Malin Ljungdahl: “ISTDP hjälper oss att inte fastna i dualismen mellan psyke och soma”

Det här är en intervju med Malin Ljungdahl. Hon är leg. läkare, specialist i psykiatri och leg. psykoterapeut. Tillsammans med några kollegor driver hon ISTDP-teamet vid Karolinska Universitetssjukhuset Huddinge som erbjuder ISTDP till patienter med funktionella neurologiska besvär. Under året påbörjar hon även ett forskningsprojekt som ska utvärdera ISTDP för funktionella neurologiska symtom.

Hur känns det att läsa coreutbildningen? 
Det känns verkligen jätteroligt! En sak som är så fantastiskt är att jag nu får vidareutveckla mig som terapeut som en del av min tjänst som psykiater. När jag började psykoterapeutprogrammet så fick jag göra det på fritiden, och det var inte alls säkert att jag någonsin skulle få verka som psykoterapeut på min arbetsplats inom det offentliga. Nu har vi ett ISTDP-team på Psykiatri Sydväst och vi får gå core, vilket innebär att vi kan erbjuda dynamisk korttidsterapi till patienter med funktionella neurologiska symtom.

Vad är det som lockar dig personligen med terapeutrollen? 
Oj, det är inte helt lätt att svara på. En aspekt är nog önskan att förstå vad det är att vara människa, att förstå mina patienter och mig själv bättre. Hur den terapeutiska relationen skapar en möjlighet att tillsammans med patienten försöka förstå vad det är som orsakar problemen, på djupet. För att därifrån kunna påbörja en förändringsprocess. Det är en förmån att få vara med på en sådan resa.

Malin Ljungdahl intervju
Malin Ljungdahl, läkare vid ISTDP-teamet vid Karolinska Universitetssjukhuset Huddinge

Till vardags arbetar du med Funktionella teamet på Karolinska Universitetssjukhuset Huddinge. Vad är det för team och vad gör ni? 
Jag jobbar som psykiater på Konsultenheten, Psykiatri Sydväst, en enhet som finns till för patienter som vårdas inneliggande eller i öppenvård på somatiska kliniker vid Karolinska Universitetssjukhuset Huddinge. Vi blir inkopplade när det finns ett behov av icke-akut psykiatrisk bedömning och behandling inom ramarna för den somatiska vården.

Vi arbetar också mycket i team kring olika patientgrupper varav ett är patienter med funktionella neurologiska symtom. I vårt funktionella team ingår neurologer, psykiatriker, fysioterapeuter, arbetsterapeuter, sjuksköterskor och kuratorer och vi utreder patienter med misstänkta funktionella neurologiska symtom och kommer med rekommendationer kring behandling. På Konsultenheten kan vi också på vår mottagning erbjuda en del av dessa patienter uppföljning och behandling. 

Kan du säga mer om vilka typer av besvär som ni behandlar? 
Funktionella neurologiska symtom är neurologiska symtom som inte beror på en neurologisk sjukdom eller skada, det är alltså inte ett strukturellt problem utan i stället funktionella på så sätt att det handlar om ett dysreglerat nervsystem. Man kan jämföra det med skillnaden mellan ett hårdvaru- och mjukvaruproblem på en dator. Funktionella problem är alltså mjukvaruproblemen: det finns inga underliggande hjärnskador eller andra strukturella problem. Symtom det kan röra sig om är svagheter, skakningar, gångsvårigheter, talsvårigheter, domningar och epilepsiliknande anfall. Det här är en vanlig diagnos som inte är så allmänt känd. Jag vill också betona att det här är symtom som finns på riktigt, de är inte påhittade eller medvetet framkallade.

Kan du ta något fiktivt exempel på en patient som kan hamna hos ert ISTDP-team? 
Det skulle kunna vara en ung kvinna med gångsvårigheter, trötthet och smärta som har fått svårt att fungera i vardagen. Hon har träffat många läkare och genomgått många utredningar och undersökningar men inte upplevt att hon har fått hjälp. Kanske har hon själv googlat och börjat undra om hon har funktionella neurologiska symtom eller så har hon till slut träffat en neurolog som ställt diagnosen. I alla fall blir hon remitterad till vårt funktionella team där hon får en förklaring och en diagnos. Behandlingsrekommendationen blir psykosomatisk fysioterapi där hon så småningom hittar tillbaka till det automatiserade gångmönstret hon tappat. Men hon upplever också att det är något hon inte riktigt kommer åt genom fysioterapin, som att det också finns ett bakomliggande problem. Kan det finnas en känslomässig koppling till symtomen? Hon och hennes fysioterapeut bestämmer sig för att remittera vidare henne till ISTDP-teamet för en provterapi.

Hur kommer det sig att du har intresserat dig för ISTDP?
Jag har alltid varit intresserad av att få ihop det där med kropp och själ, något jag verkligen får jobba med nu som psykiater inom somatiken, men under åren har jag ofta saknat det psykodynamiska perspektivet. Efter två år i Norge där jag jobbade med affektfobiterapi enligt Leigh McCullough så kände jag när jag kom hem till Sverige igen att jag ville fortsätta med psykoterapi.

När det på psykoteraputprogrammet ingick ISTDP-teori och handledning så kändes det som att det öppnades en möjlighet för mig att få ihop mina olika intressen och mina olika roller och göra vad jag kan för att öka det psykodynamiska perspektivet i psykiatrin igen. Idag tycker jag att använda sig av en processinriktad biopsykosocial sjukdomsmodell är det bästa sättet för att inte fastna i den ofta konfliktskapande dikotomin mellan psyke och soma.

Är ISTDP särskilt hjälpsamt för konsultationspsykiatrin tycker du? Och om så, varför? 
I alla fall har det varit hjälpsamt för mig. När du föreläste om ISTDP på det Nationella nätverksmötet för funktionella neurologiska symtom var det var många av mina kollegor som blev intresserade, det du sa stämde på många sätt med hur mina äldre kollegor alltid har tänkt. Många av våra patienter fyller inte kriterierna för någon egentlig psykiatrisk diagnos och det krävs att vi tänker transdiagnostiskt kring patientens problem. Att se funktionella tillstånd som omedveten ångest eller försvar enligt konflikttriangeln är hjälpsamt.

Förra året fick ni klartecken att köra igång ett ISTDP-team på Huddinge Sjukhus. Vad betyder det och hur kommer det sig att cheferna ville investera i detta? 
Det hela började med att vi var några stycken med intresse för ISTDP på Psykiatri Sydväst som träffades och åt lunch då och då. Så småningom utvecklade vi planen att se om det inte fanns möjlighet att starta ett ISTDP-team för att erbjuda ISTDP till patienter med funktionella neurologiska symtom. Konsultenheten har hela tiden uppmuntrat detta och vi på det funktionella teamet har upplevt att det saknats ett psykoterapeutiskt alternativ att erbjuda patienterna. Psykiatri Sydvästs ledning är väldigt positiv till innovation och forskning så efter att ha argumenterat för fördelarna fick vi möjlighet att starta, med villkoret att vi ska utvärdera om det verkligen fungerar så som vi tänker. Så nu har Ivan Bernholm (ST-läkare), Niklas Lanbeck (psykolog) och jag möjlighet att ägna 0,5-1 dag i veckan för ISTDP-terapier och handledning.

Vi är igång med ett forskningsprojekt som heter: ”ISTDP för patienter med
funktionella neurologiska symtom på Konsultenheten, PSV” och patienter som fått en funktionell diagnos av neurolog på Huddinge och som inte har blivit hjälpt av annan behandling kommer erbjudas att delta. Vi planerar att genomföra före- och eftermätningar för att se förändringen av kroppsliga besvär men också psykiska besvär, vårdkonsumtion och funktionsförmåga. Vi vill också intervjua patienterna för att se hur de har upplevt ISTDP-terapi som del av ett omhändertagande av ett funktionellt team.

Vad kämpar du med att lära dig som terapeut just nu? 
Mycket! Men i relation till funktionella teamet så skulle jag vilja bli bättre på att använda mig av ISTDP-principer vid bedömningar för att se om det går att undersöka om det finns ett känslomässigt problem som är kopplad till de funktionella symtomen redan vid det första bedömningsamtalet. Det är något som jag just nu tycker är väldigt svårt. 

Vad har du för framtidsvisioner inom de närmaste 5-10 åren? 
För patienter med funktionella neurologiska symtom så hoppas jag att funktionella teamet ska växa till en enhet som kan erbjuda både utredning, behandling och utbildning kring funktionella neurologiska symtom samtidigt som vi forskar på patientgruppen. För egen del hoppas jag att jag får fortsätta jobba som både psykiater och psykoterapeut, gärna med funktionella neurologiska symtom och ISTDP. De passar väldigt bra ihop. 

Har du något budskap till andra läkare som är intresserade av att arbeta psykoterapeutiskt? 
Om du vill och är beredd att satsa också egen tid och pengar på det så gör det! Det är otroligt berikande att ha en psykoterapeutisk kompetens, inte bara i terapeutiska kontakter utan också i rena läkarkontakter även om det inte nödvändigtvis gör jobbet enklare. Jag tänker att det är tur att vi läkare är intresserade av olika saker och att det också är viktigt att den psykoterapeutiska kompetensen finns också i läkarkåren för att kunna hjälpa komplexa patienter vad gäller diagnostik och behandlingsplanering. Sedan tänker jag att det svåra är att hitta en plats och ett uppdrag där ens eget psykoterapeutiska intresse kan berika också enheten man verkar i.


Här kan du hitta våra senaste intervjuer:

Sandra Ringarp: “Även välmenande kommentarer kan vara mikroaggressioner”

I den här intervjun med Sandra Ringarp diskuterar vi den föreläsning om HBTQI i terapirummet som hon höll i samband med ISTDP-föreningens årsmöte för ett par månader sedan. Vi pratar även om hennes centrala inspirationskällor som ISTDP-terapeut och hennes nya bana som ISTDP-handledare och -lärare. Sandra Ringarp är leg. psykolog och arbetar vid ISTDP-mottagningen Stockholm som ISTDP-terapeut och -handledare. Hon är knuten till svenska ISTDP-institutet.

Du föreläste nyligen om HBTQI och ISTDP för föreningens medlemmar. Hur kändes det? 
Jag var ganska nervös! Men det var väldigt roligt också, att få dela med mig av denna kunskap till vårt ISTDP-community kändes väldigt fint. Responsen var varm och nyfiken och det blev intressanta och fördjupande samtal. Jag har många patienter som söker sig till mig just för att de önskar en terapeut med HBTQI-kunskap, därför kändes det extra roligt att få föreläsa om det här.

Sandra Ringarp intervjun
Sandra Ringarp

Vad var de centrala idéerna som du förde fram och som du tycker är viktiga för ISTDP-terapeuter att känna till? 
Det räcker inte att vara öppen och välvilligt inställd i ett vårdmöte med en minoritetsgrupp. Kunskap är en förutsättning för att kunna erbjuda ett tryggt rum. Med kunskap menar jag dels kunskap om vilka de här personerna är – vad står varje bokstav i HBTQI för? Och dels kunskap om hur de här personernas levnadsvillkor ser ut i Sverige. Vad säger forskningen om psykisk ohälsa och erfarenhet av våld och trakasserier i den här gruppen? 

Det är också viktigt med kunskap om minoritetsstress vilket den här gruppen och andra minoritetsgrupper är hårt drabbade av. Minoritetsstress uppstår när minoritetsgrupper bryter mot rådande normer i vårt samhälle. Att göra det kan innebära att utsättas för okunskap, kränkningar, våld, hot om våld, trakasserier och något som kallas för mikroaggressioner. Mikroaggressioner är blickar, frågor och kommentarer som speglar okunskap eller fördomar, vilket kan ske mer eller mindre omedvetet. Även välmenande kommentarer kan vara mikroaggressioner – just för att de sätter fingret på att personen avviker från normen. Man blir helt enkelt ständigt påmind om att man avviker från normen. Det här är belastande när det händer, men också förväntan/oron för när det ska hända nästa gång är belastande. 

Även om kunskap är viktigt kan vi självklart inte veta allt. Märker jag i ett möte att jag saknar en viss kunskap är jag öppen med det och säger att jag ska läsa på tills nästa möte. Det viktiga då är att vi inte lägger ansvaret på patienten att vara den som utbildar oss.

Är det något annat som är viktigt att tänka på för oss som terapeuter i mötet med minoritetsgrupper?
I mötet med minoritetsgrupper är det också viktigt att vi som terapeuter tar en titt på oss själva. Hur är samhällets normer internaliserade i just mig? Vi har alla normer internaliserade och kan vi bli medvetna om hur de tar sig uttryck inom oss så kan det minska risken att vi till exempel utsätter våra patienter för oavsiktliga mikroaggressioner. Varför vill jag säga den här positiva kommentaren om en persons läggning? Är det för att jag blir lite nervös i mötet? Eller, frågar jag detta för att jag verkligen behöver veta det, eller är jag bara nyfiken? Om svaret är det senare får vi bita oss i tungan, för patientens integritet väger alltid tyngre än vår egen nyfikenhet. Det är viktig att ha med sig att det väcker känslor när människor bryter mot normer. Om vi kan vara förberedda på detta och ta en titt på de känslor som väcks i oss har vi kommit långt.

Det är också viktigt att vara medveten om att många HBTQI-personer har negativa erfarenheter av tidigare vårdmöten, något som såklart kan komma upp på olika sätt även i terapirummet och som vi kan behöva prata om. 

Den psykiska ohälsan är väldigt stor bland HBTQI-personer och andra personer som utsätts för olika former av strukturell diskriminering och förtryck. Finns det särskilda interventioner som ISTDP-terapeuter kan behöva lära sig för att arbeta med minoriteter? 
Jag tror faktiskt inte det. Att arbeta med minoritetsgrupper handlar inte främst om specifika interventioner, utan om kunskap. Med kunskap har vi förutsättningar för att skapa ett tryggt terapirum – vilket i sin tur är förutsättningen för att vi kan använda oss av alla de goda interventioner vi redan kan. 

Många HBTQI-personer söker sig som sagt specifikt till en terapeut med HBTQI-kompetens. Min erfarenhet är dock att det väldigt sällan är för att man vill prata om något kopplat till just sin identitet som HBTQI. Oftast vill man helt enkelt prata om precis det som alla andra vill – relationsproblem, depression, ångest, självkritik och så vidare – men man vill göra det i ett tryggt rum. 

Vilka är de vanligaste bristerna i vården i mötet med HBTQI-personer?
De tre vanligaste bristerna är dels heteronormativt bemötande, dvs. att man förutsätter att alla är heterosexuella cispersoner som lever/vill leva i tvåsamhet. Det är också vanligt med kunskapsbrist vilket leder till att personen själv behöver utbilda sin vårdpersonal vilket både blir en stress för patienten och tar upp värdefull tid som patienten behöver till att få hjälp med sina problem. Det kan handla om att man får informera vårdkontakten om vad det innebär att vara en transperson, till exempel.

Det är också vanligt med över- eller underfokusering på sexuell läggning eller könsidentitet, alltså att man som vårdpersonal antingen inte pratar om det alls eller att man lägger för stor vikt vid det.

Ibland stöter vi på patienter vars omständigheter vi inte riktigt förstår. Finns det någon enkel gräns för när man ska hänvisa en HBTQI-person till en kollega snarare än att läsa på och ta sig an ärendet själv? 
Jag tänker att det är viktigt att vara ödmjuk och öppen inför att vi inte alltid är rätt person att hjälpa en patient. Samtidigt finns det en risk att vi backar inför det okända, att vi inte vågar när vi egentligen kanske skulle kunna. Jag tror att vi behöver ställa oss två frågor, dels vad vår professionella bedömning är, har vi/kan vi skaffa oss tillräcklig kompetens eller kan vi inte det? Men också frågan ifall det handlar om bristande kompetens eller om osäkerhet inför något vi inte är vana vid? Jag hoppas på att vi blir många fler terapeuter med HBTQI-kompetens, och för att komma dit måste vi också lära oss nya saker och inte backa för det okända och nya.

En annan viktig aspekt tänker jag är att normbrytande per definition väcker känslor och när vi möter människor som bryter mot normen kan det självklart också väcka känslor i oss. Stöter vi på något som vi känslomässigt har svårt att hantera så tror jag att det kan vara bra att backa i den typen av ärenden tills man gett sig själv utrymme att hantera det som väckts, genom att t.ex. skaffa sig mer kunskap och undersöka hur samhällets normer reproduceras i våra egna reaktioner. Annars kan det nog bli onödigt svårt, både för patient och terapeut. Ingen patient ska behöva få sin identitet ifrågasatt i terapirummet, och har vi svårt att stå bakom ett sådant förhållningssätt är det istället bättre att hänvisa vidare.


Om vi pratar lite om dig som terapeut, vad håller du på att lära dig just nu? Brottas du med något särskilt?
I min utveckling som ISTDP-terapeut tycker jag att vissa nya utmaningar dyker upp allteftersom, medan andra följer mig längs vägen. Att hjälpa patienten att hitta sin egen inre drivkraft till förändring så att inte jag blir experten på patientens känsloliv är ett exempel på något som jag fortfarande kan brottas med efter snart tio år av att fördjupa mig inom ISTDP. Utöver det är jag i en spännande process som terapeut där min nya roll som utbildare och handledare i ISTDP gör att jag lär mig att titta på mig själv och mitt eget arbete på ett nytt sätt, utifrån hur jag lär mig att handleda och lära ut till andra. Att lära ut grunderna i ISTDP gör att jag själv blir påmind om alla små detaljer och skeenden, som kan vara lätta att missa men som är så viktiga för utfallet. Så man kan säga att jag lär mig ISTDP från grunden en gång till just nu!

Du ska hålla några ISTDP-utbildningar under året, är det någon särskild vinkel på ISTDP som du kommer lära ut? Vad har varit dina centrala inspirationskällor? 
Jag har inspirerats och inspireras ständigt av kollegor, handledare och utbildare, och där är namnen många. Men jag tror att min största inspiration är arbetet i sig. Min första förälskelse i ISTDP kom ur en desperation när jag arbetade på en vuxenpsykiatrisk mottagning som ny psykolog. Hur skulle jag kunna hjälpa de patienter som hade så hög ångest att det var svårt att ens sitta i rummet med mig? Att plötsligt få ett språk och konkreta terapeutiska interventioner för att hantera detta var stort och gav mersmak. Att kunna hjälpa människor ur det lidande de hamnat i och in i något nytt är något som inspirerar mig ständigt i min kliniska vardag. När det händer kan det vara som att en helt ny värld öppnar sig – kan livet se ut så här! Jag slutar heller aldrig förundras över hur överraskad jag kan bli i mötet med en patient. Det är fint att få vara förundrad och fascinerad av människan framför mig. Och det är inspirerande att se det som redan finns i varje människa, gömt under alla lager. Att det inte är något som behöver skapas, det finns redan där och vi gör tillsammans ett arbete för att det ska få komma fram. Vägen dit kan vara lång och krokig men om vi kan komma dit är det stort att få vara med om. Det är otroligt inspirerande!

Jag ser fram emot att få lära ut ISTDP på ett tydligt och lättillgängligt sätt. Det som jag själv uppskattar med ISTDP, att det är en terapimetod med konkreta terapeutiska interventioner som samtidigt ger ett stort utrymme för att hitta sin egen personliga terapeutstil, det vill jag också lära ut. Och så vill jag att vi ska ha roligt! Att inlärningsprocessen ska få vara nyfiken och kreativ. Den empati som vi har med våra patienter behöver vi ha med oss själva också, inte minst när vi lär oss något nytt.

Om vi tittar på ISTDP ur ett bredare perspektiv, har du någon vision för var vi befinner oss med ISTDP i Sverige om fem-tio år, om du får drömma lite?
Jag hoppas på en bredd i ISTDP Sverige på alla nivåer – föreläsare, utbildare, handledare och terapeuter – och ur alla perspektiv – kön och hudfärg till exempel.

Förutom det önskar jag att vi kan se flera svenska studier på utfall av ISTDP, det är viktigt för etableringen av metoden. Och såklart hoppas jag att intresset för ISTDP kommer att fortsätta att växa, att fler terapeuter får möjlighet att arbeta med denna kreativa och givande behandlingsmetod och framförallt att fler patienter kan få tillgång till ISTDP. Med en bredd i behandlingsutbudet har vi större möjlighet att kunna hjälpa fler, och jag hoppas att ISTDP ska ha en given plats ett brett utbud.


Här kan du se föreläsningen om HBTQI i terapirummet som Sandra Ringarp höll i samband med ISTDP-föreningens årsmöte:

Om du gillade den här intervjun med Sandra Ringarp så kanske du även är intresserad av några av våra andra intervjuer. Här hittar du några av de senaste intervjuerna som vi publicerat:

The limitations of ISTDP. Part 2: Patricia Coughlin

What are the limitations of ISTDP? What would a balanced view of ISTDP be like? Just as any approach to psychotherapy, ISTDP is subject to both idealization and devaluation. Over the past few years, we at ISTDPsweden.se have published quite a lot of positive stories and news about ISTDP. Now it’s time to do some balancing. We sat down with some prominent ISTDP clinicians to discuss the shortcomings and downsides of ISTDP. Here’s the second part, an interview with Patricia Coughlin. You can find the first part here.

ON LEARNING ISTDP

Just how difficult is ISTDP to learn? Should learning ISTDP be easier? 

Patricia Coughlin presentation
Patricia Coughlin

Patricia Coughlin: I don’t think it’s possible or even desirable to make the complex and challenging task of helping someone change easy. As Rilke said,”...many things must happen, many things must go right, a whole constellation of events must be fulfilled, for one human being to successfully advise or help another.”  

Our desire for life and therapy to be easy can really backfire, giving us false expectations and setting us up for a sense of inadequacy. Life is hard and complicated – so is therapy.  The danger here is to oversimplify and get reductionistic in our approach.  I believe that is already happening in ISTDP and does us all a disservice.  The masters in most fields have a great ability to tolerate complexity and uncertainty.  We would do well to expand this capacity within ourselves.

ON JARGON and research

Unlocking the unconscious is sometimes described as a unique aspect of ISTDP. But other models also facilitate emotional breakthroughs and spontaneous reporting of previously repressed material. Could the jargon mystify the therapy process and put ISTDP at risk of distancing from other models?

Patricia: From what I can see, the masters in our field readily admit overlap between models and don’t claim an exclusive corner on the market of transformation.  Many approaches find a way to access the unconscious forces responsible for the patient’s symptoms and suffering and, in so doing, help the patient resolve previously unconscious conflicts. 

That said, the development of a systematic, yet flexible, method for reliably getting there – something the central dynamic sequence of ISTDP provides – seems to be a real contribution to the field.  The research seems to suggest that ISTDP is highly effective with cases that often fail in other treatments – character disorders, treatment resistant depression, functional disorders and conversion, for example.

ON RESEARCH GAPS

Even though there’s more and more research showing the efficacy of ISTDP as a whole, there’s still not so much high-quality research on the different ingredients of the therapy. What are some of the challenges with the specific ingredients of ISTDP?

Patricia: While we have not done much research in ISTDP on the specific elements, I have gathered data from other sources to support each step of the central dynamic sequence. This material has been outlined in both Lives Transformed and Maximizing Effectiveness in Dynamic Psychotherapy. It’s my contention that it is the combination of the six factors associated with positive outcomes that are responsible for the effectiveness of ISTDP. 

While often associated with a dramatic breakthrough of feelings, this is only one of six factors involved in the application of ISTDP. Understanding all the steps and being able to implement them effectively is essential to mastery. Too many are skipping over crucial steps, such as a dynamic inquiry in which patient and therapist develop an agreement on the problems to be addressed, goals to be achieved and tasks involved in the treatment or turning patients on defenses before pressing for the experience of feelings. This often undermines the alliance and derails the process.

ON IDEALIZATION AND DEVALUATION

Historically, the ISTDP community has unfortunately been subject to sect-like behavior such as a strong idealization of charismatic figures (such as Davanloo) along with exclusion and devaluation of critical voices. Is there something in particular that makes ISTDP vulnerable to this? What can we do to safeguard against this in the present and future?

Patricia: Sadly, this seems to be a tendency in human beings, not just practitioners of ISTDP. Look at our political situation here in the US.  Idealization, demonization, and splitting are rampant.  We need to take a stand against this.

I will never forget an interaction with a young trainee who came to a seminar, having read my books. He expressed disappointment when I acknowledged being confused by what was happening in a particular session. Of interest, the group has asked to see a case in which everything did not go smoothly, but rather one in which we had to ride some rough patches to get to a positive outcome. 

Despite this conscious desire, when I presented just such a case (which ended with a good outcome, by the way), the trainee said, “I am really upset. I need to idealize you- you are supposed to know everything.” I replied with something like, “I would suggest that idealizing anyone is ill advised. We all struggle. The point is not to be perfect but to be open to feedback and constantly learning. If you trust the UTA, it will guide you.”

He continued to protest. I found this baffling, yet this desire to have someone to idealize seems pervasive. We must do what we can to combat this.

OTHER LIMITATIONS AND WEAKNESSES

Do you see other major limitations or weaknesses in ISTDP? 

Patricia: The biggest one to my mind is the exclusive focus on feelings toward and in reaction to others – what one might refer to as “attachment affects“. As Blatt pointed out so eloquently in his classic book, The Polarities of Experience, human beings have two primary drives that motivate their behavior throughout life: 1) the need to attach securely to others and 2) the need to be autonomous, self defined and self directed. 

Many of our patients sacrifice one of these needs for the other. In most cases, they sacrifice self in a desperate attempt to maintain an attachment to the other. If we join them in this preoccupation with feelings toward others and neglect their own feelings, wishes, desires and goals, we could exacerbate their problems rather than ameliorate them.  We want to help patients feel all of their feelings – about themselves, as well as others – so they can be a solid self, capable of closeness with others.

Some limitations are not inherent in the model but involve the way it is sometimes taught.  We know from all the research that focusing on specific interventions, without a clear case conceptualization of the patient to help the clinician know what to do when, the treatment is likely to be ineffective.  A heavy focus on learning a method, if not combined with an equal focus on the person of the therapist – the very vehicle of transmission of the treatment itself – will be ineffective.

Do you find there are aspects of ISTDP that we have to address and change in order for the method to thrive? 

Patricia: Healthy expression of feelings. The exclusive focus on the experience of feelings and impulses, with a relative neglect on the issue of how these feelings can be expressed in a constructive manner. It seems as if there is an assumption that if we help patients abandon defenses and experience their feelings freely, they will automatically find healthy and constructive ways to communicate these feelings to others.  That’s a pretty big assumption. After the mixed feelings have been experienced and integrated, I ask how they plan to communicate these feelings to the others involved to assess whether they can do so constructively or need some help in that area.

It’s not enough to feel one’s feelings. We also have to help patients understand what the feelings mean. Patients often develop pathological beliefs about the self that perpetuate their suffering.  I’m thinking of a case of a man who was suffering from anxiety and depression, related to pathological mourning, following the death of his first born. As I helped him abandon defenses and face the rage and grief he had been suppressing, he felt better, but still did not share these feelings with his wife. It was only as we started to explore this, that his pathological beliefs that 1) grief will drive a woman crazy (as it had his mother); and 2) real men don’t cry, were exposed and re-examined.  

So helping patients to express feelings would be another step in the development of ISTDP?

Human beings are meaning-making machines. We are most often upset – not about what happened – but what we made it mean. In my own life, I interpreted my father’s tendency to keep an emotional distance from me as a personal rejection. I thought he just didn’t like me very much.  When I was 30 years old, my mother told me that he was born during the 1918 flu epidemic, on the very day his 18 month old brother died of the virus. Subsequently, two of his younger brothers died in childhood. His father died when he was only 42. In an instant, I understood that my father’s distance was not a sign of lack of love for me, but a defensive posture.

I was very sick as a child and often hospitalized. It was because he did love me and was afraid to lose me that he couldn’t bear to come visit me. My whole view of him, myself and our relationship changed in an instant. Just feeling my feelings about what I interpreted as rejection wouldn’t get me there. Of course I could still be sad and angry that he didn’t deal with this differently, but what I felt was enormous compassion for him and we got much closer as a result. Sometimes we need to help patients ask their family about life events in order for them to get more emotional clarity.


Here’s the first part of our series of articles on the limitations of ISTDP. Below you’ll find a list of our latest interviews:

The limitations of ISTDP. Part 1: Jon Frederickson

What are the limitations of ISTDP? What would a balanced view of ISTDP be like? Just as any approach to psychotherapy, ISTDP is subject to both idealization and devaluation. Over the past few years, we at ISTDPsweden.se have published quite a lot of positive stories and news about ISTDP. Now it’s time to do some balancing. We sat down with some prominent ISTDP clinicians to discuss the shortcomings and downsides of ISTDP. Here’s the first part, an interview with Jon Frederickson.

On SUITABILITY FOR ISTDP

As we’ve talked about before, ISTDP is not a panacea. Which type of problems and patients are not suitable for ISTDP? 

Jon Frederickson discussing a balanced view of ISTDP
Jon Frederickson

Jon Frederickson: Nothing is a panacea in the field of mental health. Types of problems not suitable for ISTDP would include the treatment of traumatic brain injury, neurocognitive deficits, and genuine autism spectrum disorders (not including those mistakenly diagnosed).

Generally, we should offer supportive and not exploratory psychotherapy to patients currently abusing drugs until we have built the affect tolerance that would make exploratory therapy possible. Likewise, some psychotic patients in a severe regression and severely depressed patients may require medication and supportive psychotherapy before a trial of exploratory therapy should be attempted.

ON LEARNING ISTDP

Just how difficult is ISTDP to learn? As far as I’ve heard, no one ever graduated from Davanloo’s training. Should learning ISTDP be easier? 

Jon: It’s not just a matter of ISTDP being hard to learn. Learning to be a really good therapist is hard. That is why it is relatively rare. Twenty percent of therapists get eighty percent of the good results. And that is true within each model of therapy. It is really hard to become a highly effective therapist in any model of therapy. You may be under the illusion that you’ve “learned” the model, but the outcome research shows that there is no relationship between our perception of our ability and our actual effectiveness.  

Should learning this be easier? Should learning to be a professional musician be easier? Should learning to be a chess master be easier? No.

It should be hard because it is hard. That is reality. However, in the case of psychotherapy: should our teaching be better? Yes.

Research shows that graduate training has no effect on therapist outcome. What a disaster! Should our supervision be better? Yes, because research shows that 93% of therapy supervision is inadequate and 35% harmful.

At least in music and chess, it is clear what skills need to be learned and there are materials which train students in those skills. We have no agreement on the fundamental skills necessary for effective practice in psychotherapy and no materials for training in those skills. So, in response to your question, yes and no. Learning a complex skill like psychotherapy should be just as hard as becoming a violinist.

Yet, it is currently way too difficult to achieve this skill level as therapists because of the poor quality of supervision generally available. As well as the inadequate, indeed, useless quality of graduate training. The useless seminars offered which do not show effective treatment, and the failure to use videotapes to develop an empirically validatable model of teaching and supervision.

In case you wonder if I am outraged by this state of affairs, you read me accurately.

ON JARGON

Unlocking the unconscious is sometimes described as a unique aspect of ISTDP. But other models also facilitate emotional breakthroughs and spontaneous reporting of previously repressed material. Could the jargon mystify the therapy process and put ISTDP at risk of distancing from other models?

Jon: Obviously, any emotionally transformative human experience involves a breakthrough to feelings that were previously out of awareness. It even happens at movies! One danger in any model occurs when we use jargon to “professionalize” our field and to create a sense of mystique such that outsiders “could not possibly understand” what goes on behind closed doors.

Jargon creates another danger: we might accept a piece of jargon, usually a description, and mistake it for an explanation. As a result, steps in logic are skipped, and flaws in an argument remain invisible. In case you wonder what I mean, here are some common vague terms which are ill defined and have come to mean everything: mindfulnessawareness, and superego. Here is a term which doesn’t mean what it claims: diagnosis. In fact, what we call diagnoses are merely a description of symptoms, not a diagnosis of their cause.

Do you think there’s a need for a conceptual “makeover” in ISTDP to facilitate dialogue with other models? 

Jon: I don’t think ISTDP needs a makeover as you suggest. I think all therapists in all models need to abandon vague concepts, acronyms, and made up words for plain English, or whatever your native language is. If you cannot explain what you are doing so it could be understood by an adolescent, either your language is a barrier, or you do not fully understand what you are trying to say.

We work with humans, speaking a human language of the heart. Any theory we describe should be able to be put in these terms. If we dropped jargon, we could even talk to other clinicians. As it is, today much clinical dialogue at conferences becomes useless because the exchange of abstractions takes the place of examining the actual data. And the narcissistic display of mysterious language becomes a way to avoid the humbling act of revealing one’s actual work.

ON SUPERSHRINKS AND RESEARCH GAPS

Even though there’s more and more research showing the efficacy of ISTDP as a whole, there’s still not so much high-quality research on the different ingredients of the therapy. A notable contribution is the recent Iranian study showing that ISTDP without challenge was just as effective as standard ISTDP. Given the lack of studies, ISTDP is largely an “oral tradition” where the experience of specific prominent therapists (be that Davanloo or yourself, for example) is very influential. What are some of the challenges with the specific ingredients of ISTDP?

Jon: The Iranian study was important, but like all studies, it’s easy to forget the context. In fact, challenge is appropriate only with about 25-30% of patients, the ones who primarily regulate feelings with isolation of affect. Challenge is not appropriate for the other seventy percent of patients who are in repression and fragility. So it should be no surprise that ISTDP without challenge would be effective, because that is the effective form of ISTDP for 70% of patients!

When students try something I suggest, sometimes it works, sometimes it doesn’t. Why? Sometimes they aren’t doing what I suggest. Sometimes I was wrong; I misread the patient, and the patient’s response gives a clearer idea of how to proceed. Sometimes, the therapist is initially helpful without realizing it, but is unable to understand and categorize the patient’s subsequent responses. I don’t think the issue is the individual clinician per se, although the effect of the therapist is powerful. I see repeatedly that there are certain patterns of response across patients and across cultures. When we address these patterns – feelings, anxiety, defenses, and transference resistance – we find patterns of response to intervention.

Now we get to the interesting question: the relationship between principles and rules. For instance, when a patient is struggling to bear mixed feelings, the principle is to help the patient bear mixed feelings without anxiety shifting out of the striated muscles. Sometimes, to make things simple, people make up a rule: “Thou shalt pressure to feelings in this way. Repeat after me!” The student, alas, learns to become a clone who follows rules rather than a person who operates according to principles. There are many interventions that could embody the principle of building affect tolerance. And those interventions could be in response to specific words or dynamics the patient has used. They could arise from the therapist’s experience, feelings, and intuition. They could arise from their mutual co-created responsiveness.

In music, the voice leading (how voices related to each other, for instance, in a fugue) was not supposed to have parallel fifths. That was a rule. Suddenly Debussy comes along and he uses all kinds of parallel voice leading to create effects of great beauty. What had been a rule was revealed to be subject to a higher principle. Thus, it could be broken.

Alas, the early phase of ISTDP training often involved people following rules without understanding the overarching principles, to which those rules are subject. If we ritualistically follow rules, therapy is very easy to learn, though robotic. If we follow principles, then we understand the purpose of our interventions, and that allows for creativity in the therapist and responsiveness to the patient.

Good therapy is like jazz. A jazz musician knows the key, the melody, the harmonies, the underlying principles and he improvises based on that underlying structure. He appears to be breaking rules, yet he is guided by underlying principles. A good teacher orients you to principles whether he is teaching you chess, music, or therapy.

ON IDEALIZATION AND DEVALUATION

Historically, the ISTDP community has unfortunately been subject to sect-like behavior such as a strong idealization of charismatic figures (such as Davanloo) along with exclusion and devaluation of critical voices. Is there something in particular that makes ISTDP vulnerable to this? What can we do to safeguard against this in the present and future? 

Freud - a balanced view
Sigmund Freud

Jon: As we know from the work of Bion and other group theorists, when humans form groups, groups become irrational. 

Friedrich Nietzche said that earth is the insane asylum of the universe. Every day we see plenty of evidence for this. Idealization of teachers happens in all models to greater and lesser degrees. Think of Freud, Klein, Davanloo, Rogers, or Beck. Every one of them has been idealized, and each of them has been devalued.

There will always be some people who want to idealize their leader and devalue the rest. We have to understand this as not a problem of a given model, but a problem of the human condition. To avoid the anxiety that our knowledge is partial, our theory will be changed and surpassed is the way of all scientific knowledge, and that whatever we create today will be forgotten in the mists of time, we seek magic.

We idealize a model and view it as the final, complete answer. We idealize some figure. Then we devalue other models and teachers. Then we imagine we are part of some secret society of superior therapists in contrast to all those “others.” This pattern has been described in cults, and, sadly, this kind of cult formation is common in the therapy field. All we can do is make ourselves aware of this temptation to idealize and devalue.

Melanie Klein

And we can also step back and realize what makes us anxious: 1) our knowledge is always partial; 2) we will never have all the answers; 3) we will always be flawed and fail with some people; 4) we will never have the final, complete understanding of the human condition in our lifetime; and 5) whatever we achieve, whatever we build is transient and will disappear. This is reality.

When we cannot bear this death anxiety, we engage in the denial of death through the magical claim that we have found the eternal answer, the eternal group, and the theory that has somehow transcended time. Due to death anxiety, this pattern will probably always recur in humanity, including groups of therapists.

OTHER LIMITATIONS AND WEAKNESSES

Do you see other major limitations or weaknesses in ISTDP? 

Jon: My major concern here does not have to do with ISTDP but with the psychotherapy field as a whole. Our understandings all too often are not linked to other areas of knowledge such as sociology, group theory, family studies, and economics. These different fields appear as silos. Take for instance the study of patients who suffer from borderline personality structure or psychotic patients. There is so much good research on the relationship between their psychological difficulties and predictable patterns of family dysfunction.

Yet this research keeps getting forgotten, only to be done again by the next generation. These patients are often examined only from the individual perspective, and we forget the family system that generates these patterns. We look at psychological issues, yet we seem to have forgotten the role of social class and capitalism in character development. Fromm wrote much on that, yet today in the US it is a taboo to recognize the role of class.

Or look at racism in the US or the caste system in India as examples of the transgenerational transmission of trauma. And then there is the tendency to underestimate the role of neurocognitive deficits and brain injury in borderline and psychotic patients. The psychotherapy field has become so focused on the individual, that we easily lose sight of the group and family context, the class context, and the biological context. Then we end up with these different research silos: each reducing the patient to one of these categories, when we need to open up to the interrelationships between them.

Do you find there are aspects of ISTDP that we have to address and change in order for the method to thrive? 

Jon: It depends on how you define ISTDP. Some describe it as the method. If so, that is ritualism, and, yes, that should be changed. Some describe it as what some teachers do. If so, that is idol worship, and that should be changed. For some, it is a set of rules, and that should be changed.

For me, ISTDP is a set of meta-theoretical principles which allow us to integrate any of a number of techniques. The most important principle is to assess each patient response to intervention to find out if you met the patient’s need in the moment. And these principles are based on a psychoanalytic theory of childhood development and attachment theory. The techniques of cognitive-behavioral therapy, somatic experiencing, gestalt therapy, or internal family systems, you name it, can be incorporated because the key issue, no matter what technique you use in the moment, is: am I meeting the patient’s need in this moment as revealed in her last response to intervention?

In this sense, I am suggesting that we need to move beyond the idea of a model toward an integrative way of thinking and responding. Models can only point toward that. Replication of models does not lead to good outcome. We have to foster a kind of integrative emotional feeling and responsiveness in our work that models and theories can only point toward.

The best therapists in each model look surprisingly alike according to research. This suggests to me that the key factor is not just their model, but a quality of thinking, feeling, responsiveness, and self-reflectiveness that is filtered through their model.

It’s like driving. It doesn’t matter what kind of car we see. It’s the nut behind the wheel.


Jon Frederickson’s latest book Co-Creating Safety: Healing the Fragile Patient came out a couple of weeks ago.

If you liked this article, you might find our other material interesting. Following this link you can find more material in english. Below you’ll find a list of our recent interviews.

Howard Schubiner: “We created a simpler version of ISTDP”

In this interview with Howard Schubiner, MD, we discuss the development of Emotional Awareness and Expression Therapy, EAET, and its relationship to ISTDP. Howard has dedicated many years to developing treatments for psychophysiological disorders. In mid november, Howard is giving his first presentation in Sweden.

How do you feel about meeting a Swedish audience for the first time? 
I’m very excited to conduct a workshop in Sweden. I am a big fan of the Nordic countries having visited Norway, Sweden and Finland in the past. My wife’s family is from Norway so we have relatives there and she had an exchange student from Finland, so we have visited them as well.

Howard Schubiner interview
Howard Schubiner

This will be my first workshop in Europe, so that is very exciting. I have been very jealous of Allan Abbass, my colleague and co-author, as he has done so much teaching on the continent. I hope I can offer something of value!

How come you have such a big interest in psychophysiologic disorders?
I was introduced to mind body medicine back in the early 1970s, when I was in my university training. I read several books at the time and was influenced by several authors. However, I put those interests aside for several years while I was a young medical school and university faculty member at Wayne State University in Detroit.

In 1999, I became interested in mindfulness meditation for personal use and got some training in that modality. Soon thereafter, I began teaching mindfulness and continued doing that up until last year. In 2002, I was introduced to the writings of Dr. John Sarno, a physical medicine and rehabilitation physician in New York City. He had some radical ideas about the source of most cases of low back pain as being due to repressed emotions. His books resonated with me and reminded me of my interest in the mind body connection from my earlier years. I started seeing patients who had chronic pain and spent a long time talking to them about their illnesses and their lives. Some very interesting patterns emerged and I have been fully engaged in this work since then.

How did you end up developing EAET? 
In 2009, my colleague, Mark Lumley, and I attended a 4-day immersion workshop given by Allan Abbass on ISTDP. To put it mildly, we were “blown away” by the simplicity and power of this work. Allan and I began a friendship back then, which culminated in the publication of our book, Hidden From View, in 2019. After the workshop, I began experimenting with ISTDP and found it to be very useful in my patients with chronic pain.

A year later, Mark Lumley and I decided to write a grant to study ISTDP in patients with fibromyalgia. We were not able to find therapists in our area who had training in ISTDP and we didn’t feel it was possible to train therapists in this area in a short time frame. We decided to create a simpler version of ISTDP that could be used in a research trial. This led us to develop EAET.

What are some of the central features of EAET?
As I mentioned, EAET is based on ISTDP, so they are similar in most ways. EAET is based upon the premise that chronic pain is usually caused by neural circuits in the brain. The genesis of these circuits has to do with the danger signal in the brain. Everyone has a danger signal that creates an alarm when activated, just like a smoke alarm. People who grow up with adverse childhood events are more likely to have a danger signal that is overly sensitive and more likely to be activated later in life. That is why people with histories of trauma commonly present with chronic pain and other associated neural circuit disorders.

EAET is based upon the concept that it is often necessary to process emotions that were present at stressful and traumatic times in a person’s life. Of course, some of these events are likely to date back to childhood. During this process, we help patients to recognize, access and feel emotions such as anger, guilt, sadness and compassion. They are guided to express the emotions in fantasy in order to process them. The process usually does not use transference as with ISTDP.

There’s been some very interesting data coming out of your group, showing that EAET might have slightly stronger effects than CBT in the treatment of fibromyalgia and musculoskeletal pain. In psychotherapy research it’s uncommon to find robust differences between treatment models. Why do you think EAET has shown such impressive effects? 
We are proud of the large randomized, controlled trial we conducted in Detroit. It was funded by the NIH and is the first large scale study to show that one psychological intervention was actually superior to another psychological treatment for pain reduction. The actual difference on fibromyalgia symptoms between the EAET group and the CBT group was quite substantial. There are several reasons that we think explain this effect. First, in EAET we help the patient link stressful life events and the emotions connected to them with their painful symptoms. Second, we help them to experience, express and release powerful emotions that have been driving continued emotional distress and chronic neural circuit-based pain.

What are some of the things that we ISTDP clinicians can learn from studying EAET? 
Since EAET was developed as a brief intervention without the use of transference, it can be an attractive option for therapists in certain situations. It can be more easily learned than ISTDP and is suitable for many patients who may have lower rates of trauma. It is often used in a relatively brief time format as well. There is less emphasis on micro-observations of body language and patient feedback. EAET is more standardized and there are defined steps in the process that are useful guides.

Psychotherapy can be a hard thing to learn. Can you tell us something about what you’re learning right now as a therapist and what you’re struggling to learn? 
It seems that I am constantly learning from my patients and from others. It’s hard to say exactly what though. I am so appreciative of the privilege of working with people as they put their trust in me. It is an awesome obligation and honor.

How do you envision the future of health care when it comes to psychophysiologic disorders? 
You cannot keep good ideas down forever. The work we are doing seems so clear, so helpful, so necessary, so simple, and so powerful. There will come a tipping point when more and more convergence occurs around the mind body connection and the critical role of the subconscious mind in so many areas of medicine and psychology. I just don’t know how soon that will be.

Anything you’d like to tell the Swedish audience ahead of the event in November? 
We conducted a small randomized, controlled trial of Pain Reprocessing Therapy (PRT) for people with chronic low back pain. It was recently submitted for publication. PRT is the cognitive and behavioral version that we have developed in order to interrupt the neural circuits of pain. This therapy is based upon recognizing that the pain neural circuits are reversible, that there is no structural damage in the body, and that reduction of fear, focus and frustration with the symptoms can train the brain to decrease the activation of pain. We demonstrated remarkable success in this study.


Currently, a team of researchers at Stockholm University and Karolinska Institute are studying the effects of EAET in the treatment of medically unexplained symptoms via the internet. The research is led by Robert Johansson and Daniel Maroti.


Make sure to check out the online event with Howard Schubiner taking place on November 13th. You can also visit the webpage of the Swedish society for EAET.
If you enjoyed this Howard Schubiner interview you might have an interest in our other articles in english or other interviews. Here’s the list of our most recent interviews:

Dion Nowoweiski: “We tailor the treatment protocol to the individual”

This is an interview with the Australian ISTDP therapist and researcher Dion Nowoweiski. We reported on one of his recent publications a while back, showing promising effectiveness of ISTDP in the treatment of eating disorders. In the interview we discuss the publication and what makes ISTDP unique in the treatment of eating disorders.

Earlier this year you published one of the first empirical articles on ISTDP in the treatment of eating disorders. How do you feel about the publication? 
We’re very pleased. It took longer than anticipated but it was a real team effort from all of the authors. Each author contributed in a unique way, but it goes without saying that this publication was only possible because of the dataset that Allan Abbass has been accruing over the years.

We were able to find a small sample of patients with eating disorders who had been treated through his service in Halifax. Typically, you would find these kinds of patients presenting to specialist eating disorders services or other non-tertiary mental health services. I think one of the more interesting aspects of this study is that ISTDP may be a suitable alternative to the established eating disorder treatments currently offered, many of which show a less than 50% response rate.

Dion Nowoweiski portrait
Dion Nowoweiski

In my opinion, that’s what makes this study so important. It offers an alternative treatment paradigm for the sub-specialty of eating disorders as many of the traditional treatment paradigms are limited by issues such as poor response, high dropout rates, burnout of professionals, high demand and low capacity of mental health services and high costs associated with inpatient care, amongst some of them.

Can you tell us about the background of the study? 
The study was the brainchild of Allan Abbass. We had already done some work on a previous publication on eating disorders, so he approached me to ask if I would be interested in writing up an article of the datafile he has been collecting. We were trying to see if there was a case for whether ISTDP could be a valid treatment protocol for people with eating disorders and whether there was any evidence as to whether there were any cost savings for cases treated with ISTDP. This study is part of a series of publications that he’s been working on in relation to showing cost savings related to ISTDP in other areas, for example, emergency departments.

Why is ISTDP the treatment of choice for eating disorders? 
I wouldn’t say that ISTDP is the treatment of choice for eating disorders per se. But I do think it’s a very good treatment option for people who suffer from ego-syntonic symptoms. As many of you will know, an eating disorder can be a very difficult condition to treat. I believe that one of the factors that contributes to this is the syntonicity of the symptoms. Through my clinical work, I have found that a large proportion of people with eating disorders tend to value their eating disorder symptoms. They don’t see themselves as separate from their resistance.

Separating patient from resistance. From Allan Abbass’s book “Reaching through resistance” (Seven leaves press, 2015)

For example, for many people suffering from Anorexia Nervosa, there is a strong sense of accomplishment associated with the level of self-denial required to maintain a restrictive intake of food or with the level of self-discipline needed to maintain an excessive exercise regime. Both of these symptoms (restriction and excessive exercising) are criteria for an eating disorder diagnosis.

Yet, imposing conditions on these behaviours – which is common in many treatment models for eating disorders – fails. It’s quite possible that this fails, because the patient values these symptoms as part of a mechanism that helps them maintain a sense of self-control and reduces their fear of harm (either from being overweight or from their own impulses).

In ISTDP for eating disorders, we aren’t trying to take anything away from the patient. We’re trying to help give them choices over their life by identifying the origin of their difficulties and seeing how their eating disorder symptoms function as a mechanism that, while once might have been necessary, is no longer helpful and preventing health. By doing this, it becomes more of a conscious choice for the patient to give up the life of suffering that they had once valued. I see this as a very unique contribution of ISTDP to eating disorders.

Compared to other models that try to encourage abstinence or control over impulses to binge and purge, I find ISTDP a very helpful model as I believe it is more focused on helping people change from the inside rather than forcing someone to change from the outside.

Can you talk us through the specific things to take into consideration when initiating ISTDP for a person struggling with eating disorders? 
Identifying the problem that the patient wants to work on is one of the first steps in the psychotherapy process. When you ask the standard Trial Therapy question of “what problems can I help you with?“, many of them respond by saying “I have an eating disorder“. Obviously, this doesn’t tell us anything about their problem.

How is your eating disorder a problem for you?” is a usual follow up. But that depends on what else is happening when the patient answers my question: non-verbal signals and so on. Without going into those details here, the point I’m wanting to emphasize is that it’s a mistake to believe that the eating disorder is the problem. That’s just a set of symptoms given a label.

But this kind of answer illustrates one type of difficulty often encountered in treating this population. It may seem like the person is saying they see their eating disorder as a problem, but on further examination we find that the eating disorder is a coping mechanism. For some people, that can be clarified early on in the Trial Therapy session. For others, I may not even get to do clarification work as their anxiety tolerance may be more problematic indicating their motivation to change is not the issue we need to address at this early stage. These cases require capacity building prior to any defense work.

The mistake I used to make was to assume that if a patient could formulate a response to my question, that meant they weren’t “over threshold”. But I’ve found that for many people with a significant and chronic eating disorder history, they have adapted to starvation and have learned to function as though they weren’t over threshold – even though they sometimes are. It’s taken time to recognize this, as it’s a different type of presentation of a person who is over threshold in the more usual ways.

Understanding the starvation effects on the brain is vital at this stage and being able to recognize whether the person sitting in front of you can think clearly is so important. They may not look like they’re over threshold or suffering from starvation affects as they can reason, but when that reasoning starts to take on a circularity to it, it’s best to evaluate whether the person is fragile. For example, when you begin to challenge circular reasoning in the form of the patient saying things like “I know I’m underweight”, but if I eat more I will get fat and then I won’t be healthy”, the patient can lose concentration, become confused, appear distant or shut down in some other way. I have learned that this usually signals issue with starvation on the brain and/or poor anxiety tolerance. It’s like saying “if you interrupt my circular reasoning (defense) and I have no other mechanism for dealing with the feelings you just triggered in me by pointing out my flawed logic, I need to protect you from the impulses attached to those feelings by dissociating.

In your recent article you mention that perhaps other treatments aren’t effective for eating disorders because of insufficient attention to “structural deficits”. Can you explain what you mean? Is this an ISTDP-specific thing, or would mainstream psychoanalysis suffice?  
I don’t know whether this comes from ISTDP specifically or if it’s from mainstream psychoanalysis, as I haven’t read much on psychoanalysis. I’m pretty much just an ISTDP practitioner and haven’t branched out very much. I think this helps me as I suspect that trying to blend or combine models would confuse me too much and would result in me exceeding my learning threshold.

What is meant by that statement though (“structural deficits…“) is that as a diagnostic group, people with eating disorders can vary so much. Not understanding the psychological capacity of the individual sitting in front of you is probably not good enough. Some cases may have a neurotic structure as described by Davanloo in that they are a resistant case with little need to restructure defenses or build capacity.

Other cases may have suffered from overwhelming attachment disruptions at an earlier age and therefore they haven’t developed the same level of ego capacity as other cases. For these cases, under some level of activation of the somatic pathway of emotions, they run into problems if they only have access to the less mature defense mechanisms of projection, splitting and projective identification. Trying to offer these cases the same treatment as those with a more intact psychological structure seems unfair to me. It’s like asking someone with one leg to race against Usain Bolt and get upset with them if they lose.

I prefer a model where we tailor the treatment protocol to the individual rather than making the individual fit the treatment protocol. Unfortunately I’ve worked in specialist eating disorder services where the latter is the common service model and it used to frustrate me to see how patient’s would be selected for treatment based on whether they met the requirements of a specific treatment modality based purely on the history of the person, without even considering the psychological makeup of the person.

What are some of the main challenges doing ISTDP for ED?
Many of the challenges I’ve encountered when working with people suffering from an eating disorder from an ISTDP perspective can be categorised as 1) relating to the individual and 2) relating to the broader treatment system.

The issues relating to the individual are linked to what I mention earlier and is about working with a syntonic defensive system and working with fragile clients where capacity building is needed. As you know, and as explained by Allan, in ISTDP we need to complete a thorough psychodiagnostics assessment. This begins at the outset of treatment and is focused on helping us identify the structure/organisation of the defensive system we’re working with and the degree to which the defenses are syntonic to the patient. We also need to know about the anxiety discharge pathways and whether there is a threshold to smooth muscle activation or cognitive-perceptual disruption. And at what level of rise in the complex transference feelings the different thresholds are crossed.

Although these may sound like simple enough concepts on paper, the ability to recognize what this looks like in the room, when we’re working with a patient, is something that needed to develop over time and came with doing more treatment for me. As I’ve did more and more treatment, my ability to be confident with my skills improved as I felt more comfortable with my assessment of what’s going on in the patient. This was something that I found needed to be done more collaboratively with patients than what I had been doing early on in my career. In the beginning of my career, this was something that I didn’t understood properly. But over time I found that the more I collaborated with the patient on what I was observing, the more feedback I got and the more conscious alliance it created.

The other issues relates to doing ISTDP work in a field that appears to be quite static (as opposed to dynamic). The mainstream models of treatment for eating disorders are sometimes quite narrow and I found them somewhat punitive at times. During my time working on inpatient services, I found that the model was very rigid and my efforts to step outside of that framework were usually met with quite a bit of resistance from others.  What I learned from this has been invaluable for me, because it really taught me that we operate – as therapists – within systems and these systems can be resistant too. So, if you’re working within the eating disorder field, my advice is to take the skills you have gained through ISTDP about working with resistance and use them to help you make the system more open to different ways of working with people.

Moving on to you, what are you struggling to learn right now? 
Humility……but that’s my lifelong struggle. In relation to ISTDP, my focus currently is on learning how to teach ISTDP. I’ve been lucky in my ISTDP training to learn from so many skilled and kind people, but I know there are lots of other people I haven’t learned from. So, I’m trying to take what I’ve learned from people like Allan Abbass, Joel Town and Steve Arthey and to apply it in a way that allows me to remain consistent to the model, but flexible enough to still be me and to engage learners in the model.

It’s a complex model and it takes time to learn and I truly think it works best when we’re ourselves because the model is really about connecting. When I started out, I used phrases that came from articles and books, or from watching other people’s tapes. I think this is completely normal, but as I progressed I noticed that I did less of that and that seemed to make a difference. I still used pressure, clarification and challenge, but I was doing it as me. So my struggle is about translating that into my training of others.

Do you have other studies in the pipeline? Will we see an Australian RCT of ISTDP for ED in the future? 
Currently I’m taking a break from writing. It’s a labour of love that I currently don’t have the love for. But everyday is a research day in the office. Every day is about gathering the data and analyzing it with my co-researchers (the patients). Although I’m not doing RCT:s at the moment, I still consider myself a researcher and encourage everyone doing this work to adopt a similar approach. Every session is about gathering the data and looking at it and making sense of it and putting it to good use with the patient, whenever I can.

If you dream a bit, where would you like ISTDP and the treatment of eating disorders to go within the next 5 or 10 years? 
That’s an easy one to answer… it’s been my dream from the start: To see ISTDP-based residential treatment facilities for eating disorders. I think the model has so much to offer and that it could make such an important contribution to the development of eating disorders treatment. I suspect that offering it in that format would help bring about some great results. My utmost respect goes out to people like Kristy Lamb from BOLD Health who set out down that path for addictions, and so many of the other amazing researchers in ISTDP like Katie Aafjes-Van Doorn at Yeshiva University, Joel Town and Allan Abbass at the Centre of Emotions and Health in Halifax, Canada. We’re so lucky to have those people producing empirical research for the rest of us to have. It’s that kind of leadership that will help us bring more ISTDP therapy into the world.


Want to read more about ISTDP and eating disorders? Make sure you check out this old gem by Dion, Steve Arthey and Allan Abbass on eating disorders and fragility: Intensive Short-Term Dynamic Psychotherapy for Severe Behavioural Disorders: A Focus on Eating Disorders

If you liked this Dion Nowoweiski interview, you might find some of our other interviews interesting. Related to this one, you might be interested in the interviews with Kristy Lamb, Allan Abbass or José Verpoort-Douw. Here’s a list of our eight latest interviews:

Allan Abbass: “At first doing ISTDP felt unnatural”

At the end of the summer, on the 26-28th of August, Allan Abbass invites you to his 9th Swedish ISTDP Immersion course. We did an interview with him about the ISTDP trial therapy, and his development as a therapist.

Allan at Stockholm Immersion 2019
Allan Abbass at the 8th Swedish Immersion in late summer 2019

How does it feel to do yet another Immersion in Sweden? 
I am very much looking forward to providing another ISTDP immersion to all of the Swedish colleagues and in collaboration with the Swedish ISTDP trainers.

The theme of this year’s Immersion is the initial session, the trial therapy. How come you put so much emphasis on this part of the treatment? 
The trial therapy is in itself a treatment but also is the basis on which further treatment sessions are built. This first session is the most important part of the treatment. When this process goes well and helps the therapist to understand the patient, and the patient to understand the process, it strongly predicts a good treatment outcome.

How do you prepare for a trial therapy? Do you plan ahead in any way on what you want to aim for? 
The main preparation for the trial therapy is being knowledgeable on ISTDP psychodiagnosis and treatment processes for different groups of patients. This requires the full ISTDP training including immersions, video review of cases and so on.

As for a specific case, as a general principle I do not want to have too much knowledge about the patient ahead of time. I want to develop my own understanding of the patient and their problems.

The way I currently work is that people are referred and I look at the referral information in case there are some reasons I need more information prior to a trial therapy. Then the patient goes on a long waitlist so that by the time I see the person I don’t recall much of those details I looked at before. This way it is a fresh look at the patient and his problems

How has your understanding of the trial therapy evolved over the years? What are some of the key things you have learned? 
One of the key things that I’ve come to learn is the issue of how much conscious alliance is required versus how much the process relies on mobilizing the unconscious therapeutic alliance. This balance is different depending on the patient category. For moderate resistant patients, conscious therapeutic alliance is already present so there is no need to spend time building this. For much more complicated patients (eg. fragile patients) more time is required to build a conscious alliance coupled with some focus on unconscious processes and signaling to the patient that the unconscious will be known at some point. It is very important toward developing hope that the more disturbed patients know that their unconscious will eventually become known.

The other issue is how important psychodiagnosis is. In the early years of my work I was often not clear about the psychodiagnosis and that lead to dropouts and misalliances as well as limited treatment effects in some of those cases. With improved psychodiagnostic skills, dropouts and misalliance are less frequent.

What did Davanloo have to say about your trial therapies, if anything?
When I was in supervision with Davanloo we typically would study the trial therapy sessions. Of course that feedback varied greatly from patient to patient. Full range of feedback varied from him overly challenging me about things I had done or had not done, all the way up to saying that the treatment trial was great teaching material. It was great to get his feedback and to make adjustments in those cases where I was missing the understanding of the patient’s problems or was not having properly timed interventions.

You’ve said that doing block therapy requires a lot of knowledge about how to proceed through the different stages of therapy, and that it might not be suitable for beginning therapists. In what way does this apply to trial therapy? Should the structure and goals of the trial therapy be different for different levels of trainee development? 
One thing that varies with therapist experience is how much time it takes for trial therapy. When I started this work in 1990, I would leave the whole afternoon open for a trial therapy starting at 13.00 and sometimes would go into the early evening. When I was in training with Davanloo at McGill University in Montreal, the trial therapies would be all day long on the Monday from 08.30-17.00. He would come out and teach in between segments. Suffice it to say these were not quick trial therapies. As part of my work there, it was my job to analyze videos and produce reports as part of the research. It was quite helpful to take the time to do that.

Over time my trial therapies have shortened substantially. Now I just leave two hours, and if I need another segment of two hours I will go ahead and plan that.

For the new therapist, I do recommend leaving enough time for you to establish a conscious therapeutic alliance, gather history, do the psychodiagnosis, and see if it is possible to mobilize the unconscious therapeutic alliance in the trial. You also need time to recap, review the process, close it up and plan forward.

What do you think other treatment models could adapt from the concept of the trial therapy?
There’s no question that the information from the metapsychology of ISTDP is useful in any psychological assessment. Capacity to recognize unconscious emotional processes as well as unconscious anxiety and unconscious behavioral defenses can aid any psychotherapist doing assessment or treatment regardless of the model.

This is simply because attachment occurs in every psychotherapy model and every assessment interview. When attachment related feelings are activated, anxiety and defenses occur within the unconscious of the patient and have quite an effect on the interactional process. At the same time attachment-related feelings can activate in the psychologist and have a dramatic effect on the interactional process from this perspective.

The ISTDP framework allows the therapist to be conscious of what he is doing for his sake and the sake of the patient.

Throughout the years you’ve shown some great trial therapies at your Immersions in Stockholm. I assume these are some of your best work. How does an average or below average trial play out for you?
There are a range of responses to the trial therapy. On average there are symptom reductions and interpersonal gains based on some hundreds of trial therapies we have studied. When the trial is less effective or not effective, there are a combination of causes.

These include misreading of the front of the system, inadequate work on defenses, inadequate anxiety reduction which make the process uncomfortable for the patients. In these cases, the patient is too anxious or the process is too flat. Patient factors include heavily syntonic defense systems, conscious obstacles to engagement that the person does not share with therapist and medical factors which interrupt the process. The likelihood of these difficulties reduces after doing 100 or more trial therapies or after 2000 hours of therapy and case reviews.

Do you find you have specific patterns where you consistently find yourself being less effective during the trial therapy? Or did you have such patterns before?
In the early work I was doing, there were certain patient styles, including those with significant repression who would disappear from the treatment process and slip into a passive regressive position. With those individuals early in my training I was tending to withdraw rather than to move in and clarify and challenge these defenses. To overcome this pattern it was important for me to self-review videos and try to determine the emotions that were being triggered in me during these processes. Such video self-review is a great tool to help us access our own emotional processes in the patient interactions.

What are you currently working on improving as a therapist right now?
The area I am currently working on is that with those patients who have severe personality dysfunction including dissociative identity and psychotic disorders. There are multiple moving challenges with these patient populations.

How are you proceeding on improving your work with this patient group?
I’m using the same process I’ve used with each other patient category. Namely the review of videos, reading about these cases, feedback from the patients, trial and evaluation of different interventions at different points in time and on some occasions peer input. I’m convinced that there are some severely ill patient populations that none of us should be working in isolation with. We should all have an opportunity to review cases with someone on an as needed basis.

We’ve previously talked about the different phases in your development as a therapist. There was an early phase in the nineties, a therapist style which you’ve described as “applying a technique”, and over the years a transition to a second phase, which you’ve described as “living the technique”. Can you say something more about the development of your therapeutic style?
When I first started to learn this method, I considered myself to be a warm person who liked people and liked to talk to people and learn about them. As a beginning ISTDP therapist, I had to incorporate certain observation skills and procedural skills on top of my personality. At first it felt unnatural in some ways and felt less “warm”. The process felt mechanical. I think I lost some therapeutic efficacy in some ways in the early stages.

This mostly affected the patients who were more resistant or fragile. I found that this did not affect working with more lower resistance patients from the beginning because I was more comfortable and natural in those settings and did not need to use challenge as a therapeutic technique. Working with those low resistance patients mobilized less emotions and anxiety and defense in me as well. As my own underlying feelings started to be mobilized and could be experienced, it was vastly easier to sit and experience the feelings the patient had without resorting to mechanical techniques or other defenses.

As I got comfortable with more resistant patients and fragile patients, it became more and more natural to engage the person with my natural self. In the interviews I will show in the Immersion you will see two older ones and four newer ones that will give you an idea of these changes over time.

Really, some of the keys to becoming a successful therapist include being comfortable, having access to our own feelings and coupled with this, having technical knowledge of timing of interventions.

Anything else you’d like to add ahead of the event? 
I am looking forward to working with you. It looks like this immersion will be held online. That being the case you’ll have the privacy of your own house, as long as your kids and pets aren’t interrupting you too much, to have a personal experience while studying this trial therapy process. All the best to you in your work.


The 9th Swedish Immersion is held online at the end of the summer, 26-28th of August.

If you enjoyed this Allan Abbass interview, you might be interested in our other interviews. For more thoughts about ISTDP training, you can check out the interviews with Patricia Coughlin and Jon Frederickson. We also did a short piece with Allan last fall, which you can find here. You can find all of our english content by following this link. Below you’ll find our latest interviews:

José Verpoort-Douw: “Working in a residential setting is a very educational process for everyone”

In the midst of the CoVid-19 global pandemic we found some time for an interview with José Verpoort-Douw. José is a psychiatrist and ISTDP clinician in the Netherlands, running an ISTDP residential treatment center called “The ISTDP-House“. Before that, she was one of the lead clinicians at the state funded residential treatment center for personality disorders “De Viersprong”.

You’ve been managing the ISTDP-House for a few years now. How does it feel? 
It feels great!

What’s the background of the ISTDP-House?
The idea behind the ISTDP-House was born in February 2016. At that time I was the last man standing – so to speak – in the Viersprong working with ISTDP. At that time this was mainly a daytime treatment program. The management had decided to stop offering ISTDP at the Viersprong all together and my colleagues – José Gelens, art therapist and Tineke Roks, social worker – were suddenly told to end the group we had in treatment at that time.

José Verpoort-Douw

Coincidentally, at the time we had asked the group of patients to give their consent to make a film about the treatment program, to present in Amsterdam at the IEDTA 2016 conference. The patients enthusiastically had agreed upon this idea. They told us that their most important reason for this was that they desperately wanted to keep this treatment program alive. They said it was the best treatment they had received so far for their personality related problems. And because their privacy was at stake, we shared the decision of the management with them. So they would know that despite our film/our presentation, the program was about to stop.

To our surprise and our admiration this patient group decided to start a petition to prevent the Viersprong from ending the treatment program. Within no time the petition had over 400 signatures: ex-patients, their network, colleagues from near and afar and so on. The patients also went to the radio to talk about the treatment program and the plans to stop it. Following this, the Viersprong decided to cancel its plans of stopping the ISTDP program. They even decided to make it a larger program! But not with me, I thought… I had had enough.

We felt very supported and in a winning mood, of course, and Kees Cornelissen and me decided to pick up an old idea of ours: to start a private initiative for ISTDP treatment for patients with severe personality pathology. And two years later, in February 2018, we hired a house where the ISTDP-House was founded.

To be your own boss with no threats of managers thinking everything should be better, more innovative, more cost-efficient, more hip or more whatever. It feels great! And being able to adjust the program according to what you think is the best way forward. Patients are very satisfied with the program, just as they were at the Viersprong. Here’s our page on a site for health care reviews (it is in Dutch, I’m afraid).

“After previous treatments I came to the ISTDP-House a bit skeptical. I could not reach the pain that was so deeply hidden. But soon I felt listened to and that gave confidence. In a safe environment for me, the therapists peeled the onion to get to the core of the blocked pain. Together with the group and the openness and vulnerability of everyone, I was able to take great steps. Now that I am finishing this process, I have regained peace and positivity and will certainly recommend this treatment to everyone.”
– Patient review at Zorgkaartnederland.nl (our translation)

Why is ISTDP a good treatment of choice for personality disorders? 
ISTDP is the best choice for personality problems for principally two reasons. The first one is that personality disorders are deeply rooted within the person and are built around feelings about very painful experiences in the past. To solve these problems and these patterns, patients not only need to think differently about these experiences, but also to feel differently about them. In order to get lifelong change.

The second reason is that psychotherapy has the best yield if the therapist believes firmly in the method. That is the reason that if I am to apply psychotherapy to patients with personality disorders – ISTDP is the only frame of reference I believe in – then this will be the only frame of reference in which I can be effective. 

Did you manage to get state funding – as in De viersprong – or is this a completely private clinic where the patients pay themselves? 
The Netherlands have a good insurance network for mental health. Thus, the treatment at the ISTDP-House is paid for by insurance companies. It’s not as much money as at De Viersprong or at other big mental health institutes, but since we have less costs we manage to make it viable. I mean, we have no managers, no financial department or Human Resources department and so on.

We also ask patients to contribute in the costs if they can afford it. Our policy is that everyone who needs this treatment must be able to acquire it. Of course people with personality problems are not the most successful people in work and financial issues! So, we are glad we don’t have to ask them to pay for it themselves in the case they cannot afford it.

The Netherlands have been pioneering both ISTDP residential treatment and ISTDP group therapy. Can you describe your model?
At the moment the ISTDP-House is the only place in the Netherlands where ISTDP is offered in a residential setting. As stated earlier personality disorders are deeply rooted and by having a very intensive treatment, within a group, it is possible to make a difference in a relatively short period of time.

Our treatment duration is one year. Within this year there’s a three-month period of daytime treatment, three days a week, in a group of eight patients. They all suffer from personality disorders, mainly Cluster C. By working in a group you have several advantages. For example, in a group patients are able to confront and support each other in a very effective way. Also, to self-attack is one thing, but to see someone else do this is something completely different. Patients want to shout: stop doing that to yourself! And then they realize: Oh my god. I do this to myself too! This experience in the group setting can be very powerful.

José-Verpoort-Douw is working at the ISTDP-House
ISTDP-House in Bergen Op Zoom

What else can you tell us about the structure of the program?
It’s a big and difficult question. Well- we have a three-day day-treatment. Patients have therapy from 9.30 – 16.30 each day, where everything is done within the group of 8 patients. This is the schedule:

Monday
9.30 – 10.30. Week opening. The patients report on how they have been working on their therapeutic focus during the last four days at home and what they plan to do for the next three days in the daytime treatment. At this point, two or three patients get a “focus sentence” from the staff: One sentence pinting out what we thought of the progress of the last period and the second sentence what we think they should focus on for the next period. The focus sentences are on a list in the living room of the patients for everyone to see.
10.45. Arts therapy.
12.30. Lunch with social workers – this is a therapy session too.
13.30. Physical therapy
15.00. Sociotherapy and closing of the day.

Tuesday and Wednesday
9.30 – 12.00. The day starts with two individual sessions with group attending, followed by a group session of 45 minutes. A social worker or arts therapist is attending as a co-therapist.
12.30. Lunch
13.30. Arts therapy
15.00. Sociotherapy.

At the end of the Wednesday we make plans for how to work on the respective focusses during the next four days in their own environment.

I hope this gives you an overall idea of the structure. The pressure to change your patterns is high.

What are some of the main challenges with the residential format?
Personally I think the biggest challenge is the portrayal of anger towards other group members. As a lot of patients have run into real violence towards themselves as a child, this can be very disturbing and hard to observe. But we usually find a way to handle this, and especially the transfer after the violence helps everyone put things back in perspective. Also it helps group members to realize and accept that they themselves have these primitive feelings inside them as well.

The differences in the ego-adaptive capacity of the different group members is something where much work needs to be done. But patients are very well capable of understanding and accepting that what works for one patients might be too difficult or too disturbing for someone else, and they support each other in doing what is best for them. Most of the time I see little challenges and a lot of opportunities!

Do you collect data from your patients or do other kinds of research? A big obstacle to implementing ISTDP in Sweden is the lack of robust evidence, so it’s always interesting to see data from the real world. 
Sure we do! We are obliged to do so, using ROM, as the insurance refuses to pay if you don’t have enough questionnaires filled out by the patients (you might read the irony in this sentence). But we decided to take this obligation serious. This is a rather expensive treatment, and we are a very small company, so we see it as our duty to prove that we are worth every penny (euro cent, that is). We are having some trouble to translate our ROM-outcomes to an effect size.

The most striking results we have at this moment is the patient satisfaction measure (CQi-AMB). We aim at a higher score than 7 on two questions: did you reach your treatment goals? and would you recommend this treatment to patients with similar symptoms? On the first question we average almost an 8 and on the second question almost a 9. This makes us proud – but it might not be what you need as “robust evidence”. We’re in the process of using the BSI to calculate effect sizes and so on.

At the Amsterdam presentation you showed a “head-on collision in concert”, with the patients helping the therapists out. Can you explain what that means? Is this something that you still encourage? 
The concept is simple. Head-on collision in concert means that you and the patients of the group help one patient confront his or her resistance. We still do it. Do we encourage it? Well, it depends. On the one hand it depends a lot on the skills of the therapists and also – which might sound strange to some – on the skills of the patients. Sometimes the patients are very skilled in confronting each other on a moment-to-moment basis – sometimes not so much, which can be rather unhelpful and frustrating. It is not a technique you can find in the literature, as far as I know, but it is something I invented – in concert so to say – with the two colleagues you saw me with in Amsterdam: Tineke Roks and Josephine Gelens.

A while back – before this whole Corona experience – we had a patient who started crying whenever she was angry. This was pointed out to her in the individual sessions, but she had trouble admitting it. The group picked it up and each time she started crying (except of course, when there was real sadness!) the group asked her to stop crying and see together how she had just perceived the individual who “made her” cry. After a few times she began to see the pattern and it helped her a lot.

Moving on, what are some of the things you are struggling to learn as a therapist at this moment?
I am struggling not to get involved in rationalization instead of confrontation, clarification and challenge! Also I tend to be the hardest working person in the therapeutic process, giving the patient the opportunity to lay back and see how very well I am trying to help them. So I struggle to improve this!

Sometimes the group of patients help me out with this. After the individual session – the patient group attends the individual sessions for joint learning – they sometimes are a little bit angry at the patient. They say: José was working so hard for you and you did nothing on behalf of yourself, that really annoyed me. Then I know. I did it again! I was overworking. So working in a residential setting is a very educational process for everyone, not only for the patients.

What do you envision for the future of ISTDP?
Dreaming about the future… I would really like to think about the ISTDP-House concept becoming a standard approach, applied all over the world for patients with personality disorders. I really would like that!

ISTDP has been implemented and evaluated in residential settings in a few places around the world. Results from De Viersprong in the Netherlands have been reported in this book by Kees Cornelissen, the Drammen clinic in southern Norway has been covered in several published papers while data from the Bridges Rehab in Arizona was published last year. All of this data is very encouraging, but high-quality RCT-studies are needed to draw definitive conclusions about the effects of the model.


If you liked this José Verpoort-Douw interview you might be interested in our other interviews. Concerning ISTDP clinics and group treatment, we talked to Kristy Lamb a while ago who’s running an ISTDP treatment center in California. You can find all of our english content here. Below you’ll find our latest interviews:

Patricia Coughlin: “ISTDP is a psychoanalytic method”

Here’s an interview with Patricia Coughlin. In September this year, the Swedish society for ISTDP will have the great pleasure to welcome Patricia to Malmö – if all goes according to plan. We sat down with her to talk about learning ISTDP, about sexual conflict, about psychoanalysis and more.

Patricia Coughlin Malmö
Patricia Coughlin

How do you feel about coming back to Sweden to present? 
I am delighted to return to Sweden and welcome the opportunity!

How did you end up becoming a therapist and later on specializing in ISTDP?
I knew from an early age that I was meant to be a psychologist. I pursued this goal with great focus and determination, obtaining my PhD at the age of 25. I was always interested in depth – in understanding the patient (and myself) in a profound way. I was most interested in what was happening beneath the surface, in the unconscious. All of my early education and training was in psychoanalytic/psychodynamic theory and practice. Like Davanloo, I became frustrated and guilty about erratic results with interpretive methods. Many patients came to understand their difficulties, but only some transferred that learning into change. Meeting Davanloo in 1988 and watching tapes of the Machine Gun Woman, the German Architect, and others, was a life altering experience. I saw the unconscious crack open in the most unmistakable way, when the therapist actively intervened to identify and intensify the patient’s core conflicts. I needed to learn that! 

How did you experience training with Davanloo? 
I had good experiences with Dr. Davanloo. He was always respectful and very helpful. I learned more from him than anyone about how to intervene rapidly and effectively. I was in a core group in Montreal for three years. Most of the time, I was the only woman in the group. Many in the group had been training with Davanloo for decades, yet very few seemed to be able to master the technique. Why was that?

In my own estimation, supervision, without teaching, gets limited results. There was little reference to the theory upon which ISTDP was built. He just assumed we already knew analytic theory. Luckily, I did, so I could employ the techniques in order to gain rapid access to the unconscious. Then, all my former knowledge, skill and training, aided me in helping the patient resolve the unconscious conflicts responsible for his symptoms and suffering.

Davanloo was very impersonal in his interaction with trainees. The lack of focus on the person of the therapist was the other factor that I thought contributed to problems in learning and growing. I have tried to include a good deal of teaching, as well as a focus on dynamic case formulation and personal development of each trainee in my groups, in order to enhance the learning experience. My trainees learn the method and the theory it is based upon, and develop as people, as well as clinicians.

My experiences with Davanloo were good while I was training with him, but he cut me off, as he has everyone who goes off on their own. I haven’t heard from him since I left training, but have heard that he denies knowing me. He has done this with everyone he has ever trained, so I don’t take it personally. At the same time, this way of treating people gives ISTDP a bad name and has undermined the method expanding more widely and rapidly.

What’s your perspective on the relationship between psychoanalysis and ISTDP? 
ISTDP is a psychoanalytic method. In many ways, this technique is similar to Freud’s early work, in which he was quite active and confrontational. Over time he got more passive and pessimistic, not in the least part due to being a Jew who was driven out of his country. For many reasons, he became increasingly pessimistic about human nature all together.

Davanloo felt Freud took a wrong turn when he decided to “bow to the superego’s resistance, which sees our efforts come to nothing”. Instead, he took up resistance as soon as it was apparent, inviting the patient to face and experience the feelings he has been avoiding, in order to heal. He also put pressure on the patient to decide whether to continue hiding and avoiding painful realities and feelings or to face them courageously in order to heal. By identifying and intensifying inner conflict and ambivalence, he was able to unlock the unconscious. 

His methods are all used pre-interpretively. It’s for those patients who are locked in by defenses and unavailable for a therapeutic alliance. Once the defenses break down, and the feelings break through into consciousness, dynamic therapy ensues. Many confuse the part with the whole, and the means for the end, but his method is used to open the unconscious. Once the unconscious is open and fluid, working through previously unconscious conflicts, to a new and healthy end is the order of the day. I think this whole mid phase of therapy has been neglected in ISTDP. My colleague Jonathan Entis and I are writing a book about this presently.

Sexuality used to be a central theme in psychotherapy education and writing. This seems to have changed and psychotherapy training nowadays hardly deals with the topic at all. Or that’s at least my impression. Maybe that’s different if you’re trying to become an analyst. Are we past the time when sexuality was a central aspect of psychotherapy? 
In my experience, many patients struggle with conflicts regarding sexual feelings and impulses, as well as those regarding rivalry and competition. The idea that we only have one kind of conflict – guilt over rage toward loved ones – is dangerously narrow. When we develop a set idea about the origin of the patient’s difficulties before meeting and assessing him, we will be prone to confirmation bias. It is essential to keep an open and curious mind and to evaluate the nature, intensity and history of the patient’s problems, in order to ascertain the nature of conflicts responsible for them The neglect of these other conflicts and our narrow focus contributes to poor outcomes. I have seen many patients who suffer from jealousy and rivalry conflicts get no help from other clinicians. It is important that we take all the data into consideration.

So does ISTDP offer unique insights about sexuality and sexual conflict?
The insight about the origins of conflicts regarding sexuality, rivalry and competition are not unique to ISTDP, but confirm psychoanalytic notions of the Oedipal conflict and sibling rivalry. The rage toward the competitor, along with forbidden sexual desires for family members, generates anxiety and defenses that undermine sexual pleasure and performance and can also contribute to a pattern of staying in the position of the loser. Inhibitions about “winning” and “beating” rivals are common and can be traced to Oedipal and sibling rivalry. Understanding these conflicts and the analytic ideas associated with them are important in helping clinicians identify and resolve them, both within themselves, and in their patients.

What are some of the aspects of ISTDP that still are in need of development? 
ISTDP, like many therapeutic models developed over the last 50 years, focuses almost exclusively on conflicts around attachment. The need to attach in a secure fashion to others is only one of two primary drives in operation from birth to death. The other is the innate tendency to be a separate, unique individual. The need for autonomy, self definition, and self determination is just as important as the need for attachment. If we focus exclusively on attachment, we can support the patient’s problem, which is often an excessive reliance on support and validation from others. 

Attending to the patient’s sense of self, so that he can feel solid and secure within himself, is capable of self regulation, self definition, self mastery, and intimacy with self, as well as other, is often neglected. Getting these two drives in balance, such that the more solid one’s self of self and the better able to stand on one’s own two feet, the better able we are to attach in a secure manner. 

The more secure our attachments, the freer we are to separate. Attending to what Blatt called “The Polarities of Experience” are needed to facilitate health and optimal functioning. In contrast, relying excessively on other validation, while being unable to self validate, sets patients up for enhanced anxiety and sub optimal functioning. If we only focus on reactive feelings toward others, and neglect how the patient feels about himself (proud and capable, for example), we keep them at effect, rather than cause. When we take over the process and dictate what the patient should do (face feelings) and must stop doing (rationalizing, avoiding, etc) we reinforce passivity and a tendency to sacrifice self for other. Supporting and encouraging differentiation, as well as attachment, is often required.

In what ways have your way of doing therapy changed over the past five or ten years, and why?
My work is smoother and more integrated. And I am more myself in the process.

What are you struggling to learn as a teacher and therapist right now? 
I am always learning, and hopefully, improving in my ability to teach, supervise and support the development of the person of the therapists. The fact that so many of my current and former trainees have gone on to become real contributors in the field – writing, teaching and presenting at conferences – is a great source of satisfaction and optimism for the future.

Where do you see ISTDP going in the coming five or ten years? 
I have no idea where ISTDP will go from here and look forward to seeing how it all evolves. My greatest concern is that the method is being taught in a highly technical fashion, with little, if any reference to theory or case conceptualization. There are no short cuts and this complex method can’t be learned and practicing by rote. Of course we are all eager to pass on our knowledge, but training and expertise take time. It is a life long journey. It’s important to remember that the best therapists have superior meta-cognitive skills. They have superior working memory, are able to spot patterns as they happen, and tolerate complexity and uncertainty. Containing these polarities – being systematic but flexible, courageous and enthusiastic but humble and open to feedback – is a challenge for us all.

Would you like to say something directly to the Swedish audience ahead of the event? 
I want to wish my Swedish colleagues all the best. These are scary times. Remember to focus on what you can do rather than worrying about things we can’t control. Just three 10 minute periods of meditations on gratitude each day will significantly boost your immune system. I have just returned home from Norway and am incredibly grateful to have arrived safely and in a healthy state. I am extremely grateful that we have the internet and secure sites so we can see our patient’s remotely. I am also grateful for some down time to rest and reflect. We all tend to work a great deal. Slowing down is a good thing. I hope the virus will die down and our plans to get together in late summer will materialize.

Patricia is coming to present in Malmö, Sweden, on the 10th of September, 2020. Make sure to make a reservation now, as seating is limited. Depending on the CoVid-19 situation, the date might be subject to change.


If you liked this Patricia Coughlin interview, you might find our other interviews interesting. For example, we have done interviews with several of Patricia’s former students, such as Kristy Lamb and Jon Frederickson. Here’s a list of our recent interviews:

Karin Lindqvist: “Jag hoppas inte att internetbehandling ersätter face-to-face”

Vi har fått till en intervju med Karin Lindqvist. I förra veckan skrev vi om en ny välgjord RCT-studie på affektfokuserad terapi via internet som hon varit huvudförfattare för. Karin Lindqvist, leg. psykolog, är till vardags doktorand i klinisk psykologi vid Stockholms Universitet och utbildare inom Mentaliseringsbaserad terapi. Hon är också en av grundarna till psykodynamiskt.nu. I den här intervjun diskuterar vi den nya studien, överföringsarbete över internet, mentalisering och lite till.

Karin Lindqvist porträtt
Karin Lindqvist

Du har just fått din första RCT-studie publicerad. Grattis! Hur känns det? 
Stort tack! Det känns jätteroligt. Det är så oerhört mycket tid och arbete som ligger bakom en sån här studie, så det känns som en milstolpe att få den publicerad. Det känns såklart extra roligt att den fick så fina resultat – vi är glada att kunna bidra till forskningsstödet för psykodynamiska behandlingar. Det är ju min kollega Jakob Mechler som är huvudförfattare till behandlingen, och vi har tillsammans planerat och genomfört studien, givetvis i samarbete med hela forskarlaget, så det är verkligen häftigt att ha sett detta växa fram från ax till limpa.

Vilka är de centrala lärdomarna från studien? 
Den huvudsakliga slutsatsen är att internetbaserad affektfokuserad psykodynamisk behandling verkar ha goda effekter vid tonårsdepression. Vi ser att behandlingen ger goda effekter på såväl depressionssymptom som ångestsymptom, emotionsreglering och självmedkänsla. Vi ser också andelen som går i remission och/eller som svarar på behandlingen är i linje med andra internetbaserade behandlingar för tonårsdepression.

Hur kommer det sig att ni gjorde en studie på just affektfokuserad terapi för deprimerade tonåringar? 
Jakob Mechler som främst skrivit behandlingen är ju utbildad i och arbetar med affektfokuserad terapi. Från början var detta ”hans” projekt, som sedan växte i och med ett generöst forskningsanslag från Kavli varpå även jag gick in i det. Vi är ju båda intresserade av att utvärdera psykodynamiska behandlingar, där det finns ett stort behov av forskning. Just när det kommer till barn och tonåringar är behovet av forskning än mer skriande, varför det känns viktigt, spännande och relevant att bedriva behandlingsforskning för den gruppen.

Det här formatet skiljer sig mycket från hur affektfokuserad terapi vanligtvis bedrivs. Kan du säga något om hur det är att arbeta med guidad självhjälp plus chat? 
En uppenbar skillnad är ju att vi och patienten inte kan se varandra. Det innebär att vi rent verbalt, alltså i text, måste vara mycket mer explicita. Vi kan inte se hur patientens ångestnivå är vilket innebär att vi kan behöva vara mer försiktiga och också fråga mer. Vi behöver också vara mer tydliga i våra valideringar – de här små, ofta icke-verbala, signalerna vi ger våra patienter för att visa vår närvaro och omsorg har vi inte tillgängliga utan vi behöver formulera dem i ord.

Självhjälpsmaterialet som ingår i behandlingen

Module 1: Introducing theory on the interplay between basic emotions and attachment. Emphasis lies on how attachment needs are given priority above our emotions, thus leading to affect phobias (illustrated using the “triangle of conflict”).

Module 2: Superego, shame, and self-compassion. Focus on building the capacity for self-observation and differentiating between old habits of self-neglect and self-criticizing versus more healthy parts of the ego.

Module 3: Differentiation between optimal and too-high levels of anxiety. Anxiety regulation through an increased capacity for self-observation and breathing exercises.

Module 4: Affect theory and the visceral experience of affect. Exposure to warded-off feelings through an expressive writing exercise.

Module 5: Identifying and understanding defensive patterns. Identifying different defensive maneuvers and the long-term negative consequences connected to them.

Module 6: Especially problematic feelings: anger, sadness, and guilt. Mixed and complex emotions. How to notice, accept, and experience them viscerally.

Module 7: Interpersonal patterns of relatedness and self-definition. Identifying one’s predominant relationship patterns according to Sidney Blatt’s theory on anaclitic and introjective polarities of personality [33]. Participants are also taught how this is connected to avoidance of our emotions and how to break these patterns by going against them.

Module 8: Communicating and expressing affects appropriately and identifying and repairing relationship ruptures. Moving forward and maintaining gains.

Källa: https://www.jmir.org/2020/3/e18047/

I ISTDP betonar vi arbete med känslor här och nu i den terapeutiska relationen. Går det att arbeta “i överföringen” via text? 
Vi har sett exempel på det i våra behandlingar, och det är väldigt häftigt! Jag ska dock säga att det är väldigt ovanligt och vi fokuserar primärt på annat. Det vi framför allt kan se är patienter som till exempel skäms inför sin behandlare för att de inte ”gjort det de ska” i behandlingen, som förväntar sig kritik eller att bli dömda. Vi ser också till exempel patienter som beskriver att de inte tror att behandlaren kommer att förstå eller att det inte är någon idé att öppna sig eller hoppas på hjälp. Den typen av relationsmönster kan vi arbeta med även i text, och ibland ganska framgångsrikt! Men med det sagt, det är något annat än det ögonblicksarbete som kan göras när man sitter tillsammans i ett rum.

Är det verkligen psykodynamisk behandling om man inte fokuserar på överföringen? 
Det är en viktig och intressant fråga! Dels har vi som sagt en del överföringsarbete i behandlingen även om det inte är särskilt vanligt. Om det behövs överföringsarbete för att det ska vara psykodynamisk terapi är ju både en empirisk och en konceptuell fråga. I exempelvis Høglends forskning tycks det som att överföringsarbete inte tycks vara särskilt viktigt för en stor andel patienter. Dessutom visar vissa studier att regelrätta, ”genetiska” överföringstolkningar verkar vara ovanliga. I behandling av ångest fann man att överföringsarbete inte var relaterat till utfall om det användes tidigt i behandlingen, men vid session nio fann man en signifikant effekt av arbete i terapirelationen. Sen är jag medveten om att överföringsarbete har en framskjuten roll i till exempel ISTDP. Men i vilken utsträckning överföringsarbete är ett måste för att behandling ska kallas för psykodynamisk får nog ses som en fråga som är öppen för diskussion och olika tolkningar. Det finns gott om exempel där teoretiker och forskare funderat omkring när överföringsarbete är lämpligt och när det är mindre lämpligt att använda inom ramen för psykodynamisk psykoterapi.

Även om drygt hälften av deltagarna svarade på behandlingen (56%), så var det många som inte fick någon effekt. Vad jag kunde se var detta inget som ni diskuterade i artikeln. Har du några hypoteser om varför vissa inte blev hjälpta? 
Nej, det är en av de sakerna som vi inte hade utrymme att gå in på närmre. Det är ju ett problem som alla metoder för psykologisk behandling delar. Vi vet att våra mest välbeforskade behandlingsmetoder, oavsett format, hjälper långt ifrån alla. Hur mycket vi än önskar att det fanns en metod som hjälpte alla så har vi ännu inte hittat den metoden och jag tror personligen inte att vi kommer att göra det. Förhoppningsvis kan vi förbättra våra metoder, men samtidigt bör man vara ödmjuk inför att detta visat sig vara väldigt svårt sett till resultaten från decennier av utfallsforskning.  Kanske är det heller inte så konstigt – människor är olika varandra och även om vi försöker begränsa vårt urval med hjälp av exempelvis DSM-diagnoser så blir patientgruppen ändå väldigt heterogen.

När vi behandlar andra åkommor med läkemedel är det ingenting konstigt att man kan behöva testa flera olika läkemedel innan man hittar det som fungerar för en själv, och att detta skiljer sig mellan olika personer. När det kommer till psykologisk behandling är det som att vi ibland glömmer det och tänker oss att vi ska ha en behandling som är ”bäst” som alla ska få. Det tycker jag är synd. Det jag hoppas på, och tänker är viktigt är att vi försöker lära oss mer om vad som fungerar för vem. Nu gör vi en större studie där vi jämför vårt behandlingsprogram med internetbaserad KBT. Kan vi lära oss någonting om huruvida det finns karaktäristika hos patienter som gör att den ena eller andra behandlingen fungerar bättre skulle jag tycka att det var ett av de viktigare resultaten från studien.

Vi försöker också just nu titta på prediktorer för behandlingsutfall även i den nyss publicerade studien för att se om vi kan hitta några faktorer som påverkar hur olika deltagare svarar på behandlingen. Jag tänker att det är en empirisk fråga i första hand. Med det sagt så hade vi naturligtvis gärna hjälpt flera och sett ännu bättre siffror. Samtidigt var behandlingen åtta veckor lång så jag tycker att det tyder på att principerna för affektfokuserad behandling absolut kan tänkas vara effektiva även för deprimerade ungdomar.

Vad jag har förstått så har du tidigare arbetat mycket med mentaliseringsbaserad terapi, och också skrivit böcker om detta. Kan du säga något om förhållandet mellan mentalisering och affektfokuserad terapi? 
Det är ju en fråga som skulle kunna besvaras med en hel bok i sig! Å ena sidan är de väldigt olika varandra – de har helt olika mål för behandlingen och helt olika interventioner för att uppnå målen. Sätten man arbetar på skiljer sig en hel del. Samtidigt upplever jag att perspektiven egentligen inte säger emot varandra, teoretiskt finns många likheter och jag uppfattar även att det finns vissa likheter mellan det graderade formatet och mentaliseringsbaserat arbete. Begreppsapparaten är en annan och det finns absolut skillnader avseende såväl teori som praktik, men fokus på att etablera ett reflekterande kring starka känslor och ångest är gemensamt.

Konflikttriangeln. Triangle of conflict.
Konflikttriangeln

Vårt intryck är att många ungdomar som blir hjälpta av den här behandlingen också beskriver att den hjälpt dem med mentalisering. Till exempel säger flera att när de nu får ångest eller börjar må väldigt dåligt, kan använda sig av triangeln för att förstå vad som hänt, vilket gör att de lättare kan reglera sina känslor och så att säga återhämta sig. Det är ju ett sätt att mentalisera sig själva utifrån konflikttriangeln. Så i just den här behandlingen tycker jag att perspektiven gifter sig ganska fint. Såhär i efterhand önskar jag att vi kunnat mäta också mentalisering veckovis under behandlingen, men det får bli till nästa projekt!

Internetbehandling verkar vara här för att stanna, och vården i Sverige verkar vara inställd på att övergå mer och mer till digitala lösningar – inte minst nu under pågående coronaviruspandemi. Vad tror du att dynamisk internetbehandling kan spela för roll i detta? 
Vår förhoppning är som sagt att kunna vidga behandlingsutbudet. Som du säger finns det just nu samhällsfaktorer som gör att internetbaserad behandling plötsligt blivit betydligt mer attraktivt, men vi vet att det redan innan funnits personer som föredrar att bli hjälpta på det här sättet. Flera av ungdomarna i vår studie beskriver att de låtit bli att söka hjälp tidigare då de tycker att det är obehagligt att träffa någon, eller till exempel för att de bott långt från en mottagning och inte vill blanda in föräldrar. Flera beskriver också att de föredrar detta format och tycker att det hjälpt dem att känna sig trygga. Men just i dessa tider är det såklart extra fint att det finns möjlighet att hjälpa personer där de är.

RCT-studier på psykodynamisk guidad självhjälp via internet:
Johansson et al., 2012. Depression.
Andersson et al., 2012. Generaliserad ångest.
Johansson et al., 2013. Depression och ångest.
Johansson et al., 2017. Social fobi.
Zwerenz et al., 2017. Återgång i arbete.
Zwerenz et al., 2017. Efter slutenvård.
Lindqvist et al., 2020. Depression (tonåringar).

Effekterna som ni fick i studien är verkligen väldigt fina (d = 0,82). Tror du att vi kan använda aspekter från internetbehandling för att göra våra face-to-face terapier mer effektiva? Borde vi till exempel bli bättre på att ge ut skriftligt material till patienterna?  
Det är verkligen en spännande fråga att fundera över! Nu finns det ju ingenting som tyder på att internetbehandling är mer effektivt än face-to-face, och vi vet ännu väldigt lite om de verksamma mekanismerna i behandlingen, alltså vad det var som gav effekt. Även det är något vi försöker undersöka i uppföljande studier. Därför blir ju alla svar på den här frågan bara gissningar vilket man kanske ska vara lite försiktig med.

Det jag kan säga att jag tycker att jag blivit bättre i mina face-to-face-behandlingar av att ha arbetat med internetbaserad behandling. Det har hjälpt mig med att bli tydlig med min rational och mina konceptualiseringar på ett sätt som blir mer begripligt för patienten. Internetbehandling, särskilt med unga personer, ställer ju oerhörda krav på att vi gör våra teorier begripliga och det blir väldigt tydligt när vi inte lyckas med det. Sen tycker jag att det är en styrka med affektfokuserade behandlingar att många terapeuter redan gör detta väldigt bra. Och som sagt, huruvida det gör mina behandlingar mer effektiva eller inte vet jag ju inte!

En sista fråga. Tror du att internetbehandling kommer ersätta face-to-face i framtiden? 
Det hoppas jag verkligen inte att det kommer att göra! Jag ser på det som två helt olika saker. Bara för att många uppskattar detta format och blir hjälpta av denna behandling betyder det inte att alla blir det. Jag tror att det är många som det här inte passar för och där det är viktigt att få träffa någon face-to-face. Utmaningen för forskningen är ju som sagt att försöka lära oss mer om vad som passar vilka.


Här är referensen till Karins senaste studie:

Lindqvist, K., Mechler, J., Carlbring, P., Lilliengren, P., Falkenström, F., Andersson, G., … & Midgley, N. (2020). Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial. Journal of Medical Internet Research22(3), e18047.

Vi hoppas att du gillade vår intervju med Karin Lindqvist. Vi har tidigare intervjuat andra forskare inom affektfokuserad terapi, såsom Joel Town, Jon Frederickson och Allan Abbass. Här är våra tio senaste intervjuer: