Är challenge nödvändigt? Ny studie

I dagarna har Fateh Rahmani med kollegor vid Kurdiska Universitetet i Iran publicerat ytterligare en RCT-studie på ISTDP för socialt ångestsyndrom, där de också undersökt om challenge är ett nödvändigt element i ISTDP. Här sammanfattar vi några av slutsatserna från studien.

Fateh Rahmani har publicerat ny studie på ISTDP för social ångest
Fateh Rahmani

Challenge

I arbetet med personer som lider av känslomässig överkontroll – eller högt motstånd som Davanloo kallar det – kännetecknas ISTDP av mer konfrontativa interventioner. Högt motstånd åsyftar alltså personer som har god tillgång till intellektualiserande och rationaliserande försvar, men som är fast i dessa på ett mycket oflexibelt sätt. Detta kan leda till upplevelsen av att vara känslomässigt avstängd, distanserad och att man är som en observatör i sitt eget liv. När Davanloo utvecklade ISTDP var det bland annat för att hitta en sätt att hjälpa denna grupp av patienter att bli kvitt sitt motstånd, i en tid när de av många betraktades som omöjliga att hjälpa.

Interventioner av gradvis ökande känslomässig intensitet - från småprat till challenge
Schematisk illustration av interventioner med gradvis ökande känslomässig intensitet

Efter en första stund av arbete med att kartlägga försvaren, deras funktion och de negativa konsekvenserna av dem, så menade Davanloo att terapeuten bör övergå till att använda sig av challenge. Det här är förmodligen ett av Davanloos mest originella bidrag till psykoterapin. Från att terapeuten till en början uppmuntrar patienten att göra positiva saker (känna känslor, gå i riktning mot sina mål, undersöka sig själv och så vidare) så skiftar terapeuten här fokus till att uppmuntra patienten att sluta göra något som är negativt för dem. Så här kan en fas av challenge se ut, något förenklat:

Terapeuten: Nu har vi pratat en stund om hur du går upp i dina tankar istället för att känna efter (Intervention: Prata om försvaret: intellektualisering).

Patienten: Mm (suckar).

T: Att du går upp i tankarna är hur du undviker att vara i kontakt med vad du känner. Och undviker att vara i kontakt med mig. (Intervention: Prata om funktionen av försvaret)

P: Mm (suckar).

T: Och så länge du gör så, går upp i tankarna, kommer vi ju inte att kunna hjälpa dig i den här terapin. Eller vad tror du? (Intervention: Prata om de negativa konsekvenserna av att göra försvar)

P: Nej… jag är bara så fast i att tänka. (suckar)

T: Så vad kan vi göra åt att du fortsätter gå upp i tankarna istället för att känna efter? (Intervention: Uppmuntran att vända sig mot försvaret)

P: (suckar)

T: Vad känner du just nu om du inte går upp i dina tankar? (Intervention: Challenge)

P: Jag vet inte… (suckar)

T: Igen går du upp i tankarna. Märker du det? Så om du inte tänker efter, vad är det för känslor som dyker upp just nu? (Intervention: Challenge)

P: (suckar)

Att patienten suckar är här ett tecken på att interventionerna faller väl ut och att patienten både tolererar och kanske till och med behöver challenge för att närma sig känslor. Men challenge är ett tveeggat svärd. På grund av den konfrontativa aspekten så är interventionen något som många terapeuter har svårt att bemästra.

Om man använder sig av challenge innan patienten tydligt har sett sitt försvar, funktionen av det och priset av det, så riskerar man att skada alliansen. Patienten kan uppleva det som att samarbetet brister och att terapeuten är kritisk. Detta kallas för prematur challenge, eller “challenge at low rise”.

Och om man använder sig av challenge i arbetet med sköra patienter så tenderar detta att mobilisera så mycket känslor på en gång att patienten går långt över sin ångesttröskel och blir överväldigad. Snarare än att känslor långsamt får mobiliseras och försiktigt närma sig tröskeln så leder challenge alltså till väldigt tvära kast, med risk för alliansbrott och omfattande regressiva processer.

Den aktuella studien

I den föreliggande studien ville Rahmani med kollegor undersöka dels om ISTDP är effektivt vid socialt ångestsyndrom, och dels om challenge verkligen är en nödvändig intervention för en effektiv ISTDP-behandling. De randomiserade 42 deltagare med social ångest till antingen väntelista, ISTDP eller ISTDP utan challenge (“Interpretation-based ISTDP”, IB-ISTDP). Det var samma terapeuter som bedrev de båda behandlingarna, och de gick en kort utbildning för försäkra sig om att de på ett kompetent sätt skulle kunna arbeta utan challenge. Behandlingarna var korta, åtta sessioner. Det här upplägget påminner om den andra RCT som Rahmani med kollegor publicerade tidigare i år, där de jämförde ISTDP med känslofokus och ISTDP med försvarsfokus. Det påminner även om en välkänd studie av interpersonell terapi, “Is exposure necessary?“, där två olika traumabehandlingar – en med och en utan exponering – jämförts med varandra.

Utfallet visade att de båda behandlingsgrupperna hade stora effekter jämfört med väntelista, både efter behandling och vid sexmånadersuppföljning. Författarna själva rapporterar inte antalet patienter som gått i remission, men medelvärdet på självskattningsskalan LSAS-SR minskade med mer än 50% för båda behandlingsgrupperna och slutade under klinisk cut-off på LSAS-SR (LSAS-SR < 30 helskalepoäng). Detta indikerar en väldigt god behandlingseffekt.

Är challenge nödvändigt?

Så är det nödvändigt att använda challenge för att uppnå goda resultat inom ramarna för en ISTDP-behandling? Korta svaret: nej. Den här studien fann inget stöd för att challenge gav någon tilläggseffekt utöver de andra teknikerna som ingår i ISTDP (pressure, clarification, recap). Författarna själva tolkar detta resultat som att challenge antagligen inte behövs eftersom känslor ändå aktiveras tillräckligt mycket.

“It may be that a more gradual mobilization without prominent use of challenge, results in adequate activation of these dynamic forces in enough cases to not reveal significant differences in outcomes between groups.” (Rahmani et al., 2020).

En förklaring till detta är att många personer med socialt ångestsyndrom inte lider av överkontroll/högt motstånd utan snarare är drabbade av känslomässig underkontroll – vad vi inom ISTDP kallar för repression och skörhet. Med dessa patienter är challenge oftast kontraindicerat, eftersom det sätter för mycket press på patienten. Om vi använder challenge med en patient som är skör så kommer detta sannolikt leda till att ångesten blir för hög eller att olika primitiva försvar, såsom splitting och projektion, drar igång. ISTDP för sköra patienter kännetecknas av ett mer försiktigt tillvägagångssätt som betonar psykoedukation, kognitiva sammanfattningar och andra övningar i att intellektualisera. Antagligen var det precis detta de flesta av deltagarna i studien behövde.

Ett mer finmaskigt svar på frågan om challenge är nödvändigt skulle alltså behöva selektera en grupp patienter med högt motstånd och randomisera dem till ISTDP med eller utan challenge.

Ytterligare en möjlig förklaring till att ISTDP utan challenge klarar sig så bra är dodo bird-effekten. När två bona fide-behandlingar jämförs hittar man generellt sett inga skillnader i effekt.

Rahmani, F., Abbass, A., Hemmati, A., Ghaffari, N., Mirghaed, S.R., (2020) Challenging the role of challenge in intensive short-term dynamic psychotherapy for social anxiety disorder: A randomized controlled trial. Journal of Clinical Psychology. https://onlinelibrary.wiley.com/doi/10.1002/jclp.22993


Här är våra senaste artiklar om forskning på ISTDP:

Allan Abbass: “At first doing ISTDP felt unnatural”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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:

Jon Frederickson: “Training with Davanloo was startling”

We did an interview with Jon Frederickson ahead of his first ISTDP workshop on Finnish soil at the end of March. In the interview he discusses the relationship between psychoanalysis and ISTDP, as well as his own discovery of ISTDP and other themes.

Jon Frederickson portrait
Jon Frederickson

How do you feel about going to Finland to present for the first time? 
I’m very excited of course to teach a new group of therapists. But, honestly, what has me really excited is to be in the homeland of Sibelius. Such a giant in classical music! If only I had a little more time, I would visit his home in the woods and absorb the mood of the forest of which his music spoke.

For people who don’t know you, how did you end up becoming a therapist and later on specializing in ISTDP? 
I was initially inspired to become a therapist through the writings of Erich Fromm. Such an inspirational writer, a psychoanalyst, a sociologist, an atheistic mystic. How could I not be fascinated by such a brilliant and heartful role model! I became psychoanalytically trained and some years later had a chance to see videotape of ISTDP. It was like seeing psychoanalysis live and active in a way I had never dared to imagine.

In the nineties you had quite a lot of training with Patricia Coughlin, and later on you met Davanloo and trained with him. How did you find training with Patricia and Davanloo? 
Supervision with Patricia revolutionized my work as a therapist, making my therapy far more focused and effective. With Davanloo, it was a bit startling. I was chair of a psychoanalytic psychotherapy training program and yet with Davanloo I was for the first time understanding many concepts on far deeper levels than I ever had before. Sadly, he dismissed psychoanalysis at that point in his career. Yet his training only deepened my appreciation and understanding of its depths.

Speaking of psychoanalysis, what’s your perspective on the relationship between psychoanalysis and ISTDP? 
Freud said that any therapy is psychoanalysis if it operates with a concept of the unconscious and the transference. ISTDP meets those criteria. ISTDP is obviously more active an approach than a classical analysis done on the couch. However, its work is entirely based on the exploration of unconscious feelings, addressing unconscious anxiety, and the careful work with unconscious defenses and resistance in the transference relationship. And in line with Bion’s statement about psychoanalysis, our work is based on faith that the patient will become healed by becoming at one with the emotional truth of this moment. 

In Helsinki you’re doing a workshop on trauma. Does ISTDP offer a unique take on trauma, or is this a standard psychoanalytic perspective?
I don’t know how to answer that because psychoanalysis is such a pluralistic community now that it would be reductionistic to claim that there is “one” way psychoanalysts work with trauma. Unlike some other communities, ISTDP therapists and analysts understand that the effects of trauma depend on multiple factors such as the child’s age when the trauma occurred, nature of the trauma, genetics, temperament, and the parental response to trauma.

We also recognize that dealing with the trauma involves not just the mind but the body. And we also recognize that issues of symbolization and mentalization must be carefully attended to. And we also note whether it was a one-time trauma or a case of cumulative trauma. All these factors lead to a complexity in treatment which any psychoanalytically informed clinician must take into account.

ISTDP is in many ways still a “new form of therapy”, given that so few people have been trained in it. What are some of the aspects of ISTDP that still are in need of development? 
ISTDP, while quite effective in research studies, has yet to develop research specifically into the treatment of narcissistic personality disorder and perversions. Our recent research with drug addicts is showing a surprising amount of effectiveness with patients suffering from psychotic symptoms. So I think we need to do more research into what differentiates the near-psychotic group of patients who respond to work on splitting and projection, and the psychotic level of character structure that does not respond. Given the successes we are having, I am hoping we can build on Marcus’ work on near-psychosis in our future work.

A common reaction to reading about ISTDP or watching a presentation is that the method is confrontational and even violent. Should ISTDP be less confrontational?
ISTDP isn’t violent, defenses are. That’s we try to block and identify defenses which do violence to the patient. Let us not forget that defenses cause the patient’s problems and presenting problems. They are a form of internalized violence. And the most compassionate thing we can do is block unconscious forms of violence that hurt the patient, and to help them see these previously invisible mechanisms so that he they have a chance to do something different.

Likewise, we don’t interrupt the patient. We interrupt the defenses that interrupt the patient. We never interrupt the heart speaking from its depths, we interrupt the defenses that keep the patient from speaking from her heart. Also, the idea of confrontation makes no sense about 99% of the time. After all, if the poor patient can’t see a defense, is not using it intentionally, and is unaware of it, he just needs some compassionate help to see his defenses. Otherwise, how could he do anything different in the moment?

Think of self-attack. It’s a form of violent communication to oneself. A child who grew up with a critic becomes a critic to himself. The nicest thing we can do is interrupt this form of self-cruelty and help the patient look under that defense to see what the feelings are being warded off.

Coming back to you, in what ways have your way of doing therapy changed over the past five or ten years, and why?
Hahaha! Throughout my career, as I look back, I can see that I have increasingly surrendered my resistance to being here, now, with the patient I have. I am increasingly able to accept the patient unconditionally, without needing him to change in any way. This may sound easy or trivial to readers who believe you already do this. And, if you do, good for you! But I find that this is a universal journey we take as therapists as we give up even the tiniest resistances to reality: meaning the patient as he is. My work has become very attuned to the tiniest cues of the unconscious will-to-health. And that shift may be the most important technical shift in my work recently.

What are you struggling to learn as a teacher and therapist right now? 
I’m in the midst of several projects with the aim of developing new forms of training and supervision. The research shows that graduate training does not improve therapist effectiveness. And after graduation, research shows that therapists do not improve. Research also shows that 93% of psychotherapy supervision is ineffective and 35% actually harmful. So in this part of my career I am most interested in researching what helps therapists become more effective. That is why I am focusing on skill building exercises and DVDs. I have a skill building book coming out next year. And I’ve begun a three-year study where we will study learning processes in a training group. That research will be the basis of a book I will write on the teaching and learning of experiential therapy.

You have two new books in the making. Can you tell us something about them?
My next book, Co-Creating Safety: treating the fragile patient, is designed for therapists who want to learn how to treat the most disturbed patients in their caseloads, ranging from patients who just had a psychotic break to patients in the borderline spectrum of character structure. After that, my next book will be, Healing Through Relating, a skill building book with skill building exercises training therapists in the fifty most important skills in developing a therapeutic alliance. I was trained as a professional musician. So I’m trying to develop some “étude” books now for therapists.

Would you like to say something directly to the Finnish audience about the event? 
I look forward very much to showing you a three-hour session which will allow us to learn concepts, see them put into action, and see how a patient begins to recognize the unconscious enactments that have driven her suffering. There is something about seeing a real therapy that is helping the patient moment by moment that is unlike any other kind of learning experience. I look forward to seeing you there!


If you liked this Jon Frederickson interview, you might be interested in our other interviews. Among them, there’s another Jon Frederickson interview from last year. There’s also a recent interview with Kristy Lamb on ISTDP for addictions that might be of interest. Here are the five most recent interviews:

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