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An Interview with Jake Freedman: Depersonalisation, Derealisation, ISTDP and Dynamic Therapy

2 days ago
11 min read

Depersonalisation, Derealisation, ISTDP, and Dynamic Therapy


Depersonalisation can be difficult to describe, frightening to experience, and challenging to treat. It can leave people feeling detached from themselves, their emotions or the world around them, while still knowing that something about the experience simply doesn’t feel right.


I spoke with psychodynamic psychotherapist Jake Freedman about how he understands depersonalisation and dissociation, how these experiences may function psychologically, and how Intensive Short-Term Dynamic Psychotherapy (ISTDP) and dynamic therapy approaches them in the therapy room. Our conversation ranged from anxiety, defences and emotional regulation to self-observation, treatment goals and what “short-term” therapy actually means.


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When depersonalisation needs treatment


Kathryn Levison: What makes ordinary/transient depersonalisation cross the line into something you would actually treat?

Jake Freedman: I would treat depersonalisation at the same point I would treat anything else. Meaning, when it affects an individual's functioning, they are consumed by it, or worrying about it has taken over their life, or if they are suddenly interested in understanding its function and changing it. We must always have an intrapsychic or internal emotional problem. [ISTDP clinician, trainer and author Jon] Frederickson uses this term a lot, I think. I would, of course, have to also ensure the patient has ruled out other variables and issues they may need to discuss with their GP. [For instance,] blood test to rule out deficiencies such as testosterone, panic disorder, chronic cannabis use. In some cases, these alone may be sufficient to attend to these difficulties.


Understanding depersonalisation and dissociation


KL: Do you conceptualise depersonalisation (DP) primarily as dissociation, defence, anxiety discharge, adaptation, or does the answer depend on the patient?

JF: Yes, it does [depend on the patient], and it goes back to what I have been saying throughout: is it defence or anxiety. I think the beauty of reading [psychoanalyst Nancy] McWilliams, ISTDP, and dynamic therapy literature is we can get really precise and formulate what the depersonalisation is for that individual. That it is best conceptualised through, for example, an aspect of a particular character structure or style such as schizoid, a character defence, high anxiety such as CPD [cognitive-perceptual disruption]. We could think of it as trauma adaptation if we think about it as linked to identification with the observer or identification with the aggressor [or] other forms of abuse where the individual may identify with some external malign object over their own internal experience. It's also a responsibility of mine to be able to tolerate not knowing and to acknowledge, however helpful all these frameworks are, to never mistake the scaffolding for the patient. 


KL: If DP is protecting someone from intolerable affect, why would taking that protection away help? What has to replace it first?

JF: [Removing protection can help] Because affects that were once intolerable may now be tolerable. Of course, it depends on the individual's situation. But if they learned that they couldn't feel intense rage in their family home and were cut off from it, of course, they would be terrified of their rage [during therapy] and experience it as intolerable, because they had to cut off from it so as to not sever the attachment relationship. But that may no longer be the case [if] it has become a phobia of something internal that it is now safe to feel. Just to flag, along with the core feelings, I think [what] feeling/thought people need to learn to tolerate is a particular kind of fear: primarily the fear of losing control. Someone will remain chronically tense and anxious if they fear losing control, because they will be using enormous amounts of energy to hold themselves together. So only when they can sort of lean into the fear of losing control, can they learn to come out the other side. Nothing terrible happened, nobody died. It can be quite CBT-esque in that way [Cognitive-Behavioural Therapy].


KL: What does an ISTDP therapist or dynamic therapist actually do in the room when a patient begins depersonalising?

JF: [They’d] ask more about their anxiety. [Do they have] blurry vision, tunnel vision, blank mind, foggy thinking [and help the patient] regulate anxiety, either through cognitively mapping what happened just before they depersonalised, or moving to grounding in the room. Think deep belly breathing, looking around the room doing 5-4-3-2-1: 5 things you can see, 4 things you can feel, 3 things you can touch, 2 things you can smell, 1 thing you can taste, etc. Or, if necessary, changing topic, then checking in with the depersonalisation again to see what it's like. Essentially, once anxiety is regulated or the depersonalisation returns to baseline, would it be time to continue with ISTDP pressure, clarification, challenge, or head-on collision. Any of this would be inadvisable if depersonalisation has suddenly spiked or if it's possible the individual has a fragile character structure. Then we would move to the graded format, which would involve doing "triangle work" [feelings, anxiety, defences]. Helping the patient mentalise [understand one’s own and others’ mental states] can be very helpful here also, as it's alliance-building and builds ego adaptive capacity. 


KL: What tells you "keep exploring" versus "regulate anxiety now"?JF: Keep exploring is generally when you're seeing sighs [striated muscle anxiety]. This is known as "a moderate rise." Sighs are usually a good sign that anxiety is in a "healthy pathway." Regulate anxiety now would be when the patient reports CPD: blankness, ringing in their ears, tunnel vision, or smooth muscle anxiety like nausea or trembling. Also, I may notice in my own countertransference [the therapist’s emotional response] that the patient's anxiety is too high and we need to slow down. [ISTDP psychiatrist Robert] Neborsky refers to this as the therapist providing interpersonal "biofeedback" for the patient, which I think is a very accurate and useful metaphor. Having to be a "receiver" of the patient's anxiety levels even before they are aware of it and then regulating it. 


KL: Can a patient become more dissociated during therapy? If so, when is that expected activation and when is it evidence that treatment needs to change course?

JF: If this was a case, not of the dissociation spiking in the session and then coming back down but they stay dissociated after the session ends, I think this would be time to adopt a gentler exploratory psychodynamic approach on the more supportive end of the expressive/supportive continuum. We may also explore other treatment options first for capacity building like CBT or ERP [Exposure and Response Prevention] if the patient has obsessional thoughts about their dissociation. In these instances, I would refer out or signpost the patient to these services.  I think this is also where tape review and deliberate practice become really helpful and essential. When working with individuals where mobilising anxiety can cause primitive defences, recording material and sharing in supervision can really help the practitioner see various things. If and when they are applying too much pressure, neglecting the patient's anxiety, or when the therapist has exceeded their own capacity and therefore can't regulate the patient. This doesn't necessarily need to be done in all cases, as some people dislike the idea of being recorded. But deliberate practice, I believe, is underutilised, and is a great way of seeing if the clinician is working safely and helping them to improve. Deliberate practice is at the heart of ISTDP and other experiential dynamic therapies (EDTs). It helps the therapist learn how to improve their skills. It also helps them improve their own capacity for core feelings and anxiety. After all, we can only take patients as far as we have gone ourselves. 

Self-observation and emotional detachment


KL: How do you distinguish useful self-observation from DP's pathological observer stance?

JF: Three things would probably help. First, somatic countertransference: does the therapist feel what the patient might be feeling, or does it feel flat and lifeless in the room? If it seems flat and lifeless and the therapist is not feeling any somatic countertransference, it's likely that a pathological observer stance is in operation. Second, useful self-observation would/might include things like lots of sighs/sighing or "whispers from the unconscious alliance" [as described by] Abbass. If, in the therapist's countertransference, they begin to feel spacey, etc., that is often a good indication.


KL: If the patient already knows intellectually that they're angry/sad/frightened but can't feel it, is that DP, isolation of affect, intellectualisation, or potentially several processes at once?

JF: Yes, potentially isolation of affect and intellectualisation. At higher levels of fragility or anxiety, it could be depersonalisation. It is interesting to think about whether depersonalisation is its own defence or more like [separate ingredients for] a cake. Is depersonalisation a combination of isolation of affect, intellectualisation, psychically retreating, etc., or is it its own defence. Maybe that's a philosophical/taxonomical question. I think we'd also have to consider whether other factors are having an effect on emotional blunting. Certain medications may do this, such as SSRIs and SNRIs [antidepressant medications]. Counterintuitively, if the patient has a habit of making themselves “too relaxed”; that is, so relaxed there is no anxiety in their striated muscles even [no sighing, clenched fists, or fidgeting], this can also be unhelpful. A little bit of anxiety (striated) needs to get mobilised at some point to access the core wishes/impulses. Without the striated muscle anxiety as a signal, you then have nothing to work with to get to the underlying core affects, wishes, or impulses.


KL: Can DP itself be the defence while guilt/shame/anxiety are also defending against a still deeper feeling? 

JF: Absolutely, though sometimes the DP and guilt/shame are bound up, I suppose, or are happening at the same time. But all of these would be referred to as “inhibitory affects.” Anxiety, guilt, and shame are all inhibitory as they go inwards towards the self rather than flowing outwards like love, grief, and rage do. 


Reducing fear and recognising physiological anxiety


KL: Does symptom reduction follow insight, affect tolerance, changed defences, changed relationships, ego strengthening, or some combination?

JF: I think some combination. It definitely isn't a science, but I think it follows the same principles as symptom reduction in regular [psycho]dynamic therapy or ISTDP, in that it is a combination of: enhanced/increased ego adaptive capacity. This would include being able to discern corners of the triangle and being able to separate, for example, stimulus from feeling. [Let’s say] someone is experiencing depersonalisation or derealisation (DPDR) and they are asked what they feel towards their boss and they say "I feel attacked," then the patient is mistaking a stimulus (maybe their boss did in fact attack them) for a core feeling. When they learn that they, for example, feel angry towards their boss for attacking them, and this anger causes them to detach, then that is an example of building ego adaptive capacity; i.e. being able to separate corners of the triangle and to make a distinction between stimulus, core feeling, defence, and other important mechanisms of change. [Changes can include] enhanced and increased affect tolerance [ability to experience difficult emotions]. Ability to experience core emotions, wishes and impulses. Enhanced and increased capacity to mentalise. Sufficient corrective emotional experiences in the therapy where these "unallowable feelings" can be experienced and tolerated. DPDR is also linked to anxiety in the research, so noticing what stimuli and internal factors (feelings, wishes, impulses) can help the patient to modulate their anxiety [using] physiological anxiety regulation in the form of deep breathing, yoga, progressive muscle relaxation, etc. When their anxiety is in a tolerable window, they may start to see the causes and conditions of their DPDR. [This] gives them that window of opportunity to connect with what happened internally before the detachment. I suppose another curative aspect is being able to offer the patient hope and conveying a real interest in their experiences. So, I wouldn't say ISTDP or dynamic therapy is necessarily uniquely effective for treating DPDR, but I think it contains many of the ingredients common to all effective transdiagnostic therapies [approaches that target psychological processes shared across different conditions rather than focusing on just one].


KL: What does "success" look like besides "I don't depersonalise anymore"?

JF: Probably the same as what success looks like in any long-term psychodynamic therapy or analysis: better ego adaptive capacity [ability to adapt and cope] and ability to distinguish what's internal from what's external. Better relationships, more vitality, more of a sense of meaning. I think having fully mourned is incredibly important also, to mourn the years lost to feeling unreal or letting the feeling take over one's life. And, as we said before, it isn't always the case that the individual stops depersonalising. [Instead] their relationship to it changes such that they are able to lead a more meaningful and fulfilling life, or a "good life" in the eudaimonic sense [a meaningful fulfilling life], irrespective of symptom reduction. My academic background prior to training as a therapist was in the philosophy of mental disorder and philosophy of psychiatry at the IoPPN [The Institute of Psychiatry, Psychology & Neuroscience, a faculty of King's College London (KCL)]. I think this background, and my sensibility towards it, makes me acutely wary of new fads, promises of cure, idealisations, and factions within the profession. All of this is to say that I don't think my conception of success is different to that of the average psychodynamic therapist. 


KL: Can someone learn to experience an episode without panicking about the episode, and does reducing that secondary fear change its intensity/duration?

JF: Absolutely, without a doubt. Frequently listening to [audiobooks by] Claire Weekes, who I refer to as the "Empress of Acceptance," can help with depersonalisation enormously in this respect. The psychoeducation is incredibly helpful, but you don't necessarily experience the same comfort one would from a Claire Weekes-narrated audiobook. Her four-step process can offer enormous help, though, to people who panic about feeling DPDR or are afraid of it. The four steps are: 1. Face, 2. Accept, 3. Float, and 4. Let time pass. This can be applied to any anxiety symptom, including depersonalisation. [The Four Steps by Claire Weekes]


KL: Where does the body enter treatment? Particularly because ISTDP explicitly watches bodily anxiety discharge

JF: This is quite a big question, but the main reason is that paying attention to anxiety channels can help with anxiety regulation. If we can monitor where anxiety is [in striated muscle where it's safe to experience vs. smooth muscle and CPD where it isn't], then we can regulate the patient for as long as they need before we see sighs. When we see sighs, we have the green light to add pressure and mobilise complex unconscious feelings. 


KL: What would make you decide ISTDP or dynamic therapy is not the right treatment for this particular DP patient?JF: Primarily if the individual isn't interested in, or curious about, what inside them could be driving the DP. If they are too concerned they may be going mad, or there is so much aversion to it that they just want [to get] rid of the symptom, it may be preferable for the individual to have a symptom management treatment instead, or at least first. For these purposes, depersonalisation-focused CBT would be the main recommendation, or ACT [Acceptance and Commitment Therapy], which has a lot of things in common with Claire Weekes' approach (she was very ahead of her time). 


What short-term means in ISTDP and dynamic therapy


KL: Does "short-term" describe the method or promise the patient's timetable?

JF: I really wish "short-term" wasn't in the name. I think it means short-term relative to a full, multiple-times-weekly analysis. I really like what Nancy McWilliams has to say about this; that she assumed ISTDP was, “by definition, a very short-term therapy,” until she heard Allan Abbass discussing more fragile patients who might need “months or even years of work.”  She specifically talks about all treatments starting out offering "short-term" or time-limited and eventually moving to longer-term or open-ended models, or conceding that certain patient groups, even with ISTDP, may need years of treatment, rather than months. 


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About the contributors


Jake Freedman is a psychodynamic therapist working in Fitzrovia, Central London. His main areas of experience and interest are in states of depersonalisation and derealisation, relational trauma, and trauma-related dissociation.


Kathryn Levison is a psychoanalytically-informed freelance writer/editor with a focus on psychology and human nature.


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