S:t Lukas Educational Institute is pleased to announce the 2020 Swedish Immersion in Davanloo’s ISTDP with Dr. Allan Abbass.
Intensive Short-term Dynamic Psychotherapy (ISTDP) begins with an intensive and comprehensive evaluation and treatment session called the Trial Therapy. The trial therapy seeks to establish both a conscious and unconscious therapeutic alliance, gather a complete history of problem areas, past and present relationships, and related medical and social factors, while testing a client’s response to this therapeutic mobilization of the unconscious. By the end of the interview, therapist and patient should both have information about the suitability of this treatment, and what format of the treatment may be most beneficial. The trial therapy is typically conducted in one session, but sometimes over more than one session.
Based on a study of several hundred trial therapies, we have found that the trial therapy is effective in reducing symptoms and interpersonal problems, and also effective in reducing excess healthcare use. There is evidence that it is beneficial in the hands of new learners, and that is more effective than standard psychiatric intake interviews.
In this 9th Swedish Immersion in ISTDP, Dr. Allan Abbass and colleagues will provide a detailed video–based study of a series of trial therapies from across the two spectra of patients. Hence, we will look at entire trial therapies of patients with low to moderate resistance, high resistance, as well as patients who suffer from repression and significant fragility. The goal of this course is to assist attendees to master the understanding of functions and processes involved in the trial therapy to help build momentum from the very first session of their treatment courses.
ABOUT THE SPEAKER
Dr. Allan Abbass is Professor of Psychiatry and Psychology, Director of Psychiatric Education, and founding Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Canada. He is a leading award-winning teacher and researcher in the area of Short -Term Psychodynamic Psychotherapy, with over 250 publications and 300 invited presentations over the globe. Some of these articles can be viewed at www.allanabbass.com
He is known for simplifying the theory and technical aspects of the ISTDP model, with the use of algorithms, and through highlighting moment-to-moment processes that inform interventions. He has received numerous teaching awards, including two national awards in psychiatry, and has been honored with visiting professorships at several international universities and institutions, holds recurrent intensive training programs in Norway, Sweden, Italy, Switzerland and Canada, and provides internet-based training to professionals and groups around the world.
Location: Stockholm, Ersta Sköndal Bräcke Högskola, Campus Ersta, Stigbergsgatan 30
Fee:6950 SEK including welcome reception on first day and lunch all three days. 5600 SEK for any ISTDP core-training group members or full-time students. The fee is 75% refundable until June, 30, 2020. Non-refundable after June, 30, 2020.
Registration is mandatory as seating is limited. The course sold out last year so register now to avoid disappointment.
REGISTRATION
To register email Jan Sandström at jan.sandstrom@esh.se – Include your name, profession, invoice address and e-mail address – Please state if you have any food allergies – For Swedish registration, please include the organisation number of your workplace (if your employer is paying) or personal number (if you pay yourself)
För några veckor sedan publicerade Dion Nowoweiski med flera en observationell studie av ISTDP för ätstörningar. Psykologisk behandling av ätstörningar har visat sig vara en stor utmaning. Det finns ett stort antal studier där resultaten tyvärr varit nedslående. Vad gäller psykodynamisk terapi så blev det rubriker inom terapivärlden under 2013. Då hade en dansk forskargrupp ledd av Stig Poulsen publicerat en ny studie om behandling av bulimi. I studien (som jag tidigare beskrivit på psykodynamiskt.nu) var KBT tre gånger mer effektivt än objektrelationell psykoanalytisk behandling. Skulle det visa sig att Bruce Wampolds common factors-teori inte stämde för ätstörningar?
Forskningslägeätstörningar
Vad gäller psykologisk behandling av bulimi finns det mer forskning på KBT än någon annan metod. En Cochraneöversikt från 2009 visade att det fanns ett visst empiriskt stöd för KBT vid bulimi. Vidare finns det några jämförande studier av KBT och IPT där man visat att de båda behandlingarna har liknande effekt. Dock sker förbättringen snabbare i KBT. Efter den danska studien (se ovan) har det kommit fler studier på PDT vid bulimi med bättre resultat. Bland annat en jämförande studie där KBT och PDT visade sig vara jämbördiga för tonåringar med bulimi (runt 30% remission). I denna studie var den psykodynamiska behandlingen tydligt strukturerad och fokuserad på bulimisymptomen. Detta skilde den från Poulsens behandling som snarare instruerade terapeuten att fokusera på personlighetsorganisation.
För anorexi finns det också ett antal studier, men resultaten är dessvärre sällan särskilt övertygande. En Cochraneöversikt från 2015 menar att ingen behandling på ett övertygande sätt har visat sig överlägsen treatment-as-usual i en välkontrollerad studie. Ett undantag från detta är en forskargrupp ledda av Stephan Zipfel som 2014 publicerade en stor studie där psykodynamisk behandling jämförts med KBT. I den här studien fann man att den psykodynamiska behandlingen hade en viss fördel vid 12-månadersuppföljningen, men att KBT hade en snabbare verkningseffekt. Andelen som uppnådde “full återhämtning” var dock, nedslående nog, få: mellan 14 och 19%. Detta trots att patienterna fått runt 40 sessioner terapi.
Slutsatsen är alltså att det finns andra behandlingar som sannolikt är effektiva för ätstörningar, men att de tyvärr bara hjälper en liten andel av patienterna.
ISTDP för ätstörningar
“A potential explanation of the poor response rate to ED treatments may be due to structural deficits in the psychic organization of this patient population.” – Nowoweiski et al., 2020.
Redan 2013 publicerade Allan Abbass med kollegor en artikel där de beskriver ISTDP för ätstörningar. Artikeln, som ger en teoretisk grund för ISTDP vid ätstörningar, betonar att patientgruppen i hög utsträckning har omfattande känsloregleringsbrister (vad vi kallar för “repression” och “skörhet” i ISTDP). Kanske kan ett starkare fokus på dessa brister leda till bättre utfall? Abbass med kollegor diskuterar även att behandlingslängden då kan behöva vara långt mycket längre än “korttidsbehandling”. Uppemot 100 sessioner för de mest sköra fallen.
I den nypublicerade studien har man för första gången gjort en empirisk utvärdering av ISTDP vid ätstörningar. Det var den australiensiska psykologen Dion Nowoweiski som var studiens huvudförfattare. Studien beskriver 27 personer med anorexi, bulimi eller ätstörning-UNS som sökte behandling vid Halifaxkliniken. De hade en stor grad av samsjuklighet inklusive depression, somatoforma störningar, ångestproblematik och personlighetssyndrom. Efter i genomsnitt 9,81 sessioner ISTDP hade de erhållit stora effekter. Detta gällde både psykiatriska symptom (cohen’s d = 1,43) och på interpersonella svårigheter (cohen’s d = 1,74).
Dion Nowoweiski
KOSTNADSEFFEKTIVITET
I kostnadseffektivitetsanalysen visade man vidare att behandlingen ledde till stora kostnadsbesparingar. Man sparade runt $15000 kanadensiska dollar per patient över de tre år som följde behandlingen. Detta beror på minskade sjukhus- och läkarkostnader. Om jag räknar om det till svenska kronor och avrundar så ger alltså en investering om 10 000 SEK per patient en besparing om 110000 SEK. För varje investerad krona får samhället alltså tillbaka tio. (Läs mer om kostnadseffektivitet här eller här)
Trots sina begränsningar (litet stickprov, ostrukturerad diagnostik, inget specifikt ätstörningsmått, ingen kontrollgrupp osv.) så är det här en viktig publikation. Inte minst som ett steg på vägen mot framtida studier som kan ge mer definitiva svar på om ISTDP erbjuder en ny väg för ätstörningsbehandlingar. Ett nytt hopp för en patientgrupp där vården inte har så mycket att erbjuda.
Nowoweiski D, Abbass A, Town J, Keshen A, Kisely S. An observational study of the treatment and cost effectiveness of intensive short-term dynamic psychotherapy on a cohort of eating disorder patients. J Psychiatry Behav Sci. 2020; 3(1): 1030.
We did an interview with Jon Frederickson ahead of his first ISTDP workshop on Finnish soil at the end of March. In the interview he discusses the relationship between psychoanalysis and ISTDP, as well as his own discovery of ISTDP and other themes.
Jon Frederickson
How do you feel about going to Finland to present for the first time? I’m very excited of course to teach a new group of therapists. But, honestly, what has me really excited is to be in the homeland of Sibelius. Such a giant in classical music! If only I had a little more time, I would visit his home in the woods and absorb the mood of the forest of which his music spoke.
For people who don’t know you, how did you end up becoming a therapist and later on specializing in ISTDP? I was initially inspired to become a therapist through the writings of Erich Fromm. Such an inspirational writer, a psychoanalyst, a sociologist, an atheistic mystic. How could I not be fascinated by such a brilliant and heartful role model! I became psychoanalytically trained and some years later had a chance to see videotape of ISTDP. It was like seeing psychoanalysis live and active in a way I had never dared to imagine.
In the nineties you had quite a lot of training with Patricia Coughlin, and later on you met Davanloo and trained with him. How did you find training with Patricia and Davanloo? Supervision with Patricia revolutionized my work as a therapist, making my therapy far more focused and effective. With Davanloo, it was a bit startling. I was chair of a psychoanalytic psychotherapy training program and yet with Davanloo I was for the first time understanding many concepts on far deeper levels than I ever had before. Sadly, he dismissed psychoanalysis at that point in his career. Yet his training only deepened my appreciation and understanding of its depths.
Speaking of psychoanalysis, what’s your perspective on the relationship between psychoanalysis and ISTDP? Freud said that any therapy is psychoanalysis if it operates with a concept of the unconscious and the transference. ISTDP meets those criteria. ISTDP is obviously more active an approach than a classical analysis done on the couch. However, its work is entirely based on the exploration of unconscious feelings, addressing unconscious anxiety, and the careful work with unconscious defenses and resistance in the transference relationship. And in line with Bion’s statement about psychoanalysis, our work is based on faith that the patient will become healed by becoming at one with the emotional truth of this moment.
In Helsinki you’re doing a workshop on trauma. Does ISTDP offer a unique take on trauma, or is this a standard psychoanalytic perspective? I don’t know how to answer that because psychoanalysis is such a pluralistic community now that it would be reductionistic to claim that there is “one” way psychoanalysts work with trauma. Unlike some other communities, ISTDP therapists and analysts understand that the effects of trauma depend on multiple factors such as the child’s age when the trauma occurred, nature of the trauma, genetics, temperament, and the parental response to trauma.
We also recognize that dealing with the trauma involves not just the mind but the body. And we also recognize that issues of symbolization and mentalization must be carefully attended to. And we also note whether it was a one-time trauma or a case of cumulative trauma. All these factors lead to a complexity in treatment which any psychoanalytically informed clinician must take into account.
ISTDP is in many ways still a “new form of therapy”, given that so few people have been trained in it.What are some of the aspects of ISTDP that still are in need of development? ISTDP, while quite effective in research studies, has yet to develop research specifically into the treatment of narcissistic personality disorder and perversions. Our recent research with drug addicts is showing a surprising amount of effectiveness with patients suffering from psychotic symptoms. So I think we need to do more research into what differentiates the near-psychotic group of patients who respond to work on splitting and projection, and the psychotic level of character structure that does not respond. Given the successes we are having, I am hoping we can build on Marcus’ work on near-psychosis in our future work.
A common reaction to reading about ISTDP or watching a presentation is that the method is confrontational and even violent. Should ISTDP be less confrontational? ISTDP isn’t violent, defenses are. That’s we try to block and identify defenses which do violence to the patient. Let us not forget that defenses cause the patient’s problems and presenting problems. They are a form of internalized violence. And the most compassionate thing we can do is block unconscious forms of violence that hurt the patient, and to help them see these previously invisible mechanisms so that he they have a chance to do something different.
Likewise, we don’t interrupt the patient. We interrupt the defenses that interrupt the patient. We never interrupt the heart speaking from its depths, we interrupt the defenses that keep the patient from speaking from her heart. Also, the idea of confrontation makes no sense about 99% of the time. After all, if the poor patient can’t see a defense, is not using it intentionally, and is unaware of it, he just needs some compassionate help to see his defenses. Otherwise, how could he do anything different in the moment?
Think of self-attack. It’s a form of violent communication to oneself. A child who grew up with a critic becomes a critic to himself. The nicest thing we can do is interrupt this form of self-cruelty and help the patient look under that defense to see what the feelings are being warded off.
Coming back to you, in what ways have your way of doing therapy changed over the past five or ten years, and why? Hahaha! Throughout my career, as I look back, I can see that I have increasingly surrendered my resistance to beinghere, now, with the patient I have. I am increasingly able to accept the patient unconditionally, without needing him to change in any way. This may sound easy or trivial to readers who believe you already do this. And, if you do, good for you! But I find that this is a universal journey we take as therapists as we give up even the tiniest resistances to reality: meaning the patient as he is. My work has become very attuned to the tiniest cues of the unconscious will-to-health. And that shift may be the most important technical shift in my work recently.
What are you struggling to learn as a teacher and therapist right now? I’m in the midst of several projects with the aim of developing new forms of training and supervision. The research shows that graduate training does not improve therapist effectiveness. And after graduation, research shows that therapists do not improve. Research also shows that 93% of psychotherapy supervision is ineffective and 35% actually harmful. So in this part of my career I am most interested in researching what helps therapists become more effective. That is why I am focusing on skill building exercises and DVDs. I have a skill building book coming out next year. And I’ve begun a three-year study where we will study learning processes in a training group. That research will be the basis of a book I will write on the teaching and learning of experiential therapy.
You have two new books in the making. Can you tell us something about them? My next book, Co-Creating Safety: treating the fragile patient, is designed for therapists who want to learn how to treat the most disturbed patients in their caseloads, ranging from patients who just had a psychotic break to patients in the borderline spectrum of character structure. After that, my next book will be, Healing Through Relating, a skill building book with skill building exercises training therapists in the fifty most important skills in developing a therapeutic alliance. I was trained as a professional musician. So I’m trying to develop some “étude” books now for therapists.
Would you like to say something directly to the Finnish audience about the event? I look forward very much to showing you a three-hour session which will allow us to learn concepts, see them put into action, and see how a patient begins to recognize the unconscious enactments that have driven her suffering. There is something about seeing a real therapy that is helping the patient moment by moment that is unlike any other kind of learning experience. I look forward to seeing you there!
Förmiddagen den 15:e februari 2020 genomfördes föreningens årsmöte, vilket följdes av en föreläsning med Nina Klarin om det graderade formatet av ISTDP. Thomas Hesslow rapporterar.
Föreningens kärnverksamhet
Föreningens årsmöte i Sverigehälsans lokaler i centrala Malmö lockade precis som tidigare år ett tjugotal deltagare. Ordföranden Peter Lilliengren inledde mötet med att dra verksamhetsberättelsen för förra året och kassören Arvid Askmar Cederholm redovisade därefter ekonomin som visade en fördubblad omsättning och en ekonomi i balans. Föreningen växer stadigt både vad gäller antalet medlemmar och antalet evenemang, och ekonomin är i ordning.
Årsmötet i full gång
Därefter presenterade valberedningens representant, Joel Gruneau Brulin, ett förslag på en ny styrelse för föreningen. Presentationer av gamla och nya styrelsemedlemmar följdes av en omröstning, som resulterade i att föreningen godtog valberedningens förslag. Merparten av den tidigare styrelsen stannar kvar i styrelsen: Peter Lilliengren, Arvid Askmar Cederholm, Sandra Ringarp, Thomas Hesslow och Victoria Paglert. Maria Sandgren hade på förhand meddelat att hon inte var intresserad av att fortsätta styrelseuppdraget i nuläget. Tack för de här två åren, Maria!
Maria Sandgren
Dessutom valdes Oliver Nordh och Bonnie Liu in i den nya styrelsen. Oliver är PTP-psykolog inom psykiatrisk öppenvård i Älvängen. Han har tidigare varit aktiv i Studentnätverket för affektfokuserade terapiformer, SAffT, som bland annat arrangerat färdighetsträning för psykologstudenter vid Psykologiska Institutionen i Göteborg. Bonnie Liu är psykolog, yrkesverksam vid öppenvårdspsykiatrin i Lund. Hon har tidigare bland annat i samarbete med föreningen arrangerat heldagen med Angela Cooper i Lund under förra året.
Därefter valdes en ny valberedning, bestående av Joel Gruneau Brulin samt läkaren och terapeuten Lena Sohlberg Wagner.
Förslag på nya verksamheter och stadgar
Jämn könsfördelning
Under årsmötet diskuterades fyra förslag på nya verksamheter eller stadgar. Sandra Ringarp hade lämnat en motion om att föreningen i styrelse och valberedning ska eftersträva jämn könsfördelning. Sandra lyfte fram att det finns en tendens inom ISTDP-communityt i Sverige att män tar mer plats och oftare håller i exempelvis föreläsningar – precis som i samhället i stort – och att föreningen bör verka för att män och kvinnor ska få lika mycket plats. Efter en diskussion om hur denna förändring ska lyda röstade årsmötet FÖR denna förändring av föreningens stadgar.
Utbildningsfilm
Jag (Thomas Hesslow) hade vidare lämnat två motioner till årsmötet. Den första handlade om att föreningen bör verka för att 1) utreda och 2) producera utbildningsfilmer för att terapeuter under utbildning ska få ta del av mer videofilm än vad som i nuläget är tillgängligt. Exempelvis amerikanska psykologförbundet APA producerar utbildningsfilmer som är mycket uppskattade. Efter en längre diskussion beslutade årsmötet att rösta FÖR en nedbantad version av förslaget, som innebär att en grupp medlemmar inom föreningen kommer att få en budget om 20 000 SEK för att undersöka etiska, juridiska och praktiska förutsättningar och konsekvenser av att producera utbildningsfilm.
informationsutskott
Den andra motionen handlade om att utöka föreningens arbete med information och marknadsföring. Eftersom intresset för ISTDP just nu är så stort så resonerade jag att vi inte har något att förlora på att försöka producera mer innehåll och använda oss av fler kanaler för att nå ut till intresserade terapeuter runtom i landet. Flera inom föreningen tyckte att det var ett bra förslag, men att vi ännu inte är redo för att bygga ut denna verksamhet. Årsmötet röstade därefter EMOT detta förslag.
Kunskapsråd
Slutligen så lyfte Robert Johansson ett förslag om att föreningen ska inrätta ett “Kunskapsråd” som medlemmar och andra kan vända sig till för frågor vad gäller ISTDP. Andra terapiföreningar har liknande verksamheter. Det kan till exempel röra sig om frågor om hur en bra ISTDP-utbildning ska se ut eller etiska frågor om att bedriva ISTDP. Eftersom motionen om detta hade lämnats in för sent så skickades detta förslag vidare till styrelsen att arbeta med under det kommande året, utan att årsmötet tog ställning.
Sammanfattning
Sammanfattningsvis så var det ett väldigt livat årsmöte med starka åsikter och långa diskussioner, som för min del slutade i en fin känsla av gemenskap och engagemang – vilket jag tror att det gjorde för många andra också. Jag ser mycket fram emot kommande årsmöten där vi kan komma ännu bättre förberedda för att tillsammans besluta om föreningens framtid!
Nina Klarins föreläsning
Efter lunch så tog Nina Klarin vid med en föreläsning och videopresentation om det graderade formatet. Utifrån videoklipp illustrerade hon olika principer kring arbetet med patienter som lider av mer eller mindre allvarliga känsloregleringsbrister (“sköra patienter”). Hon diskuterade även en specifik subgrupp bland dessa patienter, nämligen de med smärtproblematik. Sjukvården kan många gånger inte erbjuda effektiv behandling för smärttillstånd, vilket leder till förlängt lidande för individen och stora kostnader för samhället. De senaste åren har det kommit en hel del evidens för ISTDP vid smärttillstånd (se exempelvis här, här, här eller här).
Nina Klarin pratar om skörhet
Ibland kan gradvis aktivering och exponering eller motsatsen – vila och återhämtning – vara effektivt vid dessa tillstånd. Men inom ISTDP vid smärttillstånd är fokus ofta på att öka självobserverande förmågor och minska självkritiska beteenden. Nina visade klipp från hur man kan kartlägga och stoppa ett starkt självkritiskt beteende (“överjagspatologi”). Hon visade också några fina klipp där hon använt sig av self-disclosure som intervention för att skapa mer närhet med sina klienter.
Nina visade också hur en effektiv terapi kan leda till att primitiva försvar över tid kan omstruktureras och hur mer mogna försvar då tar deras plats. När känsloregleringsbristerna minskar så försvinner försvar såsom repression, gråtmildhet och självtvivel, och de ersätts av mer mogna försvar: intellektualisering, ältande, rationalisering och så vidare. I samband med detta är det inte ovanligt att patienterna subjektivt upplever symptomlindring och ökad lust till lek, kärlek och arbete.
Tack Nina för en mycket lärorik och inspirerande presentation!
Till föreningens medlemmar: Nästa årsmöte kommer att ske om ungefär ett år. Tänk på att vara ute i god tid med motioner så att de andra medlemmarna kan informeras och styrelsen kan förbereda ett uttalande. Eftersom föreningen just nu växer så det knakar behöver vi tillsammans skapa ännu bättre förutsättningar för demokratiska processer.
Welcome to ISTDP PRE-CORE introductory course in Helsinki on 4-6th of May. For information in other languages, click here for Finnish and here for Swedish.
We’re very excited to offer ISTDP training in Finland for the first time. Following the workshop by Jon Frederickson at the end of March this year, to our knowledge this will be the second ISTDP event in Finland. The three-day course gives a complete introduction to the theoretical and practical foundations of Intensive Short-term Dynamic Psychotherapy, ISTDP. Alongside theoretical lectures, the course includes skills training, role-plays, observation of actual therapy video and group discussions. This is the main content:
an introduction to the central theoretical principles of ISTDP
practical skills to establish an effective working alliance and a consistent focus on affect
practical skills to assess and regulate anxiety manifestations during sessions
practical skills to identify and manage defenses and resistance
a critical introduction to the evidence base for ISTDP and other short-term dynamic therapies
The course is open for psychotherapists and psychologists, as well as students within these fields.
The course is led by lic. psychologist Thomas Hesslow. He runs the ISTDP-unit at the psychiatric outpatient clinic Kronan in northwestern Stockholm. He’s a certified ISTDP-therapist, trained by Jon Frederickson, Tobias Nordqvist and Peter Lilliengren. Currently he’s in Jon Frederickson’s Training of trainers program to become an ISTDP teacher and supervisor. He’s also on the board of the Swedish society for ISTDP and doing ISTDP-research part-time. Before doing ISTDP he specialized in dialectical behavior therapy, DBT.
Pre-core in Stockholm early 2019.
PRE-CORE is a prerequisite for later entering ISTDP Core training, which is the three year program to become a certified ISTDP therapist. Thomas Hesslow and Liv Raissi are planning for a Core training in Helsinki starting during fall 2020. More information on this is due later this spring.
For more information about the ISTDP PRE-CORE in Helsinki and details for registration, please download the flyer in English, Finnish or Swedish.
This is an interview with Kristy Lamb, who’s a psychiatrist and ISTDP clinician in California. For the past few years, she’s been running an outpatient clinic – BOLD Health – which treats addictions using an intensive format of ISTDP.
Kristy Lamb
It’s been two years now with the BOLD clinic if I’m not mistaken. How does it feel? What have you learned? We started BOLD Health in March of 2017, so we are coming up on our 3 year anniversary already. It’s all really exciting – so much has happened over the past 3 years.
Trained as a physician in Family Medicine and Psychiatry I had no background at all in business before this. So it has been a wild ride of learning as I go, trying to balance all the different aspects of the project. Learning about running a business and being an entrepreneur with regular supervision and deliberate practice for the clinical development of my staff and myself.
For better or worse, much of the learning about the business has been trial and error. So much of what I didn’t know, I didn’t realize until some issue or crisis and it was in working through the crisis that I learned. I think it is much this way in therapy that you know what to do and how to do it until you come across something new, and then, the working through, the attunement and attention to the response to intervention, helps build your working model.
What’s the background of the clinic? How are things developing? When I first graduated from residency (after five years of training in family medicine and psychiatry after medical school), I was working in a number of different environments practicing both general medicine and psychiatry from a concierge clinic to a homeless shelter and even in the jails. I had a passion for serving underserved and marginalized populations, but wanted to expose myself to all different clinical environments to see how things worked. It was clear that the system in the US creates a great chasm between the haves and the have nots.
In the county clinics I had 15 minutes to see a patient and taking extra time to do any type of therapy was frowned upon because the system was so impacted. However, in the concierge, pay-for-service model I could spend as much time as I needed with people and as you’d expect those patients got better. So I set out to start a private practice in order to have the time and space to hone my skills in ISTDP but eventually to build space to do research so we can show the long-term cost-effectiveness of ISTDP and bring the model back to the community setting. And that’s where things are now.
Why is ISTDP a suitable treatment for addictions? Aren’t there other psychological models with more scientific backing? This is such an important question. With the number of people dying from substance use each year growing exponentially, it’s imperative that we are figuring out what treatments work and what treatments don’t work. Unfortunately, in the US over 90% of treatment programs are based in the 12-step model which has only about an 8% success rate. It has no scientific backing and was started as community support, not treatment. We are certainly not against the 12-step program and encourage our patients to engage in the community of 12-step. But we also recognize that substance dependence requires psychological treatment and often medications in the early stages if patients are to have sustained sobriety and more so, sustained success in their lives.
In regard to why ISTDP is such a great model for addiction treatment, it really comes down to the way we conceptualize addiction – as Jon Frederickson says, “We are all addicted to avoiding reality.” We all use different mechanisms to numb and avoid the reality of our lives and drugs and alcohol are just one way we do this – so some people go to TV, or work, or exercise, or compulsions.
Any of our defenses can be seen as a mechanism to avoid what we are feeling. Drugs and alcohol are no different and once someone is no longer under the influence by just abstaining from the substance, they can start to look at what was driving the numbing that, in this case, can be lethal. When the substances are seen as just another defense it is clear that ISTDP is a perfect model to treat the human disease of affect intolerance.
I think another reason why ISTDP is so important in addiction are the interventions that provides the therapist with a clear and direct way to address the common defenses in this group. Handling projection of will, projection of omnipotence, denial, helplessness and hopelessness, and anxiety regulation. All of which are imperative if treatment is to be successful.
What’s the treatment format, length of treatment, rules etc? And how did it come about? Our treatment program averages 10 weeks depending on the patient’s level of acuity. When a patient signs up for the program they undergo neuro-psychological testing, a commitment interview assessing their will for engagement in treatment and then start the program with groups 3-5 days per week, once per week individual therapy and once per week as needed medication management appointments.
Each day consists of 30 minutes of biofeedback, an hour of group psychoeducation and then an hour and a half of what we call The BOLD Seat which is structured group therapy. All the group members are given an opportunity to take the BOLD Seat in front of the group to look at a specific problem for the day with the therapist leading the group. The other patients observe and participate, helping that patient see anxiety and defenses. Also, watching your peer gives you the opportunity to see yourself objectively as you may resonate with what the person in the BOLD Seat is saying but be able to see it from a different, more compassionate, distance.
Our curriculum and the entire structure were developed in collaboration with Jon Frederickson who had piloted this model at a program in Arizona, the data from which was recently published in the Journal of Addictive Diseases.
I had the good fortune of meeting Jon at a week-long training in Whidbey Island, WA, in 2016 and I was just starting to look at group therapy for addiction. We then started working on expanding the previous work that had started in Arizona and now, four years later, here we are. Jon has been an integral part of our development not only for the structure of the program but he provides weekly supervision to our team and has helped establish the ethos of the clinic – compassion, respect and integrity.
What are some of the challenges when doing ISTDP with persons who struggle with addictions? Really there is no difference in treating someone with addiction problems than any other patient if the patient is currently sober. Jon Frederickson often talks about the notion that there are specific criteria necessary to actually have a patient in the room. You can’t do therapy with someone who is actively intoxicated so monitoring for this is critical.
That being said, as we are an addiction treatment center we have to be sensitive to still welcoming people who are ambivalent about their treatment or struggling to maintain sobriety. We have to greet them with compassion and honesty: they may need a residential program or an inpatient detox or a residential program to begin with. So they can really get some time away from the drugs or alcohol, so that they later can get the most out of our program.
Accordingly, when we screen for use during the program we work to approach the patient with compassion and understanding to let them know that relapse is common. And we don’t have a right or a need to punish them, but rather use the testing as just information to let us know if their will for engagement in treatment is aligned with their actions. Knowing that that sometimes it’s not, and we just have to pull back and get clear about where they are and what they want for themselves. We work really hard not to own the will of sobriety in any of our patients.
Many patients in recovery haven’t connected to their internal motivation for treatment. They are in program because of their partner, or parents, or job, or the law are setting an ultimatum. We have to work really hard to get clear that unless the patient wants to engage, treatment won’t work.
What’s it like to do a core training with your fellow colleagues and staff? It feels like such a gift to be doing core training with our staff. When we started, part of the collaboration with Jon Frederickson was to start a new core training cohort with our staff and weekly supervision with him and Esther Rosen.
My first core training with Patricia Coughlin was personally life changing and the people I met there have become lifelong friends. But it has been a totally different experience to have all of my work colleagues now be a part of the quarterly intensive training. And for us to be able to come back to BOLD and stay motivated between core trainings with weekly skill building and supervision. So many things in place to keep focus.
It really feels like a dream to be working in a clinic based in ISTDP. Even during our lunch breaks we are chatting about defenses, portrayals and psychodynamic understandings of our patients. It creates an environment of support and collaboration like nothing I have ever experienced in any other work environment. I am incredibly grateful to Jon and our whole team for building this space.
In the swedish context there’s quite a lot of talk about deliberate practice nowadays. What are you struggling to learn right now as a therapist? I am a big fan of deliberate practice and have seen how deeply it changed my work. In 2016, I took a short course in deliberate practice and then had ongoing supervision with Tony Rousmaniere. I couldn’t agree more with Tony’s notion that the therapist’s own work is the glass ceiling between good providers and great providers. It is only when you can notice and work through your own “stuff” that comes up in sessions that you can really be present with the patient in front of you.
So the deliberate practice related to skill building is wonderful and undoubtedly makes for improved outcomes, but it is the personal work that Tony taught me that I find the most difficult and the most important. What I need to pay attention to so I can know when my anxiety comes up, where I might unconsciously avoid going with my patients, or biases I might have from my own life experiences. It is through this internally focused deliberate practice that I have been able to become more present and more available to my patients, which results in markedly more effective work. This work takes a lot of effort: making time and space for watching my own videos and – as importantly – making time for my own self-care and therapy.
If you dream a bit, where would you like ISTDP and addiction psychiatry to go within the next 5 or 10 years? Thank you for asking! I happen to be someone who sets goals that I think others often think are idealistic or impossible but at BOLD we encourage our staff to dream wildly about what can be.
I deeply believe in this model and want to see it become the standard of care for addiction treatment. We are looking to start a revolution and would love to see the BOLD Method be known across the world as the most effective treatment of addiction. Dream big! Right?
I would also love to see our clinic running as an incubator where we can continue to hone the model and build a body of research that supports what we are doing, as well as become a training facility so that we can support others to engage in this model of treatment.
If you liked this Kristy Lamb interview, maybe you’ll appreciate some of our other interviews. Below, you’ll find a list of our five most recent ones.
Also, a while back we reported on the Frederickson et al. 2019 addiction trial. You can find that article here (in swedish).For all of our content in english, please click here.
Här kommer information från Liv Raissi om en ISTDP fördjupningsworkshop som äger rum i juni.
Liv Raissi erbjuder två sammanhängande workshops där vi fördjupar oss detaljerat i den teoretiska och praktiska förståelsen av terapiinterventioner. Det kommer bli undervisning kring interventioner, en hel del anpassade övningar utifrån målmedveten träning, rollspel, diskussion, videoexempel och umgänge över ett glas vin för den som vill!
Liv Raissi föreläser 2019
Man skulle kunna säga att terapi mycket handlar om att terapeuten observerar vad patienten gör, vad terapeuten känner inför vad patienten gör mot sig själv och för sig själv, och vad terapeuten hoppas att patienten ska göra för sig själv och inte göra för sig själv. ISTDP-interventioner baseras till stor del utifrån denna princip. Ju mer man förstår bakgrunden till en intervention, desto mer genuint kan man förmedla den i egna ord och den får ökad effekt hos patienten. Patienten kommer att uppleva att man verkligen pratar till den vilket stärker alliansen och terapiprocessen kan bli smidigare. Den ökande förståelsen för innebörden i interventioner och patientens responser leder också till att man kan använda sig av sina egna fysiska och känslomässiga responser på patienten för att kunna stärka sin bedömning av patienten.
Under dessa två workshopskvällar får du lära dig att lyssna till orden som patienten säger, observera hur patienten säger det och vad du känner inför det som patienten förmedlar verbalt och icke-verbalt. Första tillfället fokuserar främst på undervisning med olika typer av tillhörande övningar och rollspel. Andra tillfället ägnas mer åt videoanalyser av terapiprocesser. Vid andra tillfället kommer det även att bjudas på vin i pausen och du är välkommen att stanna efteråt för lite mingel. Varmt välkommen med din anmälan!
Datum: 3/6 och 9/6 Tid: kl 17:00-20:30 Pris: 1500 kr ex moms för båda kvällarna (studentpris: 750 kr ex moms) Fika och vin ingår. Plats: Fjärde Långgatan 5, vån 1 i GCKs lokaler, Göteborg Målgrupp: Leg psykologer, leg psykoterapeuter, läkare, psykolog- och psykoterapistudenter Kursledare och arrangör: Liv Raissi, leg psykolog, ISTDP-terapeut/handledare Anmälan: Maila liv.raissi@affekta.se ditt namn och faktureringsadress.
Ladda ner flyer här om du vill ha informationen för utskrift
Välkommen till ISTDP PRE-CORE, introduktionsutbildning till ISTDP i Stockholm den 26-28:e maj 2020. Kursen omfattar tre heldagar och ger en grundläggande introduktion till intensiv dynamisk korttidsterapi. Utöver en teoretisk bakgrund innehåller kursen videobaserad undervisning samt rollspelsövningar där du får möjlighet att utveckla specifika färdigheter i att observera patienter och intervenera utifrån ISTDP-principer. Följande moment ingår:
en introduktion till de grundläggande teoretiska principerna inom ISTDP
praktiska färdigheter för att etablera en god arbetsallians och ett emotionellt präglat fokus för behandlingen
praktiska färdigheter för att bedöma patientens ångestnivå och reglera denna
praktiska färdigheter för att identifiera och hantera försvar och motstånd
Kursen leds av de legitimerade psykologerna Niklas Rasmussen och Thomas Hesslow, som tidigare startade ISTDP-teamet vid Psykiatri Nordväst och som båda är certifierade ISTDP-terapeuter och ISTDP-handledare. De har sedan 2015 haft kontinuerlig handledning av Tobias Nordqvist och Jon Frederickson.
Inga förkunskaper krävs. Kursen riktar sig i första hand till psykologer, psykoterapeuter och psykologstudenter, men denna kursomgång välkomnar vi även annan vårdpersonal som kan ha nytta av grundläggande ISTDP-färdigheter i sitt arbete.
pre-core vid Psykiatri Nordväst i januari 2019
Kursavgiften är 4 500 kr för alla tre dagarna och deltagarantalet är begränsat. I mån av plats kan heltidsstudenter från något av landets psykologprogram gå kursen till reducerad kostnad (3000 kr). Kursen kommer att äga rum ISTDP-mottagningen Stockholm vid Mariatorget.
PRE-CORE ger grundläggande kunskaper och färdigheter som är ett behörighetskrav för att läsa den treåriga Core-utbildningen, om du önskar göra detta senare.
I studien hade man delat in deltagarna som fick ISTDP i två grupper. En som betonade omstrukturerande av försvar (Defense focused-ISTDP, DF-ISTDP) och en som betonade upplevelsen av känslor (Feeling focused-ISTDP, FF-ISTDP). Såhär beskriver författarna de olika interventionerna:
Feeling focused-ISTDP had less attention to defense reconstructing versus Defense focused-ISTDP where every single defense and its role in the patient’s life and psychopathology was clarified. This comprehensive focus on defense modification aimed at removing the resistance.
Inga skillnader mellan behandlingarna
Precis som det brukar vara i psykoterapiforskning så fann man inga skillnader mellan de båda aktiva interventionerna. Författarna själva menar att detta kan ha att göra med stickprovets litenhet. Givetvis kan det också ha att göra med det återkommande fyndet i psykoterapiforskningen att behandlingsmanualen brukar stå för en väldigt liten del av den förklarade variansen. För ISTDP som forskningsfält är det givetvis ett intressant fynd, då det kanske kan innebära att man tar fram en “nedbantad” version av ISTDP på sikt. En version som inte är lika svår att lära sig.
Detta är ju vad man gjort inom KBT-fältet med Beteendeaktivering, som ursprungligen bara var en av många komponenter i Becks depressionsbehandling. Se till exempel den här klassiska studien på olika varianter av KBT för depression som inte heller fann några skillnader mellan den “enklare” och den “mer komplexa” behandlingsvarianten.
Studien har ett antal viktiga begränsningar, såsom att stickprovet var litet, att diagnostiska bedömningar inte gjordes strukturerat och att studien bara hade två terapeuter. Trots detta så är den ett välkommet bidrag till den ökande evidensbasen för ISTDP.
Rahmani, F., Abbass, A., Hemmati, A., Mirghaed, Sahar R., Ghaffari, N. (2020) The Efficacy of Intensive Short-Term Dynamic Psychotherapy for Social Anxiety Disorder Randomized Trial and Substudy of Emphasizing Feeling Versus Defense Work. The Journal of Nervous and Mental Disease, ahead of print.
How did it feel to present to a swedish audience? As you know, this was actually my first time both visiting Sweden as well as teaching. I was very happy to see some old friends who I’ve met at past conferences, meet many engaging new colleagues, as well as make some new friends. It was a pleasure to be with you in Sweden and to see how your ISTDP community is growing!
You presented some thought-provoking ideas for modifying the graded format of ISTDP, managing the thresholds differently. Can you explain your perspective on this? And how is it different from the standard graded approach? With the graded format, I was trained to first think about the use of ‘pressure’ to mobilize complex feelings. Next, we look for a threshold to detect when the patient is struggling to intellectually hold in mind complex emotional states and instead become flooded with anxiety. At this point, the therapist helps to reduce anxiety using different strategies. One observation around the clinical application of this approach that I spoke about during the workshop is how easily we can teach the process as though there are explicit “go” and “stop” signs.
The concept of a threshold can be helpful when initially learning this approach in order to avoid too much anxiety being triggered. But viewing patient tolerance more as a Threshold Window can allow therapists to involve patients more in the process, and help them better learn to self-regulate. I’d describe this more as principle we can be aware of during learning, teaching and supervision that can allow therapists to begin to incorporate what Allan Abbass has called “bracing” interventions. This can be done instead of formal recapping or other anxiety regulating interventions.
You offered some modifications to the phase of inquiry that were very well received by the swedish audience. How did that come about? It’s something that I noticed over time when I was reviewing trial therapy tapes. I felt like I was missing something if I wasn’t asking patients about feelings, clarifying anxiety or defences within the first few minutes. However, there were other occasions when I was using these kinds of interventions early in sessions – but I would be left questioning why am I doing this and how helpful is was. This made me think about some of the learning challenging when teaching. And it made me rethink the timing of the transition from ‘inquiry’ to phases of structured ‘pressure’ in ISTDP.
In Gothenburg, I showed a tape in which the patient came into a trial therapy exhibiting a mixed bag of responses that we might consider examples of unconscious anxiety and defence combined. In the tape, I didn’t comment explicitly on these processes for around 10 minutes and instead stuck with a phase of inquiry. The subsequent group discussion raised some good questions about the importance of the pace and timing of therapist interventions early in sessions. The audience appeared to appreciate me saying that it isn’t always entirely clear what is happening moment-to-moment, so collecting more data from sitting with the patient can be helpful.
I think in our effort to provide and teach “intensive short-term” treatments we can easily prioritise the need to intervene. We even sometimes intervene before we understand why we are intervening. During the 2-day seminar it felt like we were able to have a very a constructive discussion about these issues. My thought is that these are likely learning and training challenges in ISTDP as much as they are about technical elements related to the phase of inquiry in treatment.
What are you struggling to learn as a clinician right now? I have begun seeing a series of patients with chronic symptoms that have an explicit behavioural component such as OCD (e.g., compulsive behaviours), Tourette’s and other tic-based presentations. There hasn’t been a lot written on this topic around the use of ISTDP and in my experience these cases present infrequently to dynamically orientated therapists. It’s been a challenge and learning curve to think about how to adapt and tailor a dynamic approach to specifically target change in symptoms that involve repetitive behavioural patterns.
For instance, in ISTDP I would aim to help a patient see harmful patterns and behaviours so that they become motivated to interrupt them independently. In contrast, a traditional CBT exposure and response prevention approach involves a more directive therapist stance in advising a patient to prevent the ‘response’. In the cases I have treated so far, I am struck by how much emphasis there has needed to be on an explicit therapist stance towards response prevention. I think it is a subtle but significant shift for the ISTDP therapist to focus on interrupting an explicit in-session behaviour like a vocal tic in contrast to purely intrapsychic defences.
What are some of the current challenges for the further development and dissemination of ISTDP globally? One of the challenges for the dissemination of any psychotherapy is having the means to effectively train others to deliver the treatment. Over time, through these dissemination efforts, if enough clinicians can be trained to become both effective therapists and trainers themselves, there reaches a critical mass at which point the treatment is readily accessible for patients. There are probably only a handful of therapies which can be said to have achieved this globally.
The manualisation of psychotherapies has been a key part of what has made this possible. However, the development of treatment manuals to treating mental health as discreet “disorders” defined by symptom clusters is problematic. I think this paradigm has contributed to the numbers of patients who fail to remit or relapse following psychotherapy generally. In contrast, I think ISTDP is best described as an approach that is fundamentally built to achieve ambitious changes in personality. While my own experience as a researcher and clinician confirm that this is possible, as with other therapies, therapist factors and patient factors contribute significantly to outcomes.
I think the ISTDP Core Training programs conducted in the last decade indicate that there are many elements to ISTDP that can be taught to a broad group of therapists. The programs teach the delivery of effective treatment that is likely comparable to the outcomes achieved in other treatments. However, my current view is that I think there are other elements of ISTDP that are very difficult to learn, particularly given the training resources typically available to most therapists (e.g., access to and frequency of supervision).
If some of the more difficult-to-learn treatment elements were emphasized less, akin to dropping the ‘intensive’ from ISTDP, I think we would have a treatment that could be more easily disseminated globally. It is arguable that in doing so, we could compromise the nature of the changes possible in treatment by de-emphasizing the elements that promote personality level changes. This is a question that would need addressing empirically.
Do you think we should drop the “intensive” then? Or what do you propose? I don’t think the field needs a new treatment with a new acronym. What I am pointing out is that there are different elements to ISTDP that require different competencies to be taught and adequately mastered by a therapist. If attempting to gain competency in multiple domains limits the transferability of the treatment, I am proposing that therapists can be trained and encouraged to utilise specific elements as they are able.
This type of learning environment might help therapists to flourish and grow rather than to become discouraged and drop-out. Perhaps within the field of psychotherapy training there is a risk that in an effort to maintain the presumed integrity of the treatment, it is very possible that the alliance between therapists and their trainers/teachers can be adversely effected. I think this is a central challenge around the dissemination of ISTDP.
Do you have any upcoming research in the pipeline? I am just preparing a manuscript describing the 12-month post treatment outcomes and a cost effectiveness analysis from the Halifax Depression Study. This a randomized controlled trial that compared the outcomes of time-limited ISTDP against the effects of secondary care community mental health team treatment for treatment resistant depression (TRD). We published the initial findings in the Journal of Affective Disorders in 2017 showing ISTDP is an efficacious treatment for TRD with 36% of patients reaching full-remission at the end of treatment. The follow-up findings are also very encouraging.
What’s your vision for the future of ISTDP? Currently there are very few academic centres around the world in which ISTDP research is being conducted. For the growth of any treatment, research is an important part of dissemination alongside offering the possibility of innovation in methods and technique. In particularly, as a clinical psychologist and researcher having both trained and conducted clinical trials in ISTDP, I think my understanding of some the teaching and learning challenges around ISTDP has been enhanced greatly by this work. Moving forward, I would hope there are increasingly more opportunities for people at all stages of learning to be involved in ISTDP training and research within academic centres of excellence.
If you enjoyed this Joel Town interview, you might find our other interviews interesting. You can find the whole list here. Below you’ll find a list of five of our most recent interviews:
