Lisa Bendzsa - We have to mess up. We have to make mistakes. We have to try things that don't work. We have to take risks, right? The regressive wish can hold people back from just embracing the complexity of life.

Lisa Bendzsa is presenting at ISTDP Academy December 10. Niklas Lanbeck spoke to her about Jungian analysis, infant observation, musical training as a model for learning ISTDP, teaching psychiatry residents, the regressive wish as a specific mode of resistance, and more.

You started your career specializing in Jungian approaches to psychotherapy. How has that informed your work and later development as a therapist?

So the clinical training program that I did in psychology, there were two streams to it. A number of the professors were psychodynamically-oriented and then there were some that were Jungian. There was a Jungian institute for training in Cape Town at the time, this would have been in the 90s.

There were a couple of analysts who had trained at the Jungian Zurich school, so they were training a bunch of therapists in a four or six year training. There were lots of talks, public events, and these people who were training were also teaching us.

We were required as trainee clinicians to be in therapy ourselves and most of us were in Jungian analysis at that time as well. In South Africa it was a master's program and was the highest clinical level of training that you could do and then the PhD was just by dissertation.  So it was kind of similar to Britain and similar to, I think, a lot of Europe at that time.

There was the Zurich training, which was the traditional Jungian analytic approach. But then there was also a big interest in Michael Fordham, who was the UK Jungian analyst who started a school there, which combined Jungian work and object relations. So it was a bit of both. But my main interest took off in psychodynamic work.

Was the therapy you were in considered a training analysis?

No, it was a requirement of the masters in psychology that you had to be in individual psychotherapy and you had to be in group therapy with the full cohort. There were eight of us that did the masters at a time and the group therapy was very silent and quite dramatic at times.

Wow. What direction did your clinical work take?

I was mostly doing psychodynamic therapy at that time. There was an analyst who had trained at the Tavistock Clinic, a child analyst, and he'd come back to South Africa. So I was in supervision with him and also another psychodynamic therapist I was in supervision with.

I was really fine honing my understanding of psychodynamic therapy, shorter-term therapies in the vein of David Malan, that was my main interest. My dissertation was on the training implications with short-term psychodynamic therapy for children. I went into private practice and taught child psychotherapy in the University of Cape Town clinical psychology programme, while also having a practice there, seeing some of the more difficult cases, kids that the students couldn't see. Then I decided to go in and further my psychoanalytic training, psychodynamic training, which is when I applied to the Tavistock Institute.

A lot of South African analysts had left because of apartheid and then they trained in the UK and they started to come back in the early 90s, as things were starting to improve in South Africa and they were offering supervision to us. A bunch of us had formed a psychoanalytic society. We had reading groups, we had a full board, we had meetings and we had invited guests that came to speak.

A lot of us would go into supervision with them as well. One of them was a teacher on the faculty at the Tavistock Clinic and also was one of the head clinicians at the Lincoln Clinic, which was kind of an ally. She really recommended that I apply and she helped sort of get all the applications in for me, so I ended up going to London to specialize in psychodynamic work.

Was the focus on child psychotherapy?

At Tavistock, I did the child development program, which was infant observation studies. You observe an infant for two years. Every week for an hour we would observe the child or the infant growing up in the family. And write prolific notes, really watching and observing what happened with the child and their responses to parental input and what happened when the parent wasn't there. Also what happened when there were crises in the family, which was certainly the case with the child I was observing.

So seeing attachment issues as they happen, and then also seeing how they can resolve in a healthy family. We would then have supervision in a group so we’d get to know all of the babies and all of the situations. And it was absolutely fascinating.

Like it was a life-changing experience for me to see what happens when there is attachment trauma and how the baby responds and also how they can recover. It was really beautiful to see.

So observation only, no feedback, no intervention?

Yes. Which is hard. You know, right near the end, the little girl was almost two. Then there were times I could say something. So she would say things like she didn't want a photo

And I'd say something like, well, because you know it's time to say goodbye. And she'd nod.

She was a very bright little girl. And she was walking around with things under her sweater. I had a very strong sense the mom was pregnant just because of what this little girl was doing but I didn't say anything. Then as I was ending, the mom said you're one of the first people I'm telling, but I am pregnant. I said, I just want to let you know, I kind of knew by what your little girl was doing. That was just beautiful.

So no intervention on my part. It was especially hard when things were hard for the family, when I saw this little boy, an older kid who was struggling. He was so verbal, so able to show what was happening for him and how he was struggling. Just having to hold back and just let the family go through what they're going through.

It's hard when that's what you're trained to do, to intervene and help. But just my being there was a help for the mom, she found it helpful to just be able to talk about her baby and about what the trauma was that was going on in their lives. Even though I didn't do anything. I just listened.

In a way it's a two-year practice of restraint then?

Restraint and observation. It's a really brilliant way for a therapist to hone their observation skills. Because babies don't do a lot, but still they do so much, so to observe that and to instill meaning to it, when you see it as a response to something that's happened outside of them.

So I did that at the Tavistock and adult training at the Lincoln Center. I was just too overwhelmed, I was working full-time in a psychodynamic psychiatric hospital, I was doing these two trainings and I was in training analysis five times a week for the training. So it was just too much and I ended up just continuing with the adult program, which was really good.

That sounds like a huge undertaking. How do you find the time for that?

You know, we just did. There was a whole cohort of us, we just did. Analysis would be early in the morning prior to work, like six o'clock in the morning, and then drive off to work.

But again, being a psychodynamic psychoanalytic department, they were really supportive of everybody having their analysis, having their training.

Impressive.

Yeah. A little crazy. I continued the infant observation at the Tavistock. Then I continued the supervision and a lot of the theory at the Lincoln Center. I'd always had a half adult, half child practice. That was when I started to work more with adults. Then I came to Newfoundland and my first job was in a children's hospital. So I went back to children for a while for probably two years. And then when I went into private practice, I started veering more towards adults.

At what point did you first get interested in ISTDP?

When I came to Newfoundland, I was working in private practice. There was hardly anyone who'd had any psychodynamic training here. And so my practice was morphing and changing according to the population that I was working with here, which was very different to the UK at that time.

A friend of mine in the UK recommended a book she had just read, which was Lives Transformed by Patricia Coughlin. I read the book and I went, oh my goodness, this is how my thinking is changing, but I haven't formalized it in this kind of way. It made so much sense and I really wanted to learn more because this is exactly what I wanted to do.

As my kids were younger, I didn't have a lot of time. There wasn't Zoom or any online options at that time. So I just kind of plodded along until I started going to workshops. I went to hear Jon Fredrickson in Los Angeles, I went to some of Alan Abbass's Immersions. And started supervision with Alan.

After a few years of supervision I felt that I needed core training as a solid across the board basis. The one that just fitted best for me in many ways was the one with John Fredrickson. I liked his way of teaching, him being a musician and I was a musician, so that kind of really technical training in order to have the therapeutic process made a lot of sense to me.

What instrument do you play?

I play the flute as my primary instrument and I play the piano as well. When I went to university, I started off doing a music degree. Then changed over to mathematics and psychology. When I graduated, I went back and did a graduate diploma in music. Then I started a master's in flute performance.Then I moved to the UK so music went to the background for a while.

Do you still practice?

You know, I'm getting back into it. I've had periods where I have practiced a lot. So I lived in France for a year. With my kids and my husband. And I performed and played a lot there. And then there have been periods here where I've played, but not consistently. I've just found a pianist who wants to play so I'm starting to practice more regularly. Then I play kind of pop stuff with my son, he's a pianist.

You said the analogy of music training and psychotherapy training made sense when you started learning ISTDP.

Absolutely. That real focus on technique, on being able to see where you are in the triangle of conflict. What is the defense? How do you work with this defense? Really get the nitty gritty of how to work in the moment with the patient. Then to sort of zoom out as the technique is more embedded and kind of play the music of the therapy.

Really to do that attachment interaction of really using the technique in the service of something much, much bigger than technique. Using technique in the service of the relationship rather than for itself. I think that's what made a lot of sense, knowing what to do in each moment. That's how I learned to play music, from just relentless technique practices. To be able to play whatever music I wanted to play.

Do you think it's easier for someone who's trained in music to evaluate one's own work critically in a productive way?

That's a really good question, I've never thought about it. I wonder if it's a chicken or an egg thing. I guess, yes, I am so trained from such a young age at looking at what's happening in the moment and what needs to be adjusted in each moment. Whether it makes a difference or not, I don't know. But it made it easier for me to learn Jon's method because it was so familiar to me.

Many people report struggling in core training to find the right balance of evaluating oneself without being too critical. It seems that training as a musician provides a model for that.

I guess it depends very much on the type of experiences you have and one's own person as well. There is something in knowing how much you have to practice in order for something to become embedded and to work fluently going forward.

So there is that belief that if you keep working at something, it will come right. Then the various ways in which you can work with whatever you're struggling with so that it does fall into place. I think it is helpful in that way.

Also I was talking to a colleague who's a musician as well and we were looking back at our training and we both had really, really good teachers. I think it also does instill self-attack because especially with classical music, you're looking for perfection all of the time. Not that it's possible, but that's what you're looking for. Self-attack goes along with that, it's never quite good enough.

There might be no ideal way of learning?

It is a big question, I've thought about it so much in terms of education for kids and learning styles and how kids can be forced into a particular learning style that really doesn't help them because they need something that's true for them.There would be some who would really benefit from traditional education and others who would need a more kind of social approach to education.

It's true for core training as well, of how important it is that trainees have options and really research what kind of training would work best for them. As a trainer, I'm looking to see really what does my trainee need that would be specific to them, like we would in therapy as well.

Besides core groups, you also taught ISTDP in a psychiatry resident program.

They were in their fourth year of a five-year training in psychiatry and they were required by the Royal College in Canada to do one year of psychodynamic therapy. One morning every week in their fourth year to study this and to see a patient and have supervision.

So when I started teaching there, I developed the program, a general psychodynamic program with supervision and videotaped patients. Then as I got more proficient with ISTDP, I shifted it over to helping them learn certain concepts.

Mostly what I focused on was helping them understand the basic concepts in ISTDP. Triangle of conflict, a lot on anxiety, I think that's so important in psychiatry. They were seeing a patient for training but I also tailored the program to help them use the techniques within their psychiatry practice.

So anxiety was a big focus. Looking at self-attack and suicidal behavior as well. Throughout the supervision they learned more and more of the fundamental concepts and they found it very useful. A lot of them are still kind of using it in small ways, which is nice.

What was it like teaching people who haven't necessarily sought out that specific type of training? Usually with core groups people are highly motivated to learn exactly that method. Are there any differences?

Absolutely. I found it really exciting and just motivating for me because, yes, they came in with this very medical, biological understanding of mental health. So a lot of my teaching in the beginning was to look at attachment and at helping them to write formulations and think differently about their patients.

So in the beginning, I had a really nice group at the beginning, and they were very interested and passionate. Over time, word spread down the line to the years that were coming up, so people were quite excited.

But there were people who challenged me a lot, which I really like because it makes me think and it makes me fine-hone how I might explain concepts to them so that they'd understand it. Also to give them space to disagree until they could see for themselves what worked and what didn't.

But it was very gratifying, especially by the end, to see how they had grown as human beings and as clinicians. My hope is that that would be passed on to patients just to think about them differently and to be able to manage their anxiety.

So that even when patients are over threshold, that they can help them just to be present with them so that even if they're talking about medication, the patient can take in what's happening.

Listening to will was the other thing that was really important for me to help them to learn, to really see that the patient's will was on board. And if not, to see how you could help a patient to give them truly informed consent when possible. Obviously, if someone's floridly psychotic it's different. But a lot of their practice is people with personality difficulties and chronic depression and anxiety problems and eating disorders.

In a core group, there's a type of embedded head on collision. If you struggle with something, it's still the case that you keep coming there of your own free will. Is this different if you need to pass the training or you need the credits?

And sometimes I would have to use head on collision, but in a different way. With some of the people who were really challenging in a way that didn't allow them to learn anything, that really had problems with learning and were quite sort of rigid about how they saw things I just had to see how I could help them to broaden their minds a little bit in the service of helping the patient.

But the good thing is there's also a cohort, they're learning from each other as well. Yeah, there is that thing of they have to pass the course. Just like patients who just want to people

please, you get students who are going to do that too. They're just not going to get as much out of it. And that's it. That's also okay. It's also a learning experience.

You started teaching core groups after that.

I started teaching core groups and I actually passed over the psychiatric training to one of my trainees who really enjoyed teaching and is very good at it, so that's continuing, which I'm happy about.

My first core group was in Newfoundland, some were in other provinces in Canada but flew in for the training. The rest of them have been online. It's lovely, I really enjoy it. I've learned so much as a clinician from teaching. It's probably taught me more about ISTDP than all the excellent core training I had.

After rethinking everything I'd learned, It's almost like I came back to it with a different knowledge and what I learned from my trainees as well and their patients. Developing focus and tenaciousness. It's beautiful.

Do you only do ISTDP these days? Do you retain aspects of earlier training in your work?

It's a hard question to answer because yes, I only do ISTDP, except I do ISTDP my way. I'm me in the way that I work. While I am focused and tenacious, I'm also always working in the relationship and with the attachment and speaking to the attachment piece all the time. It's also how I teach.

It's always looking at when I'm using this technique, who am I talking to with the patient? Why am I talking this way? How am I really trying to help them have a healthier attachment relationship with me and also link it back to the genetic figures in their past. I think I bring my personality into it.

I was thinking during our discussion about what I bring from Jungian work. The thing that just shot out to me is Jung's notion of numinosity and the sense of something much bigger. There's something almost spiritual in the work that we do when the UTAs are in sync and we're in that working through phase and something deep and profound is happening.

I think that Patricia Coughlin talks about these as moments of real meeting, Something greater than the individual, I have that sense. But how am I using it? I don't know. I'm just living it with my patients when we're in that phase of therapy and it's a true moment of meeting.

Could one then call it a certain type of attunement?

Yes, it is an attunement. And it's an attunement that's not only conscious, it's an attunement of the unconscious, you know how you find yourself just saying things, and they just come out. Sometimes you even use an image the patient will say how did you know? That's exactly the images that I have in my mind. They are obviously giving me this, and I'm just finding words to put to it. Still there's something that isn't about that. I'm going to myself, where did that come from?

I think also the complexity and the, the allowing for complexity and the focus on complexity in Jung's work of the, you know, of conflict of contrast of masculine and feminine of different aspects of the individual and allowing for complexity of being. I think that comes through for me as well.

Do you find that this unconscious attunement is usually the result of good collaboration with the patient?

Certainly it’s usually not as strong near the beginning of therapy, that stage of really working for the resistance to come down and the UTA to rise. When the UTA is up there and the resistance is lower, I guess that's when that true collaboration is happening.

A shared dyadic state of working through?

It really does feel like it's something that's shared that sometimes feels almost bigger than the two of us. It's something quite profound.

It sounded like infant observation might have been equally useful concerning the attachment dimension of doing ISTDP.

That is pivotal in the way that I think about my work and think about the relationship with the patient. I am always looking at what is the unhealthy attachment that's happening in this moment? How can I offer a healthy attachment in terms of stepping out of any enactments of really helping them, allowing them to have what was forbidden for them?

What would you say changed the most in the way you practice after training in ISTDP?

Oh, everything. It changed my life in so many ways. It's changed my work. I'd reached a point with the psychodynamic work where I knew I could help certain patients, but there wee so many that I couldn't. I was getting a lot of referrals from psychiatry of patients that had had lots of therapies where nothing had worked and I just didn't know what to do. What I was doing wasn't working and that's actually what prompted me to do the core training.

So what has changed is the focus of my work, really being very clear on the problem, on helping them always with the problem that they're bringing in each moment, so that I'm always listening to what they want.

Oh, my whole conceptualization of what psychotherapy is has changed. You know, before it was always about the therapist or me as the one who had to make sense of and interpret and put together and the gift really of being able to trust the patient and to know that as you do that hard resistance work or all the work with fragility of really helping a person to integrate, that they know their story, they will put things together. I mean, it's just so beautiful for me that it comes from inside of the patient, rather than from the head down, which is the way that I had learned to do psychodynamic therapy at that time.

What's also changed is my flexibility, of really seeing where the patient is right now. Where are they stuck? How can I help them? How can I step out of helping them, in certain situations? How can I see what my patient is needing in this moment?

I also learned to be tough. Because as you will see with the case I'm presenting, it was a huge learning curve for me to become tough, to be relentless, to stand up to these resistances. And in this case, to use head-on collision for a long time and be relaxed about it and know this is the right thing to help this patient in this moment.

I'm looking forward to seeing that.

I wanted to ask you also about the regressive wish, how you came to focus on this aspect? What experiences did you have with patients that got you interested in that?

So the patient I'm going to present was one who was a great teacher to me. You will see that in the video that I present, that I recognized where I'd been focusing, which was kind of an umbrella package that would include the regressive wish. I'd been focusing on the umbrella, but it wasn't actually working. Also realizing where all of these breakthroughs, that were solid breakthroughs, were not really changing anything in the patient's life.

She taught me a lot when there was this moment where it was like oh my goodness, this is what's going on. This is the regressive wish right in front of me. How do I work with that? You will see the session where that happened.

I think this is just how things happen sometimes when you need to learn something. I had a bunch of patients who were all using the regressive wish. Once you see it, it's kind of hard to unsee it.

These are patients who are really suffering, they really want to get better. But there is this wish to hold on to an older way of being and to regress when they're in isolation of affect. It's a resistance that really holds on to their illness and are so unwilling to give it up because of wanting to retain this kind of enmeshed relationship or because of not wanting to face the complexity of life or the struggles of life.

When we're a child, things are done for us and things are made smooth, sober and made easy. But adulthood is difficult. We have to mess up. We have to make mistakes. We have to try things that don't work. We have to take risks, right? The regressive wish can hold people back from just embracing the complexity of life.

I had another patient with chronic depression who had tried so many treatments, ECT, all kinds of medications, all kinds of therapies. What became apparent within three sessions was that he didn't really want to get better, even though consciously he did. It's more than self-sabotage. There's a flavor to it that's not just that, it's actually the wish to go back to an ancient developmental stage. They actually find people who will enable that way of being, and it's easy as a therapist to get sucked into it to enable this way of being.

I had a bunch of patients, three or four patients like that and then I was supervising a trainee who had a patient who was also using the regressive wish. I could see how easy it is to get stuck in this idea that they're fragile and enact that with them. This patient was suffering. He had no life for himself and yet he was sort of wallowing in this childlike relationship in his childhood home.

Because these are often patients who were fragile but now they're healthy, we don't necessarily catch up with the patient we have in the room. They can hold onto us, too, in keeping us working with the patient that they were rather than the patient that they are. Who is healthy.

All of these experiences together and then seeing this patient, I went, yeah, this is a thing that's more than just the umbrella of transference resistance or an umbrella of self-defeating behavior. It's a very specific form of self-defeat, that's very unconscious.

Would this maybe come off as a barrier to engagement at the beginning but not enough to be a total obstacle for therapy and then emerge more fully later on in the process?

Yeah, not necessarily. It might emerge in the later phases of therapy. The patients that I'm thinking of have actually been quite ill, with fragility or repression and really suffering.Then all that work is done and you have the resistances that are coming up in the transference. They're healthier, they're able to kind of tolerate a high rise of feeling. But that's not enough.

There's a resistance that's blocking their full experience. It's got a whole lot of meanings attached to it, this transference resistance that need to be teased out. I'll talk about this in the theory part of my talk. The breakthroughs are not enough because there's something else that needs to be teased out that's relational, that is blocking the therapy and blocking them in their lives.

Sometimes it's there like with the male patient I was talking about. I used to call him Couchman because he was in a relationship with his couch and he wouldn't get off it really. His wife enabled him to stay on his couch and literally do nothing. He called it depression, but he was in isolation of affect all of the time.

And when was there any chance of him being able to live his life? For whatever his underlying reasons were that we got to over time the unconscious motivation to do that was just not there. It's not malingering where people are consciously trying to get attention, or to consciously keep some kind of relationship. It’s unconscious, they are actually suffering a lot.

So it's both. Sometimes it's there and you can see it right at the beginning. Sometimes it's other work you have to do first in order to allow your patient to access the fullness of their emotions and then they are more highly resistant. In those patients, I've seen that more often.

Or maybe that's why I get stuck more often, because maybe I see it more easily when they come in like that. But in the patients where you've really had to help them, they've really needed a lot of help. They couldn't do this on their own, and then they're healthier.Then you have to change tack to see how they are now using their illness unconsciously as a barrier to treatment. And why, what are the meanings behind it?

Last but not least, if you would describe your therapeutic flavor as something edible or drinkable, what would that be?

Gee. I'm having all kinds of images go through my mind. What comes to my mind is something like a Thai or Indian curry. The kind of really spicy. You experience it right away, but it's also very warm and it kind of spreads out. I think that's how I would describe my work. It's very focused. You might not see it with this patient, but I am also very warm. And I like spicy food.

What could that be specifically? Vindaloo, Thai red curries?

Yeah, Thai red curry! I'm just thinking it through now.

Something in particular?

Well, I'm vegan, right, so it would all be vegetables. But I'm having this image of like, you know, how in the restaurants, they'll put the curry on rice, and there's just this big bowl of the curry and the sauce. I think that's also what I want to always have in my work is a sense of a container that's there, that's holding and that's warm. For spicy things to be enjoyed, in a sense grown.