Jonathan Entis: “Defiance is the single most important defense”

In this interview, Jonathan Entis discusses his recent talk about defiance at the ISTDP academy. Jonathan is an ISTDP therapist and trainer based in Cambridge, Massachusetts. You can find his website here, and here you can find the website of the New England Center for ISTDP which is a community group that he organizes.

How do you feel about the presentation the other day? 
I feel so happy about the presentation!  I am proud of the work that I showed, and I was grateful to be so warmly received.  I was surprised and honored when Peter Lilliengren first invited me, and of course wanted it to go well but you never know how things will land.  I really felt supported and encouraged by the audience the whole time and it seemed like an atmosphere where everyone was really open to learning.  I had a blast!

For the readers who don’t know you, how did you get into ISTDP? 
Well, this is a bit of a long story.  When I first started a graduate program in psychology in my early twenties, I tried a few forms of therapy.  I was a bit lost, but I also wanted to get a sense of what types of treatments were out there that I might want to practice.  I had read Diana Fosha‘s book on the Transforming Power of Affect, and I thought I’d go see an AEDP therapist.  I got a few referrals, but in the end, the person I started working with wasn’t an AEDP therapist at all, but rather an ISTDP therapist—something I hadn’t actually heard of at the time.  I was blown away by the power and effectiveness of what they were doing.  No one had ever reached me that way.  It felt like tough love for sure, but somehow I felt spoken to and seen in a way that I never had before.  After that experience, I knew I had to be trained in this way of working.

Jonathan Entis

The problem was that there was no training in ISTDP in the graduate program I was in.  In fact, in the States, ISTDP is virtually non-existent in PhD psychology graduate programs.  I would go through various training sites and mental health centers learning CBT, psychoanalysis, DBT, etc., all the while carrying the secret that what I really wanted to do no one could teach me.  So, I basically did a lot of reading on my own, starting with Patricia Coughlin’s first book.  I didn’t have any supervisors who knew ISTDP, but I’d be trying to incorporate what I could glean from her book and sometimes it worked and sometimes it didn’t!  It was a lot of trial and error.   

At one point I grew so frustrated with not being able to study ISTDP that I decided I’d be a psychoanalyst instead.  I began training at one of the country’s oldest psychoanalytic institutes.  I loved a lot of the theory, but I struggled with what I saw as a resistance to technique and a dependence on a lot of vague terminology.  Eventually I saw an advertisement that Patricia Coughlin was going to be starting a Boston based core training group, and I jumped at the opportunity! Pretty much from that day forward, I’ve been consumed with developing my expertise in ISTDP.  One of my mentors, John Rathauser, has said that he developed his skill set by making ISTDP something of a religion.  Well, I’m right there with him on that. For the past 5 years I’ve spent 2-3 hours every day reading Davanloo transcripts, parsing apart all of his cases, and watching my own videos. 

Why did defiance catch your attention in this way, and why do you think it’s such a crucial concept in ISTDP? 
When Peter Lilliengren reached out to me to ask if I would present at the ISTDP Academy, he had just seen some of my work in a webinar I hosted with John Rathauser.  We both showed our work with syntonic defenses, and I was particularly keen to show my work there with defiance. I knew that I had something unique to offer because the way I work with defiance is quite distinct from what I’ve seen most others do in the ISTDP community. Peter’s invitation excited me in part because I knew there was a lot more to talk about with defiance that I didn’t get a chance to fully cover in the webinar.

In my opinion, defiance is the single most important defense to be familiar with as an ISTDP therapist as it is nearly universal in all patients, and is often fueling other defenses that are more apparent. As I talked about in my presentation, oftentimes when we are struggling but failing to help a patient relinquish another defense, like weepiness, it is because the defense is getting its power from defiance. If we keep addressing the weepiness without addressing the defiance underneath it, we’ll ultimately fail to remove it. It will return over and again, like déjà vu. 

But part of the difficulty with defiance is it is often invisible to both the patient and the therapist, so discerning it can be tricky.  Even once you’ve spotted it, working with it is so complex. It gets its power from all the major sources of unconscious resistance: repression, the resistance against emotional closeness, and what Davanloo referred to as the ‘perpetrator of the unconscious,’ tied to concepts of the punitive superego.

During my first years as an ISTDP therapist I was struggling a lot with the defense of passivity, and a lot of the supervision I would get was linked to my own overactivity. Passivity would get me stuck over and over again, and I was dedicating quite a lot of time to figure this out in practice as well as theoretically. Is your interest in defiance related to any of your own learning processes as a trainee?
Well, here’s the thing about what you’re saying. Davanloo did not actually recommend we counter passivity with our own passivity. There is a long-standing tradition within psychoanalytic literature that talks about this and recommends it, and it has made its way into our community as an often-talked about approach, but it’s not a Davanloo method. In fact, Davanloo maintained his activity in the face of patient passivity, and in many ways increased it.  You can see that in many of his best published cases, where he’ll have long head-on collisions and periods of pressure and challenge to the passivity.  I’ll leave it to you and the readers to make up their own minds about the best way to manage passivity in their own patients, but I tend to follow Davanloo’s method of actively confronting it, often weaving in a lot of de-activation, and head-on colliding with it. As I talked about in my presentation, when the passivity is fueled by defiance, this is the aspect that needs to be clarified for the patient, and then collided with. Working on the passivity alone is not enough; they need to see how it is intertwined with their defiance and any other dynamics at work. 

Personally, I tend not to like the counter-passive approach, and instead, if it really feels like an impasse that we cannot overcome, even with concerted attempts to understand and clarify the psychodynamics and relational dynamics at work, then I will acknowledge that with the patient putting in their best effort and me putting in mine, we’re simply not doing enough and it’s time to end the treatment (this is the ultimate pressure by the way, and at times can be the thing that turns the corner).

But to your question more specifically.  Defiance is something I struggled with when I first started, absolutely.  And even though I presented on it and have a lot to say about it, I still struggle with it.  The nature of patient defiance is to try to defeat what we’re doing; how do we not struggle with a force that wants to defeat us?  To me it feels like the ultimate resistance, and so it is the ultimate challenge to take on as a therapist.  As I’m answering this question now, I think this is part of it for me.  I always set myself very lofty goals, and trying to develop expertise in defiance feels like some sort of very worthy challenge.  And of course, like all of us, I have defiance in my own character, and I wanted to try to understand this better, too.

I know that you’re a meticulous Davanloo reader. Do you find that Davanloo has had the last word on defiance, or is there more work to be done? 
Well, one of the things that has intrigued me is that I think Davanloo sold himself short in terms of how innovative he was with defiance.  He developed a ton of techniques for how to deal with it, but the only one he seems to have written about, is de-activation. Peter von Korff, who studied with Davanloo, wrote a wonderful article on how Davanloo manages defiance, but there too he really only stresses the role of de-activation, albeit in various forms.  If you look at what all the trainers and books on ISTDP say about defiance, if they talk about it at all, is to de-activate.  De-activation is of course crucial, and is itself a very complex task.  As I talked about in the presentation, most forms of de-activation are actually essential components within the 16-component framework of Davanloo’s system of Head-On Collision.  So pretty much whenever we are doing extensive de-activation, we are engaging in head-on collision (although I think few people realize this!).

One thing that really intrigues me is that Davanloo could also be very direct and confrontational with defiance, but he doesn’t seem to explain why he switches between indirect and direct modes of management, and no one else talks about that either.  I made it my mission to really understand this kind of code switching he does, and why he does it.  Of course along the way I developed my own style of drawing out and speaking directly to defiance, heavily influenced also by my work with John Rathauser, but the tenets are essentially taken from close reading of Davanloo transcripts. I remember Patricia Coughlin told me a long time ago to pay close attention to what Davanloo does, not what he says.  Here I think she’s correct. If you read the transcripts closely, you see just how complex and layered his approach to defiance was, certainly way more than what has been written. 

I doubt he’ll have the last word on the topic, but I’m a purist at heart, and I’m quite happy to continue interpreting and perfecting his methods.

What do you find are some of the main countertransference issues that prevent the therapist from dealing effectively with defiance? 
Well, I think the biggest issue is that it often goes unnoticed.  We might see the helplessness, the passivity, or perhaps in another patient the compliance and eagerness to please, and we’re busy thinking about the best ways to address these defenses, not realizing that the bigger issue is the defiance that underpins them. We can’t address what we cannot see.

Another issue is as you say, our countertransference. Defiance in the therapeutic encounter is made possible by a projective process in which the therapist is put ‘in the shoes’ of a parent or other genetic figure who the patient now blames for childhood suffering and pain.  Von Korff does an excellent job talking about all that in his article, by the way. Of course the patient is not consciously aware of this, but a part of them is now enraged at the therapist, blaming the therapist, and intent on destroying the therapist’s efforts.  So even if the defiance isn’t coming out in overtly antagonistic ways such as sarcasm or provocation, we’re still likely to get frustrated by the fact that our efforts are failing to take hold. This can be particularly frustrating when the defiance is cloaked in a shell of compliance, and we’re proceeding along thinking we’re being so effective, all the while nothing is penetrating on a deeper level.  Soon the therapy starts stalling or sessions go on in a desultory fashion. Ultimately, our own needs to be effective are thwarted. Of course when we get angry as therapists, we’re prone to the same unconscious anxiety and defense mechanisms as our patients, so if we’re not careful we can get off kilter and engage in unhelpful re-enactments.

Moving on to you, what are you struggling to learn right now? 
Italian!  I used to speak it quite well because my wife is Italian and none of her family speak English, but because of COVID it’s been a number of years since we’ve visited.  My language skills are rusty.  With some Italian members in our Davanloo reading group, and IEDTA 2022 taking place in Venice, I’m wanting to take lessons again.  We’ll see!

I’m also shifting a lot of my time towards leadership positions, such as supervising, training, giving talks, all of which is new for me, so there’s a lot to learn there.  

See you in Venice! And as a therapist, what are you struggling to learn right now? Where’s your growth edge?
Well, I think the perennial struggle is to always be myself while also doing a technique.  As anyone who attempts ISTDP knows, we run the risk of sounding like automatons if we get too techniquey.  And of course it’s very distancing to our patients and ourselves. So, I’m always looking for openings where I can let my personality shine through while also staying true to the technique and the needs of the patient. 

I’ve seen that you’re starting up training and organizing community events in the New England area. What’s the community like around where you live? What are your visions for where you’d like things to go? 
Yes, I’ve been quite active starting up various groups and organizations recently!  New England has some wonderful ISTDP and EDT clinicians, but there’s not a real sense of community.  I know some people have tried to foster community in the past, but it hasn’t really panned out.  I’m not sure I’ll be any more successful, but I thought I’d give it a shot. 

Truthfully, I admire greatly what you’re all doing in Scandinavia.  The organizations you have host such great content and it seems like everyone really knows each other.  I’m hoping to establish something like that here, but I think it will take quite a bit of time. 

Beyond hosting guest speakers and organizing training events, I’m also really looking forward to the social aspect of the community. I’m starting to plan a long-weekend retreat that will offer training and also the opportunity for people to really get to know each other and build friendships. That kind of thing excites me.

If you dream a bit, where would you like ISTDP to be in say 5 or 10 years? 
Well, it’s so exciting to see all of the advances in research that people like you are making. So, thank you for that! I think as long as ISTDP clinicians keep publishing research and getting the word out, the community will grow and more people will have a chance to benefit from this amazing therapy. 

I’m also excited to see this new generation of ISTDP leaders emerge. Of course, those we’ve been calling ‘masters’ are wonderful, but it’s great to see a new group of ISTDP clinicians showing their work more and sharing their ideas.

Finally, I’d like to see more of a return within the community to reading Davanloo’s original work. This is something that has been talked about in the IEDTA listserv quite a bit, and Mikkel mentioned it in his interview with you, but Davanloo really did work in a very special way, and I fear that some of the best parts of his technique are not getting passed down. As I get more involved in training, I’m trying to do my part to make sure my trainees and supervisees read his transcripts to really learn the method. I’m sensing that there is a sea change with this, and I think a lot of other trainers are also interested now in sharing Davanloo’s transcripts and teaching from them. I hope in 5-10 years this becomes more of the norm in core training programs.

Yeah, during my core training, although we did study Davanloo’s texts, his texts weren’t at the center of our attention. What do you think might be missed if one relies too much on second generation literature such as, let’s say, the books by Patricia Coughlin, Allan Abbass or Jon Frederickson?
Well, I think all those writers are great and have made really wonderful contributions to the field.  They’re all doing ISTDP and they’re all fantastic at it!  Anyone who reads their books will learn a lot.  But they’re doing their own versions of ISTDP, and they’re all actually quite a bit different than what Davanloo did.  Once I started closely reading Davanloo’s transcripts, I knew I wanted to practice like that.  His intense focus on resistance, the way pressure is really applied to the defenses which then allows feelings to more naturally emerge, the moving and beautiful long-form head-on collisions or even just how often he used head-on collisions (he even does them with a patient he says is on the extreme left of the resistance spectrum–the case of the salesman!), all of it just really appealed to me as a very intuitive, honest and poetic system.  For whatever reason, that way of doing things makes sense to me on some cellular level, I can’t explain it beyond that.  So my concern is really about his style falling out of favor, or perhaps just being forgotten, in a way that it disappears.  I don’t know if ISTDP is any less effective if his way of doing things vanishes, but in my opinion it’s not as beautiful.


If you liked this Jonathan Entis interview on defiance, you might enjoy some of our other interviews, such as this dialogue with Kristy Lamb on ISTDP and addictions, this conversation with Howard Schubiner on “ISTDP light” or this Joel Town interview where he discusses the possibility of taking the ‘intensive’ out of ISTDP.

Ange Cooper: “I am my patient, they are me”

In this article we get to meet Ange Cooper. She discusses the many stages of learning ISTDP, detailing her own ISTDP journey through idealization, omnipotence, denial, depression, personal therapy, complexity, psychedelics and spirituality. Ange is an ISTDP teacher and supervisor based in Halifax, Canada. You can find her website here.

Shifting the focus to the person of the therapist

On the back of some recent conversations in the community regarding the teaching of ISTDP, you wanted to talk about your experiences as a learner. How so?
It’s time to talk about my ISTDP learning journey come what may. I have gone through many stages in my learning process and I hope by talking about these openly, it can serve as an enriching personal account that facilitates many other discussions regarding the ISTDP learning process.

Ange Cooper

So how did you learn ISTDP?
I completed my core training with Patricia in 2014, having first been introduced to ISTDP through an 8-month placement with Joel Town.  I developed a research interest in ISTDP and spent a number of days at Modum Bad Hospital in Norway being taught how to use the ATOS as a process research tool by the awesome Lene Berggraf and Pål Ulvenes.

Early in my learning I decided to do a block of therapy with Josette ten Have-de Labije as well as receiving regular supervision from Mark Stein whilst working in the NHS.  Following this, I moved to Canada to work with Allan and had weekly supervision for the best part of the last 5 years. I attended a Davanloo immersion in Montreal, then completed training with Tony Rousmaniere on deliberate practice with Tom Brod, Susan Warshow and Robin Kay.  I then went on to complete Jon Frederickson’s Training of Trainers course and continue to attend his advanced training which is now in it’s 4th year, I believe.  Amongst all of this I have had the benefit of thinking, learning, discussing and being inspired by many other folks in ISTDP, EDT, CBT, psychoanalysis, Jungian analysis and so on.

Besides learning, I have been teaching and training in ISTDP for a number of years now, having facilitated one core training to completion with another mid way through. I will start an advanced training group in November with Allan Abbass. 

All of this is to say, I have had a lot of training in ISTDP and have been committed – like a marriage – to this model for over ten years now. However, what I want to convey here, which I think is more important than my ‘ISTDP qualifications’ is the personal work I have done over this last 10 years.

But is this really a dichotomy – training in ISTDP and personal work?
Not really. I want to talk about the stages I have been through and how this has influenced and fundamentally changed how I practice ISTDP. I think this touches upon some of the points Mikkel raised in his interview but in a more personal and experiential way. 

It is my sense that this aspect of our learning isn’t spoken about enough, of course because it is personal and that can be scary and certainly vulnerable. So, I feel it is in some ways part of my growth to begin such conversations so that others may feel brave enough to do so and so that we can begin to consider how our personal and collective wounds impact our work in ISTDP. 

As Allan Abbass recently pointed out on the IEDTA-listserve, when assessing a patient video you have to consider at least eight central factors: degree and type of resistance, degree of rise in complex transference feelings, phase of treatment, degree of syntonicity, state of the conscious therapeutic alliance, presence of barriers to engagement, medication and somatic illnesses and the current front of the emotional system.

If you add to this the same number of therapist factors, well then you have a pretty huge number of interrelated factors all occurring at any one moment. Maybe someone who reads this can do the math as to how many combinations we can find?

So there’s a lot of work to be done when it comes to the therapist side of things.
It is my deep belief that what we struggle with in ISTDP or any complex endeavour for that matter, is very much tied to our own unconscious emotional processes. This is why ISTDP looks so different between different therapists and within the same therapists across time. I do believe Davanloo developed a deeply healing model of therapy, however it is my guess that even he was troubled by how complex the model was to teach and transmit.

I also think he set up his mobilisation groups in order to address some of the difficulties that therapists have to overcome to do this work well. Including issues such as the therapists own punitive superego, sadism, masochism and tendencies to get stuck in a transference neurosis. Whilst certainly controversial ethically and massively problematic in terms of power dynamics, I can see why he may have felt a desire to help therapists overcome their own emotional difficulties in order to implement ISTDP in the way he would have hoped for.  

from omnipotence to depression and beyond

Coming back to you… You said you wanted to talk about your own journey?
Here we go… In the beginning I was immersed in learning about psychodynamic conflict, the theory of ISTDP, Davanloo’s publications and the actual skill/technique of the model. Just like when you’re learning any new skill there is the excitement and inevitable frustrations that show up with each new patient. 

As I grew as a practitioner, I met my skill development with an overidentification with the model, a oneness with it and it meant everything to me. It became part of my identity and my personality at some level – I think I fell in love with the model!

The desire for oneness with the model was so strong that with it came an idealisation of its power and ‘rightness’ above all other models and devaluation of other forms of therapy. I experienced very little anxiety during this stage and as such I had some very good outcomes – because I believed in it 100% – but also some very bad ones. 

We could say I went through an oceanic stage and into the paranoid-schizoid stage that Melanie Klein speaks about – I was unable to tolerate complexity. I engaged in splitting and denial, and I was filled with my own omnipotence.

Thankfully, but painful at the time, this stage didn’t last, the more patients I saw and the more experience I gained, I started to recognize that I was struggling with a whole myriad of patients. This is when I started to move into a more depressive phase.

What was that like for you?
I started to become overly critical of my skills and capacity, I even started to resent learning ISTDP and wanted to have a life beyond it. And this was the stage where I started to look towards others models, teachers and readings that began to broaden my horizons away from the “Fathership” of ISTDP.

During this phase, my practice began to look different. I was playing with different ways of working and trying them with patients, I started to believe that there had to be more than ISTDP to heal others and myself and so we could call this phase the depressive phase but also the beginning of an experimental phase as I grew. 

I could no longer do “pure” ISTDP, I was very much in “ISTDP eclectic”, or “ISTDP-I’ll do it my way!” Again, for some patients this seemed to be helpful and for others I continued to be stuck, frustrated and despondent. All the while, I continued to study and continued to seek supervision but I started to become depressed and began to wonder, what does all of this mean? I started to lose my sense of meaning and purpose for ISTDP (and of course tied to my life in general) and even patient work. I became a little more depressed.

At my lowest points, I started to realize that I was struggling just as much as the person in front of me, so how on earth could I help them? I recognized that I had begun to treat my patients as if they were different to me, at times ‘lower’ or ‘higher’ than me and that they just weren’t co-operating with me or this therapeutic model as I saw it at the time.  I started to disconnect from patients and simultaneously disconnect from myself – and my therapeutic work started to look more like a series of technical interventions that seemed to lack compassion or heart – what had happened? I started to have some very deep conflicts within myself the more this stage progressed.  Let’s call this stage disconnection or separation consciousness.

Due to my experience of depression and fatigue during this journey, I decided to commit to my own longer term therapeutic endeavours.  At the time I didn’t really feel I was of much value or help to my patients. I had lost my mojo for therapy – I felt lost. I actually wanted to quit being a therapist, it was too painful, too difficult, too stressful and it seemed to have lost its joy, meaning and purpose.

Getting to know your blind spots

We’re very grateful to still have you around, despite what you’re telling us. What helped you find your footing again?
Over the last 5 years, I have steadily been engaged in my own work, this happened to be mainly Jungian analysis. There was just something about Jung’s way of working that intrigued me.  I wanted to find deeper connections within myself, I wanted to understand my dreams, I wanted to understand the collective unconscious and mostly I wanted to feel that life was meaningful again. To me, life had lost its wonder and I didn’t know how to get it back.  So I started therapy, I also did ISTDP block therapy every time I hit upon some big emotional wave that I felt needed to be processed with an unlocking. This was a really useful combination for me.

In addition, and with deep gratitude to Jon Frederickson, I started to bring my most difficult cases to supervision and through experiential role plays he helped me begin to understand from an experiential level – not an intellectual level – what some of my own emotional blind spots were. Blind spots that kept getting in the way of my ISTDP practice. 

Can you be more specific? What where you learning at that point?
I discovered that I had major difficulties in recognizing when I was stuck in a transference enactment especially with highly resistant patients. An inability to see that it was I who held the motivation and unconscious therapeutic alliance for the patient, along with a completely unconscious tendency to resist the patient’s resistance. In sum, this was leading me to co-create the problems that occurred in the therapy room. I was a central part of the problem.

More recently I also gained a very deep understanding that I have been identifying with my patients’ projection of guilt – which has meant that my breakthroughs to guilt, my ability to hold complexity during phases of mobilisation and my ability to do head-on collision were seriously compromised. Because of my own internal, emotional dynamics/capacities I had been unable to offer patients some of the most fundamental aspects of ISTDP model, try as I might. I wasn’t even able to see what was wrong because everything was operating at such an unconscious level – sigh.

Can you be even more specific, what did this look like in sessions?
Mostly it looked like not getting to deep breakthroughs of complex feelings, I emphasized rage above complexity. I was anxious to get to an outcome and I only partially identified the resistance. This meant that it could continue to operate. And there was minimal work with the operations of the pathological superego, since I couldn’t see it. And my head-on collisions did not land and did not create the deeper impact I had hoped for.

The outcome of such issues was that often patients only ever had partial breakthroughs, the UTA was never fully mobilized and this then compromised the deep insights and character change that the unconscious therapeutic alliance potentially brings through to the later, working through stages of the treatment. 

This is not to say that I haven’t had cases with good outcome at the same time, but it is my observation of regular patterns that were occurring within my work at this stage.

Getting unstuck: the path of spirituality and psychedelics

What was it like to see that?
Oh my goodness, I am just as stuck as the patient!

We are suffering the same difficulties and likely of a similar emotional origin and until I begin to see the patient as me – and me as them at an emotional level – I cannot move this thing. I cannot do this therapy. I cannot mobilize the unconscious enough. I cannot see in them what I cannot see in myself. 

This was my most painful stage – but also, I suppose – my most liberating.  I could no longer see the patient as different to me, I could no longer hold this human being either above or below me – I had to begin seeing them as, well at one level different, but ultimately one and the same. This started me into a new developmental stage that felt something like unity consciousness-oneness-humanness – not sure what to call it. But it would be summarized as “I am my patient, they are me”.

Stanislav Grof

How hard it can be to stay open to that shared vulnerability. What impact did this realization have on you?
At this stage of both my growing up and – we could say – waking up, I started to become deeply interested and connected to spiritual writings, integral models of therapy, transpersonal ways of thinking (Stanislov Grof, Ken Wilber) and embodiment practices – and all of this finally led me to psychedelics. I have been hesitant to talk openly about this aspect of my development, but it seems like it is the time and so I will give some brief details.

As I started to become interested in the transpersonal readings above, I hit a stage of my development that spiritual circles call the dark night of the soul. Nothing interested me, I stopped wanting to hang out with people, I wanted to become very introverted, I was in existential angst.

At one point I even wanted to start meditating. Those who know me, know that this isn’t really like me. It was so not like me – but then I started to question who am I anyway – and so meditations began. Through meditation, reading, and becoming more and more aware of some deeply rooted conflicts inside of me, I made the decision to undertake some ceremonial psychedelic sessions with an experienced medicine woman.

There’s a lot of buzz around psychedelic-assisted therapy these days, with both MDMA– and psilocybin-assisted therapy closing in on medical approval within a few years. What were the ceremonies like for you?
I won’t go into these experiences in too much depth, but they have been transformative for both my own personal healing and consequently my practice of ISTDP. In short, through some intense and at times painful experiences, I feel like my heart has been cracked open and I have been able to heal some of my deepest wounds in ways that would not have been possible through a talking therapy.

It is really beyond words to describe the experience, but it has changed my life in profound ways – It has brought me to a place in which I feel deeply connected to a spiritual process and so slowly over the last few years my sense of meaning and purpose has started to re-emerge and with it my excitement and interest in ISTDP as well as my work with patients.

It has made me want to come all the way back to ISTDP (like the hero’s journey). Except that for me, I now place ISTDP into a much bigger, broader spiritual framework that goes beyond symptom and character change.

Do you think psychedelics has an important role to play then in the teaching of ISTDP?
It is too big of a topic to go into here regarding ISTDP and psychedelics, but I am interested in the power of ISTDP and psychedelics used together in some combination– and I am also very interested in the journey of the therapist especially as it relates to the ideas of ‘waking up’ versus ‘growing up’ and how we might consider both of these aspects within our development as therapists.  People can wake up but not have grown up and there can be devastating results from this, people can also be very grown up but never really find a spiritual path – my interest is in how both of these forces come together and how we can yield these forces to massively advance our field.

I have been considering the similarities between ISTDP and psychedelics for some time. From my perspective and experience, the process of breakthrough – into guilt-love-oneness-compassion along with an unlocking of memories from the past – is very similar to the experience during a psychedelic session. But no talking and less time. 

There is something very powerful that happens in both modalities when we melt our punitive superegos, when we surrender to the power and intelligence of something much bigger than ourselves. When we fully let go of control. When we become one with the experience. When duality does not exist. It’s something truly amazing, mystical and spiritual that happens that is beyond the rational or intellectual mind and in the realm of deep knowing-intuition-transcendence.

I think there is much cross pollination of ideas and potential for growth in our understanding of psychopathology if we are willing to be open to how psychedelics work and in what ways the process of change is similar and different to ISTDP.

Learning and teaching ISTDP

So what does all of this boil down to when it comes to how we teach and learn ISTDP?
I believe Davanloo created a powerful model that when delivered optimally – has both the patient and therapist engage in a deeply meaningful spiritual endeavour. 

Davanloo had clearly grown up enough in terms of his own emotional development that he was able to conceive, develop, research and deliver this model effectively and it is integral to who he is.  As I understand it, most of the issues in ISTDP come from the learning and teaching of the model, especially when we are all at vastly different stages of growing up. 

This would mean then that given the therapist’s stage of development, what is focused upon in sessions, what is heard, what is taught, what is practiced, what is adhered to and what is focused upon is going to look very different person to person. I have a sense that what we end up focusing on in therapy can sometimes be the unconscious issues that we ourselves are struggling with and not always that of the patient. For example, I am currently in a stage of fascination or maybe even obsession with the punitive superego, and I’m seeing it everywhere I go. It so happens that this is what I am deeply working with in my own therapy and musings.

When I see ISTDP at its best, it is the same feeling I get when I hear an orchestra play, when I watch a moving film, when I see dancers move in synchrony or nature working together. It is this deep flowing unison with what is, in the present moment and it is breathtaking. When I see Patricia Coughlin, Allan Abbass, Jon Frederickson and others in their zone with a patient, I see them as deeply connected, intimate, honest, open, speaking from their hearts and deeply aligned with who they are. They’re in synchrony with powerful techniques and a deeply embedded understanding of conflict, the unconscious, as well as a deep respect for the patient’s will. In other words they are in a flow state that transcends the conscious mind. 

All of the above, to me, is what provides the furtive ground for emotional breakthroughs that lead the patient’s own unconscious therapeutic alliance into resonance with their individual and collective wounds in order to create deep healing and change. This is some of what I mean in placing ISTDP within a more spiritual framework.

Following the above, I started getting the message to read Davanloo, Freud and Jung again from their original sources and, like most learning that occurs as a spiral, I noticed that I could finally read and understand what I could not previously.

It sounds like you’ve come a long way. So where are you at in your development at this moment?
I have deeply reconnected with ISTDP and at least right now, I am able to do this in a way that at times looks like the work of those I most admire except it is embodied through me. I am now able to mobilize the unconscious in a way that I couldn’t before.  At times, I can deeply hear and feel the unconscious therapeutic alliance as it rises, I can feel when a patient is complying or if they are becoming their punitive superego, I can feel their somatized pain as well as the rage as it rises in my body as well as theirs.

This is no longer such an intellectual endeavor for me, even though I am re-reading a lot and thinking about this every day. Instead, it feels like it is coming from a place of intuition and my heart and as such I am learning to do Heart on Collisions rather than Head on Collisions as I like to view them.

I am speaking from one heart to another when I press to feelings, when I identify and clarify defenses, when I stop being the ego to someone’s superego so conflict can rise in them. And low and behold patients seem to be having breakthroughs in a way that I could not facilitate previously and it comes without the intense attachment to the outcome that I once had.

Sadly, this does not mean I am having breakthroughs with everyone, I just know that my interventions are coming from a different place these days. It is much less cerebral and more embodied as a whole part of me rather than me being split into lots of separate parts trying to speak to the different parts of the elephant.

So, this is where I find myself on this journey now and I continue to grow through seeing new patients, skill building, meditating, video review, teaching and supervising trainees. I don’t know where this stage will take me but I know at least part of it is to share my experience, to enable others to share theirs, to practice courage and bravery in speaking my truth and to help those who are struggling to recognize that in any complex endeavor that involves body, mind, heart and soul – there are stages and we all go through them – some quicker than others. But still the spiral continues.

NOTE: With the permission of the author, the text has been reconstrued as an interview to make it more accessible.


This piece was inspired by ongoing discussions on the IEDTA listserve, fueled in part by the current debate on the risks associated with ISTDP in the Norwegian psychologist’s magazine as well as this Mikkel Reher-Langberg interview we did some time ago.

For a now classic text on idealization and devaluation when learning ISTDP, please see this 2004 article by Allan Abbass “Idealization and devaluation as barriers to psychotherapy learning“.

Below you’ll find some of our latest interviews:

Mikkel Reher-Langberg: “Vi använder Davanloos ord, men musiken är annorlunda.”

I den här intervjun med Mikkel Reher-Langberg diskuterar vi hans kommande bok om Davanloo och ISTDP och mycket annat. Mikkel är psykolog och ordförande för det danska ISTDP-sällskapet. År 2018 gav han ut en bok om Freuds jagbegrepp, Faces of the Freudian ‘I’: The Structure of the Ego in Psychoanalysis. Tillsammans med några kollegor så driver han sedan några år tillbaka den privata mottagningen Emotion center i Köpenhamn.

Klik her for at se den danske version af denne tekst. Click here to read the english version of this text.

Vad är det som upptar dig just nu?
Som du vet arbetar jag på heltid på en privat ISTDP-klinik i Köpenhamn, och jag är fortfarande mycket upptagen med att lära mig hur jag ska arbeta med ISTDP. Vid sidan av det kliniska arbetet är jag på väg att skriva den bok vi ska prata om här. Dessutom har jag varit upptagen med meditation de senaste åren, vilket jag hoppas kunna ägna mig mer åt när boken är klar.

Porträtt Mikkel Reher-Langberg
Mikkel Reher-Langberg

Du håller på att avsluta arbetet med den här boken i två band om ISTDP. När jag hört dig prata om den så har jag fått intrycket av att du vill bidra till någon slags “back to the roots”-process: tillbaka till Davanloos fundament. Vad är bakgrunden till boken? 
Bakgrunden är att jag under de senaste åren har studerat för John Rathauser. Han har en stil som ligger mycket nära Davanloos teknik runt 1990. Jag såg Johns arbete på IEDTA-kongressen i Amsterdam 2016 och blev helt såld på hans stil. Jag lärde mig grunderna inom ISTDP genom Jon Fredericksons och Allan Abbass format och stilar, och har sedan jag började arbeta med John arbetat för att förstå vad som är hans unika stil. Med tiden blev Johns och mitt samarbete närmare och mer av en vänskap, och jag tror att John efter ett tag kunde se att jag ofta förstod och artikulerade hans arbete på ett sätt som han själv inte kunde. Trots att hans kliniska intuition är mycket starkare än min egen. 

John Rathauser

Vid ett tillfälle föreslog John att vi skulle skriva en bok tillsammans och dra nytta av våra olika styrkor. Det var i början av 2019. Jag föreslog att vi skulle skriva boken som en introduktion till Davanloo, vilket vi snabbt blev eniga om. Jag har i första hand intresserat mig för bokens första band, som är ett försök att presentera en sammanhängande presentation av Davanloos teori och metodik. Den andra volymen består av Johns fall, som vi har skrivit kommentarer till. Skrivandet av boken har för mig personligen varit ett sätt att integrera min förståelse av Johns arbete genom en mycket nära läsning av Davanloo.

Har du lust att berätta om några av de centrala fynd du gjort när du närläst Davanloo på det sättet som du gjort?
Det är svårt att peka ut enskilda fynd. Att vända mig tillbaka till Davanloo har krävt en grundläggande omstrukturering av vad jag trodde att jag visste om ISTDP. Det jag har varit mest intresserad av utöver Davanloos begreppsapparat har varit Davanloos sätt att tänka på och orientera det kliniska arbetet. Jag har försökt avkoda logiken i hans kliniska tänkande genom att undersöka kontrasterna mellan hans stil och senare versioner av ISTDP. På så sätt kanske jag lägger för stor vikt vid skillnaderna mellan Davanloo och andra lärare, snarare än likheterna. 

Med detta sagt anser jag samtidigt att det finns en kvalitativ skillnad mellan det sätt på vilket de flesta av oss förstår ISTDP i dag och det sätt på vilket jag anser att Davanloo förstod sitt hantverk på. Vi använder alla samma ord som Davanloo, men musiken är annorlunda, och jag tror inte att det bara beror på att Davanloo hade/har en djupare klinisk intuition än vad de flesta av oss andra. 

Ett område där jag anser att detta visar sig tydligt är att många idag verkar förstå ISTDP som en känslofokuserad eller upplevelsebaserad terapi. Till exempel har den svenska ISTDP-gruppen på Facebook en banner som säger “the deeper you feel, the more you heal”. Detta kan verka oskyldigt, men i praktiken innebär det att många ISTDP-terapeuter är mest intresserade av att “komma till känslorna”, som om det vore ett mål i sig självt att uppleva känslor. 

Detta perspektiv har naturligtvis sina styrkor, precis som andra terapiformer har sina styrkor, men jag anser att det är ett perspektiv som skiljer sig kvalitativt från Davanloos – åtminstone det perspektiv han hade fram till slutet av 1990-talet. De känslor han är (eller var) intresserad av är särskilt de som är förknippade med arbete med motstånd, och de är inte ett mål i sig – de är ett medel för att få en djupare förståelse för och arbeta sig igenom patientens omedvetna. På så sätt använder Davanloo motstånd på ett annat sätt än vad de flesta ISTDP-terapeuter gör idag, vilket har konsekvenser för hur arbetet ser ut i praktiken.

Du säger nästan att det är att tala om en ny terapiform som utvecklats “post Davanloo”. Kan du gå in mer på detaljerna i vad som är så annorlunda, kanske med ett kliniskt exempel? Hur är Davanloo/Rathauser-ISTDP skiljt från Frederickson/Abbass-ISTDP? 
Jag tycker verkligen att det är värt att överväga om det är samma form av terapi! En konkret klinisk skillnad är att många i dag har lärt sig att “gå igenom” motstånd, genom att välja vad man skulle kunna kalla “minsta motståndets väg”, medan Davanloo följer “största motståndets väg”. Men jag tror att den största skillnaden ligger i förståelsen av terapin – inte i de tekniska interventionerna. 

Om du ändrar andan i en metod, är den då fortfarande densamma? Det är svårt att ge ett kliniskt exempel, men vi kanske kan jämföra det med yoga. Om du använder de olika positionerna som gymnastik eller styrketräning, är det då fortfarande samma sak som att använda yoga som en andlig praktik? Om man förstår ISTDP som en form av exponering för känslomässig intimitet, där den terapeutiska potentialen ligger i att underlätta genombrott av känslor eller korrigerande känslomässiga upplevelser med terapeuten, vilket många gör, överskuggar det lätt den del av arbetet som handlar om att skapa insikt i det omedvetna. Vi kan säga att det ena inte utesluter det andra, men i praktiken tror jag fortfarande att många använder metoden som om exponering av de egna känslorna vore ett mål i sig. 

Det finns mycket gott i det – men jag tror att det är viktigt att vara medveten om vart det gör med terapin som helhet.

Du har tidigare skrivit en bok om Freuds jagbegrepp och intresserat dig en del för filosofi – saker som passar väl in i den psykoanalytiska litterära traditionen. Borde vi som håller på med ISTDP intressera oss mer för att läsa klassiska originaltexter? Eller är det en positiv sak att fokus i ISTDP-communityt snarare är på hantverket och att se på videoinspelningar? 
Både ja och nej – jag är inte säker på att den psykoanalytiska litteraturen är relevant för vår metod, precis som man inte lär sig att springa hundrameterslopp av en maratonlöpare. Vi använder oss inte av överföringsneuros, så det är svårt att jämföra metoderna annat än i princip. Om det ska ske ett utbyte tror jag att det finns något vackert, seriöst och generöst i vårt sätt att utbilda inom ISTDP som jag tror att den psykoanalytiska miljön skulle kunna dra nytta av. 

Ett område där jag tror att det skulle vara fruktbart att inkludera mer psykoanalytisk teori är för att förstå de psykiska nivåerna som är djupare än känslolivet. Den psykoanalytiska traditionen har ett språk för de drivkrafter och den intersubjektiva dynamik som ger upphov till manifesta känslor som vi inte alls har i ISTDP-miljön. Att införliva detta kommer att ha betydelse för hur vi förstår den terapeutiska processen som helhet. Jag tror att en av de nästa saker som kommer att behövas i ISTDP-miljön är att fler människor engagerar sig i konceptualiseringen av fas 6/7 i den centrala dynamiska sekvensen – alltså working through – som vi tyvärr inte har någon sammanhängande förståelse av för närvarande. Denna fas är nära relaterad till det sätt på vilket vi ser på själva meningsskapandet och den terapeutiska mekanismen bakom det vi håller på med. Där tror jag att det är nödvändigt att återvända till den psykoanalytiska traditionen för att få hjälp och utvidga våra perspektiv. 

Vad ser du som de stora utmaningarna för ISTDP-communityt under de kommande åren?
Jag tror att det finns många som började lära sig ISTDP ungefär samtidigt som Co-Creating Change kom ut, som har ägnat mycket tid åt teknik och som nu befinner sig vid en punkt i sin utveckling som terapeuter där de behöver något som hjälper dem att utveckla en djupare förståelse för själva den terapeutiska processen. Jag tror att vi behöver litteratur och utbildning som fokuserar på de stora processerna så att vi kan börja använda tekniken på ett smidigare sätt. 

Utöver detta har jag personligen två saker som jag skulle vilja se inom en snar framtid. För det första att någon skulle utveckla en fenomenologi för metoden – en beskrivning av strukturerna i patientens och terapeutens inre upplevelser av processen. För det andra att någon skrev mer detaljerat om terapeutens användning av försvar i processen och hur de vanligtvis ser ut. Tyvärr tror jag att vi som miljö kan ha en tendens att lägga större vikt vid patientens försvar av processen än vid våra egna, och jag tror att många av metodens tekniska fallgropar, med tanke på den senaste debatten om dess skadeverkningar, skulle kunna avhjälpas genom att vi fokuserar mer på vår egen neurotiska användning av tekniken.

Vad skulle en sådan fenomenologi beskriva och innehålla? Vill du spekulera lite?
Hur upplevs det när terapiprocessen tiltar över till överföringen? Hur upplevs det när den omedvetna alliansen är hög jämfört med när den är låg? Hur upplevs det när den medvetna alliansen är stadigt etablerad jämfört med när den inte är det? Hur upplevs ökningar i komplexa överföringskänslor innan de bryter igenom? Hur upplevs skiftet från före till efter instant repression? Hur är upplevelsen av att få en projektion deaktiverad? Hur känns det att få sitt centrala motstånd utmanat på rätt sätt, och hur känns det när terapeuten bara hamrar på utan att ha klargjort vad syftet med det är? 

Jag tror att den här typen av beskrivningar skulle göra det lättare, särskilt för nya terapeuter som ännu inte har utvecklat sin egen erfarenhet av motöverföring, att förstå patienten. För att kunna finjustera sin metod utifrån den erfarenhet som patienten uttrycker, utöver att använda sig av de mer gröva objektiva tecknen såsom suckar.

Vad kämpar du med att lära dig som ISTDP-terapeut just nu? 
Jag arbetar mest med att stabilisera min empatiska inlevelseförmåga. En sida av detta är att jag försöker hitta ett sätt att sluta använda ISTDP-terapeutrollen som ett försvar mot känslomässig intimitet. En annan är att jag försöker att lära mig att ha ett grepp om metoden som varken är för hårt eller för löst.

Det här är något som jag och många av läsarna säkert känner igen sig i – att vi använder ISTDP-terapeutrollen som ett försvar. Tror du att ISTDP är extra sårbart för den här typen av problem, med tanke på det fokus som vi lägger vid det tekniska hantverket?
Ja, jag tror att vi som ISTDP-terapeuter är sårbara på minst två områden. Den ena är den höga känslomässiga intensiteten i kontakten med patienten som ligger till grund för metoden. Det andra är att vi har mycket tydliga och högkvalitativa förebilder att förhålla oss till redan från början av vårt arbete, både när det gäller tekniska instruktioner och specifika lärares arbete. På så sätt har vi mycket stora skor att fylla, och de flesta av oss som är intresserade av ISTDP är mycket ambitiösa för vår egen och våra patienters räkning. 

Om vi tänker efter är det nästan en traumatisk situation att försätta sig i, särskilt som nyutbildad psykolog. När vi sitter där och måste navigera på en hög nivå av känslomässig intensitet som vi inte förstår helt och hållet, på en mycket hög teknisk nivå som vi inte behärskar helt och hållet, men som vi måste övertyga oss själva om att vi behärskar. Och som vi tror att vi måste övertyga patienten och våra kollegor om att vi behärskar. Då är scenen liksom bäddad för att vi ska få en terapeuteneuros, där vår terapeutpersonlighet inte underlättar vår personliga utveckling i arbetet, utan står i vägen för den eftersom den inte avspeglar oss. 

ISTDP förutsätter att vi kan gå hela vägen från inquiry till unlocking. Vi måste ha styr på systemet som helhet innan det verkligen fungerar, och på så sätt blir inlärningen av metoden som att lägga ett pussel där motivet hela tiden förändras. På så sätt är det logiskt vi kanske mer än terapeuter från andra terapiinriktningar får en slags prematur terapeutidentitet som en del av vår utveckling.


Om du uppskattade den här intervjun med Mikkel Reher-Langberg så kanske du är nyfiken på våra andra intervjuer:

Mikkel Reher-Langberg: “We all use the same words as Davanloo, but the music is different”

In this interview with Mikkel Reher-Langberg, we discuss his upcoming book on Davanloo and ISTDP and much more. Mikkel is a psychologist and president of the Danish ISTDP Society. In 2018, he published a book on Freud’s concept of the self, Faces of the Freudian ‘I’: The Structure of the Ego in Psychoanalysis. Together with some colleagues, he has been running the private clinic Emotion center in Copenhagen for a few years now.

Dansk version. Svensk version.

What’s on your mind right now?
As you know, I work full-time at a private ISTDP clinic in Copenhagen, and I’m still very busy learning how to work with ISTDP. Alongside the clinical work, I am in the process of writing the book we are going to talk about here. In addition, I have been busy with meditation for the past few years, which I hope to be able to do more of when the book is finished.

Porträtt Mikkel Reher-Langberg
Mikkel Reher-Langberg

You are finishing work on this two-volume book on ISTDP. From hearing you talk about it, I get the impression that you want to contribute to some kind of “back to the roots” process: back to Davanloo’s foundations. What is the background to the book?
The background is that I have been studying with John Rathauser for the past few years. He works in a style that is very close to Davanloo’s technique around 1990. I saw John’s work at the IEDTA congress in Amsterdam in 2016 and was completely sold on his style. I learned the basics of ISTDP through Jon Frederickson’s and Allan Abbass’ formats and styles, and since I started working with John I’ve tried to understand what is unique about his style. Over time, our collaboration has become closer and more of a friendship, and I think after a while John could see that I often understood and articulated his work in a way that he could not. Despite the fact that his clinical intuition is much stronger than my own.

John Rathauser portrait
John Rathauser

At one point, John suggested that we write a book together, drawing on our different strengths. That was in early 2019. I suggested we write the book as an introduction to Davanloo, which we quickly agreed on. I have mainly been concerned with the first volume of the book, which is basically an attempt at a coherent presentation of Davanloo’s theory and methodology. The second volume consists of John’s cases, for which we have written commentaries. For me personally, writing the book has been a way of integrating my understanding of John’s work through a very close reading of Davanloo.

Would you like to share some of the key findings you have made from reading Davanloo in the way you have?
It is difficult to point to individual findings. For me, returning to Davanloo has required a fundamental restructuring of what I thought I knew about ISTDP. What I have been most interested in beyond Davanloo’s conceptual apparatus has been his way of thinking about and orienting himself in his clinical work. I have tried to decode the logic of his clinical thinking by examining the contrasts between his style and later versions of ISTDP. In doing so, I may be placing too much emphasis on the differences between Davanloo and other teachers, rather than the similarities.

Having said that, I do think there is a qualitative difference between the way most of us understand ISTDP today and the way I think Davanloo understood his craft. We all use the same words as Davanloo, but the music is different, and I don’t think that’s just because Davanloo had/has a deeper clinical intuition than most of the rest of us.

One area where I think this is evident is that many people today seem to understand ISTDP as an emotion-focused or experiential therapy. For example, the Swedish ISTDP group on Facebook has a banner that says “the deeper you feel, the more you heal”. This may seem innocuous, but in practice it means that many ISTDP therapists are most interested in “getting to the feelings”, as if experiencing feelings is, in and of itself, important or relevant.

This perspective has its strengths, of course, just as other forms of therapy have their strengths, but I think it is a perspective that is qualitatively different from Davanloo’s – at least the perspective he held until the late 1990s. The emotions he is (or was) interested in are specifically those associated with his work on the resistance, and they are not an end in themselves – they are a means of gaining a deeper understanding of and working through the patient’s unconscious. In this way, Davanloo uses resistance in a different way than most ISTDP therapists do today, which has implications for what the work looks like in practice.

You almost say that this is talking about a new form of therapy developed post Davanloo. Can you go into more detail about what is so different, perhaps with a clinical example? How is Davanloo/Rathauser-ISTDP different from Frederickson/Abbass-ISTDP? 
I do think it’s worth considering if it’s the same form of therapy! One specific clinical difference is that many people today have learned to “press through” resistance, choosing what might be called the “path of least resistance”, whereas Davanloo follows the “path of greatest resistance”. But I think the biggest difference is in the deeper conception of the work itself – not in individual technical interventions.

If you change the spirit of a method, is it still the same? It’s hard to give a clinical example, but perhaps we can compare it to yoga. If you use the different postures for the purpose of gymnastics or strength training, are they still “the same” as when used for the purpose of spiritual practice? If you understand ISTDP as a form of exposure to emotional intimacy, where the therapeutic potential lies in facilitating the breakthrough of emotions or corrective emotional experiences with the therapist, as many do, it easily overshadows the part of the work that is about creating insight into the unconscious. We could say that one does not exclude the other, but in practice I still think that many people use the method as if exposure to their own feelings were an end in itself. 

There’s a lot of good in that – but I think it’s important to be conscious of where this leads the therapy model as a whole.

You have previously written a book on Freud’s concept of self and taken some interest in philosophy – things that fit well into the psychoanalytic literary tradition. Should we who do ISTDP be more interested in reading original classical texts? Or is it a positive thing that the focus of the ISTDP community is more on craft and watching video recordings?
Both yes and no – I’m not sure that the psychoanalytic literature is relevant to our technique, just as you don’t learn to run a hundred-meter race from a marathon runner. We don’t use the transference neurosis, so it’s hard to compare the methods other than in principle. If there is to be an exchange, I think there is something beautiful, serious and generous about our approach to ISTDP training that I think the psychoanalytic community could benefit from.

One area where I think it would be fruitful to include more psychoanalytic theory is in understanding the psychic levels which run deeper than manifest emotional life. The psychoanalytic tradition has a language for the drives and intersubjective dynamics that give rise to manifest emotions which we do not have at all in the ISTDP community. Incorporating this will have an impact on how we understand the therapeutic process as a whole. I think one of the next things that will be needed in the ISTDP community is for more people to engage in the conceptualization of phase 6/7 of the central dynamic sequence – i.e. working through – which unfortunately we do not have a coherent understanding of at the moment. This phase is closely related to the way in which we view the very purpose of the therapeutic process, as well as the therapeutic mechanisms behind what we are doing. Here I think it is necessary to return to the psychoanalytic tradition for help and to broaden our perspectives.

What do you see as the major challenges for the ISTDP community in the coming years?
I think there are many who started learning ISTDP around the same time when Co-Creating Change came out, who have spent a lot of time on technique, and who are now at a point in their development as therapists where they need something to help them gain a deeper understanding of the therapeutic process itself. I think we need literature and training that focuses on the wider processes so that we can begin to use technique in a more flexible way.

In addition to this, I personally have two things that I would like to see in the near future. First, that someone would develop a phenomenology of ISTDP – a description of the structures of the patient’s and therapist’s inner experiences of the process. Second, that someone wrote in more detail about the therapist’s use of defenses in the process and what they usually look like. Unfortunately, I think that as a community we tend to place more emphasis on the patient’s defenses than on our own, and I think that many of the technical pitfalls of the method, given the recent debate about its harmful effects, could be remedied by focusing more on our own neurotic use of the technique.

What would such a phenomenology describe and contain? Care to speculate?
How does it feel when the therapy process tilts to the transference? How is it experienced when the unconscious therapeutic alliance is high versus when it is low? How is it experienced when the conscious therapeutic alliance is firmly established versus when it is not? How are increases in complex transference feelings experienced before they break through? How is the shift from before to after instant repression experienced? What is the experience of having a projection deactivated? How does it feel to have one’s central resistance properly challenged, and how does it feel when the therapist just hammers away without having made clear what the purpose of it is?

I think this type of descriptions would make it easier, especially for new therapists who have not yet developed their own experience with countertransference, to understand the patient. To be able to fine tune their approach based on the experience expressed by the patient, in addition to using the more crude objective signs such as sighs.

What are you struggling to learn as an ISTDP therapist right now?
I’m mostly working on stabilizing my empathic listening skills. One side of this is that I am trying to find a way to stop using the ISTDP therapist role as a defense against emotional closeness. Another is that I am trying to learn how to have a grip on the method that is neither too tight nor too loose.

This is something that I and many of the readers will recognize – that we use the ISTDP therapist role as a defense. Do you think ISTDP is particularly vulnerable to this kind of problem, given the focus we place on the technical aspects of the work?
Yes, I think that as ISTDP therapists we are vulnerable in at least two areas. One is the high emotional intensity of the contact with the patient that is implicit in the method. The second one is that we have very clear and high quality role models to rely on from the very beginning of our work, both in terms of technical instructions and the work of specific teachers. In this way, we have very big shoes to fill, and most of us who are interested in ISTDP are very ambitious for our own sake and for the sake of our patients.

If we think about it, it’s almost a traumatic situation to put yourself in, especially as a newly trained psychologist. When we sit there and have to navigate a high level of emotional intensity that we don’t fully understand, a very high technical level that we don’t fully master, but that we have to convince ourselves that we have mastered. And which we believe we must convince the patient and our colleagues that we have mastered – then the stage is set for us to have a therapist neurosis, where our therapist personality does not facilitate our personal development, but stands in the way of it because it does not reflect us. 

ISTDP assumes that we can go all the way from inquiry to unlocking. We need to have control of the system as a whole before it really works, and so learning the method becomes like putting together a jigsaw puzzle where the motive is constantly changing. In this way, it makes sense that perhaps more than therapists from other therapy disciplines, we acquire a kind of premature therapist identity as part of our development.


If you enjoyed this interview with Mikkel Reher-Langberg, you might be curious about our other interviews:

Mikkel Reher-Langberg: “Vi bruger alle de samme ord som Davanloo, men musikken er en anden”

I dette interview med Mikkel Reher-Langberg taler vi om hans kommende bog om Davanloo og ISTDP og meget mere. Mikkel er psykolog og formand for Dansk selskab for ISTDP. I 2018 udgav han en bog om Freuds begreb om selvet, Faces of the Freudian ‘I’: The Structure of the Ego in Psychoanalysis. Sammen med nogle kolleger har han i nogle år drevet den private klinik Emotion center i København.

Svensk version av texten. Engelsk version.

Hvad optager dig lige nu?
Rent professionelt arbejder jeg, som du ved, fuld tid i en privat ISTDP-klinik i København, og er fortsat meget optaget af at lære at arbejde med metoden. Ved siden af det, er jeg ved at skrive den bog vi skal tale om her. Ud over det, har jeg de sidste par år været optaget af meditation, som jeg håber at kunne dedikere mig mere til, når bogen er færdig.

Porträtt Mikkel Reher-Langberg
Mikkel Reher-Langberg

Du er ved at afslutte arbejdet på en bog i to bind om ISTDP. Da jeg hørte dig tale om bogen, fik jeg det indtryk, at du ønsker at bidrage til en slags “tilbage til rødderne”-proces: tilbage til Davanloos fundament. Hvad er baggrunden for bogen?
Baggrunden for bogen er, for mit vedkommende, at jeg de sidste år har været i træning hos John Rathauser, som arbejder i en stil, der ligger meget tæt op ad Davanloos arbejde omkring 90’erne. Jeg så Johns arbejde på IEDTA-kongressen i Amsterdam i 2016, og var fuldstændigt solgt til hans stil. Oprindeligt har jeg lært ISTDP efter Fredericksons og Abbass’ formater, og siden jeg begyndte at arbejde med John har jeg arbejdet på at forstå, hvad det særlige ved Johns tilgang var. Med tiden blev Johns og mit samarbejde tættere og mere venskabeligt, og jeg tror, John kunne se, at jeg ofte kunne forstå og sætte ord på hans arbejde på måder, han ikke selv kunne, selv om hans kliniske intuition er meget stærkere end min egen.

John Rathauser

På et tidspunkt foreslog John, at vi skulle skrive en bog sammen, og gøre brug af vores forskellige styrker – det var tilbage i begyndelsen af 2019. Jeg foreslog at vi skulle skrive den som en introduktion til Davanloo, hvilket vi hurtigt blev enige om. Jeg har primært beskæftiget mig med bogens første bind, som er et forsøg på at fremlægge en sammenhængende præsentation af Davanloos teori og metode. Andet bind består af Johns cases, som vi har skrevet kommentarer til. Kort sagt har det at skrive bogen altså for mig personligt været en måde at integrere min forståelse af Johns arbejde, gennem en meget tæt læsning af Davanloo.

Vil du dele nogle af de vigtigste konklusioner, du har gjort, mens du har læst Davanloo på den måde, du har gjort det i de sidste par år?
Det er svært at sætte finger på enkelte fund – for mig har det at vende tilbage til Davanloo krævet en grundlæggende omstrukturering af, hvad jeg troede, jeg vidste om ISTDP. Det jeg har været mest optaget af, ud over Davanloos begrebsapparat, har været Davanloos måde at orientere sig i det kliniske arbejde, og at forsøge at se det særlige i hans arbejde i kontrast til nyere versioner af ISTDP. På den måde kan jeg komme til at lægge for meget vægt på forskellene mellem Davanloo og andre lærere, frem for lighederne.

Når det er sagt, så oplever jeg, der er en kvalitativ forskel på den måde, de fleste af os forstår ISTDP i dag, og den måde jeg synes, Davanloo orienterer sig i arbejdet. Vi bruger allesammen de samme ord som Davanloo, men musikken er anderledes, og jeg tror ikke kun det handler om at Davanloo havde/har en dybere klinisk intuition end de fleste af os har. Et område, hvor jeg synes, det viser sig, er at mange i dag lader til at forstå ISTDP som en følelsesfokuseret eller oplevelsesorienteret terapiform. Jeres svenske ISTDP-gruppe på facebook har f.eks. et banner med teksten “the deeper you feel, the more you heal”. Det kan virke uskyldigt, men i praksis betyder det, at mange ISTDP-terapeuter mest af alt interesserer sig for at “komme ind til følelserne”, som om det at føle følelser i sig selv var vigtigt eller relevant.

Den orientering har sine styrker, ligesom andre terapiformer også har sine styrker, men jeg synes, den er kvalitativt forskellig fra ånden i Davanloos arbejde – i hvert fald indtil slutningen af 90’erne. De følelser, han interesserer sig for, er specifikt dem, der knytter sig til arbejdet med modstanden, og de er ikke et mål i sig selv – de er et middel til at få en dybere forståelse for og gennemarbejde patientens ubevidste. På den måde bruger Davanloo også modstanden på en anden måde, end de fleste ISTDP-terapeuter gør det i dag, og det har konsekvenser for, hvordan arbejdet ser ud i praksis.

Du siger, at det næsten er som at tale om en ny form for terapi, der er udviklet “post Davanloo”. Kan du gå mere i detaljer om, hvad der er så anderledes, måske med et klinisk eksempel? Hvordan adskiller Davanloo/Rathauser-ISTDP sig fra Frederickson/Abbass-ISTDP?
Jeg synes i hvert fald, det er en overvejelse værd, om det er den samme terapiform! En konkret klinisk forskel er at mange i dag har lært at “presse igennem” modstanden, og tage hvad man kan kalde “the path of least resistance”, mens Davanloo følger “the path of maximum resistance”. Men egentlig synes jeg, den største forskel ligger mere i forståelsen af terapien – ikke i de tekniske interventioner. Hvis man ændrer ånden i en metode, er det så stadig den samme? Det er svært at give et klinisk eksempel på, men vi kan måske sammenligne det med yoga. Hvis man bruger de forskellige positioner som gymnastik eller styrketræning, er det så stadig “det samme” som yoga brugt som spirituel praksis?

Hvis man forstår ISTDP som en form for eksponering for følelsesmæssig nærhed, hvor det terapeutiske potentiale består i at facilitere gennembrud af følelser, eller korrektive emotionelle oplevelser med terapeuten, som mange gør, så overskygger det nemt den del af arbejdet, der handler om at skabe indsigt i det ubevidste. Vi kan sige, at det ene ikke udelukker det andet, men i praksis synes jeg alligevel, mange bruger metoden, som om eksponering for egne følelser udgjorde et mål i sig selv.

Det er der meget godt i – men jeg synes, det er vigtigt at være bevidst om, hvor det bringer terapiformen som helhed hen.

Du har tidligere skrevet en bog om Freuds selvbegreb og har interesseret dig lidt for filosofi – ting, der passer godt ind i den psykoanalytiske litterære tradition. Bør vi, der arbejder med ISTDP, være mere interesserede i at læse klassiske originaltekster? Eller er det en positiv ting, at ISTDP-fællesskabet fokuserer mere på håndværket og på at se videooptagelser?
Både ja og nej – jeg er ikke sikker på, hvordan den psykoanalytiske litteratur er relevant for vores metode, ligesom man ikke lærer 100-meter af en maratonløber. Vi bruger ikke overføringsneurosen, så det er svært at sammenligne metoderne andet end rent principielt. Hvis der skal være en udveksling synes jeg, der er noget smukt, seriøst og generøst i den måde vi i ISTDP-miljøet træner metode på, som det psykoanalytiske miljø måske kunne have gavn af.

Men et område, hvor jeg synes, det ville være oplagt at inddrage psykoanalytisk teori, er i forståelsen af de psykiske niveauer, der er dybere end følelseslivet. Den psykoanalytiske tradition har et sprog for de drifter og intersubjektive dynamikker, de manifeste følelser udspringer af, som vi slet ikke har i ISTDP-miljøet. At inkorporere dét vil være relevant for måden, vi forstår den terapeutiske proces som helhed. Jeg tror, noget af det næste, der kommer til at være nødvendigt i ISTDP-miljøet er, at flere beskæftiger sig med at begrebsliggøre fase 6-7 i den centrale dynamiske sekvens, som vi desværre ikke har en sammenhængende forståelse for på nuværende tidspunkt, men som hænger nært sammen med måden, vi anskuer selve meningen med og forandringsmekanismerne i den terapeutiske proces. Dér tror jeg, det kommer til at være nødvendigt at vende tilbage til den psykoanalytiske tradition efter hjælp.

Hvad ser du som de største udfordringer for ISTDP-fællesskabet i de kommende år?
Jeg tror, der er mange, der begyndte at lære ISTDP omkring det tidspunkt hvor Co-Creating Change udkom, som har brugt meget tid på teknik, og nu er nået til et punkt i deres udvikling som terapeuter, hvor de har brug noget, der kan hjælpe dem med at udvikle en dybere forståelse for selve den terapeutiske proces. Jeg synes, vi mangler litteratur og undervisning der fokuserer på de store bevægelser og meninger med arbejdet, så vi kan begynde at bruge teknikken mere smidigt.

Ud over det, har jeg personligt to ting, jeg gerne så i den nærmeste fremtid. For det første, at nogen ville udvikle en fænomenologi for metoden – en beskrivelse af strukturerne i patientens og terapeutens indre oplevelser af processen. For det andet, at nogen skrev mere udførligt om terapeutens brug af forsvar i processen, og hvordan de typisk ser ud. Jeg synes desværre, vi som miljø kan have en tendens til at tilskrive patientens forsvar større betydning for processen end vores egne, og jeg tror at mange af de tekniske faldgruber metoden har, jf. den debat der på det seneste har været omkring dens skadevirkninger, kunne afhjælpes ved, at vi fokuserede mere på vores egne neurotiske anvendelser af teknikken.

Hvad ville en sådan fænomenologi beskrive og indeholde? Har du lyst til at spekulere?
Hvordan opleves det når processen tilter over i overføringen? Hvordan opleves det når UTA er høj versus når den er lav? Hvordan opleves det når CTA er etableret versus når den ikke er? Hvordan opleves rise i CTF i overføringen, før de bryder igennem? Hvordan opleves skiftet fra før til efter instant repression? Hvordan føles det at få deaktiveret en projektion? Hvordan skal det føles at få sin major resistance udfordret korrekt, og hvordan føles det når terapeuten bare hamrer løs uden at have gjort det klart hvad meningen med det er? Jeg tror, det kunne være nemmere, særligt for nye terapeuter der endnu ikke har udviklet sin egen erfaring i modoverføringen, at finjustere vores metode efter den oplevelse, patienten giver udtryk for, som supplement til de grove objektive tegn som f.eks. suk.

Hvad kæmper du for at lære som ISTDP-terapeut lige nu?
Jeg arbejder mest med at stabilisere min indføling. En side af det er, at jeg er ved at finde ud af at aflære de måder, jeg bruger ISTDP-terapeut-rollen som et forsvar mod følelsesmæssig nærhed, og at lære at have et greb om metoden, der hverken er for fast eller for løst.

Det er noget, som jeg og mange af læserne vil genkende – at vi bruger ISTDP-rollen som et forsvar. Tror du, at ISTDP er særligt sårbar over for den slags problemer, da vi lægger vægt på teknisk håndværk?
Ja, jeg tror, vi som ISTDP-terapeuter er udsatte på i hvert fald to områder. Det ene er den høje følelsesmæssige intensitet i kontakten med patienten, der ligger til metoden. Det andet handler om, at vi har meget klare forbilleder af meget høj kvalitet at forholde os til lige fra starten af vores arbejde, både i form af tekniske anvisninger og konkrete læreres arbejde. Vi har på den måde meget store sko at fylde ud, og de fleste af os, der interesserer os for ISTDP er meget ambitiøse på vores egne og vores patienters vegne. Hvis vi tænker over det, så er det nærmest en traumatisk situation at sætte sig selv i, især som nyuddannet psykolog. Når vi sidder dér og skal navigere i en høj grad af følelsesmæssig intensitet, som vi ikke helt forstår, på et meget højt teknisk niveau, som vi ikke helt mestrer, men skal overbevise os selv om at vi mestrer, og tror vi skal overbevise patienten og vores kolleger om at vi mestrer, så er grunden ligesom lagt for at få sig en terapeut-neurose, hvor vores terapeut-personlighed ikke faciliterer vores personlige udvikling i arbejdet, men står i vejen for den, fordi den ikke afspejler os. Metoden kræver, at vi kan gå hele vejen fra inquiry til unlocking. Vi skal have styr på hele systemet, før det rigtig virker, og på den måde bliver det at lære metoden som at lægge et puslespil, hvor motivet hele tiden ændrer sig. På den måde er det oplagt, at vi måske mere end terapeuter fra andre retninger, andre tilegner os en form for præmatur terapeut-identitet som en bærende søjle for vores udvikling.


Hvis du nød dette interview med Mikkel Reher-Langberg, vil du måske også være interesseret i vores andre interviews:

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: