“The Shaking Grandmother”: Assessing and Addressing Multiple Pathways to Somatic Symptom Formation in ISTDP

Intensive Short-Term Dynamic Psychotherapy (ISTDP) can be an effective treatment for complex cases presenting with fragility, repression, character problems and multiple medically unexplained somatic symptoms. However, in such cases, the treatment is not always “short-term,” and the therapist needs to engage in the complicated task of assessing and addressing the specific mechanism involved in the formation of diverse somatic symptoms as they emerge in sessions. This case report describes the application of graded ISTDP with a patient presenting with long-standing difficulties with depression, masochistic character traits, and multiple medically unexplained somatic symptoms. Session transcripts from early, mid and late treatment phases will illustrate the assessment and therapeutic work with anxiety thresholds, as well as detecting and restructuring somatization. Further, I will illustrate how the emergence of the unconscious therapeutic alliance (UTA) in later stages of treatment can elicit high levels of anxiety in the therapist and discuss the critical role of having supervision when working with primitive unconscious phenomena in fragile patients. Outcome at termination and one-year follow-up will be presented.