Terapi via videolänk

Hur bedriva terapi via videolänk? Under mars 2020 kom viruset CoViD-19 med kraft till Sverige, och många av oss har gått över till att träffa våra patienter via videolänk istället för fysiska besök. Här finns några tips och råd till terapeuter som håller på att öppna upp för internetverksamhet.

Varför minska antalet fysiska besök?

I vanliga fall så är videolänk en bra lösning för att exempelvis träffa patienter som bor på annan ort, eller som av någon annan anledning inte kan ta sig till kontoret. Under den pågående pandemin är incitamenten givetvis fler. En av de viktigaste åtgärderna för att hindra fortsatt smittspridning av COVID-19 är social distansering. Viruset smittar via direkt och indirekt kontakt mellan människor, så genom att dra ner på dessa kan vi bidra till att antalet smittade inte ökar så fort. Vi och våra kontor är potentiella smittohärdar, så ju mer vi kan göra online, desto bättre. Jon Frederickson beskriver detta på ett konkret sätt på sin facebooksida:

Covid virus kills.

Not everyone, but enough that you don’t want to be the one responsible for passing death on to a distant person. As therapists who see lots of people who see lots of people, you are natural super-spreaders. Spread sanity, not denial.

Anyone in private practice can move their practice online. Prevent yourself from getting infected and prevent yourself from spreading the virus unwittingly to your patients and their loved ones.

If you work in outpatient clinics, urge management to move all work online until the pandemic has passed. Asking patients to come into groups where they could be infected is a violation of our ethical guidelines.

Vad säger forskningen?

Det finns en del forskning gjord på psykoterapi via videolänk. En systematisk översikt av 65 studier visar att resultaten från videolänksamtal är jämförliga med face-to-face. Ytterligare en systematisk översikt vid ångestsyndrom bekräftar detta fynd. Studier visar även att exempelvis den terapeutiska alliansen utvecklas lika väl via videolänk och att videolänk även fungerar i behandling av barn.

Majoriteten av den hittills publicerade forskningen på terapi via videolänk är gjord på KBT. Hittills finns det bara två publicerade studier på ISTDP i videolänkformat. Det är en iransk forskargrupp ledda av Behzad Chavooshi som jämfört ISTDP face-to-face med ISTDP över videolänk för att behandla medicinskt oförklarad smärta. Chavooshi med kollegor fann bekymrande nog att ISTDP via videolänk inte hade någon effekt, trots att samma terapeuter fick väldigt goda effekter med de patienter som randomiserats till face-to-face.

I artikelns diskussionsdel lyfter Chavooshi med kollegor fram två möjliga förklaringar till detta: å ena sidan bristande ljud- och bildkvalitet, och å andra sidan det faktum att ISTDP betonar ögonkontakt, vilket kan vara svårt eller omöjligt att få till genom gränssnittet kamera/skärm. Dessa resultat talar hursomhelst för vikten av att systematiskt utvärdera behandlingarna för att försäkra sig om att de verkligen är verksamma.

Vad säger psykologförbundet och socialstyrelsen?

Förutom alla de praktiska utmaningar det innebär att plötsligt kommunicera genom videokamera, mikrofon, skärm och högtalare/hörlurar så finns det också juridiska utmaningar. Den centrala saken du som terapeut behöver känna till är att Socialstyrelsen kräver att samtalen är krypterade och att de sker med så kallad stark autentisering vid digitala patientbesök. Såhär skriver psykologförbundet:

Alla typer av patientkontakter via internet sker med användande av vad Socialstyrelsen kallar ”öppna nät”. Det finns regler i Socialstyrelsens föreskrifter om vilka krav som då ställs, och som ska säkra att den personliga integriteten skyddas när uppgifter om patienter hanteras i öppna nät. De viktigaste delarna att tänka på är att själva kommunikationen ska vara krypterad. Därigenom kan inte några obehöriga ta del av de uppgifter som går via datanäten. Dessutom krävs att patientens identitet säkras innan mottagaren får del av några uppgifter, enligt föreskrifterna ska det ske genom stark autentisering, t.ex BankID. 

Psykologföretagarna kan inte ge några rekommendationer om vilka olika leverantörers internetlösningar som bör användas. Om du som företagare vill undersöka vilka digitala plattformar som kan användas bör du med leverantör undersöka;  
– hur hanteras GDPR:s regler 
– hur lagras information om användare  
– var finns servern  
– är data krypterad  
– om och var sparas/lagras data
– vem äger data

(https://www.psykologforbundet.se/aktuella-fragor/covid-19/fragor–svar—for-dig-som-egenforetagare/)

Stark autentisering betyder att patienten har bekräftat sin identitet på minst två olika sätt, exempelvis genom något man vet (ett lösenord) och något man har (en mobiltelefon). En vanlig lösning för detta är alltså BankID. Stark autentisering inkluderar också andra former av tvåfaktorautentisering, där användaren identifierar sig med ett lösenord och genom en pinkod som skickas till mobiltelefonen.

Nedan hittar du några förslag på tjänster som erbjuder videolänk med stark autentisering. Lägg märke till att flera av dem kräver att du som användare aktiverar stark autentisering i inställningarna (“two-factor authentication”, “multi-factor authentication” etc.). Du behöver också ta ställning till de andra faktorerna som psykologförbundet radar upp i citatet ovan (GDPR, lagring, kryptering osv).

Förslag på videosamtalstjänster:

Hur är det att arbeta via videolänk?

Vi bad några ISTDP-terapeuter som arbetar med terapi via videolänk dela med sig av sina erfarenheter. Binnie Kristal-Andersson och Christofer Gradin Franzén har jobbat under ett antal år via videolänk, medan Follad Yarollahi och Sandra Ringarp har kommit igång under det senaste året.

Christofer Gradin Franzén
Christofer Gradin Franzén

Hur var det att komma igång med att arbeta via videolänk?
Christofer: Jag hade en del tvivel kring hur det skulle fungera innan mitt första samtal. Det handlade framför allt om möjligheten att få en känslomässig kontakt utan möjlighet till riktig ögonkontakt, samt kring mina möjligheter att uppmärksamma kroppsliga signaler på ångest. Det visade sig dock snabbt att skärmen inte utgjorde något större hinder mot att få känslomässig kontakt. Samtalen känns förvånansvärt lika de som sker med patienter som sitter mitt emot mig i mitt mottagningsrum.

Sandra: Det har gått väldigt smidigt att komma igång tycker jag. När jag väl hade valt ett säkert sätt att arbeta via video (Kaddio) och försäkrat mig om att det tekniska fungerade så var det bara att sätta igång. Många klienter har varit positiva till det.

Follad: Jag har arbetat med samtal via telefon ett längre tag och att gå över till video tyckte jag endast medförde fördelar. Speciellt med tanke på den typ av feedback (suckar, icke-verbal kommunikation) som vi är uppmärksamma på i ISTDP. Jag betraktar det som en hierarki där besök i rummet är att föredra om den möjligheten finns, annars video och sist telefon. Jag hade såklart en del tekniska problem i början men nu skulle jag säga att tekniken mognat till den grad att det inte är ett direkt hinder längre.

Binnie: Jag började med terapi via videolänk kring 2009 när Skype släpptes för allmänheten. Det var en klient som föreslog det, då hen inte skulle ha möjlighet att genomföra fysiska besök under ett tag men ändå ville fortsätta med behandlingen. Jag var inte så tekniskt lagd, men jag lyckades få till det. Generellt har jag använt videolänk när patienter har varit ute på resande fot, som ett komplement till att träffas på kontoret. Men jag har också gjort en del onlineterapier där jag bara träffat patienten via videolänk. Jag läste ju också Coreutbildningen via Skype, så jag har suttit mycket framför skärmen! 

Vad har varit den största utmaningen med att arbeta via videolänk?
Christofer:
De talade orden och de känslor som kommer till uttryck i ansiktet tenderar att hamna i fokus, eftersom resten av kroppen oftast inte syns lika tydligt. För mig har detta inneburit att jag för att få viktig information om resten av patienten och det som väcks i mötet har behövt öva mig på att oftare bjuda in patienten till att hjälpa mig observera och dela information om vad som händer i de delar av kroppen som jag inte kan se. Utmaningen kan väl beskrivas som att jag behöver komma ihåg att det finns viktiga signaler och information som jag behöver för att kunna möta patienten där hen är, som jag inte har tillgång till och att jag behöver påminna mig själva om att ställa fler frågor om det som händer utanför eller som inte blir tydligt på skärmen. I och med att detta också tydliggör och påminner både mig och patienten om betydelsen av ett aktivt samarbete så upplever jag att den här utmaning också har haft positiva effekter på behandlingarna.

Sandra Ringarp

Sandra: Jag tycker att videosamtal fungerar väldigt bra överlag vad gäller behandling. Den största utmaningen tycker jag har varit att ha ett förstabesök över videolänk med någon som mår väldigt dåligt. Då tycker jag att det är svårare att göra en bedömning över videolänk än i ett samtal på min mottagning. Jag känner mig tryggare med att göra en suicidriskbedömning när någon sitter med mig i rummet, helt enkelt. Jag vet inte om det beror på att något går förlorat i ett besök via videolänk, eller om det snarare handlar om rädsla och ovana hos mig som behandlare. Kanske är det en kombination av båda.

Follad: Den största utmaningen för mig har varit att hitta formen för samtalet. Jag tror att terapi via videolänk kan hjälpa många att få hjälp med sin psykiska ohälsa, men det är långt ifrån lämpligt för all sorts problematik. Om man lägger sina egna och klientens förväntningar på rätt nivå så tror jag man kan åstadkomma mycket. Det var något jag funderade på en hel del i början. Vilken nivå kan man rimligen lägga sig på? Behöver man anpassa metoden på något sätt? Hur ser möjligheten ut att fånga upp signaler (man får vara mer frågvis)? Och hur man kan hantera eventuella tekniska problem som dyker upp under samtalet? Och så vidare. Exempelvis kan det vara svårt att urskilja om personen suckar, har tårar i ögonen eller byter tonläge i rösten. Har man en dålig uppkoppling så kan man lättare missa detaljerna. Eftersom vi är vana att titta på video redan så märkte jag att det inte var sådant stort hinder ändå.

Binnie: Att etablera närhet trots att skärmen är emellan oss tycker jag är det svåraste. Inom ISTDP så vill vi ju gärna se hela patientens kropp, och det går ju inte lika lätt att få till. Men övriga aspekter av terapiformen går alldeles utmärkt att göra via videolänk – pressure, mobilisera UTA, klarifiera försvar och så vidare.

Har du några tips till terapeuter som funderar på att börja arbeta via videolänk?
Christofer:
Ett tips är att komma överens innan samtalet om hur du och patienten hanterar tekniska problem. Alltså om videon av en eller annan anledning inte fungerar, hur gör ni då? Jag brukar ringa upp mina patienter, då jag tycker att det är lättare att problemlösa över telefon. I och med att jag börjat berätta om detta innan, så vet de om att jag kommer ringa och kommer därför att uppmärksamma telefonen (som de annars ofta stänger av eller sätter på ljudlös under samtalet).

Sandra: Välj en it-lösning som du känner dig trygg med. Det finns flera alternativ att välja mellan som uppfyller krav på sekretess. Testa att allt fungerar i lugn och ro innan samtalet så att du slipper krångel när det är dags. Jag brukar starta om datorn innan mitt första samtal för dagen för att minimera onödigt strul. Be patienten att justera sin dator eller position om det behövs för att få den visuella information du behöver. Men kanske mest av allt: var inte rädd för att prova. Det kan vara lätt att tro att kvalitén på samtalet automatiskt blir sämre när man inte är i samma rum, men det har inte varit min upplevelse.

Follad Yarollahi

Follad: Vänta inte med att sätta igång. Det är som med allt annat nytt, det kan vara lite ovant och pirrigt i början. Men luta dig tillbaka på dina samtalsfärdigheter så kommer du snart märka att det blir lättare. Fokusera på klienten, signalerna och innehållet. En del har jag märkt är oroliga för vad som händer om exempelvis tekniken strular under samtalet. Så det är viktigt att förbereda sig själv och klienten på vad ni gör om det händer. Ofta är det ett tillfälligt problem, kanske någon som har dålig mottagning. Viktigt är också givetvis att man sitter så man inte blir störd. Försök se fördelarna med det. Om vi inte hade tillgång till video, vilken hjälp hade min klient kunnat få då?

Binnie: Ett tips är att först testa med vänner och familj. Se alltså till att du är helt och hållet bekväm med tekniken innan du testar i skarpt läge med en patient. Det är viktigt för att hantera sin nervositet kring det tekniska. Eftersom vårt arbete handlar om att ge trygghet, så måste vi först skapa en struktur som vi själva är trygga med. I inställningarna i exempelvis Skype kan man slå på kameran innan man ringer upp. Det är bra att testköra och kolla av att du är nöjd med hur du ser ut och hur bakgrunden syns: en tom vägg, en bokhylla och så vidare.

Vilka är egentligen de största fördelarna med att arbeta via videolänk?
Sandra: En oväntad fördel som jag märkt är att det kan påverka en behandling positivt att ha samtal via videolänk. Min upplevelse är att den distans som skärmarna/kamerorna skapar ibland kan göra att patienter får lättare att släppa sina försvar. En känslomässig distans kan minskas genom att införa en fysisk distans, och arbetet kan få sig en oväntad skjuts framåt.

Binnie Kristal-Andersson

Vad är den största lärdomen du gjort av att arbeta via videolänk?
Binnie: Vikten av att vara helt och hållet närvarande. Om du vågar vara närvarande och öppen, autentisk, och äkta även genom en skärm – då kommer du komma långt. Oberoende av vilken terapiform man arbetar med så är det inte teorin som står för större delen av effekten. Det är terapeuten som person som är det centrala. Så om du är en “äkta människa”, med full uppmärksamhet på den andra personen, det är då kommer du att nå fram. Den andra lärdomen är hur starkt det kan vara att arbeta med kombinationen av att träffas fysiskt och träffas via videolänk. Om omständigheterna tillåter så kan detta göra terapierna mycket mer kraftfulla.

Tror du att digital vård bli en permanent del av vårdutbudet?
Follad: Jag tror att det som händer nu kommer ge digital vård en positiv push. Det hade tagit längre tid för världen att ta till sig digital vård som ett attraktivt alternativ. Och det hade varit synd. Jag tror att digital vård gör att man kan fånga upp många som annars inte hade sökt hjälp. Man kan tycka vad man vill om trenden med att allt fler folk sitter med sina mobiler hela tiden. Och vad det gör med vår förmåga att knyta an till varandra. Frågan för mig är hur vi som behandlare kan väcka lust och nyfikenhet kring att utforska sitt inre. Många ungdomar idag exempelvis söker sig till plattformar där tröskeln är lägre. Till exempel plattformar där man kan skicka meddelanden till en psykolog via app. Vilket jag tror sänker tröskeln för dem att sedan gå vidare till att träffa en psykolog. Därför tänker jag att fler av oss bör våga ta steget och möta dessa människor där de är. Kan vi bidra med goda erfarenheter av samtal så ger det förhoppningsvis mersmak i längden.


Om du är intresserad av att läsa fler av våra guider så hittar dem här:

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:

You can find all of our content in english by following this link.

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.

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

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!

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.

[CANCELLED] Jon Frederickson trauma workshop in Helsinki in March 2020

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

Jon Frederickson

As the writer William Faulkner once said, “The past is never dead. It’s not even past.” And what better example of that can we find than in the ways patients relive their traumas from the past in their present life. Every therapist knows that what patients cannot put into words they will put into action. The question becomes: how do we help patients move from reliving their traumas in therapy to being able to work through those traumas so that they become free to live into life in a new way.

We will study a videotaped three-hour initial session with a woman who had been in therapy for over twenty years. Her therapy had helped her understand her past cognitively, but it had not changed her emotionally. She was still suffering from depression, anxiety, and a series of relationships with abusive men.

Learning objectives:

  • to help patients work through traumatic memories and experiences.
  • how to help patients bear what was once unbearable.
  • how to link bodily experiences in therapy with past traumas.
  • how to deactivate projections onto the therapist.
  • how to help patients move from reliving the past to living in the present.

The event will take place on the 26th of March in downtown Helsinki. For more information and registration, here´s a flyer. For information in Finnish, follow this link.

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

Jon Frederickson: “Hearing a paper only helps you get better at hearing papers”

Here’s another interview on the topic of the IEDTA conference in Boston in late September. This time, we sit down with Jon Frederickson who chaired the panel on addiction

Jon Frederickson

What do you feel about being at the conference?
I enjoyed it very much. It’s always great to be among friends to and to see lots of videotape of cases. I learned a lot from seeing a wide variety of therapists working with a broad range of patients. It’s so important to have conferences where we see actual videotapes of clinical work. Research shows that the usual conferences we have seen do not improve therapist outcome. After all, hearing a paper only helps you get better at hearing papers. Watching videos of skilled clinicians, however, helps us see what we could do even better.

Was there any contribution that stood out to you?
I was very impressed by Robert Johansson’s presentation where he showed how statistical analysis can enable us to sort out which portions of a treatment model contribute to outcome and by what percentage. I look forward to his help in us analyzing our drug rehabilitation program so we can fine tune our treatment to improve outcome. I was also impressed by Allan Abbass’ work with a psychotic patient. The patient had been very disturbed and homeless. Yet, Allan’s work showed that often psychotic symptoms, though dramatic, may actually be occurring in a patient with a borderline level of character pathology. Thus, they can be treated. I also enjoyed Katie’s presentation where she is researching the effects of EDT training on therapists. She and I will do a research project next year with my next core group in Washington, DC. Steve Shapiro also showed a lovely piece of work with a borderline patient where he helped her see how her hallucination was a projection so she could take it back in. Kristy Lamb also showed some lovely work with a drug addict who projected her superego. She showed how to help the patient deactivate the projection, accept her self-criticism, then look at the anger the self-criticism was covering up. And all of this she did within a structured ISTDP group therapy model.

What was your contribution about?
I chaired the panel on EDT and addictions. So I presented a case of a woman who had worked as a prostitute to support her drug habit. She heard a voice telling her to use drugs. I showed the first twenty minutes of the first session to show the importance of deactivating projections in order to bring anxiety down. Then I showed how, as soon as we invite the patient to bear a projection inside rather than project it outside, we need to brace and support the patient at this highest level of anxiety until she can bear the projection inside without disrupting.

Do you have anything to say to someone thinking about going to the Venice conference in 2021?
I am really looking forward to it. How could we not! Some great presentations. A fantastic city to visit. Going off season when it won’t be crowded. Fantastic food and wine! We would be crazy not to go to that conference. I look forward to seeing everyone there who is reading this.

ISTDP vid beroendeproblematik: ny studie

Är ISTDP effektivt vid beroendeproblematik? En ny studie av Jon Frederickson med kollegor pekar i den riktningen.

Sverige ligger på andraplats i Europa vad gäller antalet dödsfall relaterat till missbruksproblematik. Mellan 2006 och 2014 fördubblades antalet rapporterade dödsfall, vilket tycks följa den generella utvecklingen i USA av överdoser relaterade till opioidbehandling av olika smärttillstånd. Även om vissa politiska partier håller på att svänga i riktning mot en mer stödjande narkotikapolitik (“skademinimering”), baserat på exempelvis SKL:s, EU:s eller WHO:s rekommendationer, så fortsätter svenska regeringen att representera den så kallade “nolltoleranspolitiken“: missbrukare ska jagas av polis och straffas för sitt omoraliska beteende. Oavsett politiken runt missbrukare så är det tydligt att nya behandlingar behövs, då dödsfallen fortsätter att öka och många som genomgår evidensbaserad behandling fortsätter att ha omfattande svårigheter.

Dödsfall relaterat till överdoser i Sverige 2006-2017. Källa: EMCDDA.

Jon Frederickson har under de senaste åren samarbetat med flera olika behandlingshem och mottagningar för att ta fram en ISTDP-baserad behandling för beroendeproblematik. Den första studien som rapporterar om denna behandling kommer från ett behandlingshem i Prescott, Arizona, inte långt från den mexikanska gränsen.

I studien randomiserades 60 personer med beroendeproblematik till ett månadslångt behandlingsprogram baserat på ISTDP eller sedvanlig behandling. Ungefär en fjärdedel av deltagarna hade psykotiska symptom vid behandlingsstart.

De tre centrala målen med behandlingen var att 1) reglera ångest, 2) hantera projektioner och 3) arbeta med att formulera positiva problem- och målformuleringar. Förutom två timmar psykoedukation i grupp och två timmar gruppterapi per dag så fick deltagarna 1-2 timmar individuell ISTDP per vecka. Terapeuterna instruerades att inte använda sig av konfrontativa strategier (“challenge”), baserat på bedömningen att de flesta patienterna behövde det graderade formatet av ISTDP, samt att tidigare forskning indikerat att personer med beroendeproblematik behöver behandlingar med mycket stöd och lite kontroll.

Resultaten vid sexmånadersuppföljning visade att 17,6% av kontrollgruppen var nykter, medan motsvarande siffra var 48,8% för ISTDP-gruppen. Det var alltså närapå hälften av deltagarna som var nyktra efter en månadslång ISTDP-behandling i inneliggande format. Detta trots att de flesta studieterapeuterna hade fått endast några dagar utbildning i ISTDP.

Studien kommer inom kort att publiceras i Journal of Addictive Diseases:

Frederickson, J., DenDooven, B., Abbass, A., Solbakken, O.A., & Rousmaniere, T. (in press). Pilot study: An inpatient drug rehabilitation program based on intensive short-term dynamic psychotherapy. Journal of Addictive Diseases.