White Coat, Black Art

Off work for 8 years, woman says she got her life back with unique kind of talk therapy

Intensive short-term dynamic psychotherapy, a type of talk therapy that digs into the emotional roots behind a person's physical ailments, is gaining notoriety for helping some long-suffering patients with unexplained medical symptoms.

Studies show intensive treatment helps some patients with unexplained symptoms

After eight years on disability, Kim Hawes credits her recovery from unexplained medical symptoms — and ability to go solo camping — with a unique kind of talk therapy that's gaining notoriety for helping long-suffering patients whose mysterious ailments leave physicians scratching their heads. (Submitted by Kim Hawes)

After eight years on long-term disability, Kim Hawes had nearly given up hope she'd ever be well enough to return to her job at the Nova Scotia Department of Justice.

Previously, Hawes had been a healthy mom of three until an incident at work in 1993.

"I had an exposure to some chemicals, off-gassing from some furniture, and I ended up collapsed and had to be carried out of the building," she told White Coat, Black Art host Dr. Brian Goldman.

That fainting episode set off a series of anxiety and panic attacks. 

"I lost 22 pounds in a month. I couldn't eat. I couldn't sleep. I was sometimes in the fetal position, just crying because I couldn't cope. I was unable to care for my children." 

From there, Hawes joined the ranks of somatoform patients — those who present with clinically significant but unexplained symptoms over a long period of time, baffling the physicians who try to diagnose them. Sometimes these patients are referred to as having "functional disorders." The quest for answers is costly to patients, health systems and insurance programs that often wind up paying long-term disability benefits. 

At one point, Hawes was diagnosed with environmental sensitivity to chemicals that give off a smell. A whiff of perfume or other strong odour would trigger another panic attack.  

Other somatoform patients might suffer from symptoms such as abdominal pain, headaches and dizziness. 

Hawkes tried twice to return to work, but both attempts were short-lived.

Then her case worker from the Workers' Compensation Board of Nova Scotia asked if she'd be interested in seeing Dr. Allan Abbass, a psychiatrist at QEII Health Sciences Centre in Halifax who had been getting good results helping people get back to work.

Dr. Allan Abbass heads Dalhousie University’s Centre for Emotions and Health. The centre treats patients with unexplained medical symptoms using a kind of talk therapy called intensive short-term dynamic psychotherapy (ISTDP). (Submitted by Dr. Allan Abbass)

Abbass, who is also a professor of internal medicine at Dalhousie University, is a leading researcher and practitioner of intensive short-term dynamic psychotherapy, or ISTDP, a kind of talk therapy that is gaining a reputation for helping long-suffering patients with unexplained symptoms.

Hawes said that after she completed her sessions with Abbass, she made a gradual return to work, with no sign of the panic attacks that had disabled her previously, and no ongoing problem with chemical smells. That was 16 years ago.

Emotional roots

ISTDP digs into the emotional roots behind some people's unexplained physical ailments, said Abbass.

The theory is that the panic attacks felt by Hawes, or the headaches and abdominal pains felt by some other patients, aren't due to diseases of the body, but rather emotional traumas from earlier in life. Instead of feeling emotions such as anger, fear or guilt, these patients experience very real physical symptoms, he said.

However, not everyone who treats these unexplained disorders agrees that ISTDP is the solution.

Neuropsychiatrist Dr. Anton Scamvougeras, associate clinical professor in the department of psychiatry at the University of British Columbia and co-author of a book called Understanding and Managing Somatoform Disorders, said ISTDP isn't the right fit for all cases.

He said clinicians must match treatment to the nature of the patient's problem. If it's a severe depression that's underlying the hard-to-treat physical symptoms, "you need to treat them for major depression as well as helping them with their physical symptoms."

Scamvougeras said he has "no doubt" ISTDP is helping some "individuals with somatoform disorders." However, he differs from some practitioners on whether past traumas are always at issue.

People who experience panic attacks, for example, have overactive brain circuitry causing dysregulation of their systems, he said.

"What they need is certain kinds of cognitive behavioural therapy plus medications to help them with panic attacks. They don't need therapy searching for past traumas."

A made-in-Canada therapy

ISTDP was developed at McGill University in the 1960s by Dr. Habib Davanloo in response to what he felt were unacceptably long courses of treatment for mental health patients and low success rates.

He made a detailed study of individual treatment sessions recorded on video — a practice that scandalized some members of the therapeutic community, which prizes patient confidentiality, when his work first emerged — and concluded that the key to rapid results was getting to the heart of childhood trauma, said Abbass.

The videos are used to carefully analyze how a patient responds, verbally and through body language, to prompts from the therapist, in order to get to the heart of the problem faster. 

More recently, Abbass and other researchers have been working to establish ISTDP as a treatment for patients with somatoform disorders.

Work his team did with patients who present with unexplained ailments at QEII Health Sciences Centre's emergency department, for example, was shown in a 2015 study to reduce repeat hospital visits by nearly 70 per cent. 

While not every mysterious medical symptom is the result of childhood trauma, Abbass said that, with the patients he treats, the therapy addresses a need for attachment.

If something interrupts that bond in childhood — death, illness or other stressors that make it unsafe to express emotions — "it freezes the child emotionally and it causes a lot of feelings to be stirred that are difficult to face," he said.

WATCH | Dr. Allan Abbass explains intensive short-term dynamic psychotherapy:

To address that, ISTDP practitioners start by establishing "a therapeutic bond" with the patient. This is a kind of exchange that includes more questions from the clinician than some more familiar kinds of therapy, as well as a focus on emotions instead of thoughts and behaviour.

"The caring relationship with the therapist stirs up feelings about being cared for or not being cared for in early childhood," Abbass said. "And then that shows in the office in the form of specific patterns and symptoms that we can see — physical patterns as well as behavioural patterns."

'Turning the model of therapy upside down'

Psychologist Leo Russell began using ISTDP 12 years ago after finding other therapeutic approaches didn't always produce lasting results for his patients.

They would make some short-term gains, but three months later they might be back with different kinds of symptoms, said Russell, clinical lead for a functional neurological disorder centre for the National Health Service in Exeter, U.K.

He said ISTDP "turns the model of therapy upside down."

Clinical psychologist Leo Russell, who works for National Health Service in Exeter, U.K., became interested in using ISTDP after finding that a number of other treatment methods were not getting lasting results for some of his patients. (Submitted by Leo Russell)

In a typical conversation between therapist and patient, he said, "you're inviting them to reflect on their experience; to think about it. We call that top-down processing."

"But what we do in ISTDP is, by asking people to pay attention to what's happening in the body, we're inviting them to pay attention to the bottom-up process."

Video recordings help the therapist make progress because they can carefully review — and apply to future sessions — insights from moments when the patient displays anxiety or defences that are out of step with what's going on in the room, said Russell.

"When you ask them that question, you might notice that suddenly they become quite anxious. They start fiddling around with their hands or maybe they find it hard to look at you when they respond to you," he said.

"It feels to them like they're trapped in a room with a lion when actually it's just, you know, a friendly, smiling therapist."

Some have noted that the role of the therapist in ISTDP is more proactive — even confronting — than what we've come to expect in therapy. In an article in Vice in 2013, writer Stephen Keefe, who got permission to review transcripts of ISTDP sessions for an interview with McGill's Dr. Tewfik Said, who trained under founder Habib Davanloo, described the method as having "an undeniably weird edge."

But Abbass says the method challenges the patient to think beyond their painful symptoms and start thinking about the emotion he suspects is triggering their symptoms. 

"So, for example, the person comes in and has a stomach upset and is quite anxious in the body. We focus on what feelings are coming up…. Then they're face-to-face with the different upsets and traumas that happen in childhood."

In at least 25 studies, Abbass and his colleagues have documented ISTDP's success in helping previously hard-to-treat patients get better while reducing costs, including emergency room visits.

Debilitating panic attacks prevented Hawes from returning to work despite multiple attempts. 'I believe that the panic attacks came from unresolved emotions that I had trapped in my body,' she says. (Submitted by Kim Hawes)

For Kim Hawes, exploring her past through ISTDP was key to getting better. While there wasn't any one major traumatic event in her childhood, she says there was some dysfunction and alcoholism.

"My sessions with Dr. Abbass were revisiting any painful moments of my life … and when they did come forward, I would feel the feelings that I probably should have felt at the time that it happened."

Hawes said she credits the therapy with getting her life back. While for years she couldn't drive her car in town, she now enjoys solo camping and travelling.

"You know, I walked in his office, broken and on medication and [having] panic attacks. And, you know, I wasn't really able to live a full life. And then I walked out of that office a free woman."

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