Moderate and Severe Fragility: An ISTDP Webinar.

On July 18, 2020 Jon Frederickson (2020) presented a webinar on Moderate and Severe Fragility to the Intensive Shortterm Dynamic Therapy (ISTDP) community. The day preceded the up-coming publication (December 15) of his new book Co-Creating Safety: Healing the Fragile Patient. Frederickson presented a patient who was very fragile at the beginning of therapy and was on several anti-psychotic medications. The patient had years of previous therapies. During the trial therapy, the patient did not have a psychotic level of character structure but rather was very fragile. Patients with fragile character structure have trouble tolerating the anxiety that mixed feelings generate and so they rely on primitive defenses such as splitting, projection and projective identification. Because the patient was assessed as a fragile patient, Frederickson began what is known in Intensive Short-term Dynamic Therapy (ISTDP) as a graded approach. This approach uses techniques such as pressure to feeling, that is, raising the unconscious to consciousness, while regulating anxiety. The graded approach applies these techniques in a careful and gradual way so that that patient can build ego capacity while not being overwhelmed with anxiety. “Since fragile patients have such a low level of anxiety regulation and affect tolerance, we must tailor our techniques to their capacity” (Frederickson, 2013, p. 124). Patients with fragile character structure need a way of working that helps build inner self awareness and capacity so that the patient does not use splitting and prjection as means to ward off complex mixed feelings. In fragile patients the process of splitting and projection work together to ward off mixed feelings of love and rage. As mixed feelings arise, anxiety rises usually in the form of cognitive/perceptual disruption such as dissociation, confusion, visual blurring, dizziness, or ringing in the ears. Splitting works to separate the feelings of love and rage with the patient embracing the love and rejecting the feeling of rage. Then the disavowed feeling of rage is projected outward which functions to lower anxiety. In fragile patients this process of splitting and projection is unconscious but consequently very disruptive in personal and professional relationships. The aim in therapy is to help the patient be able to observe, acknowledge and bear previously avoided feelings. As the patient is able to bear these mixed feelings, splitting and projection are no longer needed to lower anxiety. The patient experiences the relief of being able to embrace and accept all feelings. The workshop participants were able to witness the slow but steady progress of the therapy during a number of sessions with the patient. The technique of bracing was demonstrated. This is the application of a consistent mild pressure to feeling while watching for and regulating anxiety. In his 2015 book, Reaching Through Resistance, Allan Abbass introduced the concept of bracing which involves reflecting on