Etikett: istdp research

The limitations of ISTDP. Part 2: Patricia Coughlin

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

ON LEARNING ISTDP

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

Patricia Coughlin presentation
Patricia Coughlin

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

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

ON JARGON and research

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

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

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

ON RESEARCH GAPS

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

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

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

ON IDEALIZATION AND DEVALUATION

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

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

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

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

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

OTHER LIMITATIONS AND WEAKNESSES

Do you see other major limitations or weaknesses in ISTDP? 

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

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

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

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

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

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

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

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

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

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

Modifierad ISTDP för kronisk smärta: EAET

Under de senaste fyra åren har det publicerats fem randomiserade-kontrollerade studier på EAET, en modifierad variant av ISTDP för olika former av kronisk smärta. I den här artikeln sammanfattar vi resultaten från några av dessa studier.

Efter en livsomvälvande Halifaxresa började Howard Schubiner och Mark Lumley en ny etapp i sina karriärer som terapeuter och forskare. Året var 2009 och de två kollegorna hade rest till Nova Scotia för att delta vid Allan Abbass årliga Immersionkurs om ISTDP. När kursen var över gick de fram och tackade Allan, och frågade om det var rimligt att nu testa att bedriva ISTDP på egen hand. Allan svarade utan att tveka: “You can’t not do it“. Väl hemma igen började de experimentera med Allans interventioner och under åren som följde så utvecklade de en lightversion av ISTDP – Emotional awareness and expression therapy, EAET.

EAET

Schubiner, en av upphovspersonerna bakom EAET
Howard Schubiner

På en föreläsning med Howard Schubiner arrangerad av Svenska föreningen för EAET i mitten av november i år så berättar han om grunderna i behandlingen. För att möjliggöra att ISTDP sprids till en bredare grupp terapeuter så har han och Mark förenklat interventionerna på några centrala sätt. Howard beskriver EAET som en slags “ISTDP med bredare penseldrag” eller som “ISTDP light”. De har även infört användandet av expressive writing som ett sätt för patienterna att på egen hand närma sig känslor genom skrivande. Där ISTDP konsekvent fokuserar på upplevelsebaserat arbete här och nu så har EAET – i likhet med många KBT-manualer – ofta ett inplanerat psykoedukativt inslag i varje session. Detta betyder också att man tonat ned vikten av att arbeta i överföringen.

Centralt för EAET är arbetet med att skilja smärta som orsakas av känslomässiga processer, eller som Howard också säger, “pain caused by the brain” – i motsats till smärta som orsakas av faktiska strukturella skador i kroppen. När andra medicinska orsaker har uteslutits och en känslomässigt orsakad smärta har konstateras så ges patienten information och övningar i syfte att bryta den destruktiva onda spiral som lett till att patienten är rädd för smärta. Man skulle kunna säga att man till en början testar om patienten är öppen för att omvärdera sin övertygelse om att smärtan är farlig blott genom att få mer information om smärta och känslor. Därefter följer ett behandlingsprogram med fokus på att närma sig blandade känslor i utmanande situationer.

Den centrala övningen för att öva känsloreglering kallas för “Experiencing, expressing, releasing” (EER) och går ut på att uppleva, uttrycka och släppa taget om konfliktfyllda känslor. Övningen har fyra steg: 1) Utforska ilska i en konfliktfylld relation och släpp taget om försvar mot denna, 2) Utforska skuld kopplat till ilskan och sorg över hur relationen ser ut, 3) Utforska längtan efter närhet och kärlek till personen, 4) Diskutera en eventuell handlingsplan (förlåtelse? gränssättning? avsluta relationen?).

Figur från Thakur, Lumley & Schubiner (2015). “Model of Experiencing, Expressing, and Releasing: The Progression of Feelings about Stressful Relationships”

Här nedan är ett exempel på hur behandlingsplanen kan se ut i EAET över två månader:

Behandlingsplan, EAET för kronisk smärta (Yarns et al., 2020)

Individuell session: Rational för behandlingen, anamnes, emotionell palpering
Gruppsession 1: Mer rational, utforskande av kopplingen mellan känslomässig stress och symptom.
Gruppsession 2: Konflikttriangeln och information/övningar kopplade till ilska och närhet.
Gruppsession 3: Den centrala övningen “Experiencing, expressing, releasing” (EER) introduceras. Patienterna tänker på en aktuell påfrestande relationell situation och utforskar sina blandade känslor kopplade till denna.
Gruppsession 4: Mer EER. Fokus på skillnaden mellan hälsosam skuld och självanklagelser.
Gruppsession 5: Mer EER. Fokus på situationer när vi blivit sårade, negligerade.
Gruppsession 6: Mer EER. Fokus på skillnaden mellan hälsosam skuld och självdestruktiv skam.
Gruppsession 7: Fokus på interpersonell kommunikation. Gränssättande och sårbarhet/öppenhet.
Gruppsession 8: Sammanfattning, utvärdering och planering för fortsatt arbete.

Två viktiga studier

Mark Lumley, en av upphovspersonerna bakom EAET
Mark Lumley

I den första större studien av EAET så testade Schubiner och Lumley att utvärdera metoden för att behandla fibromyalgi. De randomiserade 230 fibromyalgipatienter till EAET, KBT eller psykoedukation i grupp. För att motverka så kallade “allegianceeffekter” – dvs. tendensen för forskargrupper att få resultat i enlighet med deras övertygelser –hade de rekryterat experter på KBT och psykoedukation vid fibromyalgi som såg till att dessa höll hög kvalitet. Även om skillnaderna var små på det primära utfallsmåttet både vid behandlingsavslut (d = 0,17-0,39) och uppföljning (d = 0,15 – 0,17) så var den generella bilden att EAET hade en större effekt än jämförelsebehandlingarna. Exempelvis fann man att EAET var mer effektivt för att behandla självskattade fibromyalgisymptom mätta med FM symptom scale (d = 0,35 – 0,45). Tydligast syntes skillnaden i effekt om man tittar på hur stor andel av deltagarna som fått en smärtreduktion om minst 50%. Där visade analysen att 22,5% av de som fått EAET, 8,3% av de som fått KBT och 12,0% av de som fått psykoedukation hade erhållit en smärtreduktion om minst 50%. Ett observandum var också att EAET-gruppen rapporterade fler biverkningar under behandlingens gång – till exempel att symptom förvärrades – även om det efter behandling var färre deltagare som hade försämrats i denna grupp (EAET 2,8%, KBT 3,5%, Psykoedukation 8,2%).

I en andra randomiserad-kontrollerad studie lottade man 53 äldre veteraner med muskuloskeletal kronisk smärta till gruppbehandling med antingen EAET eller KBT. Medelåldern var 75 år och över 90% var män. Effektskillnaderna var betydligt mer markanta i den här studien. Medan 10 av de som gått i EAET-grupp (41,7%) fick en kliniskt signifikant effekt så var det en av de som gått i KBT-grupp (5,4%) som fick det. Som man kan se i figuren nedan så var det flera av de som gått i EAET som gjorde dramatiska förbättringar, fyra av dem en smärtreduktion på över 70%. I termer av effektstorlekar så fann man att EAET hade en stor behandlingseffekt jämfört med KBT vid behandlingsavslut (d = 0,77) och tremånadersuppföljningen (d = 0,86).

Figur från Yarns et al., 2020.

LEVA med eller bota smärtan?

Schubiner lyfter fram att många psykologiska interventioner för smärta mer handlar om att lära ut effektiva sätt för att leva med smärta snarare än att stoppa smärtan. I dagsläget finns många behandlingsmetoder som gör just detta, såsom KBT och ACT. Även om dessa behandlingar är väldigt bra på olika sätt så menar Schubiner att de begränsas av denna idé om att lära sig att leva med, snarare än att bota smärtan. Även om EAET använder sig av vissa standardelement från dessa andra behandlingar, såsom psykoedukation och exponering, så är grundantagandet i EAET att smärta faktiskt går att “bota” eller åtminstone reducera dramatiskt.

Den centrala hypotesen om varför EAET skulle vara mer effektivt är att patienterna upprepade gånger får hjälp att närma sig sina blandade känslor kring stressfyllda och traumatiska händelser från tidigare i livet. Så hur ser då forskningsresultaten ut överlag? Här är en sammanfattning i tabellform av de randomiserade-kontrollerade studier som har gjorts.

DiagnosDeltagareSessionerResultat50% smärtminskning
Thakur et al., 2017IBS1063EAET > avslappning > WL
Lumley et al., 2017Fibromyalgi2308EAET > KBT > psykoedukation22,5% (8,3% KBT, 12% psykoedukation)
Carty et al., 2018Kronisk urogenital smärta621EAET > TAU
Ziadni et al., 2018Medicinskt oförklarade symptom751EAET > TAU
Yarns et al., 2020Kronisk smärta539EAET > KBT33,3% (0,0% KBT)
Översikt av RCT-studier av EAET

Den mest välbeforskade psykoterapeutiska behandlingsformen för kronisk smärta är utan tvekan KBT. KBT är en väletablerad behandling med mycket goda effekter vid många andra tillstånd (så som i behandling av GAD eller tvångssyndrom), men vid kronisk smärta så är effekten betydligt mer blygsam. I en nyligen publicerad cochraneöversikt hade KBT i genomsnitt en obefintlig/minimal effekt (d = 0,09) på smärta i jämförelse med aktiva kontrollgrupper. En aktuell metaanalys konstaterade att 13,3% av deltagarna (105 av sammanlagt 789 studiedeltagare) som fått KBT för fibromyalgi fått en smärtreduktion om minst 50%. När författarna till metaanalysen kommenterar effekterna skriver de att i enlighet med studiens fördefinierade analysplan, “there was no clinically relevant benefit of CBTs.“

I de två studier där EAET jämförts med KBT ser man en viss fördel i den första studien (d = 0,17), och en stor fördel i den andra (d = 0,77). Eftersom den andra studien är betydligt mindre (N = 53) bör detta resultat betraktas som lovande men preliminärt. Vi behöver fler studier för att kunna dra mer säkra slutsatser. Vidare så uppnådde 22,5% respektive 33% av deltagarna en smärtreduktion om minst 50%. Ett kortare förlopp EAET tycks alltså kunna hjälpa drygt en fjärdedel av deltagarna till en smärtreduktion som är större än 50%.

Detta innebär dessvärre att många av studiedeltagarna inte blivit “botade”, och som syntes i figuren ur Yarns et al. (2020) ovan så var det många av deltagarna som inte fick någon effekt alls. Med tanke på att en stor andel av smärtpatienterna har strukturell skörhet och behöver ett något mer tidskrävande graderat behandlingsformat bör detta inte komma som en överraskning. För framtida studier vore det intressant att se om en längre, mer omfattande behandling – kanske med fler inslag av individuella sessioner – möjligtvis kan hjälpa fler patienter.

Svenska studier

Robert Johansson och Daniel Maroti vid Stockholms Universitet/Karolinska Institutet genomförde under hösten 2019 en pilotstudie av EAET i internetformat för att behandla kroppssyndrom. De preliminära resultaten från den studien presenterades i samband med Howards föreläsning den 13:e november. De fann att EAET i internetformat gav mer än 50% smärtreduktion för ca 22,5% av deltagarna, vilket alltså i grova drag är liknande resultat som när behandlingen testats i randomiserade studier i gruppformat. Du kan se Daniels presentation i klippet nedan, ungefär 1 timme, 43 minuter och 30 sekunder in. Formatet för internetbehandlingen är det som vi beskrivit tidigare här på ISTDPsweden: guidad självhjälp.

Howard Schubiners föreläsning via Zoom den 13:e november. Uppladdad av EAET Sverige.

Tidigt under 2021 kommer Daniel, Robert och deras forskargrupp att dra igång en större, randomiserad studie av EAET som du kan läsa mer om här: http://mbsstudien.se/. I nuläget (november 2020) håller de på att rekrytera deltagare.

Den nystartade Svenska föreningen för EAET har en hemsida som du kan se här: eaet.se

Nedan hittar du våra senaste artiklar här på ISTDPsweden som handlar om nya forskningsrön:

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

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

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

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

Dion Nowoweiski portrait
Dion Nowoweiski

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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: