Ange Cooper: “I am my patient, they are me”

In this article we get to meet Ange Cooper. She discusses the many stages of learning ISTDP, detailing her own ISTDP journey through idealization, omnipotence, denial, depression, personal therapy, complexity, psychedelics and spirituality. Ange is an ISTDP teacher and supervisor based in Halifax, Canada. You can find her website here.

Shifting the focus to the person of the therapist

On the back of some recent conversations in the community regarding the teaching of ISTDP, you wanted to talk about your experiences as a learner. How so?
It’s time to talk about my ISTDP learning journey come what may. I have gone through many stages in my learning process and I hope by talking about these openly, it can serve as an enriching personal account that facilitates many other discussions regarding the ISTDP learning process.

Ange Cooper

So how did you learn ISTDP?
I completed my core training with Patricia in 2014, having first been introduced to ISTDP through an 8-month placement with Joel Town.  I developed a research interest in ISTDP and spent a number of days at Modum Bad Hospital in Norway being taught how to use the ATOS as a process research tool by the awesome Lene Berggraf and Pål Ulvenes.

Early in my learning I decided to do a block of therapy with Josette ten Have-de Labije as well as receiving regular supervision from Mark Stein whilst working in the NHS.  Following this, I moved to Canada to work with Allan and had weekly supervision for the best part of the last 5 years. I attended a Davanloo immersion in Montreal, then completed training with Tony Rousmaniere on deliberate practice with Tom Brod, Susan Warshow and Robin Kay.  I then went on to complete Jon Frederickson’s Training of Trainers course and continue to attend his advanced training which is now in it’s 4th year, I believe.  Amongst all of this I have had the benefit of thinking, learning, discussing and being inspired by many other folks in ISTDP, EDT, CBT, psychoanalysis, Jungian analysis and so on.

Besides learning, I have been teaching and training in ISTDP for a number of years now, having facilitated one core training to completion with another mid way through. I will start an advanced training group in November with Allan Abbass. 

All of this is to say, I have had a lot of training in ISTDP and have been committed – like a marriage – to this model for over ten years now. However, what I want to convey here, which I think is more important than my ‘ISTDP qualifications’ is the personal work I have done over this last 10 years.

But is this really a dichotomy – training in ISTDP and personal work?
Not really. I want to talk about the stages I have been through and how this has influenced and fundamentally changed how I practice ISTDP. I think this touches upon some of the points Mikkel raised in his interview but in a more personal and experiential way. 

It is my sense that this aspect of our learning isn’t spoken about enough, of course because it is personal and that can be scary and certainly vulnerable. So, I feel it is in some ways part of my growth to begin such conversations so that others may feel brave enough to do so and so that we can begin to consider how our personal and collective wounds impact our work in ISTDP. 

As Allan Abbass recently pointed out on the IEDTA-listserve, when assessing a patient video you have to consider at least eight central factors: degree and type of resistance, degree of rise in complex transference feelings, phase of treatment, degree of syntonicity, state of the conscious therapeutic alliance, presence of barriers to engagement, medication and somatic illnesses and the current front of the emotional system.

If you add to this the same number of therapist factors, well then you have a pretty huge number of interrelated factors all occurring at any one moment. Maybe someone who reads this can do the math as to how many combinations we can find?

So there’s a lot of work to be done when it comes to the therapist side of things.
It is my deep belief that what we struggle with in ISTDP or any complex endeavour for that matter, is very much tied to our own unconscious emotional processes. This is why ISTDP looks so different between different therapists and within the same therapists across time. I do believe Davanloo developed a deeply healing model of therapy, however it is my guess that even he was troubled by how complex the model was to teach and transmit.

I also think he set up his mobilisation groups in order to address some of the difficulties that therapists have to overcome to do this work well. Including issues such as the therapists own punitive superego, sadism, masochism and tendencies to get stuck in a transference neurosis. Whilst certainly controversial ethically and massively problematic in terms of power dynamics, I can see why he may have felt a desire to help therapists overcome their own emotional difficulties in order to implement ISTDP in the way he would have hoped for.  

from omnipotence to depression and beyond

Coming back to you… You said you wanted to talk about your own journey?
Here we go… In the beginning I was immersed in learning about psychodynamic conflict, the theory of ISTDP, Davanloo’s publications and the actual skill/technique of the model. Just like when you’re learning any new skill there is the excitement and inevitable frustrations that show up with each new patient. 

As I grew as a practitioner, I met my skill development with an overidentification with the model, a oneness with it and it meant everything to me. It became part of my identity and my personality at some level – I think I fell in love with the model!

The desire for oneness with the model was so strong that with it came an idealisation of its power and ‘rightness’ above all other models and devaluation of other forms of therapy. I experienced very little anxiety during this stage and as such I had some very good outcomes – because I believed in it 100% – but also some very bad ones. 

We could say I went through an oceanic stage and into the paranoid-schizoid stage that Melanie Klein speaks about – I was unable to tolerate complexity. I engaged in splitting and denial, and I was filled with my own omnipotence.

Thankfully, but painful at the time, this stage didn’t last, the more patients I saw and the more experience I gained, I started to recognize that I was struggling with a whole myriad of patients. This is when I started to move into a more depressive phase.

What was that like for you?
I started to become overly critical of my skills and capacity, I even started to resent learning ISTDP and wanted to have a life beyond it. And this was the stage where I started to look towards others models, teachers and readings that began to broaden my horizons away from the “Fathership” of ISTDP.

During this phase, my practice began to look different. I was playing with different ways of working and trying them with patients, I started to believe that there had to be more than ISTDP to heal others and myself and so we could call this phase the depressive phase but also the beginning of an experimental phase as I grew. 

I could no longer do “pure” ISTDP, I was very much in “ISTDP eclectic”, or “ISTDP-I’ll do it my way!” Again, for some patients this seemed to be helpful and for others I continued to be stuck, frustrated and despondent. All the while, I continued to study and continued to seek supervision but I started to become depressed and began to wonder, what does all of this mean? I started to lose my sense of meaning and purpose for ISTDP (and of course tied to my life in general) and even patient work. I became a little more depressed.

At my lowest points, I started to realize that I was struggling just as much as the person in front of me, so how on earth could I help them? I recognized that I had begun to treat my patients as if they were different to me, at times ‘lower’ or ‘higher’ than me and that they just weren’t co-operating with me or this therapeutic model as I saw it at the time.  I started to disconnect from patients and simultaneously disconnect from myself – and my therapeutic work started to look more like a series of technical interventions that seemed to lack compassion or heart – what had happened? I started to have some very deep conflicts within myself the more this stage progressed.  Let’s call this stage disconnection or separation consciousness.

Due to my experience of depression and fatigue during this journey, I decided to commit to my own longer term therapeutic endeavours.  At the time I didn’t really feel I was of much value or help to my patients. I had lost my mojo for therapy – I felt lost. I actually wanted to quit being a therapist, it was too painful, too difficult, too stressful and it seemed to have lost its joy, meaning and purpose.

Getting to know your blind spots

We’re very grateful to still have you around, despite what you’re telling us. What helped you find your footing again?
Over the last 5 years, I have steadily been engaged in my own work, this happened to be mainly Jungian analysis. There was just something about Jung’s way of working that intrigued me.  I wanted to find deeper connections within myself, I wanted to understand my dreams, I wanted to understand the collective unconscious and mostly I wanted to feel that life was meaningful again. To me, life had lost its wonder and I didn’t know how to get it back.  So I started therapy, I also did ISTDP block therapy every time I hit upon some big emotional wave that I felt needed to be processed with an unlocking. This was a really useful combination for me.

In addition, and with deep gratitude to Jon Frederickson, I started to bring my most difficult cases to supervision and through experiential role plays he helped me begin to understand from an experiential level – not an intellectual level – what some of my own emotional blind spots were. Blind spots that kept getting in the way of my ISTDP practice. 

Can you be more specific? What where you learning at that point?
I discovered that I had major difficulties in recognizing when I was stuck in a transference enactment especially with highly resistant patients. An inability to see that it was I who held the motivation and unconscious therapeutic alliance for the patient, along with a completely unconscious tendency to resist the patient’s resistance. In sum, this was leading me to co-create the problems that occurred in the therapy room. I was a central part of the problem.

More recently I also gained a very deep understanding that I have been identifying with my patients’ projection of guilt – which has meant that my breakthroughs to guilt, my ability to hold complexity during phases of mobilisation and my ability to do head-on collision were seriously compromised. Because of my own internal, emotional dynamics/capacities I had been unable to offer patients some of the most fundamental aspects of ISTDP model, try as I might. I wasn’t even able to see what was wrong because everything was operating at such an unconscious level – sigh.

Can you be even more specific, what did this look like in sessions?
Mostly it looked like not getting to deep breakthroughs of complex feelings, I emphasized rage above complexity. I was anxious to get to an outcome and I only partially identified the resistance. This meant that it could continue to operate. And there was minimal work with the operations of the pathological superego, since I couldn’t see it. And my head-on collisions did not land and did not create the deeper impact I had hoped for.

The outcome of such issues was that often patients only ever had partial breakthroughs, the UTA was never fully mobilized and this then compromised the deep insights and character change that the unconscious therapeutic alliance potentially brings through to the later, working through stages of the treatment. 

This is not to say that I haven’t had cases with good outcome at the same time, but it is my observation of regular patterns that were occurring within my work at this stage.

Getting unstuck: the path of spirituality and psychedelics

What was it like to see that?
Oh my goodness, I am just as stuck as the patient!

We are suffering the same difficulties and likely of a similar emotional origin and until I begin to see the patient as me – and me as them at an emotional level – I cannot move this thing. I cannot do this therapy. I cannot mobilize the unconscious enough. I cannot see in them what I cannot see in myself. 

This was my most painful stage – but also, I suppose – my most liberating.  I could no longer see the patient as different to me, I could no longer hold this human being either above or below me – I had to begin seeing them as, well at one level different, but ultimately one and the same. This started me into a new developmental stage that felt something like unity consciousness-oneness-humanness – not sure what to call it. But it would be summarized as “I am my patient, they are me”.

Stanislav Grof

How hard it can be to stay open to that shared vulnerability. What impact did this realization have on you?
At this stage of both my growing up and – we could say – waking up, I started to become deeply interested and connected to spiritual writings, integral models of therapy, transpersonal ways of thinking (Stanislov Grof, Ken Wilber) and embodiment practices – and all of this finally led me to psychedelics. I have been hesitant to talk openly about this aspect of my development, but it seems like it is the time and so I will give some brief details.

As I started to become interested in the transpersonal readings above, I hit a stage of my development that spiritual circles call the dark night of the soul. Nothing interested me, I stopped wanting to hang out with people, I wanted to become very introverted, I was in existential angst.

At one point I even wanted to start meditating. Those who know me, know that this isn’t really like me. It was so not like me – but then I started to question who am I anyway – and so meditations began. Through meditation, reading, and becoming more and more aware of some deeply rooted conflicts inside of me, I made the decision to undertake some ceremonial psychedelic sessions with an experienced medicine woman.

There’s a lot of buzz around psychedelic-assisted therapy these days, with both MDMA– and psilocybin-assisted therapy closing in on medical approval within a few years. What were the ceremonies like for you?
I won’t go into these experiences in too much depth, but they have been transformative for both my own personal healing and consequently my practice of ISTDP. In short, through some intense and at times painful experiences, I feel like my heart has been cracked open and I have been able to heal some of my deepest wounds in ways that would not have been possible through a talking therapy.

It is really beyond words to describe the experience, but it has changed my life in profound ways – It has brought me to a place in which I feel deeply connected to a spiritual process and so slowly over the last few years my sense of meaning and purpose has started to re-emerge and with it my excitement and interest in ISTDP as well as my work with patients.

It has made me want to come all the way back to ISTDP (like the hero’s journey). Except that for me, I now place ISTDP into a much bigger, broader spiritual framework that goes beyond symptom and character change.

Do you think psychedelics has an important role to play then in the teaching of ISTDP?
It is too big of a topic to go into here regarding ISTDP and psychedelics, but I am interested in the power of ISTDP and psychedelics used together in some combination– and I am also very interested in the journey of the therapist especially as it relates to the ideas of ‘waking up’ versus ‘growing up’ and how we might consider both of these aspects within our development as therapists.  People can wake up but not have grown up and there can be devastating results from this, people can also be very grown up but never really find a spiritual path – my interest is in how both of these forces come together and how we can yield these forces to massively advance our field.

I have been considering the similarities between ISTDP and psychedelics for some time. From my perspective and experience, the process of breakthrough – into guilt-love-oneness-compassion along with an unlocking of memories from the past – is very similar to the experience during a psychedelic session. But no talking and less time. 

There is something very powerful that happens in both modalities when we melt our punitive superegos, when we surrender to the power and intelligence of something much bigger than ourselves. When we fully let go of control. When we become one with the experience. When duality does not exist. It’s something truly amazing, mystical and spiritual that happens that is beyond the rational or intellectual mind and in the realm of deep knowing-intuition-transcendence.

I think there is much cross pollination of ideas and potential for growth in our understanding of psychopathology if we are willing to be open to how psychedelics work and in what ways the process of change is similar and different to ISTDP.

Learning and teaching ISTDP

So what does all of this boil down to when it comes to how we teach and learn ISTDP?
I believe Davanloo created a powerful model that when delivered optimally – has both the patient and therapist engage in a deeply meaningful spiritual endeavour. 

Davanloo had clearly grown up enough in terms of his own emotional development that he was able to conceive, develop, research and deliver this model effectively and it is integral to who he is.  As I understand it, most of the issues in ISTDP come from the learning and teaching of the model, especially when we are all at vastly different stages of growing up. 

This would mean then that given the therapist’s stage of development, what is focused upon in sessions, what is heard, what is taught, what is practiced, what is adhered to and what is focused upon is going to look very different person to person. I have a sense that what we end up focusing on in therapy can sometimes be the unconscious issues that we ourselves are struggling with and not always that of the patient. For example, I am currently in a stage of fascination or maybe even obsession with the punitive superego, and I’m seeing it everywhere I go. It so happens that this is what I am deeply working with in my own therapy and musings.

When I see ISTDP at its best, it is the same feeling I get when I hear an orchestra play, when I watch a moving film, when I see dancers move in synchrony or nature working together. It is this deep flowing unison with what is, in the present moment and it is breathtaking. When I see Patricia Coughlin, Allan Abbass, Jon Frederickson and others in their zone with a patient, I see them as deeply connected, intimate, honest, open, speaking from their hearts and deeply aligned with who they are. They’re in synchrony with powerful techniques and a deeply embedded understanding of conflict, the unconscious, as well as a deep respect for the patient’s will. In other words they are in a flow state that transcends the conscious mind. 

All of the above, to me, is what provides the furtive ground for emotional breakthroughs that lead the patient’s own unconscious therapeutic alliance into resonance with their individual and collective wounds in order to create deep healing and change. This is some of what I mean in placing ISTDP within a more spiritual framework.

Following the above, I started getting the message to read Davanloo, Freud and Jung again from their original sources and, like most learning that occurs as a spiral, I noticed that I could finally read and understand what I could not previously.

It sounds like you’ve come a long way. So where are you at in your development at this moment?
I have deeply reconnected with ISTDP and at least right now, I am able to do this in a way that at times looks like the work of those I most admire except it is embodied through me. I am now able to mobilize the unconscious in a way that I couldn’t before.  At times, I can deeply hear and feel the unconscious therapeutic alliance as it rises, I can feel when a patient is complying or if they are becoming their punitive superego, I can feel their somatized pain as well as the rage as it rises in my body as well as theirs.

This is no longer such an intellectual endeavor for me, even though I am re-reading a lot and thinking about this every day. Instead, it feels like it is coming from a place of intuition and my heart and as such I am learning to do Heart on Collisions rather than Head on Collisions as I like to view them.

I am speaking from one heart to another when I press to feelings, when I identify and clarify defenses, when I stop being the ego to someone’s superego so conflict can rise in them. And low and behold patients seem to be having breakthroughs in a way that I could not facilitate previously and it comes without the intense attachment to the outcome that I once had.

Sadly, this does not mean I am having breakthroughs with everyone, I just know that my interventions are coming from a different place these days. It is much less cerebral and more embodied as a whole part of me rather than me being split into lots of separate parts trying to speak to the different parts of the elephant.

So, this is where I find myself on this journey now and I continue to grow through seeing new patients, skill building, meditating, video review, teaching and supervising trainees. I don’t know where this stage will take me but I know at least part of it is to share my experience, to enable others to share theirs, to practice courage and bravery in speaking my truth and to help those who are struggling to recognize that in any complex endeavor that involves body, mind, heart and soul – there are stages and we all go through them – some quicker than others. But still the spiral continues.

NOTE: With the permission of the author, the text has been reconstrued as an interview to make it more accessible.

This piece was inspired by ongoing discussions on the IEDTA listserve, fueled in part by the current debate on the risks associated with ISTDP in the Norwegian psychologist’s magazine as well as this Mikkel Reher-Langberg interview we did some time ago.

For a now classic text on idealization and devaluation when learning ISTDP, please see this 2004 article by Allan Abbass “Idealization and devaluation as barriers to psychotherapy learning“.

Below you’ll find some of our latest interviews:

Ivar Goksøyr: “På många sätt är MDMA den perfekta terapikatalysatorn”

Under de senaste åren har forskargrupper världen över återupptagit arbetet med att undersöka de terapeutiska effekterna av psykedeliska substanser såsom LSD, psilocybin, MDMA och Ayahuasca. Inom ett par år kan både MDMA och psilocybin möjligen vara redo att godkännas som läkemedel för behandling av olika psykiatriska besvär i kombination med psykoterapi: psykedelisk psykoterapi. Ivar Goksøyr är psykolog och forskare specialiserad inom ISTDP och psykedelisk terapi, verksam i Osloområdet.

Ivar Goksøyr

Varför är psykedelisk terapi på väg tillbaka till sjukvården?
Det korta svaret är att vi nu är en ny generation som kan titta mer nyktert på vad forskningsdata om psykedelika faktiskt säger, snarare än att vara låsta i de perspektiv som bildats i kölvattnet av hippierörelsen eller kriget mot narkotika. Idag säger forskningsdata att psykedeliska substanser är säkra att använda i en klinisk miljö och att de har en terapeutisk potential för en mängd olika tillstånd (som till exempel det mänskliga tillståndet). Det är fortfarande många som inte får hjälp av dagens behandlingsmetoder och även om Davanloo hävdade att han lyckades med 100% av sina patienter så är det väl ingen som tror på det längre. Vi behöver en palett med olika metoder som kan nå olika patienter i olika stadier av deras utvecklingsprocess. I en situation där de flesta känner någon som har haft kontakt med vården men som fortfarande har det kämpigt är det absolut nödvändigt att undersöka den terapeutiska potentialen i alla lovande metoder och format. Eftersom psykedelisk terapi representerar en så pass lovande behandling vore det underligt om vi som forskare, terapeuter och medmänniskor inte intresserade oss.

De viktiga frågorna nu är inte om psykedelika är säkert och det finns en terapeutisk potential, utan snarare gäller de generaliserbarheten av denna potential, de terapeutiska mekanismerna och optimeringen av synergier med terapimetoderna. För vem, när och hur kommer psykedelikassisterad terapi att vara ett alternativ till befintliga behandlingsmetoder?

Det har kommit flera spännande studier på psykedeliska substanser de senaste åren. Kan du säga något kortfattat om någon/några av de som sticker ut? 
Vad gäller psilocybin har vi en klassisk studie från 2006 där två tredjedelar av deltagarna rankade upplevelsen bland de fem mest meningsfulla upplevelserna i livet. Hur är det alls möjligt i ett forskningslaboratorium!? Dessutom finns det fascinerande studier som visar att psilocybin har en transformativ effekt på livskvaliteten för många människor med livshotande sjukdom. Det finns också intressanta hjärnavbildningsstudier som visar en nedreglering i standardlägenätverket som används för självreflekterande processer. När jaget hamnar i bakgrunden uppstår mycket mer tvärkommunikation mellan olika delar av hjärnan som vanligtvis inte kommunicerar.

Konnektivitet i nyktert tillstånd (a) respektive under psilocybinpåverkan (b)

För MDMA-assisterad psykoterapi finns det sex högkvalitativa RCT-studier med totalt 105 PTSD-patienter. Remissionsgraden vid ett års uppföljning var 67% för ett mycket kroniskt och behandlingsresistent stickprov med breda inkluderingskriterier och höga nivåer av samsjuklighet.

På den lite mer spekulativa men ännu mer intressanta fronten visade en ny studie vid Johns Hopkins, ledd av Gul Dölen, att MDMA öppnar en kritisk utvecklingsperiod för socialt lärande hos möss. Inom klinisk praxis har man också sett en speciell typ av kontrollerad regression till mycket tidiga stadier, där det vuxna observerande egot samtidigt är intakt. Dessa indikationer från klinisk praxis och experimentella studier ger visst hopp om att MDMA kan katalysera förändringar i djupt rotade anknytningsstrukturer. Men mer forskning behövs!

På vilket sätt är du involverad i att driva detta?
Jag blev medveten om den terapeutiska potentialen hos psykedelika och ISTDP ungefär samtidigt, för nästan 10 år sedan, och har försökt att göra båda metoderna mer tillgängliga. Till vardags driver jag den ISTDP-specialiserade psykologikliniken Psykologvirke i Oslo. Jag är också knuten till forskarteamet Psykforsk – Innovativ behandlingsforskning vid sjukhuset i Østfold. Här förbereder vi det norska deltagandet i stora internationella studier med MDMA-assisterad psykoterapi för PTSD och psilocybinassisterad psykoterapi för behandlingsresistent depression. Vi håller också på att planera egna studier. Vi har genomgått utbildning i psykedelisk terapi, publicerat artiklar och driver föreläsningsverksamhet. Dessutom är jag involverad i ett forskningsprojekt där jag kontrollerar manualtrogenhet i en pågående internationell studie av psilocybin för behandlingsresistent depression i Oxford. Psykologvirke har också ett informellt samarbete med en lokal klinik som driver ketaminterapi för depression, där vi hjälper till med parallell psykoterapi.

Hur kan man förstå psykedelisk terapi ur ett ISTDP-perspektiv? Vad bidrar substanserna med?
Etymologiskt betyder psykedelika att sinnet visar sig eller manifesteras. Själsinnehåll, även omedvetet, framträder bland annat genom att egot mjukas upp och därigenom dess försvar. Psykedeliska substanser kan vid låga doser fungera som en katalysator för sedvanliga psykoterapiprocesser och vid höga doser transcendera den psykodynamiska nivå och agera på en mer existentiell nivå. Psykoterapi sjunger inte alltid för själen, men psykedeliska substanser gör ofta det.

En vanlig invändning från psykodynamiska terapimiljöer är att när man använder psykedelika så “hoppar man över” försvarsarbetet vilket gör att ingen verklig kapacitetsökning sker. Man hoppar direkt till känslorna. Det är sant att utan ett gradvist försvagande av försvaren inom ångesttrösklarna kan detta vara en mycket krävande upplevelse och den är definitivt inte för alla: It takes an ego to loose it. Uppmjukandet av egot är bra för personer på motståndsspektrat, men vid svårare skörhet kan man behöva andra mediciner. Dessa är relevanta bekymmer, men de bör inte missbrukas i splittingens tjänst. Alla terapimetoder har potentiella fallgropar åt det ena eller andra hållet. Psykedelikaassisterad terapi har ett antal fördelar jämfört med traditionell terapi, särskilt då att du på ett tillförlitligt och precist sätt kan gå i riktning mot de allra djupaste lagren av psyket och hålla dem öppna i flera timmar. När du bestämmer dig för att arbeta med omedvetna processer så har du alltså här ett robust verktyg. Vissa tycker att verktyget är för kraftfullt och oförutsägbart, som ett tveeggat svärd. Många tycker i och för sig detsamma om ISTDP och det finns ett frö av sanningen i det. Det är desto viktigare att se om det är möjligt att lära sig att hantera verktyget. Vi behöver all hjälp vi kan få när vi ställs inför motståndets råa krafter.

Det är också viktigt i detta sammanhang att nämna MDMA, som har en annan profil än klassiska psykedelika. Eftersom de senare har en mycket ospecifik effekt och inte har inneboende ångestreglerande egenskaper så kan de vara mer utmanande att arbeta med. Det förändrade medvetandetillståndet som MDMA tillhandahåller är lättare att tolerera och kännetecknas av en oxytocinrelaterad ökning av medkänsla och tillit. Detta motverkar ångest och därigenom försvar. När läkemedlet dessutom skärper de kognitiva förmågorna kan det skapa goda förutsättningar för en flera timmar lång mobilisering av UTA. På många sätt är MDMA den perfekta terapikatalysatorn och psykoterapins kinderägg: substansen reglerar ångest utan att sedera, den minskar försvaren utan att du tappar kontrollen och den skapar en grundläggande stämning av medkänsla och tillit samtidigt som den sensibiliserar för spektrat av andra känslor. Det finns, som jag nämnde tidigare, indikationer på att MDMA kan återaktivera kritiska utvecklingsperioder för socialt lärande hos möss. Kanske gäller detta även för människor? De tidiga MDMA-pionjärerna trodde att det mest unika inslaget med substansen var omstruktureringen av tidiga objektrelationer och därmed förändringen av tidiga känslomässiga scheman. Det kommer att bli spännande att se om MDMA-assisterad psykoterapi faktiskt kommer att leva upp till de förhoppningar och förväntningar som skapats av de små men välkontrollerade studierna som redan publicerats.

Vad menar du med att UTA kan mobiliseras i flera timmar? Och finns det inte risker förknippade med detta? 
MDMA har en komplex neurokemisk verkningsprofil där utsöndringen av oxytocin och andra hormoner ger en stark ökning av tillit. Patienterna känner sig trygga både i sinnet och kroppen, utan att man blir nedslöad – i motsats till hur traditionella mediciner fungerar. Tvärtom så blir man mer fokuserad och mer öppen för känslor. När du inte har ångest behöver du inte heller försvar. Kombinerat med en avsikt att arbeta med sina svårigheter inom den terapeutiska miljön, ger detta mer spelrum för UTA som inte längre blockeras av motståndet. Vissa kan fortfarande gå över ångesttrösklar, så visst finns det risker, men toleransfönstret utvidgas kraftigt och det går snabbare att reglera ner ångesten igen. För många innebär MDMA-psykoterapi att de under flera timmar i sträck kan gå in i sig själva och “läsa sig själva som en öppen bok”, som en deltagare uttryckte det.

Som jag förstått det är den vanligaste modellen för psykedelisk terapi en typ av stödterapi. Varför skulle ISTDP vara ett bra ramverk för psykedelisk terapi?
En av de saker jag verkligen gillar med både ISTDP och psykedelisk terapi är att de släpper fram de spontana, självläkande förmågor hos människor som vi alla besitter. Om psyket bara släpps in under ångesten och bakom försvaren så kommer det att, precis som övriga delar av kroppen, att börja läka sina sår på egen hand. En icke-direktiv terapimodell är vettig i detta avseendet. När UTA dominerar bör terapeuten inte stå i vägen utan följa med, lita på och lära av det som kommer upp. Samtidigt är det centralt att ha en djup psykologisk förståelse både under sessionerna innan de psykedeliska sessionerna och sedan efteråt i integrationen av materialet som dyker upp under en session. Jag tror att personer med erfarenhet av EDT kommer att ha en bra utgångspunkt för att utöva psykedelisk terapi eftersom de är vana vid att arbeta med krafter och motkrafter, vana med att vara i djup känslomässig bearbetning – och för att de inte kommer att låta sig skrämmas av lite mörker.

Jag var förresten på den otroligt solida konferensen “Colloquium on psychedelic psychiatry” som Nätverket för psykedelisk vetenskap arrangerade i Stockholm under hösten 2018. Trots ett annars mycket bra program slogs jag av att knappt några föreläsare hade ett explicit fokus på vikten av komplexa relationella känslor, och deras betydelse vad gäller utvecklingen och vidmakthållandet av psykiska störningar. Från det faktum att psykedelisk terapi i början huvudsakligen ägde rum inom en psykodynamisk ram så verkar pendeln nu ha gått långt i motsatt riktning. Nu finns det tyvärr få psykodynamiker som sätter sin prägel på fältet. Utan en djuppsykologisk inriktning är det i min mening inte möjligt att fullt ut utnyttja potentialen av psykedelikassisterad terapi. Och kanske svårare att undvika några av de vanligare fallgroparna. Den internationella mailinglistan EDT-list håller just nu på att skapa en separat undergrupp “EDT and Psychedelics” som jag hoppas att fler kommer att registrera sig för.

Hur tror du att den framtida vården kommer att se ut, kommer alla patienter att erbjudas psykedeliska substanser eller kommer det bara erbjudas vid komplexa fall? Och hur skulle du vilja att framtidens vård ska se ut?
Min största önskan för framtida vård är att patienter inte bara ska få möta wounded healers utan också healed healers. Psykedelikassisterad psykoterapi kan vara ett bra verktyg för att nå ännu djupare in i oss själva, bidra till en form av egenterapi som är nödvändig för att kunna nå tillräckligt djupt in i och uthärda det komplexa känslomässiga landskap vi vandrar runt i varje dag på jobbet.

När det gäller behandling för patienter bör inga specifika metoder erbjudas för alla. Inledningsvis kan det nog vara naturligt att tänka på att använda psykedelika som ett verktyg först vid behandlingsresistens, vid särskilda specialiserade kliniker. MDMA-assisterad psykoterapi tror jag kommer att vara lättare att implementera i bredare utsträckning, som en del av sedvanlig behandling. Och nu har jag inte ens diskuterat ketamin, där den tillgängliga forskningen är så solid att implementeringen kan ske omedelbart. För psilocybin och MDMA hoppas de drivande forskargrupperna på att substanserna blir godkända som läkemedel under de närmaste åren. Detta hänger på om de preliminära resultaten från mindre studier bekräftas i de nu pågående stora fas 3-studierna. Låt oss hoppas att alla dessa små fynd visar sig hålla i större studier och vara generaliserbara så att vi kan få fler verktyg i vårt arbete – för att hjälpa oss själva, våra patienter och våra nära och kära.

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