rise in TCR, 3943 153154
sadism vs. love, 230 mobilisation of, 33
satellite operation of, 221 MUSC application in investigation
therapeutic task and phase of of, 158159
dynamic enquiry, 3839 pathogenic core of, 18
from training programme, 208 perpetrator of, 179
from treatment, 207 phase of pressure, 9
types of, 207209 psychoanalytic investigation into,
unconscious defensive 93, 98, 146, 175, 178
organisation, 57, 6364 psychoneurotic disorders, 7
vertical position, 40 scar in, 144
trauma, intergenerational, 197 structural change in, 106, 187, 199
treatment fidelity, measure of, 240 structural pathology, 78
treatment transference neurosis, 207 transference component of
Tressel-Savelli, F., 9 resistance, 7
Triangle of Conflict, 216 twin factors of transference and
Triangle of Impairment, 119120 resistance, 6
Triangle of Person, 75, 89, 143, 155, 216, unlocking of, 7375
219 see also: intergenerational unconscious anxiety, discharge pattern
transmission of of, 1011, 22, 30, 161, 217
psychopathology see also anxiety, projective
triple network model, 242, 252254 unconscious defensive organisation
see also: Intensive Short-Term and brainwashing, 117, 127
Dynamic Psychotherapy brainwashing in psychiatric
Turbide, D., 118 profession, 119
turning away syndrome, 21, 55, 153 psychoanalytic investigation of
guilt and MUSC, 156157 unconscious, 121
murderous rage pathway, 154156 rage pathway in transference,
psychoanalytic investigation of 120121
unconscious, 158159 Triangle of Impairment, 119
unconscious emotions towards unconscious therapeutic alliance
parents, 153154 (UTA), 68, 10, 19, 32, 49,
61, 75, 95, 100, 126, 146,
unconscious, 5 see also: 151, 224
multidimensional unconscious, trail of, 161, 168169
unconscious structural chain reaction, 169
changes; pathological idealisation of destructiveness, 164
mourning; turning away lifting up neurosis, 168169
syndrome MUSC and structural changes, 167
anxiety discharge pattern, 1011 MUSC in psychoanalytic
central dynamic sequence, 910 investigation in unconscious,
chain reaction in, 137 166168
276 index

positive feelings and rage Wager, T., 252


pathways, 162163 Wagner, G., 9
rage and guilt pathways, Weiss, M., 9
163165 Whitfield-Gabrieli, S., 250
sadism, 165 Wilson-Mendenhall, C., 252
working memory see short-term memory
Vanderwerker, L., 130
Vemuri, P., 250 Yalom, I., 14
ventral tegmental area (VTA), 251
Verhulst, J., xv Zaiden, J., 5