Intensive Short-Term Dynamic Psychotherapy

10/09/2025

Supervision as a Change Experience

Jon Frederickson
MSW

Date and Time:
November 28, 2025
9 am to 3.15 pm PST

Location: Online (Zoom)

Course Objectives:

How to discern what the student needs to learn
How to assess a problem that interferes with learning
How to assess what the student is integrating and not integrating
Cost: $300 (CAD)

We regret that we are unable to offer Continuing Education credits for this workshop.

Register
We enter supervision to learn how to become better therapists. Yet research shows that 93% of supervision is inadequate, and supervision on average accounts for only 1% of patient outcome. Why is supervision so often unhelpful? What needs to change in supervision? How can supervision facilitate the change that supervisees seek?

This presentation will review a new model of psychotherapy supervision that integrates the latest research on learning, education, and metacognition. And we will analyze a video of a supervision session illustrating this integrative model. By doing so, we will learn how to assess what the student needs to learn, the problems he has learning, and how to assess what the student is integrating and not integrating moment by moment.

We often mistakenly believe that we need to teach the student. But that is the easy part. The hard part is assessing what the student is understanding and not understanding. We have to assess what the student is integrating and not integrating to help the student integrate new information.

Further, when students take in new information, old knowledge must disintegrate to integrate that new information. While this positive disintegration allows integration, the disintegration of old knowledge triggers much anxiety and distress in the student. Only by paying attention to the student’s emotional experience of new learning can we help the student manage this inevitable process of disintegration of old knowledge and integration of new information.

Through studying a video of supervision, we will see how to help supervisees with emotional problems interfering with their therapy without turning supervision into therapy. We practice forms of therapy that are experiential, where we help patients face the feelings and conflicts they usually avoid. This requires the therapist to face her own feelings and conflicts that the act of doing therapy evokes. Thus, the supervisor, to be optimally helpful, must help the student with her path of emotional growth and integration. This video of a supervision session will illustrate one way to do that.

If you have questions about this workshop, please email Zach at zach.aletheaservices@gmail.com

A smiling man with a beard is seated, wearing a maroon shirt and a patterned tie, in front of a bookshelf filled with books.
Jon Frederickson, MSW, is on the faculty of the Intensive Short Term Dynamic Psychotherapy (ISTDP) Training Program at the Washington School of Psychiatry. Jon has provided ISTDP training in Sweden, Norway, Denmark, Poland, Italy, Switzerland, India, Iran, Australia, Canada, the U.S., and the Netherlands.

His most recent book (2024) is Clinical Thinking in Psychotherapy: What It Is, How It Works, and Why and How to Teach It.

He is also the author of over fifty published papers or book chapters and four books, Co-Creating Change: Effective Dynamic Therapy Techniques, Psychodynamic Psychotherapy: Learning to Listen from Multiple Perspectives, The Lies We Tell Ourselves, and Co-Creating Safety: healing the fragile patient, Healing Through Relating, and Clinical Thinking in Psychotherapy: how to do it, why to do it, and how to teach it. His book, Co-Creating Change, won the first prize in psychiatry in 2014 at the British Medical Association Book Awards, and it has been published in Farsi, Polish, Hebrew, and Slovak, and is currently being translated into Spanish. His book The Lies We Tell Ourselves has been published in Polish, Farsi, Norwegian, German, and Danish and is currently being translated into Chinese, Arabic, and Bulgarian.

He has DVDs of actual sessions with patients who previously failed in therapy at his websites www.istdpinstitute.com and www.deliberatepracticeinpsychotherapy.com There you will also find skill-building exercises designed for therapists. He writes posts on ISTDP at www.facebook.com/DynamicPsychotherapy.

Contact
806 525 Seymour Street
Vancouver, BC V6A 1Y6
(604) 366-3112

Home On this website, we offer a series of skill-building exercise programs designed to help therapists of all orientations. As a therapist, how often are you setting time aside to develop your skills, analyze your video transcripts, watch your videotaped sessions, or going to supervision? Did you k...

10/04/2025

Are there situations so catastrophic that feelings become overwhelming or unbearable? Thanks to one of our community members for sharing this important question.

While reading Co-Creating Safety, I remembered you once said that it's never the feelings that are the problem or overwhelming, but depending on the specific case, anxiety and defenses create problems. Are there scenarios that are so catastrophic that feelings are actually overwhelming/unbearable? For example: An Iraqi man who lost his wife and 4 children to a bombing and related examples.

Of course! How does anyone bear that amount of grief? No one can bear it alone. The best we can do is try to bear it with him.
Sometimes, simply bearing witness is all the patient needs. And the last thing he needs is someone trying to "fix" what can never be fixed.

And how does someone bear that amount of rage? No one can bear it alone. The best we can do is accept it as a completely normal response to an abnormal event.

And his rage is not pathological. It's a normal response. Often, just accepting his responses as normal responses is powerful in itself.

His enormous grief and rage are not signs of pathology, but of health. And they will take time. He cannot push that natural shift that will occur over time, and neither can you. And somehow, if he realizes that you know this is normal and cannot be rushed, that, in itself, will be a powerful form of healing through validation.

He doesn't need answers because there are no answers to what he has endured.
He needs someone who knows there are no answers and doesn't try to provide them. So the questions become for us therapists: can we sit with the unbearable? Can we sit without having answers? Can we sit without offering pseudo-answers as a defense against sitting with our patient, both of us enduring the unbearable, so he is no longer alone?

One of my regrets looking back over my career is that I often thought a patient needed an answer from me when patients just needed my company, my ability to feel with them, to bear what they were feeling without having to explain it away.

The word compassion derives from the Latin, "to suffer with." Sitting with a man who lost his wife and four children is nearly impossible to bear, just as it is for him. But if we can sit with him, he is no longer alone. And if we can face the truth—there are no answers that make this go away—he can face the truth more easily because he is not alone.

Jon Frederickson, MSW
Author, Co-Creating Change: effective dynamic therapy techniques
The Lies We Tell Ourselves: how to face the truth, accept yourself, and create a better life, Co-Creating Safety: Healing the Fragile Patient
Psychotherapy videos and skill building exercises at:

Through education and training, The Intensive Short-Term Dynamic Psychotherapy Institute prepares therapists to practice ISTDP in a clinical setting.

08/30/2025

📚 Supervision Groups 2025–2026

Thursday Group – Starting September 18
For therapists, before or during Core Training
Fee: $800 for 15 meetings.
Fee for Low-income countries: $250 flat rate

Friday Group – Starting September 19
For therapists who have completed Core Training
We have been running this course for over three years, and each year we adapt and refine it to benefit you.
Fee: $1100 for 15 meeings.
Fee for Low-income countries: $250 flat rate

This year’s focus:
During the first 20 minutes with me (Yuval), we will make sure therapy is guided by the patient’s wishes, not our own. This plays a key role in the well-being of the therapist, the patient's progress, and avoiding burnout.
Course structure (each session – 1 hour 50 minutes):

0:00–0:20 – Patient wishes to heal (with Yuval)

0:20–1:20 – Supervision (with Jon)

1:20–1:50 – Group discussion & Q&A

Additional benefits:

Teachers have direct access to interact with Jon during the sessions.

All sessions are recorded and distributed to the group.

Key learnings are summarized (with the support of AI tools) and sent to participants

Payment: via PayPal → jf1844@gmail.com
Please send a copy of your payment confirmation to a.yuval7@gmail.com

🎓 Core Training 2026–2029
With Jon Frederickson and Yuval Alon
Starting in January 2026

12 blocks over 3 years (4 per year)

Each block: 3 full training days

Includes case presentations, skill development, and experiential learning.

Practice groups with Yuval (low fee) available alongside training

Fee: $1,000 per block

This program is designed for therapists who wish to advance their ISTDP knowledge to the next level.

🟦 Pre-Core Training (led by Yuval)
For individuals who want to develop basic alliance-building skills before beginning Core Training.

Dates: October 11, November 1, November 8 (3 full days)

Fee: $800

🟢 Practice Groups – Patient’s Wish to Heal (led by Yuval)
Focus: ensuring the therapy aligns with the patient’s desire to heal.

Method: experiential role-plays from your clinical work → therapists practice while gaining insight from the patient’s perspective.

Frequency: twice weekly

Monday – 11 am EST / 5 p.m. CET

Tuesday – 1 p.m. EST / 7 p.m. CET

Duration: 1 hour each

Fee: $200/month

This is a great opportunity to learn, practice, and grow in a safe environment that supports both therapists and patients.

We warmly welcome you to join us,
Yuval Alon & Jon Frederickson

Send a message to learn more

08/26/2025

See details on a conference I will give this fall in Poland with Beata Zaloga! https://www.facebook.com/share/p/14KW8C2jL6y/

07/19/2025

Supervision Course – Year 4 (2025–2026)
Co-Creating Effective and Safe Therapy

We’re excited to welcome you to the fourth year of the Supervision Course!

This year, we continue our commitment to helping you develop your therapeutic skills — with a deep focus on connecting to the patient’s wish to heal, and supporting therapists to feel more secure and effective in their work.

💡 Our Focus
In both groups, we will:

Deepen your ability to connect with the patient’s unconscious wish to heal

Strengthen the therapist’s capacity to help from a grounded and clear stance

Work in the real relationship, paying close attention to the conditions needed for collaborative, safe therapy

👥 Who is it for?
Therapists of all levels

Teachers who want to develop their supervision and teaching skills (can join either group)

📅 Group Options & Initial Dates
Each course includes 15 sessions.
🗓 Additional dates will be posted later in the year.
🟦 Pre-Core Group (Thursdays)
Time:
🕘 9:00–10:50 a.m. EST
🕒 3:00–4:50 p.m. CET
🕓 4:00–5:50 p.m. Israel time
🕟 4:30–6:20 p.m. Iran time
Initial Dates:

September 18, 25

October 2

November 20

December 4, 11 (no session on Dec 12 – conference)

December 18

🟨 Advanced Group (Fridays)
Time:
🕘 9:00–10:50 a.m. EST
🕒 3:00–4:50 p.m. CET
🕓 4:00–5:50 p.m. Israel time
🕟 4:30–6:20 p.m. Iran time
Initial Dates:

September 19, 26

October 3

November 21

December 5, 19

🧠 Session Format
0:00–0:20 — Learning with Yuval
Focus: Exploring the patient’s wish to heal and the therapist’s wish to help
0:20–1:20 — Supervision with Jon (based on participants’ cases)

1:20–1:50 — Group practice and discussion based on the case

✅ All sessions are recorded and shared with a written summary and key learning points.

💳 Fees
Group Early Bird (until July 30) Regular
Thursday (Pre-Core) $720 $800
Friday (Advanced) $980 $1100
🌍 India, Iran, and low-income countries $250 flat rate

✅ How to Register
Send payment via PayPal to: istdpisrael@gmail.com

Please add 5% to the total to cover PayPal processing fees.

For questions or to request a sliding scale: a.yuval7@gmail.com

🤝 Join us on this shared journey of growth, clarity, and connection.
--
בקרו באתר שלנו - visit our website

Send a message to learn more

06/12/2025

If rage is usually the result of splitting without complex feelings, why are we encouraging murderous rage portrayals in ISTDP?

Here are my potential answers: 1.We must ALWAYS portray ONLY if the patient indicates through signaling that there is complexity present.
2. We are talking about imaginal rage in ISTDP, as opposed to the rage being spoken of on this admirable listserve.
Help me out here if you get a moment. Thanks to one of our community members for these questions!

We explore murderous rage in portrayals ONLY if it is rage toward someone the patient LOVES.

Rage + Love = mixed feelings.

Anxiety rising in the body = "Careful, this is rage toward someone you love. Quick, use a defense to protect that person from your rage."

When a patient engages in splitting, they feel ONLY rage toward the other, having split off and denied their love. They do NOT feel mixed feelings. They split off, deny, and/or project the other feeling.

If you explore only their rage, no anxiety will rise because there is no love to trigger the anxiety.
There will be no defenses to ward off the rage either because there is no love to lead them to protect the other.
Think of people who get into physical fights or criminals: they split, view the other as all bad, and act out their rage without
any anxiety rising and without any defenses to protect the other from their violent urges. Through splitting, they view the other as all-bad and believe that person deserves the absolute worst treatment in life, even death.

That's why we do not ask for portrayals of rage with patients who split. We would be encouraging splitting and acting out.
Instead, we address the structural problem: the inability to tolerate mixed feelings toward another person.

Here, we use pressure to consciousness of splitting.
Th: You say she is a bitch, yet she is also the same person who took you to the hospital when you overdosed, and saved your life. That must be confusing to feel such rage toward someone who has been so loving."

Pressure to consciousness of splitting reminds the patient of mixed feelings so he can tolerate them and the anxiety they trigger without splitting them apart. This is a common kind of pressure we use with fragile patients to build their affect tolerance. And here, the term affect tolerance means the ability
to tolerate one's angry and loving feelings at the same time without splitting them apart.

Send a message to learn more

06/05/2025

How Can I Deal with a Narcissistic Bully in the Workplace?
How can I deal with a narcissistic bully in the workplace who has massive issues with envy and hatred of female authorities? Why do organizations find it so difficult to deal head-on with bullies? And how can victims learn to manage constant objections, nit-picking, passive aggression, 'turning the tables', and gaslighting?

For instance, when we address his problematic behaviors, he becomes visibly angry-almost menacing - i.e., stoney faced; silent; staring. He then replies, "I don't accept that,” and argues. We then feel as if we are being interrogated, as if we are wrong and unfair to give this feedback. And we fear he will retaliate since he claims we are bullying and harassing him.
I am not singling him out. He IS the only team member who challenges all the colleagues with his adversarial, defensive, and argumentative behavior. He is also extremely elitist and wants anyone more "junior" in the team to address him as "Doctor." No other therapists insist on this. Further, he tries to get them to do all of his administrative work.

When I give him feedback, he interrogates me and claims, "You are getting mixed up and confused".

He also tells lies about me to other colleagues, denigrating me and pointing out my mistakes behind my back. He is well known in the organization as someone who denigrates others, elevates himself, and claims that only he knows how to run things.

In supervision, he brings no relevant material. Instead, he only talks about the good work he is doing and the positive feedback he gets from patients. When I point out a blind spot, he becomes defensive, argumentative, angry, and disengages.

When we ask him to do something, he never ever just does it. Instead, he picks holes, objects, and enters into lengthy emails until we give up and do it ourselves.

Thanks to one of our community members for this important question!

The narcissistic bully seeks admiration more than anything because he lacks all self-worth. Any mistake plunges him into self-hatred, so he immediately turns the tables to make you feel the worthlessness that would otherwise drown him. That is why he cannot accept feedback.

Thus, his next step: “I did nothing wrong. YOU did something wrong to me and are being unfair to me by offering critical feedback.”
Since your criticism “attacked” his grandiosity, he will reverse the roles. “Now I will attack you, criticize you, and nitpick you continually so that you are the one feeling worthless and bad. When you gave me this feedback, YOU bullied me and harassed me. So I should report YOU as the victimizer.”

“Since I need constant admiration to ward off my sense of worthlessness, you must call me Doctor. If you ask me to do any task, you are attacking my grandiosity. YOU should take the one-down position and do this lowly work. I, the great one, should never have to do such lowly tasks. So I will argue with you until I get you to submit and do my work for me. Then, when you do my work, you will have rewarded me for bullying you into submission.”

“When you offer feedback, I will tell you that you are confused and mixed up. That’s how I try to convince you that you are crazy if you have any critical idea about me or my performance. I ask you to hold my craziness so that I can judge it in you.”

To be clear, these bullies do not stop themselves. They try to attack your self-esteem because they have none. They will always claim to be the victim when they victimize you.

Understanding the Problem
Common Behaviors of Workplace Narcissistic Bullies
• Defensive reactions to feedback: Becomes visibly angry, stony-faced, silent, or staring when confronted
• Role reversal tactics: Claims "I don't accept that" and turns criticism back on the feedback provider
• Gaslighting: States things like "You are getting mixed up and confused" to undermine confidence
• Reputation damage: Spreads lies and denigrates colleagues behind their backs
• Grandiosity demands: Insists on titles like "Doctor" and refuses to do administrative work
• Supervision avoidance: Only discusses positive feedback, becomes defensive about blind spots
• Task resistance: Never complies directly; instead, picks holes and objects until others give up

Why These Behaviors Persist
Narcissistic bullies lack genuine self-worth and desperately need constant admiration. Any criticism triggers intense self-hatred, which they immediately deflect by:
• Reversing victim/perpetrator roles
• Attacking the critic's competence and worth
• Creating confusion about who is being inappropriate
• Demanding special treatment to maintain their grandiose self-image

Why Organizations Struggle to Address This
• Fear factor: Management is often as intimidated as other employees
• Lack of boundary-setting skills: Leaders may not know effective limit-setting techniques
• Legal intimidation: Bullies often threaten lawsuits when confronted
• Documentation gaps: Without clear evidence patterns, action is difficult

Effective Response Strategies
Core Principle: Disengage, Don't Engage
The goal is not to change the bully (which is impossible), but to protect yourself from manipulation and gaslighting. In essence, these strategies are designed to help protect you from an emotional predator.
Specific Response Scripts
When they reject feedback:
• Bully says, "I don't accept that."
• Your response: "That's okay. You don't have to accept my feedback. I will make a note that you did not accept my feedback."
• Then, walk away immediately. Document the interaction.

When they try to delegate their work:
• Bully says, "I don't want to do this. Will you do it for me?"
• Your response: "No thanks."
• Then: Walk away. Do not argue or explain.

When they gaslight you:
• Bully says, "I think you are getting mixed up and confused."
• Your response: "No. I'm quite clear."
• Then, walk away and disengage.

When they claim not to understand:
• Bully says, "I don't understand."
• Your response: "That's okay. I don't need you to understand for me to understand."
• Then: End the discussion. Walk away and disengage.

When they send continuous emails:
• Your response: Say "No" in the first email only
• Then: Ignore all subsequent emails. Your "no" is not up for negotiation. You do not need to read the “analyses” a narcissist offers about why you refuse to be a satellite orbiting his grandiosity. Save the emails for future evidence. But do not read them. If you read them, he will be able to manipulate you through them. Deprive him of this pleasure.

Universal Guidelines
• Walk away immediately after delivering your response.
• Never explain, argue, or convince - this only fuels his need for conflict.
• Remain emotionally neutral - they feed off emotional reactions. If they see your pain, they will continue to harass you to get pleasure from your pain. Hide it to deprive them of that pleasure.
• Minimize all contact when possible. When next to him, walk away. When he invites you to argue, do not pick up the bait. When he devalues others, leave the room.
• Remember: "Never get into a fight with a pig. You just get dirty and make the pig happy."

Common Myth
A common myth is that if you punch a bully in the nose, he will back down. That is true in situations where you are in a position of power, which he will have to respect. But in this work situation, there is no power in the organization that he respects. If you verbally punch him in the nose, he just punches back. If you argue, he argues. Thus, however tempting it may be to let him have it verbally, he will just fight back more. If you humiliate him, he will lash out with more narcissistic rage.

Build Your Defense
Create a comprehensive evidence file by:
• Writing precise notes immediately after each incident
• Emailing notes to yourself to establish timestamps
• Recording patterns of behavior across multiple incidents
• Including witness information when available
• Tracking all communications (emails, messages, etc.)
This documentation serves two purposes:
1. Protection: If the bully tries to target you with HR.
2. Action: Provides evidence for potential harassment claims you might file.

Working with Management
When management finally acts, they can use your documented evidence to respond effectively:
Example Management Response:
• Bully: "Here you go attacking me, just like the others! I could sue you for harassment."
• Management: "Rather than taking advice from your supervisor and management, you threaten us with a lawsuit. As a result of your threat, we now face a legal situation. Therefore, this conversation is over. I will inform HR to take the necessary steps."

Key Reminders
• These bullies do not stop themselves - external boundaries are essential.
• Bullies ask you to have no boundaries to their abuse.
• You must set boundaries to survive in the presence of a bully.
• They will always claim to be the victim when they victimize others.
• Your goal is self-preservation, not his rehabilitation.
• Consistent documentation is your strongest protection.
• You are not alone - this behavior often affects multiple colleagues. Encourage all of them to secretly document his behaviors to protect each other as a group.

When All Else Fails
Disengagement strategies may not stop the harassment. The bully may continue because he can't do anything else. Remember that the purpose of your plan is not to change a bully, but to protect yourself against his emotional manipulation. To get rid of him, you and your colleagues need to document his harassment. Then, your documented timeline becomes the foundation for:
• HR intervention with clear evidence of patterns
• Potential legal action for workplace harassment
• Protection for yourself and colleagues who may also be targeted
The comprehensive evidence you've gathered will be difficult for any organization to ignore and provides the foundation for serious consequences if the behavior continues.

Send a message to learn more

06/04/2025

What does the interpersonal perspective reveal to us about our work?

Read what Oliver Sacks writes and think about the implications. If the therapy is stuck, we are helping to keep it stuck. We just know how we are doing it. There are two people in therapy, both influencing what is happening.

05/25/2025

"How is the causal relationship and its direction established when it comes to theorizing about chronic pain or illness? (I believe Dr. Allan Abbass says something similar to what you wrote in your post about Ulcerative Colitis and, more generally, those conditions that are currently categorized as "functional somatic disorders".)

Does this theory only apply to functional somatic disorders? What about something like Lupus - how does ISTDP understand/explain it? Has that changed as our understanding of these conditions has changed?

How could one know if the psychological issues predate the onset of the condition?

As one moves through the medical system with a condition that is not well understood, one often experiences dismissal, neglect, even abuse. Is it possible that these experiences lead to the anger that gets buried - that therapy then uncovers?

Does everyone with chronic pain/other functional somatic disorders have the same/similar attachment histories?
What a set of wonderful questions from a community member! Okay. Here goes.

1. "How is the causal relationship and its direction established when it comes to theorizing about chronic pain or illness? Sometimes the patient tells you that there condition started after an emotionally triggering event or trauma. Many times, patients see no link to the past.

So, the way we assess whether there is a causal relationship between emotions and pain is by inviting feelings in the session and observing the patient's responses. If pain repeatedly rises in response to a rise of feelings, we are dealing with a psychogenic condition that will respond to therapy. If pain does not fluctuate in response to fluctuations in the rise of feelings, the pain is not psychogenic, and the patient requires more thorough medical assessments to determine the cause.

2. Does this theory only apply to functional somatic disorders? What about something like Lupus - how does ISTDP understand/explain it? Has that changed as our understanding of these conditions has changed?

Lupus is an autoimmune disorder. While emotional triggers can exacerbate the disorder, they are not the sole cause. That is why psychotherapy that helps patients face feelings they usually avoid, regulates anxiety, and helps patients develop more affect and anxiety tolerance, can reduce the severity and frequency of episodes.

Why? High anxiety is discharged in the parasympathetic branch of the autonomic nervous system, which becomes over-activated. Instead of regulating the body and immune response, over-activation of the parasympathetic nervous system suppresses immune response making patients more vulnerable to autoimmune disorders.

Previously, autoimmune disorders were understood primarily at the biological level. More recent research has found that psychotherapy helps with anxiety regulation, reducing over-activation of the parasympathetic nervous system, so that it regains more of its regulatory capacity. As a result, we see a reduction of the frequency and severity of relapses in multiple sclerosis. This has been shown in a number of research studies. Interestingly, multiple sclerosis is often triggered by a major emotional event. I don't believe that is the case for Lupus. However, this shows that autoimmune conditions may have purely genetic causes but are influenced by psychological factors, which we can address in therapy to improve the patient's mental and physical health.

3. How could one know if the psychological issues predate the onset of the condition? The clinician can find this out through a detailed inquiry. However, keep in mind that autoimmune disorders are not usually caused by psychological factors, though they can be influenced by them. For instance, no one claims that ISTDP can "cure" Lupus or multiple sclerosis. However, ISTDP has helped a number of patients recover from IBS, irritable bowel syndrome, a condition highly influenced by anxiety going into the smooth muscles.

4. As one moves through the medical system with a condition that is not well understood, one often experiences dismissal, neglect, even abuse. Is it possible that these experiences lead to the anger that gets buried that therapy then uncovers? Sadly, some medical patients have had experiences that led to anger toward physicians. When therapy helps patients face their anger toward specific physicians, that often reduces their anxiety and ends their tendency to turn anger upon themselves. Those two changes alone will lead to a reduction in physical symptoms. It's an area of medical trauma.

5. Does everyone with chronic pain/other functional somatic disorders have the same/similar attachment histories? No. For instance, someone can have chronic pain due to scoliosis. That pain is caused medically. If we narrow our question to patients who have chronic pain that has a psychological cause, most likely the patient's anxiety is going into the smooth muscles or cognitive perceptual disruption. Most likely, the patient is using the resistance systems of repression (turning on the self) or splitting and projection. Thus, they will have physical symptoms resulting from anxiety. And they will have physical symptoms resulting from identification with the body of the person they unconsciously want to attack.

A variety of attachment histories can generate these symptoms. Physical abuse, psychological abuse, sexual abuse, neglect, abandonment, traumas of living in a war zone, traumatic accidents, and on and on. Usually, these patients have a great deal of difficulty dealing with rage toward someone they loved, and that rage goes back onto their body. That defense happens unconsciously, outside their awareness. So we start by helping them notice how pain arises just after they mention feelings toward others. Tolstoy said something to the effect that all happy families look the same, but troubled families look very different. There are many paths to suffering. So we must pay close attention to the details

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