Jonathan Entis: “Defiance is the single most important defense”

In this interview, Jonathan Entis discusses his recent talk about defiance at the ISTDP academy. Jonathan is an ISTDP therapist and trainer based in Cambridge, Massachusetts. You can find his website here, and here you can find the website of the New England Center for ISTDP which is a community group that he organizes.

How do you feel about the presentation the other day? 
I feel so happy about the presentation!  I am proud of the work that I showed, and I was grateful to be so warmly received.  I was surprised and honored when Peter Lilliengren first invited me, and of course wanted it to go well but you never know how things will land.  I really felt supported and encouraged by the audience the whole time and it seemed like an atmosphere where everyone was really open to learning.  I had a blast!

For the readers who don’t know you, how did you get into ISTDP? 
Well, this is a bit of a long story.  When I first started a graduate program in psychology in my early twenties, I tried a few forms of therapy.  I was a bit lost, but I also wanted to get a sense of what types of treatments were out there that I might want to practice.  I had read Diana Fosha‘s book on the Transforming Power of Affect, and I thought I’d go see an AEDP therapist.  I got a few referrals, but in the end, the person I started working with wasn’t an AEDP therapist at all, but rather an ISTDP therapist—something I hadn’t actually heard of at the time.  I was blown away by the power and effectiveness of what they were doing.  No one had ever reached me that way.  It felt like tough love for sure, but somehow I felt spoken to and seen in a way that I never had before.  After that experience, I knew I had to be trained in this way of working.

Jonathan Entis

The problem was that there was no training in ISTDP in the graduate program I was in.  In fact, in the States, ISTDP is virtually non-existent in PhD psychology graduate programs.  I would go through various training sites and mental health centers learning CBT, psychoanalysis, DBT, etc., all the while carrying the secret that what I really wanted to do no one could teach me.  So, I basically did a lot of reading on my own, starting with Patricia Coughlin’s first book.  I didn’t have any supervisors who knew ISTDP, but I’d be trying to incorporate what I could glean from her book and sometimes it worked and sometimes it didn’t!  It was a lot of trial and error.   

At one point I grew so frustrated with not being able to study ISTDP that I decided I’d be a psychoanalyst instead.  I began training at one of the country’s oldest psychoanalytic institutes.  I loved a lot of the theory, but I struggled with what I saw as a resistance to technique and a dependence on a lot of vague terminology.  Eventually I saw an advertisement that Patricia Coughlin was going to be starting a Boston based core training group, and I jumped at the opportunity! Pretty much from that day forward, I’ve been consumed with developing my expertise in ISTDP.  One of my mentors, John Rathauser, has said that he developed his skill set by making ISTDP something of a religion.  Well, I’m right there with him on that. For the past 5 years I’ve spent 2-3 hours every day reading Davanloo transcripts, parsing apart all of his cases, and watching my own videos. 

Why did defiance catch your attention in this way, and why do you think it’s such a crucial concept in ISTDP? 
When Peter Lilliengren reached out to me to ask if I would present at the ISTDP Academy, he had just seen some of my work in a webinar I hosted with John Rathauser.  We both showed our work with syntonic defenses, and I was particularly keen to show my work there with defiance. I knew that I had something unique to offer because the way I work with defiance is quite distinct from what I’ve seen most others do in the ISTDP community. Peter’s invitation excited me in part because I knew there was a lot more to talk about with defiance that I didn’t get a chance to fully cover in the webinar.

In my opinion, defiance is the single most important defense to be familiar with as an ISTDP therapist as it is nearly universal in all patients, and is often fueling other defenses that are more apparent. As I talked about in my presentation, oftentimes when we are struggling but failing to help a patient relinquish another defense, like weepiness, it is because the defense is getting its power from defiance. If we keep addressing the weepiness without addressing the defiance underneath it, we’ll ultimately fail to remove it. It will return over and again, like déjà vu. 

But part of the difficulty with defiance is it is often invisible to both the patient and the therapist, so discerning it can be tricky.  Even once you’ve spotted it, working with it is so complex. It gets its power from all the major sources of unconscious resistance: repression, the resistance against emotional closeness, and what Davanloo referred to as the ‘perpetrator of the unconscious,’ tied to concepts of the punitive superego.

During my first years as an ISTDP therapist I was struggling a lot with the defense of passivity, and a lot of the supervision I would get was linked to my own overactivity. Passivity would get me stuck over and over again, and I was dedicating quite a lot of time to figure this out in practice as well as theoretically. Is your interest in defiance related to any of your own learning processes as a trainee?
Well, here’s the thing about what you’re saying. Davanloo did not actually recommend we counter passivity with our own passivity. There is a long-standing tradition within psychoanalytic literature that talks about this and recommends it, and it has made its way into our community as an often-talked about approach, but it’s not a Davanloo method. In fact, Davanloo maintained his activity in the face of patient passivity, and in many ways increased it.  You can see that in many of his best published cases, where he’ll have long head-on collisions and periods of pressure and challenge to the passivity.  I’ll leave it to you and the readers to make up their own minds about the best way to manage passivity in their own patients, but I tend to follow Davanloo’s method of actively confronting it, often weaving in a lot of de-activation, and head-on colliding with it. As I talked about in my presentation, when the passivity is fueled by defiance, this is the aspect that needs to be clarified for the patient, and then collided with. Working on the passivity alone is not enough; they need to see how it is intertwined with their defiance and any other dynamics at work. 

Personally, I tend not to like the counter-passive approach, and instead, if it really feels like an impasse that we cannot overcome, even with concerted attempts to understand and clarify the psychodynamics and relational dynamics at work, then I will acknowledge that with the patient putting in their best effort and me putting in mine, we’re simply not doing enough and it’s time to end the treatment (this is the ultimate pressure by the way, and at times can be the thing that turns the corner).

But to your question more specifically.  Defiance is something I struggled with when I first started, absolutely.  And even though I presented on it and have a lot to say about it, I still struggle with it.  The nature of patient defiance is to try to defeat what we’re doing; how do we not struggle with a force that wants to defeat us?  To me it feels like the ultimate resistance, and so it is the ultimate challenge to take on as a therapist.  As I’m answering this question now, I think this is part of it for me.  I always set myself very lofty goals, and trying to develop expertise in defiance feels like some sort of very worthy challenge.  And of course, like all of us, I have defiance in my own character, and I wanted to try to understand this better, too.

I know that you’re a meticulous Davanloo reader. Do you find that Davanloo has had the last word on defiance, or is there more work to be done? 
Well, one of the things that has intrigued me is that I think Davanloo sold himself short in terms of how innovative he was with defiance.  He developed a ton of techniques for how to deal with it, but the only one he seems to have written about, is de-activation. Peter von Korff, who studied with Davanloo, wrote a wonderful article on how Davanloo manages defiance, but there too he really only stresses the role of de-activation, albeit in various forms.  If you look at what all the trainers and books on ISTDP say about defiance, if they talk about it at all, is to de-activate.  De-activation is of course crucial, and is itself a very complex task.  As I talked about in the presentation, most forms of de-activation are actually essential components within the 16-component framework of Davanloo’s system of Head-On Collision.  So pretty much whenever we are doing extensive de-activation, we are engaging in head-on collision (although I think few people realize this!).

One thing that really intrigues me is that Davanloo could also be very direct and confrontational with defiance, but he doesn’t seem to explain why he switches between indirect and direct modes of management, and no one else talks about that either.  I made it my mission to really understand this kind of code switching he does, and why he does it.  Of course along the way I developed my own style of drawing out and speaking directly to defiance, heavily influenced also by my work with John Rathauser, but the tenets are essentially taken from close reading of Davanloo transcripts. I remember Patricia Coughlin told me a long time ago to pay close attention to what Davanloo does, not what he says.  Here I think she’s correct. If you read the transcripts closely, you see just how complex and layered his approach to defiance was, certainly way more than what has been written. 

I doubt he’ll have the last word on the topic, but I’m a purist at heart, and I’m quite happy to continue interpreting and perfecting his methods.

What do you find are some of the main countertransference issues that prevent the therapist from dealing effectively with defiance? 
Well, I think the biggest issue is that it often goes unnoticed.  We might see the helplessness, the passivity, or perhaps in another patient the compliance and eagerness to please, and we’re busy thinking about the best ways to address these defenses, not realizing that the bigger issue is the defiance that underpins them. We can’t address what we cannot see.

Another issue is as you say, our countertransference. Defiance in the therapeutic encounter is made possible by a projective process in which the therapist is put ‘in the shoes’ of a parent or other genetic figure who the patient now blames for childhood suffering and pain.  Von Korff does an excellent job talking about all that in his article, by the way. Of course the patient is not consciously aware of this, but a part of them is now enraged at the therapist, blaming the therapist, and intent on destroying the therapist’s efforts.  So even if the defiance isn’t coming out in overtly antagonistic ways such as sarcasm or provocation, we’re still likely to get frustrated by the fact that our efforts are failing to take hold. This can be particularly frustrating when the defiance is cloaked in a shell of compliance, and we’re proceeding along thinking we’re being so effective, all the while nothing is penetrating on a deeper level.  Soon the therapy starts stalling or sessions go on in a desultory fashion. Ultimately, our own needs to be effective are thwarted. Of course when we get angry as therapists, we’re prone to the same unconscious anxiety and defense mechanisms as our patients, so if we’re not careful we can get off kilter and engage in unhelpful re-enactments.

Moving on to you, what are you struggling to learn right now? 
Italian!  I used to speak it quite well because my wife is Italian and none of her family speak English, but because of COVID it’s been a number of years since we’ve visited.  My language skills are rusty.  With some Italian members in our Davanloo reading group, and IEDTA 2022 taking place in Venice, I’m wanting to take lessons again.  We’ll see!

I’m also shifting a lot of my time towards leadership positions, such as supervising, training, giving talks, all of which is new for me, so there’s a lot to learn there.  

See you in Venice! And as a therapist, what are you struggling to learn right now? Where’s your growth edge?
Well, I think the perennial struggle is to always be myself while also doing a technique.  As anyone who attempts ISTDP knows, we run the risk of sounding like automatons if we get too techniquey.  And of course it’s very distancing to our patients and ourselves. So, I’m always looking for openings where I can let my personality shine through while also staying true to the technique and the needs of the patient. 

I’ve seen that you’re starting up training and organizing community events in the New England area. What’s the community like around where you live? What are your visions for where you’d like things to go? 
Yes, I’ve been quite active starting up various groups and organizations recently!  New England has some wonderful ISTDP and EDT clinicians, but there’s not a real sense of community.  I know some people have tried to foster community in the past, but it hasn’t really panned out.  I’m not sure I’ll be any more successful, but I thought I’d give it a shot. 

Truthfully, I admire greatly what you’re all doing in Scandinavia.  The organizations you have host such great content and it seems like everyone really knows each other.  I’m hoping to establish something like that here, but I think it will take quite a bit of time. 

Beyond hosting guest speakers and organizing training events, I’m also really looking forward to the social aspect of the community. I’m starting to plan a long-weekend retreat that will offer training and also the opportunity for people to really get to know each other and build friendships. That kind of thing excites me.

If you dream a bit, where would you like ISTDP to be in say 5 or 10 years? 
Well, it’s so exciting to see all of the advances in research that people like you are making. So, thank you for that! I think as long as ISTDP clinicians keep publishing research and getting the word out, the community will grow and more people will have a chance to benefit from this amazing therapy. 

I’m also excited to see this new generation of ISTDP leaders emerge. Of course, those we’ve been calling ‘masters’ are wonderful, but it’s great to see a new group of ISTDP clinicians showing their work more and sharing their ideas.

Finally, I’d like to see more of a return within the community to reading Davanloo’s original work. This is something that has been talked about in the IEDTA listserv quite a bit, and Mikkel mentioned it in his interview with you, but Davanloo really did work in a very special way, and I fear that some of the best parts of his technique are not getting passed down. As I get more involved in training, I’m trying to do my part to make sure my trainees and supervisees read his transcripts to really learn the method. I’m sensing that there is a sea change with this, and I think a lot of other trainers are also interested now in sharing Davanloo’s transcripts and teaching from them. I hope in 5-10 years this becomes more of the norm in core training programs.

Yeah, during my core training, although we did study Davanloo’s texts, his texts weren’t at the center of our attention. What do you think might be missed if one relies too much on second generation literature such as, let’s say, the books by Patricia Coughlin, Allan Abbass or Jon Frederickson?
Well, I think all those writers are great and have made really wonderful contributions to the field.  They’re all doing ISTDP and they’re all fantastic at it!  Anyone who reads their books will learn a lot.  But they’re doing their own versions of ISTDP, and they’re all actually quite a bit different than what Davanloo did.  Once I started closely reading Davanloo’s transcripts, I knew I wanted to practice like that.  His intense focus on resistance, the way pressure is really applied to the defenses which then allows feelings to more naturally emerge, the moving and beautiful long-form head-on collisions or even just how often he used head-on collisions (he even does them with a patient he says is on the extreme left of the resistance spectrum–the case of the salesman!), all of it just really appealed to me as a very intuitive, honest and poetic system.  For whatever reason, that way of doing things makes sense to me on some cellular level, I can’t explain it beyond that.  So my concern is really about his style falling out of favor, or perhaps just being forgotten, in a way that it disappears.  I don’t know if ISTDP is any less effective if his way of doing things vanishes, but in my opinion it’s not as beautiful.


If you liked this Jonathan Entis interview on defiance, you might enjoy some of our other interviews, such as this dialogue with Kristy Lamb on ISTDP and addictions, this conversation with Howard Schubiner on “ISTDP light” or this Joel Town interview where he discusses the possibility of taking the ‘intensive’ out of ISTDP.

ISTDP Academy hösten 2021

Svenska Föreningen för ISTDP har inlett ett samarbete med vår systerförening i Danmark (Danske Selskab for ISTDP, www.istdp-danmark.dk) med syfte att anordna digitala kvällsföreläsningar om ISTDP i höst. En uttalad ambition är att bjuda in presentatörer från Norden och andra delar av världen samt att visa på bredd i olika tillämpningar av ISTDP. Alla presentationer sker på engelska med undertexter på filmklippen. Föreläsningarna kommer ske via Zoom och ligger kvällstid kl 17.00-19.30.  

Höstens schema ser ut så här: 

  • Onsdag 1:a september:  Sara Basso (Italien): ”ISTDP principles in childhood psychotherapy” 
  • Onsdag 6:e oktober – Jonathan Entis (USA): ”Working with defiance in Davanloo´s ISTDP” 
  • Onsdag 3:e november – Marvin Skorman (USA): ”You can´t change anyone, even in therapy!” 
  • Onsdag 8:e december – Peter Lilliengren (Sverige): ”Resolving social anxiety with ISTDP” 

Kostnaden är 1200 kr för alla fyra föreläsningarna för medlemmar i Svenska Föreningen för ISTDP. Är du ännu inte medlem i föreningen kan du bli det i samband med anmälan. Anmälan sker här: https://registreringar.istdpsweden.se  

Är du medlem i den danska föreningen så kan du anmäla dig via den danska sidan (https://istdp-danmark.dk/store/istdp-akademiet-2-serie/). 

Har du några frågor tveka inte att vända dig till vår kontaktperson och ordförande, Peter Lilliengren (peter.lilliengren@affekta.se

Information om föreläsningarna

Onsdag 1:a september:  Sara Basso (Italien):
”ISTDP principles in childhood psychotherapy” 

The presentation will focus on the integration of ISTDP in psychotherapy for children. This integration of the ISTDP graded format, thanks to the use of the principles and techniques of ISTDP and other projective techniques, such as drawing, story-telling and playing, allows young patients to become aware of their anxiety and to express their distressing unconscious emotional contents, giving them the opportunity to process these aspects over the course of the therapeutic relationship.

The presentation will focus both on theoretical/technical elements and clinical practice through an illustrative clinical case regarding a 10-year-old little girl with a strong anxiety and related scholastic difficulties.

Sara Basso, Psychologist and Psychotherapist, completed her IEDTA certified Core Training in 2017 with Leone Baruh. She works with children, adolescents and young adults at Centro MasterMind, a private clinical center of psychotherapists in Italy. In collaboration with her colleagues she has been examining unexplored opportunities to integrate ISTDP with other psychotherapeutic models used with children.

Onsdag 6:e oktober – Jonathan Entis (USA):
”Working with defiance in Davanloo´s ISTDP” 

This presentation will cover various aspects of working with defiance, and its twin, compliance, in Davanloo’s ISTDP. These two defenses are often invisible to the patient and at times to the therapist, presenting unique challenges for the alliance. All patients with a history of early developmental trauma have access to these two defenses as indirect ways of managing their feelings and distancing from others, thus knowledge of how to identify them and work with them is fundamental to a deep understanding of Davanloo’s metapsychology. In this presentation, Dr. Entis will thoroughly review the concepts of defiance and compliance and how to work with them technically, and will use case presentations to illustrate.

Jonathan Entis, PhD, is a psychologist in private practice in Cambridge, Massachusetts. He is licensed in both Massachusetts and New York.
He is on the faculty of Harvard Medical School, where for the past three years he has taught and supervised in ISTDP. He is an IEDTA-certified teacher in ISTDP, and presented at the IEDTA international conference in Boston in 2019.
In 2021 he co-presented with John Rathauser, PhD, a 2-day seminar on working with syntonic defenses in Davanloo’s ISTDP. He will also be assisting Dr. Rathauser in his next 3-year core training program in New Jersey. Jonathan completed a 3-year core training in ISTDP with Patricia Coughlin and has been in weekly supervision with both Patricia Coughlin, PhD and John Rathauser, PhD.

Onsdag 3:e november – Marvin Skorman (USA):
”You can´t change anyone, even in therapy!” 

Information kommer vid ett senare tillfälle.

Onsdag 8:e december – Peter Lilliengren (Sverige):
”Resolving social anxiety with ISTDP” 

Social anxiety symptoms involve fears of being negatively and/or harshly judged by others and subsequent avoidance of situations where conflict and anxiety is triggered. In psychodynamic terms, this fear is typically based on projection of own angry feelings and/or negative self-judgment (i.e. the “Super-Ego”) onto others. Such phenomena are quite common and may present across both the “psychoneurotic” and “fragile” spectrums of patients we treat with ISTDP. Thus, depending on the patient’s level of anxiety tolerance, capacity for reality testing and syntonicity, patients may need different interventions in order to resolve the problems.

In this 2.5 hour presentation, I will present a case of a young man with long-standing problems with social anxiety, meeting DSM5 criteria for Social Anxiety Disorder (SAD) and avoidant personality features. The patient was assessed as “mildly fragile” and was treated with the graded format of ISTDP. Treatment consisted of a total of 14 sessions and the presentation will include video segments from the initial trial therapy as well as several later sessions, including assessment of changes at termination.

The specific learning objectives of the presentation include:
– How to conduct a psychodiagnostical assessment to determine the patient’s problems and capacity for ISTDP treatment
– Detecting and dealing with “projective anxiety”
– Establishing a conscious and unconscious alliance
– Detecting anxiety thresholds and working with the graded format to increase affect tolerance
– Working through, including breakthroughs to complex mixed feelings related to past attachment traumas

Peter Lilliengren is a licensed psychologist and psychotherapist by the Swedish National Board of Health and Welfare. He currently maintains a private practice in Stockholm. Besides seeing private patients, he is involved in teaching, supervision and psychotherapy research at Stockholm University, Ersta Sköndal Bräcke University College and several other psychotherapy training sites in Sweden. He has been learning, practicing and teaching ISTDP for over 10 years and has been trained by Patricia Coughlin, Jon Frederickson and Allan Abbass. He currently co-runs a 3-year ISTDP core training program in Stockholm together with his colleague Tobias Nordqvist. Peter has PhD in clinical psychology and authored or co-authored over 20 peer-reviewed psychotherapy research papers. He is currently president of the Swedish Society for ISTDP.