Etikett: english

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

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

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

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

José Verpoort-Douw

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday and Wednesday
9.30 – 12.00. The day starts with two individual sessions with group attending, followed by a group session of 45 minutes. A social worker or arts therapist is attending as a co-therapist.
12.30. Lunch
13.30. Arts therapy
15.00. Sociotherapy.
At the end of the Wednesday we make plans for how to work on the respective focusses during the next four days in their own environment.

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

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

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

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

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

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

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

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

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

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

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

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

Patricia Coughlin: “ISTDP is a psychoanalytic method”

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

Patricia Coughlin Malmö
Patricia Coughlin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[POSTPONED] Patricia Coughlin on sexuality in Malmö

On September 10, the Swedish association for ISTDP welcomes you to a one-day conference with Patricia Coughlin in Malmö, southern Sweden. EDIT: Due to CoVid-19, this event has been postponed until 2021.

Understanding and resolving sexual conflicts with Intensive Short-Term Dynamic Psychotherapy (ISTDP)

We’re very happy to welcome Patricia Coughlin back to Malmö for this one-day conference. The focus of the talk will be on understanding conflicts around sexuality. Patricia Coughlin, a renowned expert in ISTDP, will discuss how to detect the presence of these conflicts in your patients, and present methods designed to resolve them. Authentic videotaped examples of work with patients who struggle with conflicts around sex, jealousy and rivalry will be shown.

Patricia Coughlin portrait

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).

Registration and info

Location: Nobel house, Act room, Per Weiiersgatan 6, 211 34 Malmö, Sweden

Date: Thursday, September 10th, 2020 At some point during 2021

Time: Registration starts at 8.30, workshop 09.00–17.00 (lunch approx. 12.00-13.00), book signing 17.00-18.30

Price: 2000 SEK for non-members, 1500 SEK for members of the Swedish society for ISTDP, 750 SEK for full-time students (regardless of membership). Lunch and coffee is included in the price. 15% discount for “early bird” registrations before April 15th! Register now – seating is limited!

Registration: E-mail your full name, work title, any food allergies or preferences and full invoice information to Victoria Paglert (vpaglert@gmail.com) for registration.

Contact: Victoria Paglert (vpaglert@gmail.com), Peter Lilliengren (peter.lilliengren@affekta.se)

This information is also available in this flyer.

Welcome! We’re looking forward to seeing you in Malmö next year.

For information about our other events (in Swedish and English), make sure to check out our events page.

[POSTPONED] ISTDP PRE-CORE. Introductory course in Helsinki, 4-6th of May

CANCELLED. Due to the coronavirus pandemic, this event has been postponed (2020-03-12).

Welcome to ISTDP PRE-CORE introductory course in Helsinki on 4-6th of May. For information in other languages, click here for Finnish and here for Swedish.

We’re very excited to offer ISTDP training in Finland for the first time. Following the workshop by Jon Frederickson at the end of March this year, to our knowledge this will be the second ISTDP event in Finland. The three-day course gives a complete introduction to the theoretical and practical foundations of Intensive Short-term Dynamic Psychotherapy, ISTDP. Alongside theoretical lectures, the course includes skills training, role-plays, observation of actual therapy video and group discussions. This is the main content:

  • an introduction to the central theoretical principles of ISTDP
  • practical skills to establish an effective working alliance and a consistent focus on affect
  • practical skills to assess and regulate anxiety manifestations during sessions
  • practical skills to identify and manage defenses and resistance
  • a critical introduction to the evidence base for ISTDP and other short-term dynamic therapies

The course is open for psychotherapists and psychologists, as well as students within these fields.

The course is led by lic. psychologist Thomas Hesslow. He runs the ISTDP-unit at the psychiatric outpatient clinic Kronan in northwestern Stockholm. He’s a certified ISTDP-therapist, trained by Jon Frederickson, Tobias Nordqvist and Peter Lilliengren. Currently he’s in Jon Frederickson’s Training of trainers program to become an ISTDP teacher and supervisor. He’s also on the board of the Swedish society for ISTDP and doing ISTDP-research part-time. Before doing ISTDP he specialized in dialectical behavior therapy, DBT.

ISTDP pre-core
Pre-core in Stockholm early 2019.

PRE-CORE is a prerequisite for later entering ISTDP Core training, which is the three year program to become a certified ISTDP therapist. Thomas Hesslow and Liv Raissi are planning for a Core training in Helsinki starting during fall 2020. More information on this is due later this spring.

For more information about the ISTDP PRE-CORE in Helsinki and details for registration, please download the flyer in English, Finnish or Swedish.

CANCELLED. Due to the coronavirus pandemic, this event has been postponed (2020-03-12)

Kristy Lamb: “I want ISTDP to become the standard of care for addiction treatment”

This is an interview with Kristy Lamb, who’s a psychiatrist and ISTDP clinician in California. For the past few years, she’s been running an outpatient clinic – BOLD Health – which treats addictions using an intensive format of ISTDP.

Kristy Lamb portrait
Kristy Lamb

It’s been two years now with the BOLD clinic if I’m not mistaken. How does it feel? What have you learned? 
We started BOLD Health in March of 2017, so we are coming up on our 3 year anniversary already. It’s all really exciting – so much has happened over the past 3 years.

Trained as a physician in Family Medicine and Psychiatry I had no background at all in business before this. So it has been a wild ride of learning as I go, trying to balance all the different aspects of the project. Learning about running a business and being an entrepreneur with regular supervision and deliberate practice for the clinical development of my staff and myself. 

For better or worse, much of the learning about the business has been trial and error.  So much of what I didn’t know, I didn’t realize until some issue or crisis and it was in working through the crisis that I learned.  I think it is much this way in therapy that you know what to do and how to do it until you come across something new, and then, the working through, the attunement and attention to the response to intervention, helps build your working model.  

What’s the background of the clinic? How are things developing? 
When I first graduated from residency (after five years of training in family medicine and psychiatry after medical school), I was working in a number of different environments practicing both general medicine and psychiatry from a concierge clinic to a homeless shelter and even in the jails. I had a passion for serving underserved and marginalized populations, but wanted to expose myself to all different clinical environments to see how things worked. It was clear that the system in the US creates a great chasm between the haves and the have nots. 

In the county clinics I had 15 minutes to see a patient and taking extra time to do any type of therapy was frowned upon because the system was so impacted. However, in the concierge, pay-for-service model I could spend as much time as I needed with people and as you’d expect those patients got better. So I set out to start a private practice in order to have the time and space to hone my skills in ISTDP but eventually to build space to do research so we can show the long-term cost-effectiveness of ISTDP and bring the model back to the community setting. And that’s where things are now. 

Why is ISTDP a suitable treatment for addictions? Aren’t there other psychological models with more scientific backing? 
This is such an important question. With the number of people dying from substance use each year growing exponentially, it’s imperative that we are figuring out what treatments work and what treatments don’t work.  Unfortunately, in the US over 90% of treatment programs are based in the 12-step model which has only about an 8% success rate. It has no scientific backing and was started as community support, not treatment. We are certainly not against the 12-step program and encourage our patients to engage in the community of 12-step. But we also recognize that substance dependence requires psychological treatment and often medications in the early stages if patients are to have sustained sobriety and more so, sustained success in their lives. 

In regard to why ISTDP is such a great model for addiction treatment, it really comes down to the way we conceptualize addiction – as Jon Frederickson says, “We are all addicted to avoiding reality.” We all use different mechanisms to numb and avoid the reality of our lives and drugs and alcohol are just one way we do this – so some people go to TV, or work, or exercise, or compulsions. 

Any of our defenses can be seen as a mechanism to avoid what we are feeling. Drugs and alcohol are no different and once someone is no longer under the influence by just abstaining from the substance, they can start to look at what was driving the numbing that, in this case, can be lethal.  When the substances are seen as just another defense it is clear that ISTDP is a perfect model to treat the human disease of affect intolerance. 

I think another reason why ISTDP is so important in addiction are the interventions that provides the therapist with a clear and direct way to address the common defenses in this group. Handling projection of will, projection of omnipotence, denial, helplessness and hopelessness, and anxiety regulation. All of which are imperative if treatment is to be successful.

What’s the treatment format, length of treatment, rules etc? And how did it come about? 
Our treatment program averages 10 weeks depending on the patient’s level of acuity.  When a patient signs up for the program they undergo neuro-psychological testing, a commitment interview assessing their will for engagement in treatment and then start the program with groups 3-5 days per week, once per week individual therapy and once per week as needed medication management appointments. 

Each day consists of 30 minutes of biofeedback, an hour of group psychoeducation and then an hour and a half of what we call The BOLD Seat which is structured group therapy. All the group members are given an opportunity to take the BOLD Seat in front of the group to look at a specific problem for the day with the therapist leading the group. The other patients observe and participate, helping that patient see anxiety and defenses. Also, watching your peer gives you the opportunity to see yourself objectively as you may resonate with what the person in the BOLD Seat is saying but be able to see it from a different, more compassionate, distance.  

Our curriculum and the entire structure were developed in collaboration with Jon Frederickson who had piloted this model at a program in Arizona, the data from which was recently published in the Journal of Addictive Diseases.

I had the good fortune of meeting Jon at a week-long training in Whidbey Island, WA, in 2016 and I was just starting to look at group therapy for addiction. We then started working on expanding the previous work that had started in Arizona and now, four years later, here we are. Jon has been an integral part of our development not only for the structure of the program but he provides weekly supervision to our team and has helped establish the ethos of the clinic – compassion, respect and integrity.

What are some of the challenges when doing ISTDP with persons who struggle with addictions? 
Really there is no difference in treating someone with addiction problems than any other patient if the patient is currently sober. Jon Frederickson often talks about the notion that there are specific criteria necessary to actually have a patient in the room.  You can’t do therapy with someone who is actively intoxicated so monitoring for this is critical. 

That being said, as we are an addiction treatment center we have to be sensitive to still welcoming people who are ambivalent about their treatment or struggling to maintain sobriety. We have to greet them with compassion and honesty: they may need a residential program or an inpatient detox or a residential program to begin with. So they can really get some time away from the drugs or alcohol, so that they later can get the most out of our program. 

Accordingly, when we screen for use during the program we work to approach the patient with compassion and understanding to let them know that relapse is common. And we don’t have a right or a need to punish them, but rather use the testing as just information to let us know if their will for engagement in treatment is aligned with their actions. Knowing that that sometimes it’s not, and we just have to pull back and get clear about where they are and what they want for themselves. We work really hard not to own the will of sobriety in any of our patients.

Many patients in recovery haven’t connected to their internal motivation for treatment. They are in program because of their partner, or parents, or job, or the law are setting an ultimatum. We have to work really hard to get clear that unless the patient wants to engage, treatment won’t work. 

What’s it like to do a core training with your fellow colleagues and staff? 
It feels like such a gift to be doing core training with our staff.  When we started, part of the collaboration with Jon Frederickson was to start a new core training cohort with our staff and weekly supervision with him and Esther Rosen. 

My first core training with Patricia Coughlin was personally life changing and the people I met there have become lifelong friends. But it has been a totally different experience to have all of my work colleagues now be a part of the quarterly intensive training. And for us to be able to come back to BOLD and stay motivated between core trainings with weekly skill building and supervision. So many things in place to keep focus.

It really feels like a dream to be working in a clinic based in ISTDP. Even during our lunch breaks we are chatting about defenses, portrayals and psychodynamic understandings of our patients. It creates an environment of support and collaboration like nothing I have ever experienced in any other work environment. I am incredibly grateful to Jon and our whole team for building this space.

In the swedish context there’s quite a lot of talk about deliberate practice nowadays. What are you struggling to learn right now as a therapist? 
I am a big fan of deliberate practice and have seen how deeply it changed my work. In 2016, I took a short course in deliberate practice and then had ongoing supervision with Tony Rousmaniere. I couldn’t agree more with Tony’s notion that the therapist’s own work is the glass ceiling between good providers and great providers. It is only when you can notice and work through your own “stuff” that comes up in sessions that you can really be present with the patient in front of you.

So the deliberate practice related to skill building is wonderful and undoubtedly makes for improved outcomes, but it is the personal work that Tony taught me that I find the most difficult and the most important. What I need to pay attention to so I can know when my anxiety comes up, where I might unconsciously avoid going with my patients, or biases I might have from my own life experiences. It is through this internally focused deliberate practice that I have been able to become more present and more available to my patients, which results in markedly more effective work. This work takes a lot of effort: making time and space for watching my own videos and – as importantly – making time for my own self-care and therapy. 

If you dream a bit, where would you like ISTDP and addiction psychiatry to go within the next 5 or 10 years? 
Thank you for asking! I happen to be someone who sets goals that I think others often think are idealistic or impossible but at BOLD we encourage our staff to dream wildly about what can be. 

I deeply believe in this model and want to see it become the standard of care for addiction treatment. We are looking to start a revolution and would love to see the BOLD Method be known across the world as the most effective treatment of addiction. Dream big! Right?

I would also love to see our clinic running as an incubator where we can continue to hone the model and build a body of research that supports what we are doing, as well as become a training facility so that we can support others to engage in this model of treatment. 

If you liked this Kristy Lamb interview, maybe you’ll appreciate some of our other interviews. Below, you’ll find a list of our five most recent ones.

Also, a while back we reported on the Frederickson et al. 2019 addiction trial. You can find that article here (in swedish). For all of our content in english, please click here.

Joel Town: “Teaching the ‘intensive’ is the central challenge”

This is an interview with Joel Town. Joel Town is one of the most important ISTDP researchers out there, being the first author of several empirical studies of ISTDP. Among them is the most rigorous ISTDP study thusfar, the “Halifax Depression Study“. He is an Assistant Professor at Dalhousie University, a lead researcher at the Halifax Centre for Emotions and Health and he runs Dynamic Health Psychological Services. Last year, he visited Göteborg for a two-day workshop on treatment-resistant depression. We had a chat with him about where ISTDP is at and where it should go.

joel town portrait
Joel Town

How did it feel to present to a swedish audience? 
As you know, this was actually my first time both visiting Sweden as well as teaching. I was very happy to see some old friends who I’ve met at past conferences, meet many engaging new colleagues, as well as make some new friends. It was a pleasure to be with you in Sweden and to see how your ISTDP community is growing!

You presented some thought-provoking ideas for modifying the graded format of ISTDP, managing the thresholds differently. Can you explain your perspective on this? And how is it different from the standard graded approach?
With the graded format, I was trained to first think about the use of ‘pressure’ to mobilize complex feelings. Next, we look for a threshold to detect when the patient is struggling to intellectually hold in mind complex emotional states and instead become flooded with anxiety. At this point, the therapist helps to reduce anxiety using different strategies. One observation around the clinical application of this approach that I spoke about during the workshop is how easily we can teach the process as though there are explicit “go” and “stop” signs.

The concept of a threshold can be helpful when initially learning this approach in order to avoid too much anxiety being triggered. But viewing patient tolerance more as a Threshold Window can allow therapists to involve patients more in the process, and help them better learn to self-regulate. I’d describe this more as principle we can be aware of during learning, teaching and supervision that can allow therapists to begin to incorporate what Allan Abbass has called “bracing” interventions. This can be done instead of formal recapping or other anxiety regulating interventions. 

You offered some modifications to the phase of inquiry that were very well received by the swedish audience. How did that come about?
It’s something that I noticed over time when I was reviewing trial therapy tapes. I felt like I was missing something if I wasn’t asking patients about feelings, clarifying anxiety or defences within the first few minutes. However, there were other occasions when I was using these kinds of interventions early in sessions – but I would be left questioning why am I doing this and how helpful is was. This made me think about some of the learning challenging when teaching. And it made me rethink the timing of the transition from ‘inquiry’ to phases of structured ‘pressure’ in ISTDP.

In Gothenburg, I showed a tape in which the patient came into a trial therapy exhibiting a mixed bag of responses that we might consider examples of unconscious anxiety and defence combined. In the tape, I didn’t comment explicitly on these processes for around 10 minutes and instead stuck with a phase of inquiry. The subsequent group discussion raised some good questions about the importance of the pace and timing of therapist interventions early in sessions. The audience appeared to appreciate me saying that it isn’t always entirely clear what is happening moment-to-moment, so collecting more data from sitting with the patient can be helpful.

I think in our effort to provide and teach “intensive short-term” treatments we can easily prioritise the need to intervene. We even sometimes intervene before we understand why we are intervening. During the 2-day seminar it felt like we were able to have a very a constructive discussion about these issues. My thought is that these are likely learning and training challenges in ISTDP as much as they are about technical elements related to the phase of inquiry in treatment.

What are you struggling to learn as a clinician right now?
I have begun seeing a series of patients with chronic symptoms that have an explicit behavioural component such as OCD (e.g., compulsive behaviours), Tourette’s and other tic-based presentations. There hasn’t been a lot written on this topic around the use of ISTDP and in my experience these cases present infrequently to dynamically orientated therapists. It’s been a challenge and learning curve to think about how to adapt and tailor a dynamic approach to specifically target change in symptoms that involve repetitive behavioural patterns.

For instance, in ISTDP I would aim to help a patient see harmful patterns and behaviours so that they become motivated to interrupt them independently. In contrast, a traditional CBT exposure and response prevention approach involves a more directive therapist stance in advising a patient to prevent the ‘response’. In the cases I have treated so far, I am struck by how much emphasis there has needed to be on an explicit therapist stance towards response prevention. I think it is a subtle but significant shift for the ISTDP therapist to focus on interrupting an explicit in-session behaviour like a vocal tic in contrast to purely intrapsychic defences.

What are some of the current challenges for the further development and dissemination of ISTDP globally?
One of the challenges for the dissemination of any psychotherapy is having the means to effectively train others to deliver the treatment. Over time, through these dissemination efforts, if enough clinicians can be trained to become both effective therapists and trainers themselves, there reaches a critical mass at which point the treatment is readily accessible for patients. There are probably only a handful of therapies which can be said to have achieved this globally.

The manualisation of psychotherapies has been a key part of what has made this possible. However, the development of treatment manuals to treating mental health as discreet “disorders” defined by symptom clusters is problematic. I think this paradigm has contributed to the numbers of patients who fail to remit or relapse following psychotherapy generally. In contrast, I think ISTDP is best described as an approach that is fundamentally built to achieve ambitious changes in personality. While my own experience as a researcher and clinician confirm that this is possible, as with other therapies, therapist factors and patient factors contribute significantly to outcomes. 

I think the ISTDP Core Training programs conducted in the last decade indicate that there are many elements to ISTDP that can be taught to a broad group of therapists. The programs teach the delivery of effective treatment that is likely comparable to the outcomes achieved in other treatments. However, my current view is that I think there are other elements of ISTDP that are very difficult to learn, particularly given the training resources typically available to most therapists (e.g., access to and frequency of supervision).

If some of the more difficult-to-learn treatment elements were emphasized less, akin to dropping the ‘intensive’ from ISTDP, I think we would have a treatment that could be more easily disseminated globally. It is arguable that in doing so, we could compromise the nature of the changes possible in treatment by de-emphasizing the elements that promote personality level changes. This is a question that would need addressing empirically.

Do you think we should drop the “intensive” then? Or what do you propose? 
I don’t think the field needs a new treatment with a new acronym. What I am pointing out is that there are different elements to ISTDP that require different competencies to be taught and adequately mastered by a therapist. If attempting to gain competency in multiple domains limits the transferability of the treatment, I am proposing that therapists can be trained and encouraged to utilise specific elements as they are able.

This type of learning environment might help therapists to flourish and grow rather than to become discouraged and drop-out. Perhaps within the field of psychotherapy training there is a risk that in an effort to maintain the presumed integrity of the treatment, it is very possible that the alliance between therapists and their trainers/teachers can be adversely effected. I think this is a central challenge around the dissemination of ISTDP.

Do you have any upcoming research in the pipeline?
I am just preparing a manuscript describing the 12-month post treatment outcomes and a cost effectiveness analysis from the Halifax Depression Study. This a randomized controlled trial that compared the outcomes of time-limited ISTDP against the effects of secondary care community mental health team treatment for treatment resistant depression (TRD). We published the initial findings in the Journal of Affective Disorders in 2017 showing ISTDP is an efficacious treatment for TRD with 36% of patients reaching full-remission at the end of treatment. The follow-up findings are also very encouraging. 

What’s your vision for the future of ISTDP? 
Currently there are very few academic centres around the world in which ISTDP research is being conducted. For the growth of any treatment, research is an important part of dissemination alongside offering the possibility of innovation in methods and technique. In particularly, as a clinical psychologist and researcher having both trained and conducted clinical trials in ISTDP, I think my understanding of some the teaching and learning challenges around ISTDP has been enhanced greatly by this work. Moving forward, I would hope there are increasingly more opportunities for people at all stages of learning to be involved in ISTDP training and research within academic centres of excellence.  

If you enjoyed this Joel Town interview, you might find our other interviews interesting. You can find the whole list here. Below you’ll find a list of five of our most recent interviews:

[CANCELLED] Beata Zaloga workshop on fragile character structure in April 2020

CANCELLED. This event has been cancelled.

In April, the polish ISTDP therapist and teacher Beata Zaloga visits Göteborg for a one-day workshop on the topic of fragile character structure. Fragile character structure refers to patients whose identity is fragmented and dependent on primitive defenses such as projection, somatization and splitting.

Beata Zaloga
Beata Zaloga

Fragile character structure represents one of the greatest challenges in the psychotherapeutic field. The group of patients with this profile suffer from longstanding difficulties with projection, denial and splitting, often resulting in severe psychiatric symptoms including borderline personality organization. In ISTDP, a combination of the graded format and structural integration is needed to help patients build more emotional capacity and a more stable sense of self. Over time, increases in emotional capacity allows feelings to break through into consciousness.

This case presentation will show you how to:

  • Help the patient to face feelings they avoided through their self-neglect
  • Help the patient see and let go of defences of somatization, weepiness and projection
  • Use the technique of bracing to build the capacity to bear feelings without using primitive defences
  • Help the patient process unconscious feelings so they do not need to ward them off through self-punishment.

Beata Zaloga brings a uniquely warm and delicate touch to the therapy encounter. Another reminder of how different voices around the world give us a richer perspective on how ISTDP can embody the human encounter.

Jon Frederickson

For more information about this Beata Zaloga workshop and registration, see this flyer.

[CANCELLED] Jon Frederickson workshop on character resistance in Göteborg, October 18th, 2020

[CANCELLED]: This workshop has been cancelled because of the current CoVid-19 situation. In October, Jon Frederickson invites you to a workshop in Göteborg on how to use ISTDP in the treatment of “character resistance”. Character resistance refers to patients who are heavily identified with self-negligent and self-destructive behaviors.

Jon Frederickson portrait
Jon Frederickson

Imagine you meet a patient who has defeated every therapist he has seen for thirty years. He’s not sure he has a problem. He’s not sure anyone can help him. He has given up. He thinks his previous therapist was “bullshit.” He has come only because someone sent him. Then he asks: “What should I do here?”

How do we begin therapy if no problem is declared? Can we explore anything if it is not the patient’s will to do therapy? What’s a good way to handle projection? What do we do when the patient devalues the therapist? In this presentation of a videotaped initial session, Jon Frederickson will show how to work with treatment destructive defenses that would prevent any therapeutic alliance from forming. The case will also show how to mobilize an unconscious therapeutic alliance when there is no conscious therapeutic alliance.

In this workshop, you will learn how to:

  • Maintain a therapeutic focus in the face of provocation and acting out.
  • Deactivate projections.
  • Mobilize the patient’s will to the task.
  • Turn the patient against his treatment destructive defenses

We will go through the videotape moment by moment to show how to assess and intervene on a microscopic level. The emphasis will be not just on learning theory, but on developing intervention skills.

For more information, see this flyer. Welcome to Göteborg!

Reiko Ikemoto-Joseph: “This is one of the aspects of ISTDP I love the most: its infinite flexibility”

At the end of January 2020, Reiko Ikemoto-Joseph, Licensed Marriage and Family Therapist, is presenting her work on the healing power of guilt at Ersta Bräcke Sköndal Högskola. We had a chat with her to find out more about what she thinks about ISTDP, couples therapy and working with creative people, among other things.

How did you find ISTDP or did ISTDP find you? 
I was very fortunate to have discovered ISTDP very early in my clinical training at a day seminar offered in Los Angeles. I watched a videotaped session of a man who was struggling with inexplicable rage toward his 4-year-old daughter. When I saw the use of pressure and challenge, my jaw hit the ground. I didn’t exactly understand what I was seeing but I knew right then that I wanted to learn how to do it. I immediately enrolled in an introductory ISTDP course and from there I was hooked. It’s been nine years since that day and I am as enthralled, obsessed and curious as ever about Davanloo’s metapsychology and the many different ways it can be understood, applied and adapted. So I supposed I found ISTDP first but it has certainly found its way into my psyche and grabbed hold. 

Can you say something about your style of ISTDP? What do you emphasize in your work and what do you appreciate most about working with ISTDP? 
During my training I have consciously and unconsciously integrated the styles and interventions of my teachers. However, over time they have become my own. I find a great deal of joy and satisfaction in re-interpreting my teachers’ interventions in my own language and creating new interventions to suit the specific needs of my patients. This is one of the aspects of ISTDP I love the most: its infinite flexibility. Once you integrate the metapsychology, it’s possible to adapt the approach to nearly every person you treat. I would say that I always emphasize the working alliance. All of my initial interventions target the specific barriers that prevent an active and involved partnership with my patient. 

All of us struggle to learn ISTDP. Starting out, after a few years and also after a number of years. Can you tell us something about what you’re learning right now and what you’re struggling with? 
Right now I’m experimenting (and struggling) with the best way to approach extreme fragility. I’ve always enjoyed working with moderately fragile patients but patients on the extreme side of the fragile spectrum are especially challenging for me because the pace of the work is so slow. ISTDP is known for its ability to effect rapid change and I find it very exciting to facilitate major unlockings early in the treatment. This is not possible with extremely fragile patients. With these patients, the bulk of the work involves meticulous and painstaking restructuring. Additionally, many patients with early and severe abuse quickly flood with anxiety, dissociate, and cannot tolerate working in the transference. So recently I’ve been experimenting with using bilateral stimulation and EMDR resourcing techniques with such patients to stabilize them at the beginning of each session. So far it has proved very useful in reducing anxiety and creating the conditions for a conscious and unconscious working alliance.

You specialize in couples therapy. I’ve heard some people do couples therapy in a format where they do individual therapy with the other partner as audience, and then you alternate during or between sessions. What kind of format do you use? Did you have to modify ISTDP in some ways to make it fit couples work? 
As you noted, this is a particular interest of mine. I love working with couples. One of the nice things about couples work is that the couple usually comes “pre-mobilized,” meaning that the partners already have complex feelings activated toward each other when they walk through the door. They also find it very easy to identify specific examples of their problems with one another. The aspects of ISTDP that are fairly easy to adapt to couples work are: (1) directing the partners’ attention to their respective triangles of conflict and triangles of persons. I help each of them see how these two triangles work together to perpetuate their difficulties. This in turn helps them see and take responsibility for their specific contribution to the problem instead of blaming each other. One innovation that I developed with my colleague, Catherine Lockwood, is redirecting rage into the transference. For example, if one partner is lashing out at the other, I’ll interrupt and help the enraged partner observe his or her anxiety, rage and discharge. Next, I’ll invite him/her to experience and regulate the rage with me instead. Often it’s possible to make a cognitive link to an earlier genetic figure or distressing memory. This is usually extremely illuminating (and a huge relief) to the observing partner. I save ample time at the end of each session to invite both partners to summarize what they experienced and observed and to link it to their presenting problem.

On your website you mention that you work with people in the creative community. Do you find that this group is different to treat than other groups of clients? 
From a metapsychological perspective, creative clients are no different than other types of clients. However, I find that as a group, creatives tend to be very identified with their punitive superegos. Their torment shows up as relentless self-criticism of their creative efforts, which they often rationalize as “good for them.” For me, creative clients are a lot of fun to work with because they resonate so strongly with metaphor and archetypical themes (e.g. exile, freedom, revenge). 

What’s your vision for the future of ISTDP? Where do you see us going as a community in say, 5 or 10 years? 
My vision for the future of ISTDP is greater recognition in the psychotherapy community at large and wider availability of clinicians. There are some states in the U.S. without a single ISTDP practitioner. Finding ISTDP clinicians to refer to is a constant struggle. I’d also like to see us create more opportunities for collaboration and cross-pollination with other emotion-focused and/or trauma-based models such as EFT or EMDR. I have some training in both of these modalities and find there is a surprising degree of overlap with ISTDP. 

Do you have anything in particular to say to the people going to or thinking about going to the event in January? 
I will be showing two cases that feature major unlockings of the unconscious, including some very surprising visual transfers. I presented the first case at the most recent Boston IEDTA conference for the session on highly complex and resistant cases. This is a unique opportunity to see examples of the twin factors (transference and resistance) activating an unusually strong unconscious therapeutic alliance. It’s also a great opportunity to see the profound healing power of guilt in Davanloo’s ISTDP.

Make sure to register for the January event soon as seating is limited. See the flyer for more information.

Below you’ll find some of our other recent interviews:

Jon Frederickson depression workshop in Stockholm on March 6th

Jon Frederickson

To treat depression, we must know what causes it. And by learning to assess each patient response, we can figure out what causes depression even in the therapy. Then we can address the cause and help the patient overcome her depression.

In this videotape presentation of a therapy session, we will learn how to identify what makes patients depressed so we can help them recover. The patient had suffered for years in spite of various therapies. She had a pattern of overworking, doing the work of others, and not being able to stand up for herself. Her husband was unemployed by choice, so she was the sole source of support. Due to her self-criticism, she couldn’t see her genuine capacities and strengths.

Through the moment-to-moment analysis of the session, we will learn how to support depressed patients, how to help them build the inner strength they need to face the feelings they have feared, and how to help them bear together with us what they could not bear alone.

This one-day workshop will take place at Ersta Bräcke Sköndal Högskola on the 6th of March 2020. For information and registration, download this flyer.