For pa­tients with mys­tery ill­nesses, help is com­ing from an un­ex­pected source

The Globe and Mail (Prairie Edition) - - FRONT PAGE - Erin An­der­ssen re­ports

For peo­ple with med­i­cally un­ex­plained symp­toms, the pain is real. But their best chance for re­lief won’t come from their fam­ily doc­tor or emer­gency room.

At his psy­chi­atric clinic at QEII Health Sci­ences Cen­tre in Hal­i­fax, Al­lan Ab­bass is show­ing video clips of his ther­apy ses­sions.

A man ar­rives via wheel­chair, drag­ging frozen feet the last few steps, lean­ing heav­ily on a cane. He takes a seat, talks to Dr. Ab­bass. When he leaves, he car­ries his cane un­der his arm.

A pixie-haired woman who has not spo­ken for a month sits be­fore him in an­other clip. She’s been seen by a team of doc­tors, who found noth­ing. By the end of the first ses­sion, she speaks, in full, clear sen­tences.

A mid­dle-aged of­fice man­ager with an un­con­trol­lable tre­mor is be­ing con­sid­ered for brain surgery; 90 min­utes of ther­apy later, she tri­umphantly waves a sta­pler in the air, her tre­mor gone.

Dr. Ab­bass knows how it sounds. He’s used to skep­tics, at least un­til he rolls the tape.

But these aren’t mir­a­cles, he says. This is sci­ence.

The peo­ple Dr. Ab­bass and his small team see are some of the most ex­pen­sive in the health­care sys­tem, and of­ten among the long­est suf­fer­ing. Re­search sug­gests they ac­count for up to half of all vis­its to fam­ily doc­tors and about 15 per cent of spe­cial­ist ap­point­ments, re­port­ing ail­ments that are of­ten sur­pris­ingly com­mon, such as mi­graines, lower back pain and up­set stom­ach, but that can’t be traced to a med­i­cal cause. In the worst cases, they re­turn again and again, haunt­ing wait­ing rooms and emer­gency de­part­ments, en­dur­ing rounds of tests and in­tru­sive ex­am­i­na­tions that come back neg­a­tive. As em­ploy­ees, they rack up sick days. Many end up on long-term dis­abil­ity. They are of­ten un­fairly sus­pected of fak­ing. But their pain is real, Dr. Ab­bass says. It’s just been caused, or made worse, by psy­cho­log­i­cal fac­tors.

Dr. Ab­bass, the head of Dal­housie Univer­sity’s Cen­tre for Emo­tions and Health, treats pa­tients with these un­ex­plained med­i­cal symp­toms, a phe­nom­e­non also known as so­mato­form dis­or­der, with an in­no­va­tive form of talk ther­apy that’s pro­duc­ing im­pres­sive re­sults. Called in­ten­sive short-term dy­namic psy­chother­apy, or ISTDP, the psy­cho­log­i­cal ap­proach deals with un­con­scious neg­a­tive emo­tions – of­ten guilt or anger linked to an emo­tional trauma suf­fered years or decades ear­lier – which have man­i­fested as a phys­i­cal symp­tom. Once the dev­as­tat­ing event is ad­dressed, the un­ex­plained symp­tom can dis­ap­pear or be sig­nif­i­cantly re­duced, Dr. Ab­bass says, in as many as three-quar­ters of pa­tients. In some cases, all it takes is a hand­ful of ses­sions.

Dr. Ab­bass and other health­care pro­fes­sion­als who’ve stud­ied ISTDP say the ap­proach, which is now be­ing tested more ex­ten­sively through pilot projects in Nova Sco­tia, could save the health-care sys­tem many mil­lions of dol­lars – to say noth­ing of eas­ing suf­fer­ing for the up to 25 per cent of pa­tients who may be af­fected by med­i­cally un­ex­plained symp­toms. One ex­am­ple, Dr. Ab­bass says, can be seen with ir­ri­ta­ble bowel syn­drome, a di­ag­no­sis that can have a psy­cho­log­i­cal cause. Ac­cord­ing to a re­cent pre­sen­ta­tion he made to the Nova Sco­tia gov­ern­ment, the 40,000 Nova Sco­tians alone with this con­di­tion bill roughly $160-mil­lion a year in di­rect health-care costs and dis­abil­ity pay­ments.

Dr. Ab­bass has a grow­ing stack of re­search to sup­port his case. In stud­ies, ISTDP has been found to re­duce hos­pi­tal stays, emer­gency-room vis­its and doc­tors’ ap­point­ments. One study, pub­lished in the Jour­nal of Psy­chi­atric Re­search in 2015, which fol­lowed roughly 890 Nova Sco­tians with

psy­chi­atric or med­i­cally un­ex­plained symp­toms over three years, re­ported an av­er­age sav­ings in health-care bills of $12,628 for each pa­tient who un­der­went ISTDP com­pared with a control group of pa­tients who didn’t. The av­er­age cost for ISTDP treat­ment for the pa­tients in the study was $708. A sim­i­lar study showed that 56 per cent of pa­tients on med­i­cal leave who re­ceived the ther­apy re­turned to their jobs – sav­ing mil­lions of dol­lars in dis­abil­ity pay­ments.

The ther­apy is get­ting at­ten­tion in other parts of Canada and in­ter­na­tion­ally. John Ogrod­niczuk, the di­rec­tor of the Univer­sity of Bri­tish Columbia Psy­chother­apy Pro­gram, who has worked with Dr. Ab­bass, calls his ap­proach “a model to fol­low,” one that “holds tremen­dous prom­ise” for hard-to-treat pa­tients. In Bri­tain, psy­chol­o­gist Leo Rus­sell, a for­mer stu­dent who now prac­tices ISTDP and heads a pub­lic clinic that spe­cial­izes in treat­ing so­mato­form pa­tients, says the re­search by Dr. Ab­bass presents “an ex­cel­lent so­lu­tion to an un­en­vi­able prob­lem of our time; how to get more for less.”

Dr. Ab­bass’s work could help count­less peo­ple. But more broadly, it chal­lenges the way so­ci­ety – and the med­i­cal sys­tem – have tra­di­tion­ally sep­a­rated phys­i­cal symp­toms from mental ill­ness and emo­tions, di­vid­ing what the body feels from what the mind thinks. So stom­ach pain gets treated in one build­ing, and anx­i­ety in an­other, and sur­geons don’t reg­u­larly con­sult with psy­chi­a­trists. The no­tion that stress can make us phys­i­cally sick is hardly new. But if a pa­tient is told that the pain they feel is “all in their head,” they’d prob­a­bly be in­sulted.

Yet if a bad day can cause a headache, why can’t many bad days cause more se­ri­ous phys­i­cal problems, even decades later?

Why, when we ex­pe­ri­ence pain, does a tu­mour make more sense than a trauma?

Elizabeth Burns, 56, is one of the pa­tients that Dr. Ab­bass shows on video. She ar­rives to her first ther­apy ses­sion in flow­ered pa­ja­mas, walk­ing gin­gerly from the Hal­i­fax hos­pi­tal room where she’s been liv­ing for seven months. She’s car­ry­ing a vomit tray. Weak­ened by mal­nu­tri­tion, her voice has with­ered to a whis­per.

Her doc­tors booked the ap­point­ment with Dr. Ab­bass be­cause they couldn’t find a so­lu­tion to her se­vere stom­ach problems – not even af­ter pok­ing and prod­ding by spe­cial­ists, and a marathon of ul­tra­sounds, CT scans and un­suc­cess­ful drug ther­a­pies. When Ms. Burns learned they were send­ing her to see a shrink, she raged at them. She fig­ured the doc­tors had given up, that they thought she was nuts. As if any­one, she says, could – or would – fake months of un­con­trolled vom­it­ing, stom­ach pain that felt worse than child­birth, and never be­ing able to eat with­out a bucket at the ready.

On the video, she slumps wearily in her chair, greet­ing Dr. Ab­bass’s si­lence with a hos­tile stare. As she ex­plains later in an in­ter­view, run­ning through her mind is this thought: “What the hell are you go­ing to do for me?”

Years ago, work­ing in fam­ily prac­tice and emer­gency rooms in Nova Sco­tia, Dr. Ab­bass was ask­ing him­self the same ques­tion when con­fronted by pa­tients such as Ms. Burns. He would run the ap­pro­pri­ate tests and come up empty.

“I didn’t have a clue,” he re­calls. “But I knew some­thing wasn’t right.”

In the fall of 1990, he took a year off to study at McGill Univer­sity, where, by chance, he at­tended a pre­sen­ta­tion by a psy­chi­a­trist named Habib Da­van­loo, who had pi­o­neered ISTDP two decades ear­lier and was demon­strat­ing the re­sults with pa­tient videos. “I was shocked by what could hap­pen in an hour or two of in­ter­views,” Dr. Ab­bass re­calls.

“I was con­vinced this was some­thing im­por­tant.” Two years later, he went on to com­plete a psy­chi­atric res­i­dency, study­ing for a decade un­der Dr. Da­van­loo, who is now in his 90s and a pro­fes­sor emer­i­tus.

The ther­apy is based on the idea that re­pressed neg­a­tive emo­tions can emerge as phys­i­cal symp­toms, and that trig­ger­ing, or re­leas­ing, those emo­tions can re­lieve them. Where cog­ni­tive be­havioural ther­apy (CBT), for in­stance, fo­cuses on chang­ing thought pat­terns to al­ter be­hav­ior, ISTDP draws a client’s at­ten­tion to their phys­i­cal re­sponses to ad­dress un­re­solved feel­ings such as anger or guilt. One unique fea­ture of the ther­apy is that ses­sions are video­taped so that ther­a­pists can re­view their work with col­leagues and some­times with pa­tients them­selves. At the Hal­i­fax clinic, pa­tients come for a sin­gle ses­sion, de­signed as a test to see if the ther­apy might work for them; on av­er­age, treat­ment lasts about seven ap­point­ments, al­though Dr. Ab­bass has treated his most se­ri­ous cases for as many as 60 ses­sions.

True to its name, the ses­sions are in­tense: This is not warm and fuzzy ther­apy. Dr. Ab­bass calls it “tough coach­ing,” or a “pos­i­tive ir­ri­tat­ing process.” In ISTDP, clin­i­cians do not sit back, tak­ing notes, pos­ing oc­ca­sional queries, while the pa­tient takes the lead. They are ac­tive par­tic­i­pants, ask­ing ques­tions and chal­leng­ing an­swers.

Though tow­er­ing at a lean 6foot-9, Dr. Ab­bass has mas­tered shrink­ing in a chair, and pos­ing dark ques­tions with ge­nial cu­rios­ity: “Did you feel so an­gry to­ward your [abu­sive] mother that you wanted to kill her? How did you want to kill her? What is your body do­ing right now, think­ing about that?”

“The idea from the first ses­sion,” he ex­plains, “is to stir up emo­tions so that symp­toms come and go – ev­i­dence that there’s a psy­cho­log­i­cal cause, and also, con­fir­ma­tion that doc­tors haven’t missed a phys­i­cal ex­pla­na­tion.” (Usu­ally, by the time, they ar­rive in Dr. Ab­bass’s clinic, ev­ery pos­si­bil­ity has been ex­plored, he says, but in rare cases, his team has sent pa­tients back to the re­fer­ring spe­cial­ist, rec­om­mend­ing more tests – one woman had a de­vel­op­ing case of pneu­mo­nia; a male pa­tient was found to have gall­stones.)

Stir up emo­tions, Dr. Ab­bass says, and what you find, in as many as 95 per cent of his cases, is a child­hood story, one that’s been buried deep, car­ried like a ma­lig­nant cell into adult­hood, un­til it emerges as headaches or stom­ach pain or any num­ber of phys­i­cal ail­ments. The story could be abuse, aban­don­ment or ne­glect. The death of a par­ent. A toxic di­vorce. Re­searchers call these “ad­verse child­hood ex­pe­ri­ences,” and more stud­ies are link­ing early trauma to later-in-life problems, not only ad­dic­tion and mental ill­ness, but di­a­betes, heart dis­ease and so­matic or un­ex­plained med­i­cal symp­toms.

For some, the symp­toms may ap­pear af­ter a sud­den shock, and re­cent stress­ful event – walk­ing in on a cheat­ing spouse, for in­stance. Some­times, Dr. Ab­bass says, the event isn’t even neg­a­tive – a big pro­mo­tion or life change can also be a trig­ger. De­pres­sion and anx­i­ety, or per­son­al­ity dis­or­ders, also play a sig­nif­i­cant role.

In the video ex­am­ples, Dr. Ab­bass waits for the pa­tients to metaphor­i­cally open a door – a ref­er­ence, typ­i­cally, to a dif­fi­cult fam­ily mem­ber or painful past event – and then pushes them to ex­press their fear or anger or guilt, draw­ing at­ten­tion to the way they tense up or make a fist or take a big sigh. In­deed, on the videos, pa­tients tended to bring up the trauma al­most spon­ta­neously, like a gasp af­ter be­ing un­der wa­ter too long. Even so, Dr. Ab­bass says, the pa­tient will of­ten deny feel­ing any­thing, un­til he

points out their body’s re­sponse. He might en­cour­age them to imag­ine their rage be­ing ex­pressed by a third per­son, or even di­rected at him, their per­sis­tent in­ter­viewer. Some pa­tients, he says, of­fer graphic de­scrip­tions of their pain – the sen­sa­tion of a hand tight­en­ing on their neck or a knife stuck in their chest – and “you can pre­dict what the rage is go­ing to do.”

In one ses­sion, a 68-year-old pa­tient refers to pain “like his head is be­ing blown off”; as the ses­sion goes on, he an­grily de­scribes hat­ing an abu­sive par­ent so much that as a child he wanted to shoot them in the head. By the eighth ses­sion, af­ter four decades of un­ex­plained pain, the pa­tient re­ported be­ing vir­tu­ally symp­tom-free, Dr. Ab­bass says. “At the end of my life,” the pa­tient says on the tape, in his last ses­sion, “I am start­ing again.”

In the di­verse field of psy­chol­ogy, ISTDP does have crit­ics. Alan Kar­bel­nig, a psy­chol­o­gist in Cal­i­for­nia who at­tended a con­fer­ence in 2016 at which Dr. Ab­bass spoke and showed videos of his ses­sions, sug­gests that ISTDP “cre­ates a bizarre, stress­ful en­vi­ron­ment for pa­tients,” in which they may to be too quick to please their ther­a­pist by pro­vid­ing the right an­swers.

Dr. Kar­bel­nig spe­cial­izes in psy­cho­anal­y­sis, a long-term, pa­tient-led ther­apy that also ex­plores links be­tween the un­con­scious and the con­scious, so his ob­jec­tions to a more forced, short-term ap­proach are per­haps not sur­pris­ing. But even fans of Dr. Ab­bass point to some of the ther­apy’s short­com­ings.

“Inel­e­gantly per­formed ISTDP can be a source of emo­tional harm,” sug­gests Robert Tarzwell, a clin­i­cal as­sis­tant pro­fes­sor of psy­chi­a­try at UBC, who has con­ducted brain-imag­ing re­search with Dr. Ab­bass, “whereas this is less likely with tech­niques such as CBT.”

As well, un­like CBT, which can be prac­tised from a man­uaI, ISTDP takes longer to learn, with stu­dents un­der close su­per­vi­sion. In fact, Dr. Ab­bass cur­rently trains clin­i­cians around the world in the ther­apy, in­clud­ing in Bri­tain, and in Nor­way, where ther­a­pists study for six years be­fore be­ing cer­ti­fied and where the pub­licly funded use of ISTDP is ex­pand­ing for treat­ment-re­sis­tant psy­chi­atric pa­tients, in­clud­ing those with med­i­cally un­ex­plained symp­toms. (In Canada, al­though gov­ern­ments have been ex­pand­ing ac­cess to talk ther­apy in the pub­lic sys­tem, more spe­cial­ized treat­ments such as ISTDP aren’t widely avail­able, but there are prac­ti­tion­ers scat­tered across the coun­try, mostly in pri­vate prac­tice.)

Other Cana­dian ex­perts who treat so­mato­form dis­or­ders sug­gest pa­tients need bet­ter ac­cess to a va­ri­ety of op­tions. The Health Psy­chol­ogy Clinic at the Royal Univer­sity Hos­pi­tal in Saska­toon, for in­stance, treats peo­ple with un­ex­plained symp­toms with a less-in­ten­sive ver­sion of ISTDP ther­apy. At UBC’s Neu­ropsy­chi­a­try Clinic, pa­tients with med­i­cally un­ex­plained symp­toms are of­fered physio or oc­cu­pa­tional ther­apy, as well as coun­selling and med­i­ca­tion, de­pend­ing on their sit­u­a­tion. (Two of the clinic’s psy­chol­o­gists, An­ton Scamvougeras and An­drew Howard, pub­lished a book this fall call­ing for more re­sources and physi­cian ed­u­ca­tion for these pa­tients.)

ISTDP, as with any treat­ment, isn’t a so­lu­tion for ev­ery­one – as Dr. Ab­bass read­ily ad­mits. Not ev­ery­one gets bet­ter, and in many of his pa­tients, symp­toms im­prove but still linger.

And he ac­knowl­edges the con­cerns about ISTDP – when he first watched the video as a stu­dent, he, too, was con­vinced the ther­a­pist was “at­tack­ing the pa­tient.” But clin­i­cians are trained to push, he says, only as far as the pa­tient will al­low. He also points out that, un­like the closed-door ap­proach of many ther­a­pies that still rely largely on a clin­i­cian’s own notes and sub­jec­tive con­clu­sions, the video­tap­ing, pa­tient feed­back sur­veys and peer-re­view as­pects of ISTDP cre­ate a level of su­per­vi­sion that safe­guards pa­tients and catches off-track ther­apy quickly. The re­sults, he ar­gues, speak for them­selves.

“This isn’t the ex­pla­na­tion for all hu­man suf­fer­ing,” Dr. Ab­bass says. But for many pa­tients, “we can’t just put a pill on it. It just doesn’t work.”

A few years ago, Sa­muel Camp­bell was called to the emer­gency room at the QEII to see a woman com­plain­ing of stom­ach pain. She had been in three times in as many days, ask­ing for mor­phine so in­sis­tently that the nurses be­lieved she was ex­ag­ger­at­ing to get drugs.

When Dr. Camp­bell pulled back the cur­tain to ex­am­ine her, he found her writhing in pain. The reg­u­lar tests, how­ever, had found noth­ing. But Dr. Camp­bell re­called a pre­sen­ta­tion he had just heard by a psy­chi­a­trist in the hos­pi­tal, and so he asked her a new ques­tion: What was hap­pen­ing in her life?

She told him, in a flood of emo­tion, about her adult daugh­ter who had moved back into her home to flee an abu­sive re­la­tion­ship. They didn’t have much money, and she was wor­ried about how to sup­port her. Dr. Camp­bell lis­tened, sug­gested her pain might be caused by stress and pro­posed an ap­point­ment with Dr. Ab­bass.

When he came back, ready to give her a script to help with the pain, she de­clined. The pain, she told him, was gone.

But it was still real, says Dr. Camp­bell, the chief of the emer­gency and trauma cen­tre. “Peo­ple aren’t com­ing at six in the morn­ing, and wait­ing six hours in emer­gency, be­cause noth­ing is wrong with them.”

Their problems, how­ever, don’t reg­is­ter on a tra­di­tional med­i­cal scan. Ac­cord­ing to Dr. Camp­bell, as many as 20 per cent of pa­tients who come to emer­gency leave with­out a con­firmed di­ag­no­sis. (On a med­i­cal chart, it’s of­ten checked as NYD – no­tyet di­ag­nosed.) The doc­tor rules out a heart at­tack or a blood clot and sends them home. At other times, “we give it our best guess,” he says. Some­times, that best guess sticks – what med­i­cal pro­fes­sion­als call “di­ag­nos­tic mo­men­tum” – and the pa­tient leaves con­vinced that their prob­lem has been solved, car­ry­ing a la­bel back to their GP and set­ting up a new round of un­nec­es­sary test­ing.

But there’s good rea­son for this: Doc­tors are afraid to miss some­thing. “The one thing in medicine you don’t want to do is to tell peo­ple they have stress-re­lated ill­ness, and it turns out they have cancer,” Dr. Camp­bell says.

The risk of mov­ing too quickly to a psy­chi­atric ex­pla­na­tion trou­bles Michael Ne­gra­eff, the head of pain man­age­ment at UBC’s Depart­ment of Anes­the­si­ol­ogy, Phar­ma­col­ogy and Ther­a­peu­tics, al­though he con­cedes it runs both way – when a phys­i­cal ex­pla­na­tion is found, doc­tors “for­get” the role of psy­cho­log­i­cal fac­tors. “There’s stigma if we over­at­tribute to psy­chol­ogy,” he says. “But there’s risk of over­med­i­cal­iz­ing problems if we over­at­tribute to bi­ol­ogy.” To de­sign a bet­ter sys­tem, he says, “we just need to re­mem­ber that all fac­tors are im­por­tant, not to dis­miss any pre­ma­turely.”

But pa­tients want an­swers, un­der­stand­ably, ones with­out a so­cial stigma at­tached to them. Some­times, when Dr. Camp­bell pro­poses an ap­point­ment with psy­chi­a­try, peo­ple storm out. “One pa­tient wrote a sar­cas­tic note on the in­ter­net and called me an idiot.” In some cases, they just want a la­bel slapped on their symp­toms – and doc­tors give in. “I am not judg­ing,” Dr. Camp­bell says. “I was also do­ing this for the last 10 years. It was my way of keep­ing the con­veyor belt go­ing.”

Cre­at­ing a closer con­nec­tion be­tween ER doc­tors and clin­i­cians at the Cen­tre for Emo­tions and Health ap­pears to have slowed at least one con­veyor belt. Re­peat ER vis­its for so­mato­form pa­tients fell, on av­er­age, by 69 per cent fol­low­ing a pilot pro­ject. With the ad­di­tional fund­ing from the pro­ject, doc­tors were ed­u­cated on how to iden­tify peo­ple with med­i­cally un­ex­plained symp­toms and a se­nior psy­chi­a­try res­i­dent was tem­po­rar­ily placed in the ER to foster re­fer­rals.

A sec­ond pilot pro­ject, ex­tended from three to four years and funded by the prov­ince, al­lowed the cen­tre to hire ad­di­tional staff to of­fer ISTDP to pa­tients at sever- al pri­mary-care clin­ics. As a re­sult of early pos­i­tive find­ings, the N.S. Health Depart­ment is now con­sid­er­ing a provincewide pro­gram that would place more clin­i­cians in more lo­ca­tions, giv­ing lo­cal emer­gency de­part­ments and fam­ily doc­tors bet­ter ac­cess to ISTDP for their pa­tients. The pro­gram would cost $1.8-mil­lion a year, Dr. Ab­bass es­ti­mates, but based on the re­search, he says, it could save at least $5-mil­lion.

Dr. Camp­bell says his col­lab­o­ra­tion with Dr. Ab­bass has al­ready made his work more ef­fi­cient. When he sus­pects a so­mato­form dis­or­der, he now ex­plains how stress works, and sug­gests a psy­chi­atric eval­u­a­tion at the same time that he pro­poses other med­i­cal tests.

He wants pa­tients to un­der­stand that an emo­tional cause should be in­ves­ti­gated with the same cred­i­bil­ity as angina or mi­graines – not as the hail-Mary pass for a baf­fled doc­tor but, in the right cases, as le­git­i­mate as the CT scan check­ing for tu­mours.

It’s been nearly two years since com­puter spe­cial­ist Matthew Is­nor fin­ished his stretch of ISTDP to treat a case of Tourette’s-like symp­toms, which came on sud­denly at age 21.

By the time, he was re­ferred to Dr. Ab­bass, he’d seen a neu­rol­o­gist and a psy­chol­o­gist and was tak­ing half a dozen pre­scrip­tions, the side ef­fects of which, he says, were even worse than the con­stant fa­cial twitches, snorts and ticks. On his video, he ar­rives, clear­ing his throat painfully, ev­ery 15 sec­onds or so. When he leaves, the snort­ing and hack­ing has less­ened. Fast for­ward seven ses­sions, and they are barely no­tice­able.

In an in­ter­view in­ter­rupted only by oc­ca­sional throat-clear­ing, Mr. Is­nor says Dr. Ab­bass is “like a hawk” dur­ing ther­apy. “When he is ask­ing you ques­tions, he is pay­ing at­ten­tion to what you are say­ing, how you are say­ing it, even what your eye­brows are do­ing.” Over a to­tal of 20 ses­sions, they talked about un­re­solved anger from his child­hood and the stress of hav­ing a brother with se­vere Tourette’s, which is why Mr. Is­nor’s symp­toms were first as­sumed to be hered­i­tary. Dig­ging deep into that emo­tional his­tory, he says, is what slowly made him bet­ter. His symp­toms are mild enough now that he has stopped his med­i­ca­tion and re­sumed a nor­mal life.

An­other pa­tient, Kim Hawes is a pub­lic ser­vant who re­turned to work af­ter eight years on dis­abil­ity fol­low­ing 45 ses­sions with Dr. Ab­bass. She com­pares the ther­apy to “emp­ty­ing pock­ets” of emo­tion one by one, “un­til they were all gone, and I walked out a free woman.” Fol­low­ing an ac­ci­den­tal chem­i­cal ex­po­sure at work, she de­vel­oped de­bil­i­tat­ing sen­si­tiv­i­ties to cer­tain en­vi­ron­ments. At one point, she could barely han­dle leav­ing her house. Last year, she took the train across the coun­try. She has be­come a spokesper­son for ex­pand­ing the treat­ment to more pa­tients. “I thought I would be on dis­abil­ity for­ever.”

And then there this is Elizabeth Burns, the pa­tient with un­con­trolled vom­it­ing, who ar­rived at her sec­ond ses­sion pre­pared to give ther­apy a chance. That day, she spoke about the sex­ual abuse that forced her to leave home when she was a teenager. Un­til then, she had told no one but her hus­band, her high-school sweet­heart.

“How do you feel?” Dr. Ab­bass asks, at the end of their sec­ond meet­ing.

“Lighter,” she says. “Guilt and rage can weigh down a per­son,” he tells her. “In their bones, they can feel bad.”

A few days later, Ms. Burns went home from the hos­pi­tal. “I guess he was treat­ing me, not my stom­ach,” she says.

Now she is back to her nor­mal life, gar­den­ing and spend­ing time with her fam­ily, en­joy­ing meals, crack­ing jokes. In the last year, she says she felt that fa­mil­iar sick­ness in her stom­ach only twice.

When it hap­pens, she slips away and pre­tends she is back in the room with Dr. Ab­bass, re­mem­ber­ing their con­ver­sa­tions. “Then I feel bet­ter, and I go back up, and join the world again.”

PHO­TOS BY DARREN CALABRESE/ THE GLOBE AND MAIL

Right: Kim Hawes suf­fered for more than eight years from a chem­i­cal sen­si­tiv­ity, ago­ra­pho­bia, anx­iey and de­pres­sion that left her on dis­abil­ity from a job in the Nova Sco­tia Jus­tice Depart­ment. Af­ter par­tic­i­pat­ing in in­ten­sive short-term dy­namic psy­chother­apy (ISTDP) with Dr. Al­lan Ab­bass, Ms. Hawes was able to re­turn to work and is off her med­i­ca­tion.

IL­LUS­TRA­TION MATT FRENCH

Cen­tre: Dr. Ab­bass, mid­dle, re­views video of ther­apy ses­sions with col­leagues An­gela Cooper, left, and Joel Town. Dr. Ab­bass spe­cial­izes in a form of ther­apy called ISTDP. Left: Matthew Is­nor de­vel­oped Tourette’s-like symp­toms when he was 21. His fa­cial twitches and throat-clear­ing all but dis­ap­peared af­ter seven ses­sions with Dr. Ab­bass.

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