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Maury Joseph: “How much does our theory shape the patient’s experience?”

Maury Joseph is a licensed clinical psychologist and ISTDP clinician based in Pennsylvania. Before relocating his practice, he served as the faculty chair of the ISTDP program at the esteemed Washington School of Psychiatry. In recent years, Maury has been at the helm of two fascinating seminars, one focused on psychoanalytic listening and the other on interpersonal/relational psychoanalysis. In this interview, we explore the concept of a “relational turn” in ISTDP and what it could mean for the field. Please note that this is a long read.

Thomas: What are you excited about right now?

Maury: I am very excited about this chance you’ve given me to share some ideas that 11 years of study of ISTDP and psychoanalysis have impregnated my mind with. I haven’t put pen to paper on any of the ideas I’ve been working over in the past few years regarding a “relational turn in ISTDP”, so you’ve given me a great challenge and opportunity here. That said, I am also quite nervous about it.

Relational ideas are inherently critical, highlighting and interrogating our biases and preconceptions. If I look at the history of psychoanalysis as a reference, those who bring forth questions that challenge emotionally invested, mainstream ideas tend not to make many friends in the process.

So this is a challenging thing for me—on the one hand loving ISTDP, wishing to conserve and develop Davanloo’s contribution, loving my friends and teachers in this community, and, fundamentally, as a person, wanting more than anything to be liked; and on the other hand, having ideas that might press against and challenge what I conceive of as unexamined group-level assumptions, a practice that has not been known to generate only fond feelings. So I am excited to share these ideas, but also in prayer regarding their reception.

Relational psychoanalysis

For the past years, you’ve been leading a reading group focusing on relational psychoanalysis. For the reader who is not familiar with this branch of psychoanalysis, what are the central principles of relational psychoanalysis?

Relational psychoanalysis is a big tent with a long history, but I’ll summarize what stands out as important to me and what I think might be useful to ISTDP readers. It will inevitably be a biased sample! I recommend some study of authors within the interpersonal/relational tradition to all your readers so they can form their own impressions and see how they compare to mine. Anyone looking for an introductory syllabus, or who might like to hop into one of my reading groups, is welcome to contact me.

For me, relationality is about recognizing and understanding how the therapist’s subjectivity, their history, unconscious biases, preconceptions, theories, neuroses etc., influence the therapeutic process; how the therapist’s mind is in concert with the patient’s mind in shaping the therapy, both the new, maturational experiences and the repetitive, stagnating ones. This is in contrast to other perspectives that see the therapist as more like an objective observer of, and non-participant in intrapsychically-mediated processes unfolding spontaneously and organically from the within patient, unimpacted by the therapist’s unique person.

Relational thinkers give special attention to unconscious enactment—how the patient’s and therapist’s minds conspire to unconsciously live out interpersonal dynamics that turn out to have meaning to both of them. They suggest this is an inevitable, necessary, and ultimately helpful aspect of therapy, part of the therapeutic action.

A relationalist would not aspire to some kind of perfect technique, but would instead value and strive for reflection and conversation about the imperfect human mess that is happening, and for fastidious observation of their participation in it. For this reason, therapeutic success in a relational conception will usually require maturation and growth for both participants; both will become more conscious of their unconscious needs and patterns. This is in contrast to the notion of the therapist as ever-sane, mature, thoroughly analyzed, and able to see the patient’s gambits for interpersonal reenatctment without accidentally (unconsciously) falling into them.

Relational theory is a field theory, in which every clinical event has conscious and, more importantly, unconscious inputs from each participant, such that we are challenged to think about the unconscious co-creation of clinical events like “resistance” or “projection”. We ask questions like, “In what ways is this therapist’s technique unconsciously contributing to the very resistance they’re seeking to reduce?” “Is it possible that the therapist’s approach to reducing this projection is unwittingly reinforcing it?” This is in contrast to an approach that see’s all the pathology and destructiveness in the relationship as coming from the patient’s neurosis, and all the therapist’s behavior as perfectly sound.

Relational thinking also challenges notions of objectivity in the therapist, suggesting that our biases and unconscious blindspots, in addition to the interpersonal pressures we encounter in the relationship, are so pervasive that we ought to approach any of our conclusions with skepticism, bearing in mind the multiple factors that shape them, and keep an open mind to alternative interpretations. This is in contrast to an approach that grants objectivity to the therapist, a capacity to “see things as they are”, without bias.

Following that, there is also a critique of our metapsychologies, our theories about the structures and constituents of the mind. Whereas a dogmatic Freudian might look at certain of Freud’s conclusions as ultimate Truths, a relationalist might look at them as plausible interpretations of data, plausible narratives constructed about the lived interpersonal experiences of one time- and culture-bound man, but not necessarily as universal, ultimate truths.

A relationalist might interrogate theoretical conclusions by thinking about the history, biases and preconceptions, and cultural surround of the theorist, and explore how the techniques he used could unintentionally shape his patient’s responses in a particular way, biasing the range of metapsychological conclusions he could reach.

That is less than the tip of the iceberg, but perhaps good enough for our purposes.

A relational critique of Istdp

What do you think the relational school can offer ISTDP?

One very difficult thing here is the issue that ISTDP is not a monolith, and that I have a deep wish not to let this devolve into a “straw dog” type conversation. Depending on who you’ve trained with, how long you’ve trained, what your training was before you came to ISTDP (including the training of being a child in your particular family), all ISTDP therapists will have different degrees of development of what you could call a “relational sensibility”.

So, I’ll say this: I think that any therapy benefits from increased willingness on the part of the therapist to interrogate their own assumptions. In fact, Jon Frederickson recently related to me a finding that metacognitive capacity in the therapist, our ability to think critically about our thinking, is a better predictor of effectiveness than their intelligence. I think relational ideas provide tools for self-critical thinking that, to me, enhance our integrity and trustworthiness as therapists.

Here are a few questions that relational thinkers might offer us if we wished to do some kind of relational inquiry into our own work as ISTDP therapists, teachers and supervisors:

Where do we locate pathology in the therapeutic interaction?

Do we tend to see resistance as mainly a product of the patient’s pathology, history, trauma, or do we also take into consideration the ways our presence and technique might evoke, contribute to, or reinforce this thing we label “resistance”?

In a “one-person”, pre-relational psychology, we tend to locate the pathology in the ill, distorting patient, whereas the therapist is seen as sane and perceptive, unobstrusively facilitating the emergence of the patient’s inner life.

The relational perspective might be nicely summarized with some quotes by Heinrich Racker: “We are still babies and neurotics even when we are adults and analysts,” or, “The truth is that [the therapy] is an interaction between two personalities, in both of which the ego is under pressure from the id, the superego, and the external world; each personality has its internal and external dependencies, anxieties, and pathological defenses; each is also a child with his internal parents…”

“We are still babies and neurotics even when we are adults and analysts”
Heinrich Racker

Do we, in resonance with Racker, consider our neurotic contributions to therapy stalemates? Is there room in our theory for the patient’s sanity and perceptiveness, and for the possibility that the phenomena we are coding as “resistance” might plausibly represent the patient’s efforts at self-protection from some unconscious countertransference on our part?

To what extent can we use the concept of “transference” as a defensive denial of our own contribution to the patient’s perceptions of us? Can we consider that some description of us that we wish to code as “projection” might also represent a plausible description of our behavior, but one that we’ve been unconscious of?

I think, in general, we come out of ISTDP training with a highly advanced sensitivity to the ways patients show us their history through resistance and defenses. A relational critique would ask us to expand our theory and clinical thinking to include the ways the therapist’s history also unconsciously emerges in the therapy, and even to consider this a normal part of the therapy process, which can be turned to constructive use if we do not deny its presence. We might also ask how many of our misalliances are the result of such denial?

What is our theory of what triggers transference?

My understanding is that the conventional belief among early analysts was that transference was a “spontaneous”, intrapsychically-driven response to the “ideal conditions” provided by the analysis: anonymity, neutrality, frame, supine position, etc. At least that’s the straw dog retelling of it.

Later analysts, notably Ida Macalpine and then, later, Leo Stone instead suggested that the analytic situation had very specific contours, very salient valances that would stimulate very particular memory networks. They felt that conventional analytic technique “pulled” for specific rather than nonspecific developmental schemata to be transferred into the relationship. Stone felt, for instance, that because of the inherent separateness built into the situation, separation-related conflicts and memories would be the most likely to emerge in treatment. Interesting theory.

I think that for the most part, in the ISTDP community, our theory of what triggers transference is that it is our “concern”, our “relentless efforts to attach”, our “offering of a secure relationahip”, and the way our interventions, which are both irritating and loving, “trigger mixed feelings that link to past attachments”.

Relational theorists would challenge us to think more deeply and in specific about the forms our “efforts to attach” take, so we can more consciously consider what kinds of patient responses we might prime. I think it would be useful to examine how our particular interventions might “pull” for particular types of responses from patients, prime particular developmental schema or associative and memory networks, resulting in the emergence of particular transferences from particular developmental levels or having to do with particular developmental conflicts.

Macalpine, Stone, and many others called into question the idea that must simply create the “ideal conditions” for the spontaneous unfolding of the patient’s repressed mental life, and they challenge us to carefully describe the unique conditions that we create, and to consider how those particular conditions might evoke selective rather than general aspects of the patient.

Along those lines would be questions about our metapsychology.

Insofar as any technique will prime particular associative networks, evoke particular interpersonal schema, etc., then the findings of our work are always somewhat biased or shaped by our approach to the patient. From those findings, we make extrapolations about the nature and constituents of the mind, our metapsychological claims.

In the ISTDP world there does seem to be strong consensus about the metapsychology of the unconscious, the “concentric circles” (see below), the cascade of feelings of warm bond, trauma to the bond, pain of trauma, reactive rage, guilt about the rage, and defenses against that. At conferences and presentations, our technique seems to confirm this by turning up this same pattern again and again, and I think we tend to assume that what we find through our technique represents a kind of bedrock of human psychology.

A relational critique would invite us to ask whether and to what extent our sense of the bedrock of human psychology could be an artifact of the way we approach the human subject, and whether a different approach might point to a different underlying structure of the mind, or of neurosis? We’d be invited to wonder whether our approach selectively evokes some reactions and not others, and whether this is shaping our conclusions about the nature and constituents of the mind in a biased way.

The concentric circles. Figure from Davanloo, H. (1995d). Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient – Part II. The Course of the Trial Therapy After Partial Unlocking. *International Journal of Short-Term Psychotherapy, vol. 10.*

Finally, and very much following on #3, a relational critique might ask us questions about our relationship to our theory.

To what extent does our theory—our ideas of how the mind works, what makes symptoms, what a mind needs to experience in order to have less symptoms, etc.—guide our relationship to the patient?

In what ways do our theory and preconceptions lead us to pursue some lines of inquiry and not others; to make certain inferences about the deeper meaning of what they’re saying and not others? How much does our theory shape the patient’s experience in their therapy? How much and in what ways should our knowledge and preconceptions drive their therapy process? Do we guard adequately against situations of submission and compliance, in which the patient conforms to the agenda that our theory presents to them?

ISTDP is, in my opinion, unique among the dynamic therapies in that it has the best-developed system for monitoring unconscious signals from the patient and detecting error-correcting feedback; ISTDP-trained therapists are, in my opinion, usually uniquely capable of staying close to the patient’s experience, letting the patient’s productions lead, learning from the patient as they go.

However, ISTDP also has – perhaps uniquely among the dynamic therapies – a highly schematized procedure with an avowed hierarchy of optimal outcomes. This creates a kind of identity conflict for the therapist: I am uniquely well-trained to follow the patient, but I also am uniquely filled up with ideas about where the patient ought to go.

So perhaps there is a unique need for us to examine our relationship to our theory, and to pay careful attention to the vicissitudes that occur in that relationship during sessions. This would be very much in the spirit of relational inquiry.

To me, the perspective that the therapeutic reality is co-created by the analytic dyad is an attractive, sympathetic one. But there’s been quite a lot of critique that this perspective leads to relativism, and that relational psychoanalysis represents a postmodern dilution of psychoanalysis. One of the strengths of ISTDP is its assertive use of “concrete reality” when encouraging the patient to face reality and turn against defenses. Do you think a relational turn in ISTDP would risk losing some of this strength?

I think it is overreliance and inflexibility around a particular perspective, not the particular perspective itself, that can take away our strength. I can sin equally against the patient in the name of knowing or of not knowing reality.

Some therapists are more vulnerable to anxiety about knowing—do I dare have an opinion? Authority? They will characteristically have trouble asserting themselves, setting boundaries, making confrontations, and this, of course, will threaten alliances and weaken their work.

Others are more vulnerable to anxiety about not knowing, and will tend to defensively superimpose clarity on experiences that are probably still open to multiple interpretations. Perhaps they will tend to relate to the patient dogmatically, ritualistically. Therapy here will be weakened because the we will not be able to perceive and cope with the full complexity of the encounter, and patients will feel stuffed into a tiny preconception, or stretched on a bed of Procrustes.

I think what a real relational turn would ask is not a radical relativism, which has indeed been much critiqued, but instead a disciplined attention to our relationship to knowing, an intentional inquiry into how we experience vicissitudes in knowing during the clinical encounter, and an effort to make meaning out of that.

For example, I feel very sure of my perspective on reality right now—what does that mean? Could that be an artifact of forces in this relationship? Is that a position that I’m uniquely attracted to due to my own anxieties, or one that the patient uniquely longs for me to embody because of hers? Or, alternatively, Why am I so anxious about confronting this patient right now? Am I allowed to share my perspective on reality in this relationship? What about in other relationships? Does my hesitance have resonance with dynamics from the patient’s other relationships or early life? Mine?

A subjective sense of knowing or not knowing “concrete reality” can have a wide range of rich meanings, and I think attention to these meanings can only serve to strengthen our work. Without this analysis we can devolve into pseudo-omniscience, believing we know reality because we feel like we know reality, which would ultimately weaken us.

practicing ISTDP

In what ways has your own practice changed as a consequence of diving deeper into relational thought?

I’d say I listen longer before I intervene and intervene more cautiously, and importantly, I have begun to take very seriously the observation of my own participation. I pay a great deal of attention to the pressures and anxieties I feel in the sessions and try to use those feelings to make sense of what’s happening, wondering what those feelings say about the patient, about me, about possible unconscious determinants of our interaction.

I try to listen to the words that are coming to my mind or out of my own mouth, and I try to think about the ways my thoughts and interventions might reflect or represent some heretofore unconscious (now becoming conscious) participation in an enacted relationship paradigm.

I’ve also become quite a bit more forgiving of my humanness. It used to be that when I’d have some kind of enactment or misalliance, I’d run to supervision and hit the books looking for a way to perfect my technique so that I wouldn’t be in that embarrassingly normal situation ever again! I think that now I try to do my best with what does happen, learn from it, and try to make meaning out of it, rather than push myself or the patient to embody some image I have of what “should”happen.

I am striving to have fidelity to the patient’s unconscious signaling system more than anything else, even when that requires that I abandon any wish for fidelity to a particular technique or metapsychology.

What are you struggling to learn as a therapist at this moment?

I’ll take your question in a slightly different direction to what I’m struggling with as a teacher. One question I’m wrestling with a lot is how to teach ISTDP in a way that evades, to whatever degree possible, dogmatism, ritualism, and idealization. Some amount of all of this is inevitable because it depends in part on the psychology of the trainee. However, I am trying to figure out how I can teach in a way that ensures I am not feeding that tendency or am actively countering it. I’d be happy to go into more detail about that, but that’s probably another interview.

As a therapist, the task for me right now, as always, is continuing to expand affect tolerance and continue to tolerate the shattering and death of ideals and preconceptions. They go hand in hand fortunately. I think my unconscious motivations for becoming a therapist, how I thought it would go, are more or less the opposite of how it actually has gone. I went to some Jon Frederickson presentations, saw these amazing sessions, and Jon would get a round of applause at the end, and at some level that is what I thought it would be.

The hard learning thus far for me is that therapy is actually painstaking work, with only occasional gratification and many injuries and insults along the way. This has been a difficult adjustment that has required much work. So that’s the big ever-struggle, the work on me. But I am lucky to be surrounded by family, friends, and colleagues who help me.

Where do you want to see ISTDP going in the coming years?

I don’t know where ISTDP is going, but if I could have a wish granted I would love to see us have a domain-specific journal where controversies and conflicts could be hashed out. Without an ISTDP journal most new ideas are published in formats like this, or on social media platforms, where there is no peer review, no refereed platform for scholarly debate. I think that could weaken our field over time. I think there is much room for debate and controversy left in ISTDP, and many questions that we treat as settled could benefit from some reopening and interrogation. We can’t do that without a journal and editorial board.

Another wish I’d love to have granted in the coming years would be the disappearance of the phrase, “It’s interesting,” or, “Maybe it’s therapy, but it’s not ISTDP”. I have been hearing it a whole bunch lately! To me it reflects a ritual-based conception of ISTDP, where ISTDP is about using some specific vernacular rather than what I think is, in my opinion, it’s essence—careful fidelity to the signaling system of the unconscious. I think we need an examination of exactly what is ISTDP, and if we had a journal it would be fun to hash this out.

To me, ISTDP is at least 2 things—an assessment system for determining the “position of the unconscious”, and, separately, a package of interventions. Lately I have encountered, much to my dismay, numerous people holding the opinion that if you are not using the package of interventions (pressure, challenge, and head-on-collision) in a way that at least partially uses the boiler-plate language of the founder, then what you’re doing is not ISTDP. I see it differently, and would love to have my perspective considered:

My current working definition of ISTDP is any approach that works with resistance and transference and utilizes – what I think is Davanloo’s most important discovery – a signaling system of the unconscious. I aim for a kind of “optimized” (by attention to signaling) dynamic therapy.

For my purposes at this point, ISTDP is no longer defined by what I say to the patient, even if my words are occasionally modeled on words I learned from Davanloo, nor by specific events like unlocking, even if they do occur anyway, but instead by a careful attention to the manifestations of unconscious communication via the body and speech of the patient, and by a highly focused effort to make interventions that facilitate the continued emergence of such communications.

I understand that mine is a loose definition of ISTDP, but I also think it allows me a great deal of room for creativity, a creativity that I find very necessary in working through the thorny moments of clinical practice that no book or training could have prepared me for. I worry about what kinds of creativity are choked off, and what kinds of therapeutic processes and experiences are missed, when we limit our definition of ISTDP to a particular set of words and discrete processes, as opposed to an infinite set of interventions and processes that have a shared essence.

Perhaps one final thing is that I’d love to see continued critical appraisal of Davanloo’s ideas. I think a major step in this direction is represented by Mikkel Reher-Langsborg’s recent lecture on YouTube, dismantling the notion of Davanloo as a monolithic, tracing an evolution and thinking critically about that evolution. Bravo, Mikkel!

Mikkel Reher-Langberg presenting at the Malmö Center for ISTDP in May 2022 on the theme of Davanloo’s development over time.

Like early Freudians we tend not to critique Davanloo. We take his findings as a final say. I think the style in which his articles are written has contributed to this. Only his interpretation of the events is given, and are often asserted with a certaintistic verbiage. Alternative perspectives are rarely given, and if they are given at all, are dismissed or even mocked. As an author he positions himself as beyond critique, beyond alternative explanations, and I think this has fostered some of the idealization of him. His writing style plays right into the ideal-seeking tendencies of many trainees, though it surely pushes others away.

I think there is quite a lot from Davanloo that could bear some interrogation.

Psychoanalysts have had to sort out what aspects of Freud’s ideas were sociohistorical artifacts, or products of his own unconscious biases so that they can identify and conserve those aspects that show a more timeless power and relevance. We have had none of that in ISTDP, and I think that part of the conservation of Davanloo’s genius contribution will also require a critical appraisal. Right now there is none of that in the literature, so I think we tend more towards unthinking acceptance that inhibits creativity, exploration, and new discovery.

This is a terrible irony—Davanloo gave us very powerful tools for exploration and discovery, and yet we seem to only want to confirm again and again what he already found. So, I think that is, more than anything, what I’d like to see in ISTDP in the coming years—new discoveries.

If you liked this interview with Maury Joseph, you might like some of our other interviews that we’ve published previously. For example, you might appreciate this Patricia Coughlin interview on the limitations of ISTDP, or this interview with Johannes Kieding on the vulnerabilities of ISTDP to misalliance. Or have a look at this list of the last seven interviews (in different langagues):

Johannes Kieding: “ISTDP is uniquely vulnerable to misalliances”

In September, we have the great pleasure of welcoming Johannes Kieding to the ISTDP Academy, where he’s presenting on the theme of defiance. Johannes is a LCSW in private practice in Tuscon, Arizona. He was trained by Marvin Skorman and runs a much appreciated Youtube channel where he puts out educational material for ISTDP and ISTDP-informed therapists. He’s also the administrator of a large facebook community for ISTDP therapists, “ISTDP Peer Community“. We have previously published a text by him outlining some of his main ideas. In this interview we discuss alliance-ruptures, relational ISTDP, defiance, systems of resistance, challenges to learning ISTDP and a few other things.

What do you feel inside right now?
Excited and ready for a day to see my wonderful clients and supervisees. This career is a dream come true.

You’ve worked with Marvin Skorman for many years, and last year we published one of your texts about your take-aways from working with him. Marvin is now retired. How is work without Marvin coming along? Are you noticing changes?
Indeed indeed. Initially it was a bit rough on me, but it’s also good to really find my own feet and experience my independence. Few people on this planet have influenced me like Marvin, so in a way I feel that I carry part of his signature in me, but it has molded itself into my own style. When I am with patients I am hearing more and more things come out of my mouth that I don’t know where they came from. So I seem to be finding my own way of doing things.

To me you represent a strong voice in the ISTDP community for the “real relationship” approach to ISTDP. Relational ISTDP if you will. Why do you think you came to approach ISTDP in this way?
Before I answer how I came to it, I want to define our terms. What you think of as relational may not be what I have in mind. By ‘relational’ I mean I am trying to work with, not ‘on’ the patient. This means I am not laying a trip on the patient, not engaging my schtick, not just applying a technique.

Instead I try to understand the patient on their terms, to look at things through their eyes and seek their feedback that I have understood their first person perspective. This is a big part of what dynamic exploration and inquiry is about — really getting to know the patient and the themes in their lives that relate to their chief complaints and to their strengths that I will want to capitalize on during the work.

This part of the work is about developing a shared language together, short-hand references that may be totally unique to the particular patient. Though I attend to latent content, I do not ignore the manifest content, I do not ignore what the patient is actually saying. When I offer alternative or new perspectives, I check in to see if what I am saying tracks for them, if they agree or disagree.

I try to hone in on the patient’s will, their priorities, and go out of my way to ensure that I am not pushing my own agenda on the patient. So when I ask if they want to take an honest look at their feelings, I monitor the response to make sure the patient is really behind their “yes.” I try to ensure that I have a real collaborator and continuously stress the client’s autonomy and right to choose.

To me this overall seems like standard ISTDP principles. But what do you think stands out in your approach?
Through the prism of what I think will further the patient’s goals, I may include some of my subjective responses to the patient. If I am asking the patient to be totally open, I don’t think it makes sense for me to be reticent about being self-revealing when that seems to be what the patient needs. Certainly not self-revealing for its own sake, but when the patient seems to need that.

Even if I am working vertically, if the aforementioned ingredients have been established it’s a working with, not working on, even though at that stage I am blocking every single patient response until we get the unlocking — this can certainly look like I am working on, not with. But the key is whether or not I’ve built a foundation where the patient and I are truly on the same side, pulling in the same direction, both going after the resistance.

As for the question of why I came to stress this approach to ISTDP: one reason is that when I was not working relationally, I had a lot more misalliances. I had patients walk out of my office sometimes. I had clients who had repeated unlockings but still were not getting better. So I came to the conclusion that in order for unlockings to be truly healing, they have to occur within a context of a really trusting relationship. A secure attachment, if you will.

If I am just applying techniques like a technician, I may get lucky and help the client have some unlockings, but this didn’t seem that helpful.

Think of sex: you can mechanically produce an orgasm through skilled technical maneuvering, but this kind of orgasm is quite empty. The orgasm that comes from making love, where you are truly connecting with your whole being, is far richer and more meaningful. This is the difference between unlockings that come from merely applying techniques and unlockings that come after more relationship building and more clarity for the patient.

I think the other reason is that my teacher and mentor, Marvin, was steering me in this direction based on his prior mistakes and experiences where his rigidity created less than optimal therapeutic outcomes. So I got it both from my own experiences with clients and from my mentor.

Earlier this year you did a few presentations on repairing alliance ruptures. How come you emphasize this in your work? Do you think alliance ruptures are more common in ISTDP than in other schools of therapy?
Hopefully my previous response gives you an idea of my response to this question. Based on my own experience, Marvin’s experience, and countless cases where trainees present their work to me, I do indeed believe that ISTDP is uniquely vulnerable to misalliances.

This is greatly mitigated the better we become, the more we attend to the unique themes related to the patent’s difficulties, the less invested we become in a specific outcome, and the more we emphasize the conscious alliance, which of course includes clear, non-compliant agreements around problem and task.

When I saw Davanloo’s work (especially from the 1980s and before), and when I read his transcripts, more often than not I see him being incredibly attuned to the patient. Truly meeting them where they are, then bringing the patient along with him so that they can truly see why they may want to face what they have been avoiding.

Somehow when many of us try to do something akin to Davanloo, in our eagerness to have a breakthrough or unlocking we miss this part that has to do with really meeting the patient where they are, and step-by-step bringing the patient along with us to ensure real buy-in and conscious understanding of the therapeutic task. I can’t tell you how many times I have seen trainees try to drag a patient through the central dynamic sequence, without having a real collaborator. That is what I refer to as laying a trip on the patient. It’s exhausting for the therapist and typically not very therapeutic for the patient.

I’ll never forget this one supervision session from some years ago where the trainee showed a case and where the patient was very forthcoming, collaborative and open, but because the trainee saw some tension and a moment where the patient looked away, the trainee labeled this rather undefended patient “highly resistant,” and thought it proper to begin repeated pressures to feeling. The patient was quite undefended actually.

This suggests to me that there is an element in how people are being trained where the ratio of interpretation to experience is too high and too theory forward. For an accurate psychodiagnostic picture, there needs to be sufficient pressure, but accurately targeted to the front of the system. I see people decide on a psychodiagnostic category based on far too little data.

Davanloo’s diagnostic roadmap is an interactive one — I may have a patient in front of me aimlessly rambling, but this doesn’t tell me anything in and of itself. I need to bring this to the patient’s attention and see how they respond. The patient may bounce back and readily get back on track and focus again, or they may evade the issue.

Only by carefully monitoring the patient’s responses when I identify the main barrier to progress do we have meaningful psychodiagnostic information. I see people just look at an initial presentation, or patient responses to the therapist intervening but the intervention does not address the main progress-preventing behavior, and then come to diagnostic conclusions without availing themselves of sufficient data.

Here’s another example. A trainee labels the defense of diversification and changing the topic, but because of insufficient dynamic exploration, they are not linking these defenses into the larger themes. The patient may be changing the topic because they are pulling for a supportive relationship where they just want to be heard and have a fire-place chat, and are therefore trying to get away from goal focused work. If we are too narrowly focused we just see the most pronounced aspect of the defense (changing the topic and diversifying). But if we zoom out and attend to the larger themes, we might see that the defense of changing the subject ties into a life-long pattern where the patient is constantly looking for comfort and self-soothing. ‘Self-soothing mode’ would in this case be the actual major column of defense, but we don’t see that if we are not able to zoom out and get the bigger picture, the bigger themes that the individual defenses are rooted in.

Over the last year we’ve had a few discussions on the problems with the conceptualization of fragility. I sustain the value of the “systems of resistance” approach suggested by Jon Frederickson, where we have three distinct diagnostic categories (resistance, repression, fragility) that each need different treatment approaches. And you, on the other hand, have come to stress the underlying similarities behind these difficulties, arguing that the dividing of these categories might introduce more conceptual complexity than needed. Can you say something about where you stand regarding this right now?
I am for whatever helps the patient, so if using this theoretical construct helps, I am for that.

I do not see resistance as a stable trait. The person of the therapist, the therapist’s approach, the particular zone in the unconscious that is being approached, the nature of what the patient is resisting, the strength of the stimulus that is evoking feelings, the particular juncture of the treatment — all of this impacts the picture of resistance.

And again, in the spirit of being clear on what we mean by our terms: I have heard resistance being defined by how a patient avoids (eg. high resistance being defined by resistance to emotional closeness), and I have heard resistance defined in terms of level of collaboration and openness (eg. is this patient willing to work hard and be open about what’s going on inside?). I tend to find the latter understanding more helpful.

The issue I have taken with the implication of the theoretical model you refer to (at least as you described it to me) is the notion that a fragile patient is somehow less defended than a patient with higher ego-adaptive capacity. Surely a fragile client will not have access to a certain class of defenses, but defending against feelings and real contact through distortions (splitting and projecting) is just another way of defending. In other words, regressive defenses still amount to ways of defending and distancing from undistorted feelings and undistorted three-dimensional others.

The most helpful and accurate way of defining the level or degree of resistance that I have heard comes down to how invested a patient is in defending their own defenses once these defenses are pointed out. If memory serves, I first heard of this conceptualization from Patricia Coughlin.

The client’s capacity will determine what kind of defenses the patient will have in their arsenal, but I disagree with the idea that a fragile client is somehow by default less defended. Less access to higher order defenses, certainly, but regressive defenses still constitute forms of resistance.

Though it’s important to be clear with our metapsychology and have a firm grasp on the principles that guide our work, at the end of the day I think that being overly focused on these conceptual frameworks can detract from the work.

My heart is in the trenches where it’s about the patient in front of me, the trainee in front of me, and I do not always find these sort of theoretical constructs helpful when it comes down to it, when it comes down to where the rubber hits the road. But if others do, that is fine by me.

The ‘systems of resistance’ lens can be very useful. I have it in the back of my mind and sometimes it comes in handy. But generally I rely more on the model that breaks down formal defenses into either repressive or regressive, and then also looks at tactical defenses — where the tactical defenses are either free-floating or tied into a major resistance. But really, as long as we do not allow our theoretical maps to get in the way of connecting with the patient, I am for whatever gets the job done.

Related to the above question, do you think there is one ISTDP or many ISTDPs? And do you think ISTDP should be further developed or is it at this point more important that we try and comprehend what Davanloo was offering?
I am having a hard time connecting to this question. Davanloo spent his life developing this incredible way of working, and since none of us are a carbon copy of Davanloo (and few even in good standing with Davanloo), everyone is doing some adaptation of what they learned from Davanloo or Davanloo’s students.

As long as we acknowledge that we are engaging in some form of adaptation of Davanloo’s work and that none of us are some final authority on his work, I think we are above board. Spending time thinking about who is and who is not doing ISTDP does not seem like time well spent, to my mind.

We are all engaged in some adaptation, as far as I am concerned. I encourage people to bring their own personality into their work and to do what works. If that looks like classic ISTDP, great, and if not, also great. Pointless turf wars about who is the real deal and who is not do not appeal to me.

You work hard to make ISTDP available to a broader audience through your youtube channel. What’s driving that?
I think I offer something unique and feel strongly about making that available to those that are interested.

What are you struggling with right now as a therapist? What’s your learning edge?
With highly resistant patients, when it’s time to ramp up with peppered pressures and challenges, it’s important to be very precise about the major column of defense and to not allow much time between the interventions and to not allow the patient to interrupt the process with their defenses, so my growth edge at the moment is to be more crisp and firm and really hit the major column with the right pressures and challenges in a way that blocks every single patient response short of an unlocking. That’s where I could improve a bit.

In September at the ISTDP Academy you’ll be speaking on the theme of defiance. Why this topic? What can we look forward to in the presentation?
Defiance, and its flip-side — compliance — is a universally common defense, and it can be difficult to work with. You will see how I work with deep-seated defiance that is more or less conscious, and you will see how much I stress undoing the omnipotent transference resistance, which involves not doing more than my part and not watering down the head-on collisions.

You will see a different way of “reaching for the patient” that ensures that I do not give the patient anything to defy. You will see a kind of inverted pressure.

I will also show the working through phase, and parts of the termination session, to really demonstrate what character change looks like.

Where do you see ISTDP going in 5-10 years? Where do you want it to go?
I hope that it will be more widely accessible to a larger swath of therapists, and that those who rely on other methods can still make use of some of the principles of ISTDP.

I imagine that there will always be the true believers and I hope that these people will engage the model in a way that includes their humanity and the ingredients I referred to when I spoke of the relational approach to ISTDP, and that there will be room for the ISTDP-informed therapist who enhance their work through aspects of ISTDP, short of the kind of immersion of the true believer.

Over the years, we’ve done a number of interviews with ISTDP therapists and teachers here at ISTDP-sweden. Here are the latest ones:

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.

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.

Johannes Kieding: Key Take-Aways from over a Decade of Training in ISTDP with Marvin Skorman

By: Johannes Kieding

Background

Though this text is ultimately about my own perspective, this perspective has indeed been very influenced by Marvin Skorman (he wishes to be named simply “Marvin”). Therefore I want to briefly mention a few things about him, his background, and our relationship.

As Marvin’s time as a teacher draws to a close (after nearly 42 years in the field), I am reflecting back on the years we have had together. I met him in 2007, learned informally from him till 2012, at which point I began weekly audio-visual supervision as well as core training with him.

As far as I can tell, his perspective on practicing and teaching ISTDP is unique. I use the term perspective to suggest a particular flavor and emphasis, and as an acknowledgment that there are likely differences in degree, if not in kind, between how Marvin has adapted ISTDP to fit with his personality and intuitions and what may be termed orthodox ISTDP. I imagine that most practitioners and teachers, even those who aim to adhere rather strictly to a Davanloo-esque approach, adapt the model to some degree or another to fit with their own temperaments.

Marvin was one of Dr. Davanloo’s right-hand men in the 1980s, had a falling out with Dr. Davanloo in 1991, and the two reconnected in 2012. Mr. Skorman worked briefly with Dr. Davanloo again in 2015. Since the 1980s Mr. Skorman remained in close collegial contact and collaboration with James Schubmehl, MD. and Deborah J. Lebeaux, CSW, both students of Dr. Davanloo.

He has eschewed the limelight (i.e., having him give his seal of approval to this text was a pain), he has felt repelled by some of the “seeking and finding religion” culture that can be connected with ISTDP, and besides the little professional association in Rochester, NY with Schubmehl and Lebeaux, he has not wanted to be associated with any institutions or associations, though he is clear that he believes institutes have their place as bodies of knowledge and serve an important function in offering historical continuity.

He coined the term “ISTDP attachment disorder,” cementing his strong emphasis on flexibility and concern around formulaic treatment. The issues with being overly rigid and formulaic are not unique to ISTDP, but can apply to any therapeutic modality.

What I have learned and have carried with me from the years of core training and audio-visual learning from Marvin may be different from his other students and trainees, which in itself speaks to what it is like to train with him. Having had years of both individual and group supervisions with Marvin, it is clear that he approaches everyone differently.

From left to right: Johannes Kieding and Marvin Skorman

Some of my training experiences have also helped me clarify where I depart from Marvin in terms of emphasis, so my perspective is influenced by him, a product from working with him, but contains my own adaptations, elaborations, and colorations from other teachers, peers, and studies.

What follows is my assessment of the key take-aways that I have absorbed, carry with me, and have incorporated into how I practice and teach Intensive Short-Term Dynamic Psychotherapy (ISTDP).

INSIDE AND outside the ISTDP roadmap

A phrase Marvin sometimes uses that has stuck to my ribs: “Therapy is about two imperfect human beings — each with their own triangle of conflicts —working out a relationship.” Nothing supersedes maintaining this felt sense of connection to the patient, which includes factoring in who we are and who the patient is at any given moment in time. This includes being connected to ourselves as therapists in the session — aware of what is happening inside of us, helping the patient be aware and convey to us of what is happening inside of them, and directly addressing any barriers that eclipse this awareness and emotional closeness. What maintains this connection can vary a great deal: for some it may look very supportive, for others it may look like heavy pressure and systematic challenge. When this is accomplished, not perfectly but sufficiently, the treatment outcome will be positive, no matter which therapeutic modality is used.

I have found that for me and many of my students, what goes into making and maintaining this emotional connection typically involves frequent recapping and clarification work, always making sure that the therapist can picture precisely what the patient is saying, to the point where the therapy session takes on the sensation of patient and therapist “sharing the same dream,” to use Marvin’s terminology. I place a tremendous value on dynamic inquiry and exploration, which I believe myself to see repeatedly in a host of Davanloo’s transcripts (H. Davanloo, Unlocking the Unconscious, 1990, and Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, 2000).

A sign that this connection is happening is that therapist and patient nod along together, sometimes even finishing each other’s sentences. It includes agreement around goals and the therapeutic task, but it goes beyond that. The patient should have the sense that the therapist is in their corner, and a sense that the therapist is concerned with their suffering. When this goes well, the patient does not experience the therapist as laying a trip on them, as pushing an agenda on them, and this sense of collaboration and togetherness continues even during heavy pressure and challenge (when and if heavy pressure and challenge is called for).

Not until the process of getting a clear phenomenological, descriptive picture of the presenting problems as well as the patient’s emotions is impeded by resistance does inquiry stop and give rise to focused defense work (prior to this juncture, tactical defenses may be briefly commented on). This can of course happen right out of the gate in the first minute of the first session, or further down the road — depending on rightward or leftward location on the psychoneurotic or fragile spectrum. Depending on ego-adaptive capacity, what “focused defense work” looks like varies a great deal.

It is important to underscore that some level of mobilization of the patient’s unconscious affective system is desired even during the phase of inquiry, but I distinguish between organic, lower level mobilization (tier one) and higher level mobilization (tier two) through targeted forms of added pressure on the foundation of a conscious therapeutic alliance. More on what I mean by added pressure in a minute. If I learned but one thing from Marvin, it was to not move to the second level of mobilization until there has been sufficient work done on the conscious therapeutic alliance, and when a graded format is called for, this added pressure is graded indeed (J. Whittemore, 1996).

Another prominent feature in the flavor of ISTDP that I have internalized is that even when a patient has the ego-adaptive capacity to face the de-repression of the unconscious, I do not automatically press ahead towards an unlocking. Some patients with higher ego-adaptive capacity want to take the edge off their symptoms and, in spite of seeing the down side of their defenses, are not interested in reaching “the top of the mountain,” so I go with what the patient is clear on that they want and thereby avoid a battle of wills scenario or a situation where I end up pushing an agenda on the patient.

I may say to a patient, “You have clearly made a lot of progress, but there are also signs you are not out of the woods fully. Is this good enough for you?” The patient may say that it is. If the patient has a track record of selling themselves short and not being honest about what they really want in their heart of hearts, I may press a bit, “are you sure? Are you settling in a way that sells you short?” But at the end of the day, if the patient says that where they are is good enough for them, then it is and I accept that.

There may also be sessions dedicated to taking a victory lap, celebrating the progress in the patient’s life, perhaps even ending the session early because the patient is wanting to just enjoy where they currently are, knowing that next week they may again wish to dig deeper. Bottom line: regardless of the patient’s capacity, I do not get ahead of their conscious will and I am open to the possibility that for some patients, unlocking the unconscious is just not where it is at for them, and other, different types of therapeutic work is what is needed. Remaining in touch with not just overt psychodiagnostic information but also with my felt sense (more covert, counter transferential diagnostics) helps me make the determinations of what, when, and with whom.

I also stress the importance of arriving at a dynamic formulation of the psychodynamic conflicts giving rise to the patient’s presenting problems. The triangle of person as well as nuanced, unique themes related to the patient’s intrapsychic conflicts are a major focus in how I engage with ISTDP. I am reminded of the many times Marvin asked: “What is the formulation here?”

A doctrinaire application of ISTDP technique

In the context of reflecting on past mistakes, seeing what trainees struggle with, and comparing notes with Marvin, some troubling trends come to the fore (trends neither Marvin or myself are immune from). I am thinking of trainees and practitioners of ISTDP being out of step with their patients for one reason or another. Some applying well-rehearsed straight-lines and rote techniques, others so focused on looking for signs of unconscious communication that they aren’t actually hearing what the patients are saying, yet others so focused on dragging patients through the central dynamic sequence — that the foundation gets lost, the actual contact and connection between patient and therapist is often not there, replaced by attempts at applying techniques.

The basics of dynamic inquiry, understanding how the patient sees things, ensuring the therapist has properly understood the meaning of what the patient is trying to convey by summarizing and underscoring key themes with dynamic significance, establishing a conscious alliance, arriving at a formulation of the core conflicts driving the patient’s problems, these are the type of things that appear lacking and stand out as problematic themes.

I recall Marvin speculating that these issues might boil down to what he calls “the suffering of therapists.” When he gives me supervision on how I supervise trainees, he frequently makes the point that the intervention-response principle is not just for our patients, but also for our trainees. The trainee’s subjective responses to the supervision are attended to and factored into the didactics — their anxiety also needs to be in a therapeutic range and if this is not attended to — if I offer my perceptions and suggestions without regard for where the trainee is, it often creates a misalliance between us and creates suffering for the trainee. For others, a “just tell me what you see and what you would do” approach works. I learned from Marvin to meet my trainees where they are and that a conscious alliance with them is just as important as with
patients.

Though Marvin truly adores Dr. Davanloo, he reflects on his core training with him and tells me that there was a major focus on unlocking the unconscious, and that he eventually came to feel that this single-minded emphasis on the unlocking of the unconscious experience sometimes came at the expense of not just the human relationship and connection with the patient, but also an openness to seeing other, unique ways of helping the patient not involving an unlocking of the unconscious, that may be more optimal. Having been trained in this way, I find it important to stay open to the collective unconscious between the patient and myself, and allowing interventions to come from that place — interventions that may be unique to a given patient at a given moment, that may never be repeated again.

During one of our discussions, Marvin shared the following with me: “Davanloo used to say, ‘With the help of each other, if we work hard, we can get to the bottom of your problems.’ That was his way of saying it [that the heart of this work is about the emotional connection and collaboration between patient and therapist].” Marvin continued: “So much of that essence of Davanloo seems to have gotten lost, the admiration and affection part, it somehow got ‘techniqued’ away. The technique was secondary for Davanloo, it came from his intuition, which I think is an invitation to all of us to use our intuition.”

Technique as a background element

With the emphasis on emotional closeness and connection with the patient, some may think that what I learned from Marvin de-emphasizes specific techniques. This is true. Marvin really is concerned about an over-emphasis on technique and an excessive attachment to diagnostic categories that get in the way of a human-to-human connection with the patient.

Yet I have learned a great deal when it comes to assessment and technical execution. Stand-out items that come to mind: working with malignant forms of resistance where “talking down to the super-ego,” is important (super-ego as a motivational force, not a noun), not “bargaining with the super-ego,” undoing projections by being different from the projection. For example, a patient projects their super-ego functions onto me and accuses me of putting them down. A defensive response aimed at trying to get the patient to be different would reinforce the projection. A response of, “So you see me as putting you down. That is concerning, if I am doing that, that would be really bad. What makes you come to this conclusion?” asked in a sincere manner will counteract this kind of a projection. Part of the needed therapist mindset here involves staying open to the possibility that the patient’s perception may have merit.

Another important concept I have learned from Marvin has to do with not allowing patients to manipulate me out of having an opinion, or getting sucked into colluding with the patient’s maladaptive defenses, i.e., pampering, coddling, or otherwise going along with an insecure attachment with the patient (insecure attachment reference — Jon Frederickson, personal communication, 2020). Most importantly, understanding when and with whom to do what with, based on an ability to assess the patient and engage with the interactive diagnostic roadmap that Dr. Davanloo developed.

Enter the head-on collision.

Marvin has had a role in my deep appreciation for the head-on collision. I have learned about many different kinds of them depending on the patient’s ego-adaptive capacity and the strength of the conscious and unconscious therapeutic alliance. A complete taxonomy of the different types of head-on collisions that I use is outside the scope of this text, but in addition to ego-adaptive capacity and the status of the conscious and unconscious alliance, the patient’s unique history, ego-syntonicity vs. ego-dystonicity of defenses, and severity of the need for self-defeat also factor in.

For example, with a patient with signs of fragility and a history fraught with rejection and abandonment, I may leave out the “if you remain distant like this, this process is doomed to fail.” Instead I may just say with a calm, edge-free tone, “So when you are like this, you are out of reach, and we are treading water, aren’t we.” I may add, “and that is of course your right, I am not going anywhere, I am here if you decide you would like to engage.”

Fragility does not mean that I do not point out reality, but I do this in a manner that makes it very clear that I do not need the patient to change, that I am not pressuring the patient to be different — the impetus to change needs to come from them. The emphatic “why do you want to do this to yourself?” interventions are truly superb, appealing to both the conscious and unconscious alliance with pressure on the patient to do something about the resistance, but I reserve this way of working for very different contexts than the beginning work with patient’s with fragility.

A few paragraphs down, under the “the problem of premature pressure” subsection, I give another example of a type of head-on collision that conveys both empathy for the patient’s conflict while still pointing out the reality that the therapist cannot be helpful while the patient remains guarded.

A different presentation, say an absence of fragility, ego-dystonic defenses, a highly malignant, destructive form of resistance may call for a head-on collision using a “talking down to tone” that not only underscores that the therapy will fail but also questions the point of even meeting, in line with what Dr. Davanloo referred to as conveying “studied disrespect” towards the defenses (H. Davanloo, Unlocking the Unconscious, 1990, p. 214).

While on this topic I cannot refrain from mentioning an article written by Allen Kalpin, MD, where he describes the head-on collision. It is titled Effective Use of Davanloo’s “Head-On Collision” (1994). The article covers a great deal about this intervention, from the “partial head-on collision with the character resistance,” to issues of timing, the differential aim regarding restructuring or unlocking, and the recognition that some forms of head-on collision are done prior to a rise in complex feelings and others after.

This article by Dr. Kalpin does a particularly good job highlighting the importance of not watering down the power of head-on collisions by being prepared and open to the fact that the patient may decide to leave and not try to change themselves. The article also does a beautiful job of underscoring use of silence, “not filling in the gaps,” the need for the therapist to not over-function, to not resist the patient’s resistance, so that when the therapist observes to the patient that therapy grinds to a halt, the patient can truly experience the halting and the self-destructive consequences of their resistance (p. 34).

The head on-collision is often critical, not just in order to undo the omnipotent transference resistance, intensify intrapsychic conflict towards the needed crisis-point, but also in order to cement and solidify the conscious therapeutic alliance and help the patient turn against her maladaptive defenses. When I help a patient see that there is a battle inside of them between the side that wants to remain guarded and the side that wants freedom, and ask the patient: “Which side are you on?” I am inviting the conscious will, I am “putting the patient at choice” to use Dr. Patricia Coughlin’s terminology (Personal Communication, 2017). When and if the patient convincingly declares that they are on the side that wants to discontinue the avoidance strategies, the patient “turns against” her defenses and the conscious therapeutic alliance is solidified.

This may clarify that I am not anti-technique or theory, but instead I am against a technical mindset getting in the way, becoming a therapist-created barrier against emotional closeness. I very much believe that it is very important to have sufficient theoretical understanding, discipline, and skill when it comes to moment-to-moment assessment of patient-response, assessing ego-adaptive capacity, and ability to effectively intervene based on these factors.

I have wished Marvin placed more value on theory, an area where we depart a bit from each other. He seems to have an ability to allow his own unconscious to connect with the patient’s unconscious and be guided by that, which I very much admire, but recognize that not everyone is able to do, giving rise to a need for theoretical and conceptual structures.

On the topic of staying present with the patient and not mechanically plowing ahead in a cook-book fashion (allowing theory and technique to get in the way), I am reminded of a comment Marvin makes from time to time: “this is intervention-response, not intervention, intervention, intervention, and ‘I’ll see you next week.’”

The problem of premature pressure

A major principle that I have internalized is to not apply any added pressure — added as in additional pressure on top of the inherent pressure contained in inquiry into the patient’s problems and their will — without the patient having convincingly declared their will to let go of defenses in favor of facing feelings. Then again, the perceptive reader will note that in order for there to be a question of turning against defenses, some level of mobilization and pressure to affect would first need to be there.

This goes back to the two tiers of mobilization. The first tier can be achieved conversationally by simply asking about the patient’s priorities and feelings, making links, and reflecting back to the patient what is observed about their responses. The second tier is when I ratchet up the pressure but at that point I want a conscious alliance as the foundation. Moving ahead to second-tier level pressure without adequate foundational work is what is often problematic, and not something I am always immune from.

In other words, I generally do not try to get a high rise on complex transference feelings before there is a sturdy conscious therapeutic alliance and the patient has begun to turn against their defenses. Since some variety of the head-on collision is often central to helping the patient turn against her defenses, this intervention (modified to be suited to the patient in front of me) is typically done prior to a high rise of complex transference feelings, and later repeated (typically in abbreviated format so as to not deflate rise in feeling) as needed. An early head-on collision here is not meant to “block” defenses but is done conversationally and matter of factly so as to help the patient make an informed decision around holding onto or letting go of their defenses. As alluded to in the previous paragraph regarding the two tiers of pressure, some level of mobilization is typically desired and needed even prior to using added pressure and the head-on collision. Again, I cannot help a patient meaningfully turn against her defenses outside the context of some level of feelings and defenses being stirred up.

In fact, not until the stage of increasing pressure and challenge where I aim for an unlocking of the unconscious by decisively blocking all defenses (blocking everything that is not the experience of raw feeling and impulse) — also known as unremitting pressure and systematic challenge — does the conversational quality of the treatment give way to what is more clearly and overtly an applied technique, though Marvin stresses that even then, if the pressure and systematic challenge fails to enhance the felt sense of connection with the patient, it may be best to hold off on these more advanced interventions until they can be done without sacrificing the sense of collaboration and closeness with the patient. This portion is not used in the graded format.

In the context of defenses and resistance impeding the progression of therapy, and the patient being reluctant to let go of their defenses, I can’t count the times I have heard Marvin very calmly say something to this effect: “I understand, allowing people close to you hasn’t been a good experience for you so far. And yet this represents a dilemma in our work, because the one thing I need in order to have a shot at being helpful to you is access to your most intimate thoughts and feelings, and it is also the one thing you say you abhor the most, letting people in, close to you. So here we are.” At these types of junctures, this is a conversation, not an attempt to mobilize complex transference feelings (though it often does).

The bottom line: without a conscious alliance around facing feelings, I don’t exert heavy pressure toward feelings. Without a conscious alliance around letting go of defenses, I don’t exert heavy pressure to relinquish defenses. Not getting ahead of the patient’s conscious will is a central tenet in how I practice and teach ISTDP. There are no repeated “so what feelings are coming up” or “how do you experience that feeling” questions until the patient is on board with such a focus and has a crystal clear understanding of how those questions (and that task) relate to their concerns and priorities for treatment.

Creativity

I really appreciate creativity. On this topic, I can think of several instances where Marvin has helped me think outside the box and be creative. Perhaps the best example of the creativity I have observed and be inspired by centers around his development of a way of facilitating couples therapy, obviously an adaptation but still grounded in ISTDP principles.

Since Davanloo developed ISTDP for individuals, with the aim of resolving intrapsychic conflict, and couples therapy primarily deals with interpersonal conflict, the adaptation component looms large, but the principles around emotional closeness and resistance against emotional closeness, and each person’s triangle of conflict are foundational in this approach to couples therapy. Unlocking of the unconscious is not the primary aim, but sometimes spontaneously occurs. The intrapsychic conflicts of the individuals comprising the couple play a major role in their interpersonal conflicts, so I attend to this dimension as well even though the couple itself is the patient.

This approach to couples therapy is elegant and often very effective (though I have no research to back that up, so it is considered experimental). A YouTube video exists that explains this approach in detail, you can find it here.

Supervision and Teaching

Influenced by Marvin, my approach to teaching and supervision is characterized by using who the trainee is, their life and clinical experience as a starting point, and then integrating ISTDP into that so as to enhance the trainee’s strengths, rather than trying to make the trainee void who they are in order to fit into a mold. This is hopefully how all teachers supervise, but I bring it up because of much it was stressed to me in my own teacher training.

When difficulties arise, my default assumption is that my training approach needs to be questioned or adjusted, not that the trainee is defective. Like most all trainers I assume, I encourage my trainees to find their own voice and integrate whatever they learn into their own personality.

If there is ever a choice between didactics — introducing ways of understanding what is going on with the patient and letting the trainee know what they could have done differently with their patients — or meeting the trainee where they are and modeling how to not get ahead of the patient by not getting ahead of where the trainee is, I opt for the latter, shelving didactics in favor of a conscious alliance with the trainee and modeling how to be with patients.

As previously mentioned, Marvin has remained apart from institutionalized ISTDP places of learning. On several occasions he tried to help Dr. Davanloo formalize and codify certification programs in ISTDP, but these efforts never succeeded. Without institutionalized backing, there is nevertheless a more informal practice around transmitting the recognition of readiness to teach to students in the community around Marvin. Marvin’s tenacity in fighting off my attempts to have him create something more formal has bested my efforts.

Closing remarks

As I am writing this in 2021, I realize it’s been 14-years of intensive immersion in learning on this path, and that capturing the stand-out items of this learning is a tall order. A text like this cannot do justice to the task of trying to capture the distilled essence of what I learned.

As Marvin heads for the exit, I mourn the loss of this teacher that has been so formative for me. To my mind, our profession is losing a giant who chose to live, practice, and teach in relative obscurity. His wish has been for his students to take what they can from him but then chart their own course, keeping the flame alive but in a way that honors the uniqueness of who we are as individuals.

I raise a metaphorical glass to him, to Dr. Davanloo, who made all of this possible, and to other teachers and peers who supplement and contribute to my learning.

References and acknowledgment:

Elad Jair Chone, Clinical psych. — close student of Marvin — in an
editorial capacity, has graciously assisted in the making of this text.

Marvin Skorman, LMHC, Personal Communications (2007 – 2021).

Davanloo, H. (1990). Unlocking the Unconscious (p. 3). N.p.: John Wiley & Sons.

Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD Chichester, England: John Wiley & Sons.

Kalpin, A. Effective use of Davanloo’s “head-On Collision”. International journal of short-term psychotherapy, 9, 19-36.

Whittemore, Joan W. “Paving the Royal Road: An. Overview of Conceptual and Technical Features in the Graded Format of Davanloo’ s Intensive Short-Term Dynamic Psychotherapy.” International Journal of Short-Term Psychotherapy, vol. 11, 1996, pp. 21-39.

Dr. Patricia Coughlin, Personal Communication, (2017).

Jon Frederickson, MSW, Personal communication, (2020).

This text was previously published here.

You can find the webpage of Johannes Kieding here, and he also runs a YouTube channel, which you can find here. Since a few years back, he runs a much appreciated community discussion group on Facebook called “ISTDP Peer Community”, which you can find here.

Here’s a recent ISTDP presentation by Marvin and Johannes

In the spirit of having a nuanced and critical discussion on ISTDP, we at ISTDP Sweden have published a series of articles during the last year. In this recent piece by Ange Cooper, she talks about the problems of idealizing or devaluing ISTDP during training. Mikkel Reher-Langberg is currently finishing his work on a two-volume book about Davanloo’s work, and in this interview you can learn about some of what he’s been learning during the process of writing. Earlier this year we published to interviews on the topic of limitations of ISTDP, one with Jon Frederickson and one with Patricia Coughlin.

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.

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

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

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

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

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

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

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

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

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

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

from omnipotence to depression and beyond

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

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

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

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

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

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

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

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

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

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

Getting to know your blind spots

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

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

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

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

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

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

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

Getting unstuck: the path of spirituality and psychedelics

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

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

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

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

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

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

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

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

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

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

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

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

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

Learning and teaching ISTDP

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

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

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

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

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

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

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

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

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

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

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

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

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:

What’s love got to do with it?

On December 6 and 13, 2021, Patricia Coughlin offers an online two-day seminar on the topic of therapeutic love.

In a letter to Jung, Freud wrote, “Psychoanalysis is a cure through love”. What did he mean? What does love have to do with the practice of ISTDP?

Patricia Coughlin presentation — Patricia Coughlin

In this two day webinar we discuss the central importance of love in the healing process. Human beings are wired for love and connection. However, loss, disappointment and even abuse in close relationships creates intensely mixed feelings which prove difficult, if not impossible, to bear. Defenses against these painful and guilt laden feelings often become a resistance to closeness which prevents the giving and receiving of love. Unless removed, these defenses and resistances will undermine treatment efforts and perpetuate suffering, resulting in frustrated therapists and patients destined to live lonely, isolated lives.

ISTDP is a method of therapy designed to dismantle these defenses and resistances in order to reach the patient and free him to love and be loved. Rilke wrote, “For one human being to love another. That is the most difficult of all our tasks, the last test and proof, the work for which all other work is but preparation.” This is just as true for us, as for our patients. Are we open, available, engaged and responsive or hiding behind our theories and techniques. It is my contention that we must BE the change we seek to facilitate in others. We will discuss and share our experience of love in the therapeutic process.

We will follow a number of cases from beginning to end in order to observe the process of healing wounds that impair our ability to give and receive love.

When Davanloo started to innovate, he recorded sessions and reviewed them with patients, once their therapy had concluded. It was during one of these feedback sessions that a patient alerted Davanloo to interpersonal defenses, designed to keep the therapist and others, at an emotional distance. He came to refer to these strategies as “tactical defenses” which operate as a resistance to emotional closeness. Unless such defenses and resistances are recognized and removed, treatment will remain superficial and largely ineffective.

We will observe a number of cases in which defenses against emotional closeness figure prominently. We will follow the process from defense to feeling to insight and change in several cases. We will use the case of “Broken Bird” and “The Man with Pain and Depression” and “The Man who couldn’t get divorced” to illustrate the process through which the unresolved conflicts from the past block the patient’s inability to give and receive love.

For more information and tickets: click here.

The event is organized by ISTDP Israel.

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: 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:

Niklas Rasmussen: “Det är så lätt att tappa bort sig själv i ISTDP”maj 11, 2023
Maury Joseph: “How much does our theory shape the patient’s experience?”december 23, 2022
Ola Berge: “ISTDP erbjuder ett perspektiv som saknas i psykiatrin”september 14, 2022
Johannes Kieding: “ISTDP is uniquely vulnerable to misalliances”juni 16, 2022
Jonathan Entis: “Defiance is the single most important defense”oktober 18, 2021
Ange Cooper: “I am my patient, they are me”september 29, 2021
Mikkel Reher-Langberg: “Vi använder Davanloos ord, men musiken är annorlunda.”augusti 18, 2021

The limitations of ISTDP. Part 1: 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

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: mindfulness, awareness, 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

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.

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.

Niklas Rasmussen: “Det är så lätt att tappa bort sig själv i ISTDP”maj 11, 2023
Maury Joseph: “How much does our theory shape the patient’s experience?”december 23, 2022
Ola Berge: “ISTDP erbjuder ett perspektiv som saknas i psykiatrin”september 14, 2022
Johannes Kieding: “ISTDP is uniquely vulnerable to misalliances”juni 16, 2022
Jonathan Entis: “Defiance is the single most important defense”oktober 18, 2021
Ange Cooper: “I am my patient, they are me”september 29, 2021
Mikkel Reher-Langberg: “Vi använder Davanloos ord, men musiken är annorlunda.”augusti 18, 2021
Mikkel Reher-Langberg: “We all use the same words as Davanloo, but the music is different”augusti 18, 2021
Mikkel Reher-Langberg: “Vi bruger alle de samme ord som Davanloo, men musikken er en anden”augusti 18, 2021
Malin Ljungdahl: “ISTDP hjälper oss att inte fastna i dualismen mellan psyke och soma”april 28, 2021

Online presentation with Patricia Coughlin

Mastering the trial therapy in ISTDP – AN online presentation with Patricia Coughlin

At the end of November this year, Patricia Coughlin will give an online presentation on the topic of the ISTDP “trial therapy”. ISTDP often begins with a longer therapy session, usually 2-3 hours, where we assess the patient and the suitability of the treatment model to the patient – the trial therapy. Research has shown that this first session in itself can have long-lasting benefits on mood symptoms and interpersonal problems.

In this video based webinar you will learn how to work effectively with a highly resistant patient with both a character disorder and anxiety and depression. You will observe the process of a trial therapy, in which a specific set of interventions is employed as a vehicle for determining the nature of the unconscious conflicts responsible for the patients symptoms and suffering. We will also discuss suitability for treatment with Intensive Short-Term Dynamic Psychotherapy (ISTDP). The webinar is organized by a group of ISTDP therapists in Oslo, Norway: Psykologvirke

Date: November 23rd

Time: CET 12.00 – 20.00

Price: 1800 NOK

Registration and more information: click here

PATRICIA COUGHLIN

Patricia Coughlin Della Selva, Ph.D., is a licensed Clinical Psychologist with over 35 years of clinical experience. Currently she is Clinical Faculty at the University of New Mexico School of Medicine. Over the past 20 years she has written professionally, given presentations at professional conferences and conducted workshops for mental health professionals internationally. Currently, she is conducting training groups in New York, Australia, Denmark, and Poland. Patricia last presented in Sweden in the fall of 2016.

Patricia has authored three books which are all considered essential readings for anyone interested in ISTDP: Intensive Short-term Dynamic Psychotherapy: Theory and Technique (1996), Lives Transformed (2006; in collaboration with Dr. David Malan) and Maximizing Therapeutic Effectiveness in Dynamic Psychotherapy (2016).

A while back we did an interview with Patricia Coughlin, which you can find here.

Here are some of our other recent interviews:

Niklas Rasmussen: “Det är så lätt att tappa bort sig själv i ISTDP”maj 11, 2023
Maury Joseph: “How much does our theory shape the patient’s experience?”december 23, 2022
Ola Berge: “ISTDP erbjuder ett perspektiv som saknas i psykiatrin”september 14, 2022
Johannes Kieding: “ISTDP is uniquely vulnerable to misalliances”juni 16, 2022
Jonathan Entis: “Defiance is the single most important defense”oktober 18, 2021

You can find other articles and materials in english by following this link.

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

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

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

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

Dion Nowoweiski portrait — Dion Nowoweiski

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Niklas Rasmussen: “Det är så lätt att tappa bort sig själv i ISTDP”maj 11, 2023
Maury Joseph: “How much does our theory shape the patient’s experience?”december 23, 2022
Ola Berge: “ISTDP erbjuder ett perspektiv som saknas i psykiatrin”september 14, 2022
Johannes Kieding: “ISTDP is uniquely vulnerable to misalliances”juni 16, 2022
Jonathan Entis: “Defiance is the single most important defense”oktober 18, 2021
Ange Cooper: “I am my patient, they are me”september 29, 2021
Mikkel Reher-Langberg: “Vi använder Davanloos ord, men musiken är annorlunda.”augusti 18, 2021
Mikkel Reher-Langberg: “We all use the same words as Davanloo, but the music is different”augusti 18, 2021