För att kunna förstå den person vi har framför oss behöver vi först och främst beakta dennes responser på våra interventioner som kliniska data. Då kan vi tillämpa våra teoretiska koncept för att analysera responserna, till exempel: är det känslor, ångest eller försvar?
Därefter sätter vi in koncepten i ett mönster på en högre abstraktionsnivå, till exempel: vi ser personens konflikt i dennes mönster av känslor, ångest och försvar.
På nästa nivå av abstraktion kan vi sedan sätta ihop en serie av mönster till ett övergripande teoretiskt koncept, till exempel: överjagspatologi.
Genom att ägna oss åt kliniskt tänkande på flera nivåer möjliggörs ett mer komplext och mänskligt samspel grundat på en fördjupad förståelse, till skillnad mot att använda slumpmässiga terapeutiska tekniker med ett objekt. I stället för färdiga och inövade fraser så övergår våra interventioner till frågor som avser att testa en rad olika hypoteser. Om patientens respons motsäger vår hypotes korrigerar vi hypotesen i syfte att nå ett mer hjälpsamt samspel över tid.
Som deltagare i denna workshop får du möjligheten att fördjupa din förståelse för hur teori, teoretiska koncept och ISTDP-principer samspelar på flera nivåer inom ramen för en mänsklig relation med terapeutisk målsättning. För den som vill finns möjligheten att interaktivt träna sitt kliniska tänkande under videopresentationen och därmed stärka detta i en simulerad miljö. Vi kommer även se exempel på hur handledning kan hjälpa oss återta vårt kliniska tänkande när vi fastnat i terapiprocessen.
Glenn Kristoffersson är leg. psykolog, certifierad ISTDP-terapeut samt lärare och handledare vid ISTDP-institutet. Efter coreutbildningen har han fullföljt två års Advanced Training med Jon Frederickson. Sedan 2020 specialiserar han sig ytterligare genom månadsvis handledning med Allan Abbass respektive John Rathauser. Glenn arbetar kliniskt inom specialistpsykiatrin i ett ISTDP-team tillsammans med Hanna Pedersen. Parallellt med detta handleder han ISTDP-terapeuter i privat regi och undervisar på den treåriga coreutbildningen i Stockholm tillsammans med Sandra Ringarp. Glenn läser sedan 2020 Jon Fredericksons 3,5-åriga lärar- och handledarutbildning Training of Trainers.
MÅLGRUPP: Denna workshop är öppen för legitimerade psykologer, psykoterapeuter och läkare samt för studenter under utbildning till psykolog eller psykoterapeut.
Frida Salman Lisak håller en introduktionskurs i ISTDP s.k.”pre-core” i Göteborg den 14-16 mars 2022. Kursen av omfattar tre heldagar (kl 9-17). Den kommer innehålla både teoretiska och praktiska moment samt presentera videobaserade exempel på interventioner.
Bland annat kommer du lära dig:
Meta-psykologin bakom ISTDP
Att etablera medveten allians och upprätthålla ett intra-psykiskt fokus
Att fokusera på affekter
Att bedöma och reglera ångestnivå
Känna igen och arbeta med olika typer av försvar och motstånd
Kursen ger grundläggande kunskaper och färdigheter för att kunna gå vidare med en full core-utbildning för den som så önskar.
Lärare: Frida Salman Lisak är leg. psykolog, leg psykoterapeut cert. ISTDPterapeut, handledare/lärare. Hon har lång erfarenhet av kliniskt arbete med olika patientgrupper samt av utbildning och handledning.
Plats: Centrala Göteborg
Datum: 14-16 mars 2022
Tid: Kl 9-17 varje dag
Kostnad: 6000 kr exkl. moms (4500 kr exkl. för begränsat antal heltidsstudenter)
Anmälan: Frida Salman Lisak firstname.lastname@example.org, 070-6892538, Ange faktureringsadress och önskemål om ev specialkost.
Nästa omgång av ISTDP-institutets introduktionsutbildning i Stockholm hålls 4-6 april 2022, med Sandra Ringarp och Glenn Kristoffersson som lärare. Kursgruppen träffas under tre dagar för teoretisk undervisning, färdighetsbyggande övningar och videobaserad undervisning.
Kursen omfattar tre heldagar och kommer att innehålla föreläsning, filmvisning från terapisessioner och rollspel där du får möjlighet att öva på specifika färdigheter. Teorin bakom ISTDP kommer att varvas med praktiska övningar. Vi kommer att fokusera på din arbetsallians med patienten, på att identifiera och reglera ångest på olika nivåer och på att känna igen och arbeta med olika typer av hinder i terapiprocessen – allt för att du tillsammans med patienten ska kunna jobba för att nå dennes mål.
Introduktionskursen är ett behörighetskrav för att läsa den treåriga ISTDP-utbildningen Core, om du önskar göra detta senare. Flera coreutbildningar kommer att starta på olika platser i Sverige under 2022, och vi planerar för att starta en coreutbildning i Stockholm till hösten 2022. Mer information om utbildningar kan du hitta på www.istdpinstitutet.se.
Sandra Ringarp är leg psykolog och certifierad ISTDP-terapeut samt lärare och handledare vid ISTDP-institutet. Sandra har arbetat med ISTDP sedan 2013 inom vuxenpsykiatrin, smärtvården och nu i privat regi på ISTDP-mottagningen i Stockholm. Hon är också upphandlad som handledare inom region Stockholm. Efter att ha avslutat sin coreutbildning 2016 har Sandra fortlöpande specialiserat sig inom ISTDP genom utbildningar och avancerad handledning, med bland annat Allan Abbass och Reiko Ikemoto-Joseph. Sedan 2018 sitter Sandra i styrelsen för Svenska föreningen för ISTDP. Sandra har HBTQI-kompetens och särskild kompetens inom långvarig smärta och utmattningssyndrom och undervisar studenter på Psykologprogrammet vid Stockholms universitet i HBTQI.
Glenn Kristoffersson är leg psykolog, certifierad ISTDP-terapeut samt lärare och handledare vid ISTDP-institutet. Efter coreutbildningen har han fullföljt två års Advanced Training med Jon Frederickson. Sedan 2020 specialiserar han sig ytterligare genom månadsvis handledning med Allan Abbass respektive John Rathauser. Glenn arbetar kliniskt inom specialistpsykiatrin i ett ISTDP-team tillsammans med Hanna Pedersen. Parallellt med detta handleder han ISTDP-terapeuter i privat regi och undervisar på den 3-åriga coreutbildningen i Stockholm.
Både Sandra och Glenn genomgår sedan 2020 Jon Fredericksons 3,5-åriga lärar- och handledarutbildning Training of Trainers.
För er som vill lära känna Sandra och Glenn ännu bättre så finns deras respektive föreläsning/workshop nedan.
I samband med att Svenska föreningen för ISTDP höll årsmöte den sista helgen i januari 2021 föreläste Sandra om HBTQI i terapirummet, med ett särskilt fokus på transpersoner och minoritetsstress:
Här finns Glenns workshop på temat vilja utifrån ett ISTDP-perspektiv:
Kursen riktar sig till leg psykologer, leg psykoterapeuter, psykologstudenter som påbörjat utbildningens kliniska del samt andra yrkesgrupper med grundläggande psykoterapiutbildning.
Vårterminen 2022 startar en ny omgång av den 3-åriga coreutbildningen i Intensive Short-Term Dynamic Psychotherapy (ISTDP) i Stockholm. Utbildningen syftar till att hjälpa deltagarna utveckla kunskaper och färdigheter i ISTDP och leder fram till ISTDP-institutets internationella certifiering. Utbildningen är även ackrediterad som tre kurser inom specialistutbildningen i klinisk psykologi för psykologer. Coreutbildningen är indelad i 12 undervisningsmoduler. Varje modul består av tre heldagar i följd (mån-ons, kl 9-17) som ges vid fyra tillfällen/år. Varje modul innehåller:
Undervisning kring modulens specifika tema med videoillustrationer
Handledning i grupp på egna videofilmade sessioner
Färdighetsträning med rollspel kring modulens tema
Reflektionsgrupp kring egna processer
Utöver modulerna ingår även en individuell handledningstimme mellan varje modul. Vidare så ingår egen inläsning av litteratur och artiklar (totalt ca 2500 sidor) samt egen träning med rollspel vilket studenten själv ombesörjer under utbildningen.
Kursansvarig huvudlärare, handledare och examinator för utbildningen är fil dr., leg psykolog, leg. psykoterapeut Peter Lilliengren. Någon eller några moduler kommer även hållas av externa lärare (i nuläget inte helt klart vem eller när under utbildningen).
Kurstillfällen 2022: 7-9 feb (modul 1), 16-18 maj (modul 2), 12-14 sep (modul 3), 5-7 dec (modul 4).
Plats: Centralt i Stockholm
Pris: Varje utbildningsmodul kostar 7 000 kr (exkl moms) och betalning sker genom faktura i anslutning till varje undervisningsmodul. Tillkommer (minst) 10 timmar obligatorisk handledning som faktureras separat (1200 kr/tim exkl moms). Totalt uppskattas utbildningen således kosta ca 96 000 kr (exkl moms) fördelat över tre år. Ytterligare kostnad för litteratur och rollspelsövningar (ca 2000 kr) tillkommer.
Antal deltagare: max 10
Förkunskapskrav: Studenten ska ha genomgått introduktionskurs (s.k. ”pre-core”) eller ha förvärvat motsvarande kunskaper genom kurser/handledning (bedöms av kursansvarig). Eftersom studenten förväntas kunna arbeta självständigt med patienter är det krav på legitimation inom hälso- och sjukvård.
Bedömningskriterier: Studenten förväntas delta aktivt i samtliga delmoment. Studenten skall ta med (minst) en videoinspelad terapisession till varje modul.
Välkommen att kontakta Peter Lilliengren (email@example.com) för anmälan och/eller ytterligare frågor om utbildningen!
How do you feel about the presentation the other day? I feel so happy about the presentation! I am proud of the work that I showed, and I was grateful to be so warmly received. I was surprised and honored when Peter Lilliengren first invited me, and of course wanted it to go well but you never know how things will land. I really felt supported and encouraged by the audience the whole time and it seemed like an atmosphere where everyone was really open to learning. I had a blast!
For the readers who don’t know you, how did you get into ISTDP? Well, this is a bit of a long story. When I first started a graduate program in psychology in my early twenties, I tried a few forms of therapy. I was a bit lost, but I also wanted to get a sense of what types of treatments were out there that I might want to practice. I had read Diana Fosha‘s book on the Transforming Power of Affect, and I thought I’d go see an AEDP therapist. I got a few referrals, but in the end, the person I started working with wasn’t an AEDP therapist at all, but rather an ISTDP therapist—something I hadn’t actually heard of at the time. I was blown away by the power and effectiveness of what they were doing. No one had ever reached me that way. It felt like tough love for sure, but somehow I felt spoken to and seen in a way that I never had before. After that experience, I knew I had to be trained in this way of working.
The problem was that there was no training in ISTDP in the graduate program I was in. In fact, in the States, ISTDP is virtually non-existent in PhD psychology graduate programs. I would go through various training sites and mental health centers learning CBT, psychoanalysis, DBT, etc., all the while carrying the secret that what I really wanted to do no one could teach me. So, I basically did a lot of reading on my own, starting with Patricia Coughlin’s first book. I didn’t have any supervisors who knew ISTDP, but I’d be trying to incorporate what I could glean from her book and sometimes it worked and sometimes it didn’t! It was a lot of trial and error.
At one point I grew so frustrated with not being able to study ISTDP that I decided I’d be a psychoanalyst instead. I began training at one of the country’s oldest psychoanalytic institutes. I loved a lot of the theory, but I struggled with what I saw as a resistance to technique and a dependence on a lot of vague terminology. Eventually I saw an advertisement that Patricia Coughlin was going to be starting a Boston based core training group, and I jumped at the opportunity! Pretty much from that day forward, I’ve been consumed with developing my expertise in ISTDP. One of my mentors, John Rathauser, has said that he developed his skill set by making ISTDP something of a religion. Well, I’m right there with him on that. For the past 5 years I’ve spent 2-3 hours every day reading Davanloo transcripts, parsing apart all of his cases, and watching my own videos.
Why did defiance catch your attention in this way, and why do you think it’s such a crucial concept in ISTDP? When Peter Lilliengren reached out to me to ask if I would present at the ISTDP Academy, he had just seen some of my work in a webinar I hosted with John Rathauser. We both showed our work with syntonic defenses, and I was particularly keen to show my work there with defiance. I knew that I had something unique to offer because the way I work with defiance is quite distinct from what I’ve seen most others do in the ISTDP community. Peter’s invitation excited me in part because I knew there was a lot more to talk about with defiance that I didn’t get a chance to fully cover in the webinar.
In my opinion, defiance is the single most important defense to be familiar with as an ISTDP therapist as it is nearly universal in all patients, and is often fueling other defenses that are more apparent. As I talked about in my presentation, oftentimes when we are struggling but failing to help a patient relinquish another defense, like weepiness, it is because the defense is getting its power from defiance. If we keep addressing the weepiness without addressing the defiance underneath it, we’ll ultimately fail to remove it. It will return over and again, like déjà vu.
But part of the difficulty with defiance is it is often invisible to both the patient and the therapist, so discerning it can be tricky. Even once you’ve spotted it, working with it is so complex. It gets its power from all the major sources of unconscious resistance: repression, the resistance against emotional closeness, and what Davanloo referred to as the ‘perpetrator of the unconscious,’ tied to concepts of the punitive superego.
During my first years as an ISTDP therapist I was struggling a lot with the defense of passivity, and a lot of the supervision I would get was linked to my own overactivity. Passivity would get me stuck over and over again, and I was dedicating quite a lot of time to figure this out in practice as well as theoretically. Is your interest in defiance related to any of your own learning processes as a trainee? Well, here’s the thing about what you’re saying. Davanloo did not actually recommend we counter passivity with our own passivity. There is a long-standing tradition within psychoanalytic literature that talks about this and recommends it, and it has made its way into our community as an often-talked about approach, but it’s not a Davanloo method. In fact, Davanloo maintained his activity in the face of patient passivity, and in many ways increased it. You can see that in many of his best published cases, where he’ll have long head-on collisions and periods of pressure and challenge to the passivity. I’ll leave it to you and the readers to make up their own minds about the best way to manage passivity in their own patients, but I tend to follow Davanloo’s method of actively confronting it, often weaving in a lot of de-activation, and head-on colliding with it. As I talked about in my presentation, when the passivity is fueled by defiance, this is the aspect that needs to be clarified for the patient, and then collided with. Working on the passivity alone is not enough; they need to see how it is intertwined with their defiance and any other dynamics at work.
Personally, I tend not to like the counter-passive approach, and instead, if it really feels like an impasse that we cannot overcome, even with concerted attempts to understand and clarify the psychodynamics and relational dynamics at work, then I will acknowledge that with the patient putting in their best effort and me putting in mine, we’re simply not doing enough and it’s time to end the treatment (this is the ultimate pressure by the way, and at times can be the thing that turns the corner).
But to your question more specifically. Defiance is something I struggled with when I first started, absolutely. And even though I presented on it and have a lot to say about it, I still struggle with it. The nature of patient defiance is to try to defeat what we’re doing; how do we not struggle with a force that wants to defeat us? To me it feels like the ultimate resistance, and so it is the ultimate challenge to take on as a therapist. As I’m answering this question now, I think this is part of it for me. I always set myself very lofty goals, and trying to develop expertise in defiance feels like some sort of very worthy challenge. And of course, like all of us, I have defiance in my own character, and I wanted to try to understand this better, too.
I know that you’re a meticulous Davanloo reader. Do you find that Davanloo has had the last word on defiance, or is there more work to be done? Well, one of the things that has intrigued me is that I think Davanloo sold himself short in terms of how innovative he was with defiance. He developed a ton of techniques for how to deal with it, but the only one he seems to have written about, is de-activation. Peter von Korff, who studied with Davanloo, wrote a wonderful article on how Davanloo manages defiance, but there too he really only stresses the role of de-activation, albeit in various forms. If you look at what all the trainers and books on ISTDP say about defiance, if they talk about it at all, is to de-activate. De-activation is of course crucial, and is itself a very complex task. As I talked about in the presentation, most forms of de-activation are actually essential components within the 16-component framework of Davanloo’s system of Head-On Collision. So pretty much whenever we are doing extensive de-activation, we are engaging in head-on collision (although I think few people realize this!).
One thing that really intrigues me is that Davanloo could also be very directand confrontational with defiance, but he doesn’t seem to explain why he switches between indirect and direct modes of management, and no one else talks about that either. I made it my mission to really understand this kind of code switching he does, and why he does it. Of course along the way I developed my own style of drawing out and speaking directly to defiance, heavily influenced also by my work with John Rathauser, but the tenets are essentially taken from close reading of Davanloo transcripts. I remember Patricia Coughlin told me a long time ago to pay close attention to what Davanloo does, not what he says. Here I think she’s correct. If you read the transcripts closely, you see just how complex and layered his approach to defiance was, certainly way more than what has been written.
I doubt he’ll have the last word on the topic, but I’m a purist at heart, and I’m quite happy to continue interpreting and perfecting his methods.
What do you find are some of the main countertransference issues that prevent the therapist from dealing effectively with defiance? Well, I think the biggest issue is that it often goes unnoticed. We might see the helplessness, the passivity, or perhaps in another patient the compliance and eagerness to please, and we’re busy thinking about the best ways to address these defenses, not realizing that the bigger issue is the defiance that underpins them. We can’t address what we cannot see.
Another issue is as you say, our countertransference. Defiance in the therapeutic encounter is made possible by a projective process in which the therapist is put ‘in the shoes’ of a parent or other genetic figure who the patient now blames for childhood suffering and pain. Von Korff does an excellent job talking about all that in his article, by the way. Of course the patient is not consciously aware of this, but a part of them is now enraged at the therapist, blaming the therapist, and intent on destroying the therapist’s efforts. So even if the defiance isn’t coming out in overtly antagonistic ways such as sarcasm or provocation, we’re still likely to get frustrated by the fact that our efforts are failing to take hold. This can be particularly frustrating when the defiance is cloaked in a shell of compliance, and we’re proceeding along thinking we’re being so effective, all the while nothing is penetrating on a deeper level. Soon the therapy starts stalling or sessions go on in a desultory fashion. Ultimately, our own needs to be effective are thwarted. Of course when we get angry as therapists, we’re prone to the same unconscious anxiety and defense mechanisms as our patients, so if we’re not careful we can get off kilter and engage in unhelpful re-enactments.
Moving on to you, what are you struggling to learn right now? Italian! I used to speak it quite well because my wife is Italian and none of her family speak English, but because of COVID it’s been a number of years since we’ve visited. My language skills are rusty. With some Italian members in our Davanloo reading group, and IEDTA 2022 taking place in Venice, I’m wanting to take lessons again. We’ll see!
I’m also shifting a lot of my time towards leadership positions, such as supervising, training, giving talks, all of which is new for me, so there’s a lot to learn there.
See you in Venice! And as a therapist, what are you struggling to learn right now? Where’s your growth edge? Well, I think the perennial struggle is to always be myself while also doing a technique. As anyone who attempts ISTDP knows, we run the risk of sounding like automatons if we get too techniquey. And of course it’s very distancing to our patients and ourselves. So, I’m always looking for openings where I can let my personality shine through while also staying true to the technique and the needs of the patient.
I’ve seen that you’re starting up training and organizing community events in the New England area. What’s the community like around where you live? What are your visions for where you’d like things to go? Yes, I’ve been quite active starting up various groups and organizations recently! New England has some wonderful ISTDP and EDT clinicians, but there’s not a real sense of community. I know some people have tried to foster community in the past, but it hasn’t really panned out. I’m not sure I’ll be any more successful, but I thought I’d give it a shot.
Truthfully, I admire greatly what you’re all doing in Scandinavia. The organizations you have host such great content and it seems like everyone really knows each other. I’m hoping to establish something like that here, but I think it will take quite a bit of time.
Beyond hosting guest speakers and organizing training events, I’m also really looking forward to the social aspect of the community. I’m starting to plan a long-weekend retreat that will offer training and also the opportunity for people to really get to know each other and build friendships. That kind of thing excites me.
If you dream a bit, where would you like ISTDP to be in say 5 or 10 years? Well, it’s so exciting to see all of the advances in research that people like you are making. So, thank you for that! I think as long as ISTDP clinicians keep publishing research and getting the word out, the community will grow and more people will have a chance to benefit from this amazing therapy.
I’m also excited to see this new generation of ISTDP leaders emerge. Of course, those we’ve been calling ‘masters’ are wonderful, but it’s great to see a new group of ISTDP clinicians showing their work more and sharing their ideas.
Finally, I’d like to see more of a return within the community to reading Davanloo’s original work. This is something that has been talked about in the IEDTA listserv quite a bit, and Mikkel mentioned it in his interview with you, but Davanloo really did work in a very special way, and I fear that some of the best parts of his technique are not getting passed down. As I get more involved in training, I’m trying to do my part to make sure my trainees and supervisees read his transcripts to really learn the method. I’m sensing that there is a sea change with this, and I think a lot of other trainers are also interested now in sharing Davanloo’s transcripts and teaching from them. I hope in 5-10 years this becomes more of the norm in core training programs.
Yeah, during my core training, although we did study Davanloo’s texts, his texts weren’t at the center of our attention. What do you think might be missed if one relies too much on second generation literature such as, let’s say, the books by Patricia Coughlin, Allan Abbass or Jon Frederickson? Well, I think all those writers are great and have made really wonderful contributions to the field. They’re all doing ISTDP and they’re all fantastic at it! Anyone who reads their books will learn a lot. But they’re doing their own versions of ISTDP, and they’re all actually quite a bit different than what Davanloo did. Once I started closely reading Davanloo’s transcripts, I knew I wanted to practice like that. His intense focus on resistance, the way pressure is really applied to the defenses which then allows feelings to more naturally emerge, the moving and beautiful long-form head-on collisions or even just how often he used head-on collisions (he even does them with a patient he says is on the extreme left of the resistance spectrum–the case of the salesman!), all of it just really appealed to me as a very intuitive, honest and poetic system. For whatever reason, that way of doing things makes sense to me on some cellular level, I can’t explain it beyond that. So my concern is really about his style falling out of favor, or perhaps just being forgotten, in a way that it disappears. I don’t know if ISTDP is any less effective if his way of doing things vanishes, but in my opinion it’s not as beautiful.
Though this text is ultimately about my own perspective, this perspective has indeed been very influenced by Marvin Skorman (he wishes to be named simply “Marvin”). Therefore I want to briefly mention a few things about him, his background, and our relationship.
As Marvin’s time as a teacher draws to a close (after nearly 42 years in the field), I am reflecting back on the years we have had together. I met him in 2007, learned informally from him till 2012, at which point I began weekly audio-visual supervision as well as core training with him.
As far as I can tell, his perspective on practicing and teaching ISTDP is unique. I use the term perspective to suggest a particular flavor and emphasis, and as an acknowledgment that there are likely differences in degree, if not in kind, between how Marvin has adapted ISTDP to fit with his personality and intuitions and what may be termed orthodox ISTDP. I imagine that most practitioners and teachers, even those who aim to adhere rather strictly to a Davanloo-esque approach, adapt the model to some degree or another to fit with their own temperaments.
Marvin was one of Dr. Davanloo’s right-hand men in the 1980s, had a falling out with Dr. Davanloo in 1991, and the two reconnected in 2012. Mr. Skorman worked briefly with Dr. Davanloo again in 2015. Since the 1980s Mr. Skorman remained in close collegial contact and collaboration with James Schubmehl, MD. and Deborah J. Lebeaux, CSW, both students of Dr. Davanloo.
He has eschewed the limelight (i.e., having him give his seal of approval to this text was a pain), he has felt repelled by some of the “seeking and finding religion” culture that can be connected with ISTDP, and besides the little professional association in Rochester, NY with Schubmehl and Lebeaux, he has not wanted to be associated with any institutions or associations, though he is clear that he believes institutes have their place as bodies of knowledge and serve an important function in offering historical continuity.
He coined the term “ISTDP attachment disorder,” cementing his strong emphasis on flexibility and concern around formulaic treatment. The issues with being overly rigid and formulaic are not unique to ISTDP, but can apply to any therapeutic modality.
What I have learned and have carried with me from the years of core training and audio-visual learning from Marvin may be different from his other students and trainees, which in itself speaks to what it is like to train with him. Having had years of both individual and group supervisions with Marvin, it is clear that he approaches everyone differently.
Some of my training experiences have also helped me clarify where I depart from Marvin in terms of emphasis, so my perspective is influenced by him, a product from working with him, but contains my own adaptations, elaborations, and colorations from other teachers, peers, and studies.
What follows is my assessment of the key take-aways that I have absorbed, carry with me, and have incorporated into how I practice and teach Intensive Short-Term Dynamic Psychotherapy (ISTDP).
INSIDE AND outside the ISTDP roadmap
A phrase Marvin sometimes uses that has stuck to my ribs: “Therapy is about two imperfect human beings — each with their own triangle of conflicts —working out a relationship.” Nothing supersedes maintaining this felt sense of connection to the patient, which includes factoring in who we are and who the patient is at any given moment in time. This includes being connected to ourselves as therapists in the session — aware of what is happening inside of us, helping the patient be aware and convey to us of what is happening inside of them, and directly addressing any barriers that eclipse this awareness and emotional closeness. What maintains this connection can vary a great deal: for some it may look very supportive, for others it may look like heavy pressure and systematic challenge. When this is accomplished, not perfectly but sufficiently, the treatment outcome will be positive, no matter which therapeutic modality is used.
I have found that for me and many of my students, what goes into making and maintaining this emotional connection typically involves frequent recapping and clarification work, always making sure that the therapist can picture precisely what the patient is saying, to the point where the therapy session takes on the sensation of patient and therapist “sharing the same dream,” to use Marvin’s terminology. I place a tremendous value on dynamic inquiry and exploration, which I believe myself to see repeatedly in a host of Davanloo’s transcripts (H. Davanloo, Unlocking the Unconscious, 1990, and Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, 2000).
A sign that this connection is happening is that therapist and patient nod along together, sometimes even finishing each other’s sentences. It includes agreement around goals and the therapeutic task, but it goes beyond that. The patient should have the sense that the therapist is in their corner, and a sense that the therapist is concerned with their suffering. When this goes well, the patient does not experience the therapist as laying a trip on them, as pushing an agenda on them, and this sense of collaboration and togetherness continues even during heavy pressure and challenge (when and if heavy pressure and challenge is called for).
Not until the process of getting a clear phenomenological, descriptive picture of the presenting problems as well as the patient’s emotions is impeded by resistance does inquiry stop and give rise to focused defense work (prior to this juncture, tactical defenses may be briefly commented on). This can of course happen right out of the gate in the first minute of the first session, or further down the road — depending on rightward or leftward location on the psychoneurotic or fragile spectrum. Depending on ego-adaptive capacity, what “focused defense work” looks like varies a great deal.
It is important to underscore that some level of mobilization of the patient’s unconscious affective system is desired even during the phase of inquiry, but I distinguish between organic, lower level mobilization (tier one) and higher level mobilization (tier two) through targeted forms of added pressure on the foundation of a conscious therapeutic alliance. More on what I mean by added pressure in a minute. If I learned but one thing from Marvin, it was to not move to the second level of mobilization until there has been sufficient work done on the conscious therapeutic alliance, and when a graded format is called for, this added pressure is graded indeed (J. Whittemore, 1996).
Another prominent feature in the flavor of ISTDP that I have internalized is that even when a patient has the ego-adaptive capacity to face the de-repression of the unconscious, I do not automatically press ahead towards an unlocking. Some patients with higher ego-adaptive capacity want to take the edge off their symptoms and, in spite of seeing the down side of their defenses, are not interested in reaching “the top of the mountain,” so I go with what the patient is clear on that they want and thereby avoid a battle of wills scenario or a situation where I end up pushing an agenda on the patient.
I may say to a patient, “You have clearly made a lot of progress, but there are also signs you are not out of the woods fully. Is this good enough for you?” The patient may say that it is. If the patient has a track record of selling themselves short and not being honest about what they really want in their heart of hearts, I may press a bit, “are you sure? Are you settling in a way that sells you short?” But at the end of the day, if the patient says that where they are is good enough for them, then it is and I accept that.
There may also be sessions dedicated to taking a victory lap, celebrating the progress in the patient’s life, perhaps even ending the session early because the patient is wanting to just enjoy where they currently are, knowing that next week they may again wish to dig deeper. Bottom line: regardless of the patient’s capacity, I do not get ahead of their conscious will and I am open to the possibility that for some patients, unlocking the unconscious is just not where it is at for them, and other, different types of therapeutic work is what is needed. Remaining in touch with not just overt psychodiagnostic information but also with my felt sense (more covert, counter transferential diagnostics) helps me make the determinations of what, when, and with whom.
I also stress the importance of arriving at a dynamic formulation of the psychodynamic conflicts giving rise to the patient’s presenting problems. The triangle of person as well as nuanced, unique themes related to the patient’s intrapsychic conflicts are a major focus in how I engage with ISTDP. I am reminded of the many times Marvin asked: “What is the formulation here?”
A doctrinaire application of ISTDP technique
In the context of reflecting on past mistakes, seeing what trainees struggle with, and comparing notes with Marvin, some troubling trends come to the fore (trends neither Marvin or myself are immune from). I am thinking of trainees and practitioners of ISTDP being out of step with their patients for one reason or another. Some applying well-rehearsed straight-lines and rote techniques, others so focused on looking for signs of unconscious communication that they aren’t actually hearing what the patients are saying, yet others so focused on dragging patients through the central dynamic sequence — that the foundation gets lost, the actual contact and connection between patient and therapist is often not there, replaced by attempts at applying techniques.
The basics of dynamic inquiry, understanding how the patient sees things, ensuring the therapist has properly understood the meaning of what the patient is trying to convey by summarizing and underscoring key themes with dynamic significance, establishing a conscious alliance, arriving at a formulation of the core conflicts driving the patient’s problems, these are the type of things that appear lacking and stand out as problematic themes.
I recall Marvin speculating that these issues might boil down to what he calls “the suffering of therapists.” When he gives me supervision on how I supervise trainees, he frequently makes the point that the intervention-response principle is not just for our patients, but also for our trainees. The trainee’s subjective responses to the supervision are attended to and factored into the didactics — their anxiety also needs to be in a therapeutic range and if this is not attended to — if I offer my perceptions and suggestions without regard for where the trainee is, it often creates a misalliance between us and creates suffering for the trainee. For others, a “just tell me what you see and what you would do” approach works. I learned from Marvin to meet my trainees where they are and that a conscious alliance with them is just as important as with patients.
Though Marvin truly adores Dr. Davanloo, he reflects on his core training with him and tells me that there was a major focus on unlocking the unconscious, and that he eventually came to feel that this single-minded emphasis on the unlocking of the unconscious experience sometimes came at the expense of not just the human relationship and connection with the patient, but also an openness to seeing other, unique ways of helping the patient not involving an unlocking of the unconscious, that may be more optimal. Having been trained in this way, I find it important to stay open to the collective unconscious between the patient and myself, and allowing interventions to come from that place — interventions that may be unique to a given patient at a given moment, that may never be repeated again.
During one of our discussions, Marvin shared the following with me: “Davanloo used to say, ‘With the help of each other, if we work hard, we can get to the bottom of your problems.’ That was his way of saying it [that the heart of this work is about the emotional connection and collaboration between patient and therapist].” Marvin continued: “So much of that essence of Davanloo seems to have gotten lost, the admiration and affection part, it somehow got ‘techniqued’ away. The technique was secondary for Davanloo, it came from his intuition, which I think is an invitation to all of us to use our intuition.”
Technique as a background element
With the emphasis on emotional closeness and connection with the patient, some may think that what I learned from Marvin de-emphasizes specific techniques. This is true. Marvin really is concerned about an over-emphasis on technique and an excessive attachment to diagnostic categories that get in the way of a human-to-human connection with the patient.
Yet I have learned a great deal when it comes to assessment and technical execution. Stand-out items that come to mind: working with malignant forms of resistance where “talking down to the super-ego,” is important (super-ego as a motivational force, not a noun), not “bargaining with the super-ego,” undoing projections by being different from the projection. For example, a patient projects their super-ego functions onto me and accuses me of putting them down. A defensive response aimed at trying to get the patient to be different would reinforce the projection. A response of, “So you see me as putting you down. That is concerning, if I am doing that, that would be really bad. What makes you come to this conclusion?” asked in a sincere manner will counteract this kind of a projection. Part of the needed therapist mindset here involves staying open to the possibility that the patient’s perception may have merit.
Another important concept I have learned from Marvin has to do with not allowing patients to manipulate me out of having an opinion, or getting sucked into colluding with the patient’s maladaptive defenses, i.e., pampering, coddling, or otherwise going along with an insecure attachment with the patient (insecure attachment reference — Jon Frederickson, personal communication, 2020). Most importantly, understanding when and with whom to do what with, based on an ability to assess the patient and engage with the interactive diagnostic roadmap that Dr. Davanloo developed.
Enter the head-on collision.
Marvin has had a role in my deep appreciation for the head-on collision. I have learned about many different kinds of them depending on the patient’s ego-adaptive capacity and the strength of the conscious and unconscious therapeutic alliance. A complete taxonomy of the different types of head-on collisions that I use is outside the scope of this text, but in addition to ego-adaptive capacity and the status of the conscious and unconscious alliance, the patient’s unique history, ego-syntonicity vs. ego-dystonicity of defenses, and severity of the need for self-defeat also factor in.
For example, with a patient with signs of fragility and a history fraught with rejection and abandonment, I may leave out the “if you remain distant like this, this process is doomed to fail.” Instead I may just say with a calm, edge-free tone, “So when you are like this, you are out of reach, and we are treading water, aren’t we.” I may add, “and that is of course your right, I am not going anywhere, I am here if you decide you would like to engage.”
Fragility does not mean that I do not point out reality, but I do this in a manner that makes it very clear that I do not need the patient to change, that I am not pressuring the patient to be different — the impetus to change needs to come from them. The emphatic “why do you want to do this to yourself?” interventions are truly superb, appealing to both the conscious and unconscious alliance with pressure on the patient to do something about the resistance, but I reserve this way of working for very different contexts than the beginning work with patient’s with fragility.
A few paragraphs down, under the “the problem of premature pressure” subsection, I give another example of a type of head-on collision that conveys both empathy for the patient’s conflict while still pointing out the reality that the therapist cannot be helpful while the patient remains guarded.
A different presentation, say an absence of fragility, ego-dystonic defenses, a highly malignant, destructive form of resistance may call for a head-on collision using a “talking down to tone” that not only underscores that the therapy will fail but also questions the point of even meeting, in line with what Dr. Davanloo referred to as conveying “studied disrespect” towards the defenses (H. Davanloo, Unlocking the Unconscious, 1990, p. 214).
While on this topic I cannot refrain from mentioning an article written by Allen Kalpin, MD, where he describes the head-on collision. It is titled Effective Use of Davanloo’s “Head-On Collision” (1994). The article covers a great deal about this intervention, from the “partial head-on collision with the character resistance,” to issues of timing, the differential aim regarding restructuring or unlocking, and the recognition that some forms of head-on collision are done prior to a rise in complex feelings and others after.
This article by Dr. Kalpin does a particularly good job highlighting the importance of not watering down the power of head-on collisions by being prepared and open to the fact that the patient may decide to leave and not try to change themselves. The article also does a beautiful job of underscoring use of silence, “not filling in the gaps,” the need for the therapist to not over-function, to not resist the patient’s resistance, so that when the therapist observes to the patient that therapy grinds to a halt, the patient can truly experience the halting and the self-destructive consequences of their resistance (p. 34).
The head on-collision is often critical, not just in order to undo the omnipotent transference resistance, intensify intrapsychic conflict towards the needed crisis-point, but also in order to cement and solidify the conscious therapeutic alliance and help the patient turn against her maladaptive defenses. When I help a patient see that there is a battle inside of them between the side that wants to remain guarded and the side that wants freedom, and ask the patient: “Which side are you on?” I am inviting the conscious will, I am “putting the patient at choice” to use Dr. Patricia Coughlin’s terminology (Personal Communication, 2017). When and if the patient convincingly declares that they are on the side that wants to discontinue the avoidance strategies, the patient “turns against” her defenses and the conscious therapeutic alliance is solidified.
This may clarify that I am not anti-technique or theory, but instead I am against a technical mindset getting in the way, becoming a therapist-created barrier against emotional closeness. I very much believe that it is very important to have sufficient theoretical understanding, discipline, and skill when it comes to moment-to-moment assessment of patient-response, assessing ego-adaptive capacity, and ability to effectively intervene based on these factors.
I have wished Marvin placed more value on theory, an area where we depart a bit from each other. He seems to have an ability to allow his own unconscious to connect with the patient’s unconscious and be guided by that, which I very much admire, but recognize that not everyone is able to do, giving rise to a need for theoretical and conceptual structures.
On the topic of staying present with the patient and not mechanically plowing ahead in a cook-book fashion (allowing theory and technique to get in the way), I am reminded of a comment Marvin makes from time to time: “this is intervention-response, not intervention, intervention, intervention, and ‘I’ll see you next week.’”
The problem of premature pressure
A major principle that I have internalized is to not apply any added pressure — added as in additional pressure on top of the inherent pressure contained in inquiry into the patient’s problems and their will — without the patient having convincingly declared their will to let go of defenses in favor of facing feelings. Then again, the perceptive reader will note that in order for there to be a question of turning against defenses, some level of mobilization and pressure to affect would first need to be there.
This goes back to the two tiers of mobilization. The first tier can be achieved conversationally by simply asking about the patient’s priorities and feelings, making links, and reflecting back to the patient what is observed about their responses. The second tier is when I ratchet up the pressure but at that point I want a conscious alliance as the foundation. Moving ahead to second-tier level pressure without adequate foundational work is what is often problematic, and not something I am always immune from.
In other words, I generally do not try to get a high rise on complex transference feelings before there is a sturdy conscious therapeutic alliance and the patient has begun to turn against their defenses. Since some variety of the head-on collision is often central to helping the patient turn against her defenses, this intervention (modified to be suited to the patient in front of me) is typically done prior to a high rise of complex transference feelings, and later repeated (typically in abbreviated format so as to not deflate rise in feeling) as needed. An early head-on collision here is not meant to “block” defenses but is done conversationally and matter of factly so as to help the patient make an informed decision around holding onto or letting go of their defenses. As alluded to in the previous paragraph regarding the two tiers of pressure, some level of mobilization is typically desired and needed even prior to using added pressure and the head-on collision. Again, I cannot help a patient meaningfully turn against her defenses outside the context of some level of feelings and defenses being stirred up.
In fact, not until the stage of increasing pressure and challenge where I aim for an unlocking of the unconscious by decisively blocking all defenses (blocking everything that is not the experience of raw feeling and impulse) — also known as unremitting pressure and systematic challenge — does the conversational quality of the treatment give way to what is more clearly and overtly an applied technique, though Marvin stresses that even then, if the pressure and systematic challenge fails to enhance the felt sense of connection with the patient, it may be best to hold off on these more advanced interventions until they can be done without sacrificing the sense of collaboration and closeness with the patient. This portion is not used in the graded format.
In the context of defenses and resistance impeding the progression of therapy, and the patient being reluctant to let go of their defenses, I can’t count the times I have heard Marvin very calmly say something to this effect: “I understand, allowing people close to you hasn’t been a good experience for you so far. And yet this represents a dilemma in our work, because the one thing I need in order to have a shot at being helpful to you is access to your most intimate thoughts and feelings, and it is also the one thing you say you abhor the most, letting people in, close to you. So here we are.” At these types of junctures, this is a conversation, not an attempt to mobilize complex transference feelings (though it often does).
The bottom line: without a conscious alliance around facing feelings, I don’t exert heavy pressure toward feelings. Without a conscious alliance around letting go of defenses, I don’t exert heavy pressure to relinquish defenses. Not getting ahead of the patient’s conscious will is a central tenet in how I practice and teach ISTDP. There are no repeated “so what feelings are coming up” or “how do you experience that feeling” questions until the patient is on board with such a focus and has a crystal clear understanding of how those questions (and that task) relate to their concerns and priorities for treatment.
I really appreciate creativity. On this topic, I can think of several instances where Marvin has helped me think outside the box and be creative. Perhaps the best example of the creativity I have observed and be inspired by centers around his development of a way of facilitating couples therapy, obviously an adaptation but still grounded in ISTDP principles.
Since Davanloo developed ISTDP for individuals, with the aim of resolving intrapsychic conflict, and couples therapy primarily deals with interpersonal conflict, the adaptation component looms large, but the principles around emotional closeness and resistance against emotional closeness, and each person’s triangle of conflict are foundational in this approach to couples therapy. Unlocking of the unconscious is not the primary aim, but sometimes spontaneously occurs. The intrapsychic conflicts of the individuals comprising the couple play a major role in their interpersonal conflicts, so I attend to this dimension as well even though the couple itself is the patient.
This approach to couples therapy is elegant and often very effective (though I have no research to back that up, so it is considered experimental). A YouTube video exists that explains this approach in detail, you can find it here.
Supervision and Teaching
Influenced by Marvin, my approach to teaching and supervision is characterized by using who the trainee is, their life and clinical experience as a starting point, and then integrating ISTDP into that so as to enhance the trainee’s strengths, rather than trying to make the trainee void who they are in order to fit into a mold. This is hopefully how all teachers supervise, but I bring it up because of much it was stressed to me in my own teacher training.
When difficulties arise, my default assumption is that my training approach needs to be questioned or adjusted, not that the trainee is defective. Like most all trainers I assume, I encourage my trainees to find their own voice and integrate whatever they learn into their own personality.
If there is ever a choice between didactics — introducing ways of understanding what is going on with the patient and letting the trainee know what they could have done differently with their patients — or meeting the trainee where they are and modeling how to not get ahead of the patient by not getting ahead of where the trainee is, I opt for the latter, shelving didactics in favor of a conscious alliance with the trainee and modeling how to be with patients.
As previously mentioned, Marvin has remained apart from institutionalized ISTDP places of learning. On several occasions he tried to help Dr. Davanloo formalize and codify certification programs in ISTDP, but these efforts never succeeded. Without institutionalized backing, there is nevertheless a more informal practice around transmitting the recognition of readiness to teach to students in the community around Marvin. Marvin’s tenacity in fighting off my attempts to have him create something more formal has bested my efforts.
As I am writing this in 2021, I realize it’s been 14-years of intensive immersion in learning on this path, and that capturing the stand-out items of this learning is a tall order. A text like this cannot do justice to the task of trying to capture the distilled essence of what I learned.
As Marvin heads for the exit, I mourn the loss of this teacher that has been so formative for me. To my mind, our profession is losing a giant who chose to live, practice, and teach in relative obscurity. His wish has been for his students to take what they can from him but then chart their own course, keeping the flame alive but in a way that honors the uniqueness of who we are as individuals.
I raise a metaphorical glass to him, to Dr. Davanloo, who made all of this possible, and to other teachers and peers who supplement and contribute to my learning.
References and acknowledgment:
Elad Jair Chone, Clinical psych. — close student of Marvin — in an editorial capacity, has graciously assisted in the making of this text.
Marvin Skorman, LMHC, Personal Communications (2007 – 2021).
Davanloo, H. (1990). Unlocking the Unconscious (p. 3). N.p.: John Wiley & Sons.
Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD Chichester, England: John Wiley & Sons.
Kalpin, A. Effective use of Davanloo’s “head-On Collision”. International journal of short-term psychotherapy, 9, 19-36.
Whittemore, Joan W. “Paving the Royal Road: An. Overview of Conceptual and Technical Features in the Graded Format of Davanloo’ s Intensive Short-Term Dynamic Psychotherapy.” International Journal of Short-Term Psychotherapy, vol. 11, 1996, pp. 21-39.
Dr. Patricia Coughlin, Personal Communication, (2017).
Jon Frederickson, MSW, Personal communication, (2020).
You can find the webpage of Johannes Kieding here, and he also runs a YouTube channel, which you can find here. Since a few years back, he runs a much appreciated community discussion group on Facebook called “ISTDP Peer Community”, which you can find here.
In the spirit of having a nuanced and critical discussion on ISTDP, we at ISTDP Sweden have published a series of articles during the last year. In this recent piece by Ange Cooper, she talks about the problems of idealizing or devaluing ISTDP during training. Mikkel Reher-Langberg is currently finishing his work on a two-volume book about Davanloo’s work, and in this interview you can learn about some of what he’s been learning during the process of writing. Earlier this year we published to interviews on the topic of limitations of ISTDP, one with Jon Frederickson and one with Patricia Coughlin.
Examensarbete: Terapeuters upplevelser av digital ISTDP
Några psykologstudenter vid Umeå Universitet söker CORE-utbildade ISTDP-terapeuter som bedriver minst en terapi via digitala mötestjänster för att delta i en studie. Studien undersöker hur ISTDP-terapeuter upplever likheter och skillnader mellan digitala och fysiska besök. Deltagandet innebär ifyllande av en kort enkät som tar cirka 5 minuter. Klicka här för att komma till enkäten!
In this article we get to meet Ange Cooper. She discusses the many stages of learning ISTDP, detailing her own ISTDP journey through idealization, omnipotence, denial, depression, personal therapy, complexity, psychedelics and spirituality. Ange is an ISTDP teacher and supervisor based in Halifax, Canada. You can find her website here.
Shifting the focus to the person of the therapist
On the back of some recent conversations in the community regarding the teaching of ISTDP, you wanted to talk about your experiences as a learner. How so? It’s time to talk about my ISTDP learning journey come what may. I have gone through many stages in my learning process and I hope by talking about these openly, it can serve as an enriching personal account that facilitates many other discussions regarding the ISTDP learning process.
So how did you learn ISTDP? I completed my core training with Patricia in 2014, having first been introduced to ISTDP through an 8-month placement with Joel Town. I developed a research interest in ISTDP and spent a number of days at Modum Bad Hospital in Norway being taught how to use the ATOS as a process research tool by the awesome Lene Berggraf and Pål Ulvenes.
Early in my learning I decided to do a block of therapy with Josette ten Have-de Labije as well as receiving regular supervision from Mark Stein whilst working in the NHS. Following this, I moved to Canada to work with Allan and had weekly supervision for the best part of the last 5 years. I attended a Davanloo immersion in Montreal, then completed training with Tony Rousmaniere on deliberate practice with Tom Brod, Susan Warshow and Robin Kay. I then went on to complete Jon Frederickson’s Training of Trainers course and continue to attend his advanced training which is now in it’s 4th year, I believe. Amongst all of this I have had the benefit of thinking, learning, discussing and being inspired by many other folks in ISTDP, EDT, CBT, psychoanalysis, Jungian analysis and so on.
Besides learning, I have been teaching and training in ISTDP for a number of years now, having facilitated one core training to completion with another mid way through. I will start an advanced training group in November with Allan Abbass.
All of this is to say, I have had a lot of training in ISTDP and have been committed – like a marriage – to this model for over ten years now. However, what I want to convey here, which I think is more important than my ‘ISTDP qualifications’ is the personal work I have done over this last 10 years.
But is this really a dichotomy – training in ISTDP and personal work? Not really. I want to talk about the stages I have been through and how this has influenced and fundamentally changed how I practice ISTDP. I think this touches upon some of the points Mikkel raised in his interview but in a more personal and experiential way.
It is my sense that this aspect of our learning isn’t spoken about enough, of course because it is personal and that can be scary and certainly vulnerable. So, I feel it is in some ways part of my growth to begin such conversations so that others may feel brave enough to do so and so that we can begin to consider how our personal and collective wounds impact our work in ISTDP.
As Allan Abbass recently pointed out on the IEDTA-listserve, when assessing a patient video you have to consider at least eight central factors: degree and type of resistance, degree of rise in complex transference feelings, phase of treatment, degree of syntonicity, state of the conscious therapeutic alliance, presence of barriers to engagement, medication and somatic illnesses and the current front of the emotional system.
If you add to this the same number of therapist factors, well then you have a pretty huge number of interrelated factors all occurring at any one moment. Maybe someone who reads this can do the math as to how many combinations we can find?
So there’s a lot of work to be done when it comes to the therapist side of things. It is my deep belief that what we struggle with in ISTDP or any complex endeavour for that matter, is very much tied to our own unconscious emotional processes. This is why ISTDP looks so different between different therapists and within the same therapists across time. I do believe Davanloo developed a deeply healing model of therapy, however it is my guess that even he was troubled by how complex the model was to teach and transmit.
I also think he set up his mobilisation groups in order to address some of the difficulties that therapists have to overcome to do this work well. Including issues such as the therapists own punitive superego, sadism, masochism and tendencies to get stuck in a transference neurosis. Whilst certainly controversial ethically and massively problematic in terms of power dynamics, I can see why he may have felt a desire to help therapists overcome their own emotional difficulties in order to implement ISTDP in the way he would have hoped for.
from omnipotence to depression and beyond
Coming back to you… You said you wanted to talk about your own journey? Here we go… In the beginning I was immersed in learning about psychodynamic conflict, the theory of ISTDP, Davanloo’s publications and the actual skill/technique of the model. Just like when you’re learning any new skill there is the excitement and inevitable frustrations that show up with each new patient.
As I grew as a practitioner, I met my skill development with an overidentification with the model, a oneness with it and it meant everything to me. It became part of my identity and my personality at some level – I think I fell in love with the model!
The desire for oneness with the model was so strong that with it came an idealisation of its power and ‘rightness’ above all other models and devaluation of other forms of therapy. I experienced very little anxiety during this stage and as such I had some very good outcomes – because I believed in it 100% – but also some very bad ones.
We could say I went through an oceanic stage and into the paranoid-schizoid stage that Melanie Klein speaks about – I was unable to tolerate complexity. I engaged in splitting and denial, and I was filled with my own omnipotence.
Thankfully, but painful at the time, this stage didn’t last, the more patients I saw and the more experience I gained, I started to recognize that I was struggling with a whole myriad of patients. This is when I started to move into a more depressive phase.
What was that like for you? I started to become overly critical of my skills and capacity, I even started to resent learning ISTDP and wanted to have a life beyond it. And this was the stage where I started to look towards others models, teachers and readings that began to broaden my horizons away from the “Fathership” of ISTDP.
During this phase, my practice began to look different. I was playing with different ways of working and trying them with patients, I started to believe that there had to be more than ISTDP to heal others and myself and so we could call this phase the depressive phase but also the beginning of an experimental phase as I grew.
I could no longer do “pure” ISTDP, I was very much in “ISTDP eclectic”, or “ISTDP-I’ll do it my way!” Again, for some patients this seemed to be helpful and for others I continued to be stuck, frustrated and despondent. All the while, I continued to study and continued to seek supervision but I started to become depressed and began to wonder, what does all of this mean? I started to lose my sense of meaning and purpose for ISTDP (and of course tied to my life in general) and even patient work. I became a little more depressed.
At my lowest points, I started to realize that I was struggling just as much as the person in front of me, so how on earth could I help them? I recognized that I had begun to treat my patients as if they were different to me, at times ‘lower’ or ‘higher’ than me and that they just weren’t co-operating with me or this therapeutic model as I saw it at the time. I started to disconnect from patients and simultaneously disconnect from myself – and my therapeutic work started to look more like a series of technical interventions that seemed to lack compassion or heart – what had happened? I started to have some very deep conflicts within myself the more this stage progressed. Let’s call this stage disconnection or separation consciousness.
Due to my experience of depression and fatigue during this journey, I decided to commit to my own longer term therapeutic endeavours. At the time I didn’t really feel I was of much value or help to my patients. I had lost my mojo for therapy – I felt lost. I actually wanted to quit being a therapist, it was too painful, too difficult, too stressful and it seemed to have lost its joy, meaning and purpose.
Getting to know your blind spots
We’re very grateful to still have you around, despite what you’re telling us. What helped you find your footing again? Over the last 5 years, I have steadily been engaged in my own work, this happened to be mainly Jungian analysis. There was just something about Jung’s way of working that intrigued me. I wanted to find deeper connections within myself, I wanted to understand my dreams, I wanted to understand the collective unconscious and mostly I wanted to feel that life was meaningful again. To me, life had lost its wonder and I didn’t know how to get it back. So I started therapy, I also did ISTDP block therapy every time I hit upon some big emotional wave that I felt needed to be processed with an unlocking. This was a really useful combination for me.
In addition, and with deep gratitude to Jon Frederickson, I started to bring my most difficult cases to supervision and through experiential role plays he helped me begin to understand from an experiential level – not an intellectual level – what some of my own emotional blind spots were. Blind spots that kept getting in the way of my ISTDP practice.
Can you be more specific? What where you learning at that point? I discovered that I had major difficulties in recognizing when I was stuck in a transference enactment especially with highly resistant patients. An inability to see that it was I who held the motivation and unconscious therapeutic alliance for the patient, along with a completely unconscious tendency to resist the patient’s resistance. In sum, this was leading me to co-create the problems that occurred in the therapy room. I was a central part of the problem.
More recently I also gained a very deep understanding that I have been identifying with my patients’ projection of guilt – which has meant that my breakthroughs to guilt, my ability to hold complexity during phases of mobilisation and my ability to do head-on collision were seriously compromised. Because of my own internal, emotional dynamics/capacities I had been unable to offer patients some of the most fundamental aspects of ISTDP model, try as I might. I wasn’t even able to see what was wrong because everything was operating at such an unconscious level – sigh.
Can you be even more specific, what did this look like in sessions? Mostly it looked like not getting to deep breakthroughs of complex feelings, I emphasized rage above complexity. I was anxious to get to an outcome and I only partially identified the resistance. This meant that it could continue to operate. And there was minimal work with the operations of the pathological superego, since I couldn’t see it. And my head-on collisions did not land and did not create the deeper impact I had hoped for.
The outcome of such issues was that often patients only ever had partial breakthroughs, the UTA was never fully mobilized and this then compromised the deep insights and character change that the unconscious therapeutic alliance potentially brings through to the later, working through stages of the treatment.
This is not to say that I haven’t had cases with good outcome at the same time, but it is my observation of regular patterns that were occurring within my work at this stage.
Getting unstuck: the path of spirituality and psychedelics
What was it like to see that? Oh my goodness, I am just as stuck as the patient!
We are suffering the same difficulties and likely of a similar emotional origin and until I begin to see the patient as me – and me as them at an emotional level – I cannot move this thing. I cannot do this therapy. I cannot mobilize the unconscious enough. I cannot see in them what I cannot see in myself.
This was my most painful stage – but also, I suppose – my most liberating. I could no longer see the patient as different to me, I could no longer hold this human being either above or below me – I had to begin seeing them as, well at one level different, but ultimately one and the same. This started me into a new developmental stage that felt something like unity consciousness-oneness-humanness – not sure what to call it. But it would be summarized as “I am my patient, they are me”.
How hard it can be to stay open to that shared vulnerability. What impact did this realization have on you? At this stage of both my growing up and – we could say – waking up, I started to become deeply interested and connected to spiritual writings, integral models of therapy, transpersonal ways of thinking (Stanislov Grof, Ken Wilber) and embodiment practices – and all of this finally led me to psychedelics. I have been hesitant to talk openly about this aspect of my development, but it seems like it is the time and so I will give some brief details.
As I started to become interested in the transpersonal readings above, I hit a stage of my development that spiritual circles call the dark night of the soul. Nothing interested me, I stopped wanting to hang out with people, I wanted to become very introverted, I was in existential angst.
At one point I even wanted to start meditating. Those who know me, know that this isn’t really like me. It was so not like me – but then I started to question who am I anyway – and so meditations began. Through meditation, reading, and becoming more and more aware of some deeply rooted conflicts inside of me, I made the decision to undertake some ceremonial psychedelic sessions with an experienced medicine woman.
There’s a lot of buzz around psychedelic-assisted therapy these days, with both MDMA– and psilocybin-assisted therapy closing in on medical approval within a few years. What were the ceremonies like for you? I won’t go into these experiences in too much depth, but they have been transformative for both my own personal healing and consequently my practice of ISTDP. In short, through some intense and at times painful experiences, I feel like my heart has been cracked open and I have been able to heal some of my deepest wounds in ways that would not have been possible through a talking therapy.
It is really beyond words to describe the experience, but it has changed my life in profound ways – It has brought me to a place in which I feel deeply connected to a spiritual process and so slowly over the last few years my sense of meaning and purpose has started to re-emerge and with it my excitement and interest in ISTDP as well as my work with patients.
It has made me want to come all the way back to ISTDP (like the hero’s journey). Except that for me, I now place ISTDP into a much bigger, broader spiritual framework that goes beyond symptom and character change.
Do you think psychedelics has an important role to play then in the teaching of ISTDP? It is too big of a topic to go into here regarding ISTDP and psychedelics, but I am interested in the power of ISTDP and psychedelics used together in some combination– and I am also very interested in the journey of the therapist especially as it relates to the ideas of ‘waking up’ versus ‘growing up’ and how we might consider both of these aspects within our development as therapists. People can wake up but not have grown up and there can be devastating results from this, people can also be very grown up but never really find a spiritual path – my interest is in how both of these forces come together and how we can yield these forces to massively advance our field.
I have been considering the similarities between ISTDP and psychedelics for some time. From my perspective and experience, the process of breakthrough – into guilt-love-oneness-compassion along with an unlocking of memories from the past – is very similar to the experience during a psychedelic session. But no talking and less time.
There is something very powerful that happens in both modalities when we melt our punitive superegos, when we surrender to the power and intelligence of something much bigger than ourselves. When we fully let go of control. When we become one with the experience. When duality does not exist. It’s something truly amazing, mystical and spiritual that happens that is beyond the rational or intellectual mind and in the realm of deep knowing-intuition-transcendence.
I think there is much cross pollination of ideas and potential for growth in our understanding of psychopathology if we are willing to be open to how psychedelics work and in what ways the process of change is similar and different to ISTDP.
Learning and teaching ISTDP
So what does all of this boil down to when it comes to how we teach and learn ISTDP? I believe Davanloo created a powerful model that when delivered optimally – has both the patient and therapist engage in a deeply meaningful spiritual endeavour.
Davanloo had clearly grown up enough in terms of his own emotional development that he was able to conceive, develop, research and deliver this model effectively and it is integral to who he is. As I understand it, most of the issues in ISTDP come from the learning and teaching of the model, especially when we are all at vastly different stages of growing up.
This would mean then that given the therapist’s stage of development, what is focused upon in sessions, what is heard, what is taught, what is practiced, what is adhered to and what is focused upon is going to look very different person to person. I have a sense that what we end up focusing on in therapy can sometimes be the unconscious issues that we ourselves are struggling with and not always that of the patient. For example, I am currently in a stage of fascination or maybe even obsession with the punitive superego, and I’m seeing it everywhere I go. It so happens that this is what I am deeply working with in my own therapy and musings.
When I see ISTDP at its best, it is the same feeling I get when I hear an orchestra play, when I watch a moving film, when I see dancers move in synchrony or nature working together. It is this deep flowing unison with what is, in the present moment and it is breathtaking. When I see Patricia Coughlin, Allan Abbass, Jon Frederickson and others in their zone with a patient, I see them as deeply connected, intimate, honest, open, speaking from their hearts and deeply aligned with who they are. They’re in synchrony with powerful techniques and a deeply embedded understanding of conflict, the unconscious, as well as a deep respect for the patient’s will. In other words they are in a flow state that transcends the conscious mind.
All of the above, to me, is what provides the furtive ground for emotional breakthroughs that lead the patient’s own unconscious therapeutic alliance into resonance with their individual and collective wounds in order to create deep healing and change. This is some of what I mean in placing ISTDP within a more spiritual framework.
Following the above, I started getting the message to read Davanloo, Freud and Jung again from their original sources and, like most learning that occurs as a spiral, I noticed that I could finally read and understand what I could not previously.
It sounds like you’ve come a long way. So where are you at in your development at this moment? I have deeply reconnected with ISTDP and at least right now, I am able to do this in a way that at times looks like the work of those I most admire except it is embodied through me. I am now able to mobilize the unconscious in a way that I couldn’t before. At times, I can deeply hear and feel the unconscious therapeutic alliance as it rises, I can feel when a patient is complying or if they are becoming their punitive superego, I can feel their somatized pain as well as the rage as it rises in my body as well as theirs.
This is no longer such an intellectual endeavor for me, even though I am re-reading a lot and thinking about this every day. Instead, it feels like it is coming from a place of intuition and my heart and as such I am learning to do Heart on Collisions rather than Head on Collisions as I like to view them.
I am speaking from one heart to another when I press to feelings, when I identify and clarify defenses, when I stop being the ego to someone’s superego so conflict can rise in them. And low and behold patients seem to be having breakthroughs in a way that I could not facilitate previously and it comes without the intense attachment to the outcome that I once had.
Sadly, this does not mean I am having breakthroughs with everyone, I just know that my interventions are coming from a different place these days. It is much less cerebral and more embodied as a whole part of me rather than me being split into lots of separate parts trying to speak to the different parts of the elephant.
So, this is where I find myself on this journey now and I continue to grow through seeing new patients, skill building, meditating, video review, teaching and supervising trainees. I don’t know where this stage will take me but I know at least part of it is to share my experience, to enable others to share theirs, to practice courage and bravery in speaking my truth and to help those who are struggling to recognize that in any complex endeavor that involves body, mind, heart and soul – there are stages and we all go through them – some quicker than others. But still the spiral continues.
NOTE:With the permission of the author, the text has been reconstrued as an interview to make it more accessible.
Intensiv dynamisk korttidsterapi (ISTDP) utvecklades under 1980- och 1990-talet i Kanada. Behandlingsmetoden är specifikt utvecklad för komplexa och kroniska tillstånd där andra behandlingar inte haft önskad effekt, men går även att anpassa till mildare former av psykologiska besvär. Den här kursen lär under tre intensiva dagar ut de teoretiska och praktiska grunderna i metoden.
Intensiv dynamisk korttidsterapi (ISTDP) är en modern psykodynamisk behandlingsmetod som betonar upplevelsebaserat arbete som fokuserar på känslor. Under 2010-talet har metoden etablerats i Sverige, och ISTDP har blivit ett allt vanligare inslag på landets psykolog- och psykoterapeutprogram. Vid Stockholms Universitet och Karolinska Institutet genomförs forskning på metoden som i nuläget erbjuds på ett femtiotal vårdmottagningar i Sverige.
Kursen omfattar tre heldagar och ger en grundläggande introduktion till ISTDP. 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
Introduktionskursen är ett behörighetskrav för att läsa den treåriga ISTDP-utbildningen Core, om du önskar göra detta senare. Flera coreutbildningar kommer att starta på olika platser i Sverige under 2022, och vi planerar för att starta minst en coreutbildning i Malmö under 2022. Mer information om utbildningar kan du hitta på www.istdpinstitutet.se
Kursen riktar sig till psykologer, läkare, socionomer, fysioterapeuter, psykoterapeuter och studenter inom dessa yrken, men vi välkomnar även annan vårdpersonal som kan ha nytta av ISTDP-färdigheter i sitt arbete.
Tid och plats
Kursen kommer att hållas centralt i Malmö 24-26:e januari 2022. Tiderna är 09.00-16.30
Kursen hålls av och Nina Klarin och Thomas Hesslow. Nina är leg. läkare, specialist i psykiatri, leg. psykoterapeut och handledarutbildad. Hon är certifierad ISTDP-terapeut av ISTDP Institute i Washington DC. Hon arbetar med terapi, handledning och utbildning på heltid, och undervisar bland annat vid Lunds Universitet. Nina har arbetat drygt 15 år som överläkare inom psykiatrisk specialistvård innan hon lämnade för ett samverkansavtal med Region Skåne där hon nu bedriver sin verksamhet. Nina gick core för Allan Abbass och Jon Frederickson. Efter det gick hon en fortsättningsutbildning för Patricia Coughlin. Hon tar examen från Jon Fredericksons treåriga lärar- och handledarutbildning Training of Trainers under hösten 2021.
Thomas är leg. psykolog och certifierad ISTDP-terapeut av ISTDP Institute i Washington DC. Han är styrelsemedlem i den svenska föreningen för ISTDP och en av grundarna till det svenska ISTDP-institutet. Han arbetar med terapi, handledning och utbildning på heltid, och undervisar bland annat vid Stockholms Universitet och Lunds Universitet. Innan han specialiserade sig inom ISTDP arbetade han med KBT/DBT. Han gick coreutbildningen för Tobias Nordqvist och Jon Frederickson, och tar examen från Jon Fredericksons treåriga lärar- och handledarutbildning Training of trainers under hösten 2021.
Kursen kostar 4500 SEK exkl. moms. Heltidsstudenter betalar 3000 SEK exkl. moms. Då ingår undervisning, kursmaterial och fika under de tre dagarna.
Kursen arrangeras av Thomas Hesslow och Nina Klarin i samarbete med ISTDP-institutet, ett nätverk för ISTDP-utbildning i Sverige (www.istdpinstitutet.se).
Vi har läst en ny studie som är den första att systematiskt undersöka Freuds hypotes om att depression går att förstå som “ilska vänd inåt”.
Ända sedan Freuds klassiska text om depression från 1915, Sorg och melankoli, har den psykodynamiska traditionen uppmärksammat sambandet mellan ilska gentemot anknytningspersoner och depression. I syfte att skydda viktiga personer från vår ilska vänder vissa av oss ilskan inåt. Vi attackerar oss själva i tanken, verbalt eller fysiskt – något som kan leda till depressiva symptom.
I dagarna publicerades så – mer än 100 år efter Freuds artikel om melankoli – den första studien som på ett systematiskt sätt undersöker huruvida Freuds hypotes om “ilska vänd inåt” håller. Det är halifaxforskarna Joel Town och Allan Abbass som i samarbete med den svenske forskaren Fredrik Falkenström och britten Chris Stride analyserat processdata från Halifax Depression Study som vi skrivit om tidigare.
I den ursprungliga RCT-studien randomiserades sextio personer med depression som inte fått effekt i minst ett tidigare behandlingsförsök till antingen 20 sessioner ISTDP eller sedvanlig behandling (TAU). Resultaten visade att ISTDP var effektivt på kort och lång sikt för att behandla depression, och dessutom att behandlingen var mycket kostnadseffektiv.
Att systematiskt titta på terapiinspelningar
Den nya studien undersökte de terapeutiska mekanismer som leder till positiva utfall i ISTDP. När Davanloo formulerade sina grundläggande hypoteser om vad som leder till terapeutisk förändring betonade han den fysiologiska upplevelsen av känslor och hur detta tycks bereda vägen för patientens inneboende längtan efter förändring – den omedvetna terapeutiska alliansen. I Melanie Kleins efterföljd lyfte Davanloo fram skuldkänslorna: att inom en terapi få hjälp att uppleva tidigare undvikta skuldkänslor över verkliga (och fantiserade) aggressiva handlingar leder till försoning och läkning.
Forskarlaget tittade igenom videoinspelningar från studiens samtliga terapisessioner, och gjorde ett register över hur mycket affektexponering och insikt som ägde rum minut för minut utifrån kodningsschemat ATOS, Achievement of Therapeutic Objectives Scale. Affektexponering skattas enligt ATOS utifrån intensitet, duration och lättnad efteråt. Dessutom tar skattaren ställning till om affekterna bedöms vara defensiva – dvs. att personen exempelvis använder ilska för att undvika sorg eller vice versa – eller om de till större delen blandas upp med samtidiga ångestreaktioner. Insikt skattas enligt ATOS utifrån om patienten gör länkar enligt konflikttriangeln (känslor-ångest-försvar) eller persontriangeln (terapeuten-pågående relationer-tidigare relationer).
Ilska, sorg eller skuld?
Den första hypotesen som undersöktes var om exponering för ilska under sessionen ledde till minskade depressionssymptom en vecka senare. Dessutom antogs att effekten av detta skulle vara olika stark hos patienter med respektive utan omfattande personlighetspatologi – effekten antogs på förhand vara svagare hos de med fler drag av personlighetsproblematik (t.ex. känslomässig instabil, konfliktbenägen, konflikträdd, grandios, självhatande osv.).
Det visade sig att denna hypotes höll: när en session innehöll exponering för ilska ledde detta till minskade depressionssymptom sju dagar senare – men denna direkta effekt fanns bara bland de studiedeltagare som hade en låg grad av personlighetssyndrom. Varken exponering för skuldkänslor eller sorg hade några direkta effekter på depressionssymptom.
Indirekta effekter av ökad insikt och arbetsallians
Den andra hypotesen som Town med kollegor undersökte var att effekten av ilskeexponering på depressionssymptom skulle ske indirekt genom vad som kallas för mediation. Samarbetsalliansen respektive patientensinsikt antogs vara de mediatorer som indirekt ledde till minskade depressionssymptom. Se figur nedan för en schematisk framställning av denna statistiska modell.
För gruppen med låg grad av personlighetsproblematik visade det sig att effekten av exponering för ilska verkade indirekt genom att öka patientens insikter. För denna mer högfungerande grupp var det alltså genom att de kunde göra vissa kognitiva insikter efter exponering för känslor som man såg minskningar i depressionssymptom.
Med ISTDP-terminologi skulle man kanske kunna säga att studien visar att patienter med måttligt eller högt motstånd behöver hjälp att få till tydliga länkar på de båda trianglarna efter en stark exponering för känslor. Om detta sammanfattande konsolideringsarbete inte sker så verkar effekten på depressiva symptom begränsas.
För gruppen med hög grad av personlighetsproblematik, alltså de mer svårt sjuka deltagarna, visade det sig att effekten av exponering för ilska verkade indirekt genom att öka behandlingens arbetsallians. När patienten som en följd av intensiv exponering för känslor fann att sessionens mål och uppgift var tydligare, samt att bandet till terapeuten var starkare, då såg man effekter på depressionssymptom. När exponering för ilska inte sammanföll med ökningar i arbetsalliansen såg man också ett samband i negativ riktning för den här gruppen – mer upplevd ilska ledde då till ökade depressiva symptom.
Med ISTDP-terminologi skulle vi här kunna säga att för patienter med mer skörhet (= mer personlighetsproblematik) behöver behandlingen vara särskilt varsam med hur arbetsalliansen utvecklar sig. En exponering för ilska kan inte ske på ett bra sätt om t.ex. patienten inte förstår syftet fullt ut eller om projektioner står i vägen, den verkar till och med vara kontraproduktiv då.
Depression som ilska vänd inåt
Sammanfattningsvis gav studien alltså stöd till Freuds hypotes om att depression till viss del går att förstå som ilska vänd inåt. När vi slutar rikta den inåt och får hjälp att uppleva den i kroppen inom ramarna för ett gott terapeutiskt samarbete så leder detta till minskade depressionssymptom redan en vecka senare. Dessutom visade studien att högfungerande patienter behöver hjälp att efter känslomässiga genombrott skapa en intellektuell förståelse för sina känslor (“insikt”), annars uteblir den positiva effekten, medan det för lågfungerande patienter är extra viktigt att känslomässiga genombrott sker inom ramarna för en stark arbetsallians.
Att ISTDP är så pass strukturerat för att arbeta med denna typ av process är en av studiens begränsningar – det är oklart om behandlingar som arbetar med ilska på andra sätt skulle finna liknande samband, oavsett om det rör sig om psykodynamisk terapi eller andra terapiformer.
Vad gäller Davanloos framlyftande av skuldkänslor så kunde den här studien inte finna att de spelar en så stor roll – så framtida studier får undersöka detta på ett ännu mer finmaskigt sätt för att kunna bekräfta eller avfärda denna hypotes. Kanske fyller skuldkänslor en viktigare funktion i längre terapier där ett mer omfattande arbete med karaktärsförändring kan ske – på bara 20 sessioner är det få deprimerade patienter som hinner bli redo för den mycket specifika upplevelsen av somatic pathway of guilt.
Om du är intresserad av att läsa mer om ISTDP-forskning så finner du mer material här. Du kan se hela listan över publicerade ISTDP-studier här. Här är våra senaste nyhetsartiklar om ISTDP-studier: