Ange Cooper: “I am my patient, they are me”

In this article we get to meet Ange Cooper. She discusses the many stages of learning ISTDP, detailing her own ISTDP journey through idealization, omnipotence, denial, depression, personal therapy, complexity, psychedelics and spirituality. Ange is an ISTDP teacher and supervisor based in Halifax, Canada. You can find her website here.

Shifting the focus to the person of the therapist

On the back of some recent conversations in the community regarding the teaching of ISTDP, you wanted to talk about your experiences as a learner. How so?
It’s time to talk about my ISTDP learning journey come what may. I have gone through many stages in my learning process and I hope by talking about these openly, it can serve as an enriching personal account that facilitates many other discussions regarding the ISTDP learning process.

Ange Cooper

So how did you learn ISTDP?
I completed my core training with Patricia in 2014, having first been introduced to ISTDP through an 8-month placement with Joel Town.  I developed a research interest in ISTDP and spent a number of days at Modum Bad Hospital in Norway being taught how to use the ATOS as a process research tool by the awesome Lene Berggraf and Pål Ulvenes.

Early in my learning I decided to do a block of therapy with Josette ten Have-de Labije as well as receiving regular supervision from Mark Stein whilst working in the NHS.  Following this, I moved to Canada to work with Allan and had weekly supervision for the best part of the last 5 years. I attended a Davanloo immersion in Montreal, then completed training with Tony Rousmaniere on deliberate practice with Tom Brod, Susan Warshow and Robin Kay.  I then went on to complete Jon Frederickson’s Training of Trainers course and continue to attend his advanced training which is now in it’s 4th year, I believe.  Amongst all of this I have had the benefit of thinking, learning, discussing and being inspired by many other folks in ISTDP, EDT, CBT, psychoanalysis, Jungian analysis and so on.

Besides learning, I have been teaching and training in ISTDP for a number of years now, having facilitated one core training to completion with another mid way through. I will start an advanced training group in November with Allan Abbass. 

All of this is to say, I have had a lot of training in ISTDP and have been committed – like a marriage – to this model for over ten years now. However, what I want to convey here, which I think is more important than my ‘ISTDP qualifications’ is the personal work I have done over this last 10 years.

But is this really a dichotomy – training in ISTDP and personal work?
Not really. I want to talk about the stages I have been through and how this has influenced and fundamentally changed how I practice ISTDP. I think this touches upon some of the points Mikkel raised in his interview but in a more personal and experiential way. 

It is my sense that this aspect of our learning isn’t spoken about enough, of course because it is personal and that can be scary and certainly vulnerable. So, I feel it is in some ways part of my growth to begin such conversations so that others may feel brave enough to do so and so that we can begin to consider how our personal and collective wounds impact our work in ISTDP. 

As Allan Abbass recently pointed out on the IEDTA-listserve, when assessing a patient video you have to consider at least eight central factors: degree and type of resistance, degree of rise in complex transference feelings, phase of treatment, degree of syntonicity, state of the conscious therapeutic alliance, presence of barriers to engagement, medication and somatic illnesses and the current front of the emotional system.

If you add to this the same number of therapist factors, well then you have a pretty huge number of interrelated factors all occurring at any one moment. Maybe someone who reads this can do the math as to how many combinations we can find?

So there’s a lot of work to be done when it comes to the therapist side of things.
It is my deep belief that what we struggle with in ISTDP or any complex endeavour for that matter, is very much tied to our own unconscious emotional processes. This is why ISTDP looks so different between different therapists and within the same therapists across time. I do believe Davanloo developed a deeply healing model of therapy, however it is my guess that even he was troubled by how complex the model was to teach and transmit.

I also think he set up his mobilisation groups in order to address some of the difficulties that therapists have to overcome to do this work well. Including issues such as the therapists own punitive superego, sadism, masochism and tendencies to get stuck in a transference neurosis. Whilst certainly controversial ethically and massively problematic in terms of power dynamics, I can see why he may have felt a desire to help therapists overcome their own emotional difficulties in order to implement ISTDP in the way he would have hoped for.  

from omnipotence to depression and beyond

Coming back to you… You said you wanted to talk about your own journey?
Here we go… In the beginning I was immersed in learning about psychodynamic conflict, the theory of ISTDP, Davanloo’s publications and the actual skill/technique of the model. Just like when you’re learning any new skill there is the excitement and inevitable frustrations that show up with each new patient. 

As I grew as a practitioner, I met my skill development with an overidentification with the model, a oneness with it and it meant everything to me. It became part of my identity and my personality at some level – I think I fell in love with the model!

The desire for oneness with the model was so strong that with it came an idealisation of its power and ‘rightness’ above all other models and devaluation of other forms of therapy. I experienced very little anxiety during this stage and as such I had some very good outcomes – because I believed in it 100% – but also some very bad ones. 

We could say I went through an oceanic stage and into the paranoid-schizoid stage that Melanie Klein speaks about – I was unable to tolerate complexity. I engaged in splitting and denial, and I was filled with my own omnipotence.

Thankfully, but painful at the time, this stage didn’t last, the more patients I saw and the more experience I gained, I started to recognize that I was struggling with a whole myriad of patients. This is when I started to move into a more depressive phase.

What was that like for you?
I started to become overly critical of my skills and capacity, I even started to resent learning ISTDP and wanted to have a life beyond it. And this was the stage where I started to look towards others models, teachers and readings that began to broaden my horizons away from the “Fathership” of ISTDP.

During this phase, my practice began to look different. I was playing with different ways of working and trying them with patients, I started to believe that there had to be more than ISTDP to heal others and myself and so we could call this phase the depressive phase but also the beginning of an experimental phase as I grew. 

I could no longer do “pure” ISTDP, I was very much in “ISTDP eclectic”, or “ISTDP-I’ll do it my way!” Again, for some patients this seemed to be helpful and for others I continued to be stuck, frustrated and despondent. All the while, I continued to study and continued to seek supervision but I started to become depressed and began to wonder, what does all of this mean? I started to lose my sense of meaning and purpose for ISTDP (and of course tied to my life in general) and even patient work. I became a little more depressed.

At my lowest points, I started to realize that I was struggling just as much as the person in front of me, so how on earth could I help them? I recognized that I had begun to treat my patients as if they were different to me, at times ‘lower’ or ‘higher’ than me and that they just weren’t co-operating with me or this therapeutic model as I saw it at the time.  I started to disconnect from patients and simultaneously disconnect from myself – and my therapeutic work started to look more like a series of technical interventions that seemed to lack compassion or heart – what had happened? I started to have some very deep conflicts within myself the more this stage progressed.  Let’s call this stage disconnection or separation consciousness.

Due to my experience of depression and fatigue during this journey, I decided to commit to my own longer term therapeutic endeavours.  At the time I didn’t really feel I was of much value or help to my patients. I had lost my mojo for therapy – I felt lost. I actually wanted to quit being a therapist, it was too painful, too difficult, too stressful and it seemed to have lost its joy, meaning and purpose.

Getting to know your blind spots

We’re very grateful to still have you around, despite what you’re telling us. What helped you find your footing again?
Over the last 5 years, I have steadily been engaged in my own work, this happened to be mainly Jungian analysis. There was just something about Jung’s way of working that intrigued me.  I wanted to find deeper connections within myself, I wanted to understand my dreams, I wanted to understand the collective unconscious and mostly I wanted to feel that life was meaningful again. To me, life had lost its wonder and I didn’t know how to get it back.  So I started therapy, I also did ISTDP block therapy every time I hit upon some big emotional wave that I felt needed to be processed with an unlocking. This was a really useful combination for me.

In addition, and with deep gratitude to Jon Frederickson, I started to bring my most difficult cases to supervision and through experiential role plays he helped me begin to understand from an experiential level – not an intellectual level – what some of my own emotional blind spots were. Blind spots that kept getting in the way of my ISTDP practice. 

Can you be more specific? What where you learning at that point?
I discovered that I had major difficulties in recognizing when I was stuck in a transference enactment especially with highly resistant patients. An inability to see that it was I who held the motivation and unconscious therapeutic alliance for the patient, along with a completely unconscious tendency to resist the patient’s resistance. In sum, this was leading me to co-create the problems that occurred in the therapy room. I was a central part of the problem.

More recently I also gained a very deep understanding that I have been identifying with my patients’ projection of guilt – which has meant that my breakthroughs to guilt, my ability to hold complexity during phases of mobilisation and my ability to do head-on collision were seriously compromised. Because of my own internal, emotional dynamics/capacities I had been unable to offer patients some of the most fundamental aspects of ISTDP model, try as I might. I wasn’t even able to see what was wrong because everything was operating at such an unconscious level – sigh.

Can you be even more specific, what did this look like in sessions?
Mostly it looked like not getting to deep breakthroughs of complex feelings, I emphasized rage above complexity. I was anxious to get to an outcome and I only partially identified the resistance. This meant that it could continue to operate. And there was minimal work with the operations of the pathological superego, since I couldn’t see it. And my head-on collisions did not land and did not create the deeper impact I had hoped for.

The outcome of such issues was that often patients only ever had partial breakthroughs, the UTA was never fully mobilized and this then compromised the deep insights and character change that the unconscious therapeutic alliance potentially brings through to the later, working through stages of the treatment. 

This is not to say that I haven’t had cases with good outcome at the same time, but it is my observation of regular patterns that were occurring within my work at this stage.

Getting unstuck: the path of spirituality and psychedelics

What was it like to see that?
Oh my goodness, I am just as stuck as the patient!

We are suffering the same difficulties and likely of a similar emotional origin and until I begin to see the patient as me – and me as them at an emotional level – I cannot move this thing. I cannot do this therapy. I cannot mobilize the unconscious enough. I cannot see in them what I cannot see in myself. 

This was my most painful stage – but also, I suppose – my most liberating.  I could no longer see the patient as different to me, I could no longer hold this human being either above or below me – I had to begin seeing them as, well at one level different, but ultimately one and the same. This started me into a new developmental stage that felt something like unity consciousness-oneness-humanness – not sure what to call it. But it would be summarized as “I am my patient, they are me”.

Stanislav Grof

How hard it can be to stay open to that shared vulnerability. What impact did this realization have on you?
At this stage of both my growing up and – we could say – waking up, I started to become deeply interested and connected to spiritual writings, integral models of therapy, transpersonal ways of thinking (Stanislov Grof, Ken Wilber) and embodiment practices – and all of this finally led me to psychedelics. I have been hesitant to talk openly about this aspect of my development, but it seems like it is the time and so I will give some brief details.

As I started to become interested in the transpersonal readings above, I hit a stage of my development that spiritual circles call the dark night of the soul. Nothing interested me, I stopped wanting to hang out with people, I wanted to become very introverted, I was in existential angst.

At one point I even wanted to start meditating. Those who know me, know that this isn’t really like me. It was so not like me – but then I started to question who am I anyway – and so meditations began. Through meditation, reading, and becoming more and more aware of some deeply rooted conflicts inside of me, I made the decision to undertake some ceremonial psychedelic sessions with an experienced medicine woman.

There’s a lot of buzz around psychedelic-assisted therapy these days, with both MDMA– and psilocybin-assisted therapy closing in on medical approval within a few years. What were the ceremonies like for you?
I won’t go into these experiences in too much depth, but they have been transformative for both my own personal healing and consequently my practice of ISTDP. In short, through some intense and at times painful experiences, I feel like my heart has been cracked open and I have been able to heal some of my deepest wounds in ways that would not have been possible through a talking therapy.

It is really beyond words to describe the experience, but it has changed my life in profound ways – It has brought me to a place in which I feel deeply connected to a spiritual process and so slowly over the last few years my sense of meaning and purpose has started to re-emerge and with it my excitement and interest in ISTDP as well as my work with patients.

It has made me want to come all the way back to ISTDP (like the hero’s journey). Except that for me, I now place ISTDP into a much bigger, broader spiritual framework that goes beyond symptom and character change.

Do you think psychedelics has an important role to play then in the teaching of ISTDP?
It is too big of a topic to go into here regarding ISTDP and psychedelics, but I am interested in the power of ISTDP and psychedelics used together in some combination– and I am also very interested in the journey of the therapist especially as it relates to the ideas of ‘waking up’ versus ‘growing up’ and how we might consider both of these aspects within our development as therapists.  People can wake up but not have grown up and there can be devastating results from this, people can also be very grown up but never really find a spiritual path – my interest is in how both of these forces come together and how we can yield these forces to massively advance our field.

I have been considering the similarities between ISTDP and psychedelics for some time. From my perspective and experience, the process of breakthrough – into guilt-love-oneness-compassion along with an unlocking of memories from the past – is very similar to the experience during a psychedelic session. But no talking and less time. 

There is something very powerful that happens in both modalities when we melt our punitive superegos, when we surrender to the power and intelligence of something much bigger than ourselves. When we fully let go of control. When we become one with the experience. When duality does not exist. It’s something truly amazing, mystical and spiritual that happens that is beyond the rational or intellectual mind and in the realm of deep knowing-intuition-transcendence.

I think there is much cross pollination of ideas and potential for growth in our understanding of psychopathology if we are willing to be open to how psychedelics work and in what ways the process of change is similar and different to ISTDP.

Learning and teaching ISTDP

So what does all of this boil down to when it comes to how we teach and learn ISTDP?
I believe Davanloo created a powerful model that when delivered optimally – has both the patient and therapist engage in a deeply meaningful spiritual endeavour. 

Davanloo had clearly grown up enough in terms of his own emotional development that he was able to conceive, develop, research and deliver this model effectively and it is integral to who he is.  As I understand it, most of the issues in ISTDP come from the learning and teaching of the model, especially when we are all at vastly different stages of growing up. 

This would mean then that given the therapist’s stage of development, what is focused upon in sessions, what is heard, what is taught, what is practiced, what is adhered to and what is focused upon is going to look very different person to person. I have a sense that what we end up focusing on in therapy can sometimes be the unconscious issues that we ourselves are struggling with and not always that of the patient. For example, I am currently in a stage of fascination or maybe even obsession with the punitive superego, and I’m seeing it everywhere I go. It so happens that this is what I am deeply working with in my own therapy and musings.

When I see ISTDP at its best, it is the same feeling I get when I hear an orchestra play, when I watch a moving film, when I see dancers move in synchrony or nature working together. It is this deep flowing unison with what is, in the present moment and it is breathtaking. When I see Patricia Coughlin, Allan Abbass, Jon Frederickson and others in their zone with a patient, I see them as deeply connected, intimate, honest, open, speaking from their hearts and deeply aligned with who they are. They’re in synchrony with powerful techniques and a deeply embedded understanding of conflict, the unconscious, as well as a deep respect for the patient’s will. In other words they are in a flow state that transcends the conscious mind. 

All of the above, to me, is what provides the furtive ground for emotional breakthroughs that lead the patient’s own unconscious therapeutic alliance into resonance with their individual and collective wounds in order to create deep healing and change. This is some of what I mean in placing ISTDP within a more spiritual framework.

Following the above, I started getting the message to read Davanloo, Freud and Jung again from their original sources and, like most learning that occurs as a spiral, I noticed that I could finally read and understand what I could not previously.

It sounds like you’ve come a long way. So where are you at in your development at this moment?
I have deeply reconnected with ISTDP and at least right now, I am able to do this in a way that at times looks like the work of those I most admire except it is embodied through me. I am now able to mobilize the unconscious in a way that I couldn’t before.  At times, I can deeply hear and feel the unconscious therapeutic alliance as it rises, I can feel when a patient is complying or if they are becoming their punitive superego, I can feel their somatized pain as well as the rage as it rises in my body as well as theirs.

This is no longer such an intellectual endeavor for me, even though I am re-reading a lot and thinking about this every day. Instead, it feels like it is coming from a place of intuition and my heart and as such I am learning to do Heart on Collisions rather than Head on Collisions as I like to view them.

I am speaking from one heart to another when I press to feelings, when I identify and clarify defenses, when I stop being the ego to someone’s superego so conflict can rise in them. And low and behold patients seem to be having breakthroughs in a way that I could not facilitate previously and it comes without the intense attachment to the outcome that I once had.

Sadly, this does not mean I am having breakthroughs with everyone, I just know that my interventions are coming from a different place these days. It is much less cerebral and more embodied as a whole part of me rather than me being split into lots of separate parts trying to speak to the different parts of the elephant.

So, this is where I find myself on this journey now and I continue to grow through seeing new patients, skill building, meditating, video review, teaching and supervising trainees. I don’t know where this stage will take me but I know at least part of it is to share my experience, to enable others to share theirs, to practice courage and bravery in speaking my truth and to help those who are struggling to recognize that in any complex endeavor that involves body, mind, heart and soul – there are stages and we all go through them – some quicker than others. But still the spiral continues.

NOTE: With the permission of the author, the text has been reconstrued as an interview to make it more accessible.


This piece was inspired by ongoing discussions on the IEDTA listserve, fueled in part by the current debate on the risks associated with ISTDP in the Norwegian psychologist’s magazine as well as this Mikkel Reher-Langberg interview we did some time ago.

For a now classic text on idealization and devaluation when learning ISTDP, please see this 2004 article by Allan Abbass “Idealization and devaluation as barriers to psychotherapy learning“.

Below you’ll find some of our latest interviews:

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:

The limitations of ISTDP. Part 1: Jon Frederickson

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 first part, an interview with Jon Frederickson.

On SUITABILITY FOR ISTDP

As we’ve talked about before, ISTDP is not a panacea. Which type of problems and patients are not suitable for ISTDP? 

Jon Frederickson discussing a balanced view of ISTDP
Jon Frederickson

Jon Frederickson: Nothing is a panacea in the field of mental health. Types of problems not suitable for ISTDP would include the treatment of traumatic brain injury, neurocognitive deficits, and genuine autism spectrum disorders (not including those mistakenly diagnosed).

Generally, we should offer supportive and not exploratory psychotherapy to patients currently abusing drugs until we have built the affect tolerance that would make exploratory therapy possible. Likewise, some psychotic patients in a severe regression and severely depressed patients may require medication and supportive psychotherapy before a trial of exploratory therapy should be attempted.

ON LEARNING ISTDP

Just how difficult is ISTDP to learn? As far as I’ve heard, no one ever graduated from Davanloo’s training. Should learning ISTDP be easier? 

Jon: It’s not just a matter of ISTDP being hard to learn. Learning to be a really good therapist is hard. That is why it is relatively rare. Twenty percent of therapists get eighty percent of the good results. And that is true within each model of therapy. It is really hard to become a highly effective therapist in any model of therapy. You may be under the illusion that you’ve “learned” the model, but the outcome research shows that there is no relationship between our perception of our ability and our actual effectiveness.  

Should learning this be easier? Should learning to be a professional musician be easier? Should learning to be a chess master be easier? No.

It should be hard because it is hard. That is reality. However, in the case of psychotherapy: should our teaching be better? Yes.

Research shows that graduate training has no effect on therapist outcome. What a disaster! Should our supervision be better? Yes, because research shows that 93% of therapy supervision is inadequate and 35% harmful.

At least in music and chess, it is clear what skills need to be learned and there are materials which train students in those skills. We have no agreement on the fundamental skills necessary for effective practice in psychotherapy and no materials for training in those skills. So, in response to your question, yes and no. Learning a complex skill like psychotherapy should be just as hard as becoming a violinist.

Yet, it is currently way too difficult to achieve this skill level as therapists because of the poor quality of supervision generally available. As well as the inadequate, indeed, useless quality of graduate training. The useless seminars offered which do not show effective treatment, and the failure to use videotapes to develop an empirically validatable model of teaching and supervision.

In case you wonder if I am outraged by this state of affairs, you read me accurately.

ON JARGON

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?

Jon: Obviously, any emotionally transformative human experience involves a breakthrough to feelings that were previously out of awareness. It even happens at movies! One danger in any model occurs when we use jargon to “professionalize” our field and to create a sense of mystique such that outsiders “could not possibly understand” what goes on behind closed doors.

Jargon creates another danger: we might accept a piece of jargon, usually a description, and mistake it for an explanation. As a result, steps in logic are skipped, and flaws in an argument remain invisible. In case you wonder what I mean, here are some common vague terms which are ill defined and have come to mean everything: mindfulnessawareness, and superego. Here is a term which doesn’t mean what it claims: diagnosis. In fact, what we call diagnoses are merely a description of symptoms, not a diagnosis of their cause.

Do you think there’s a need for a conceptual “makeover” in ISTDP to facilitate dialogue with other models? 

Jon: I don’t think ISTDP needs a makeover as you suggest. I think all therapists in all models need to abandon vague concepts, acronyms, and made up words for plain English, or whatever your native language is. If you cannot explain what you are doing so it could be understood by an adolescent, either your language is a barrier, or you do not fully understand what you are trying to say.

We work with humans, speaking a human language of the heart. Any theory we describe should be able to be put in these terms. If we dropped jargon, we could even talk to other clinicians. As it is, today much clinical dialogue at conferences becomes useless because the exchange of abstractions takes the place of examining the actual data. And the narcissistic display of mysterious language becomes a way to avoid the humbling act of revealing one’s actual work.

ON SUPERSHRINKS AND 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. A notable contribution is the recent Iranian study showing that ISTDP without challenge was just as effective as standard ISTDP. Given the lack of studies, ISTDP is largely an “oral tradition” where the experience of specific prominent therapists (be that Davanloo or yourself, for example) is very influential. What are some of the challenges with the specific ingredients of ISTDP?

Jon: The Iranian study was important, but like all studies, it’s easy to forget the context. In fact, challenge is appropriate only with about 25-30% of patients, the ones who primarily regulate feelings with isolation of affect. Challenge is not appropriate for the other seventy percent of patients who are in repression and fragility. So it should be no surprise that ISTDP without challenge would be effective, because that is the effective form of ISTDP for 70% of patients!

When students try something I suggest, sometimes it works, sometimes it doesn’t. Why? Sometimes they aren’t doing what I suggest. Sometimes I was wrong; I misread the patient, and the patient’s response gives a clearer idea of how to proceed. Sometimes, the therapist is initially helpful without realizing it, but is unable to understand and categorize the patient’s subsequent responses. I don’t think the issue is the individual clinician per se, although the effect of the therapist is powerful. I see repeatedly that there are certain patterns of response across patients and across cultures. When we address these patterns – feelings, anxiety, defenses, and transference resistance – we find patterns of response to intervention.

Now we get to the interesting question: the relationship between principles and rules. For instance, when a patient is struggling to bear mixed feelings, the principle is to help the patient bear mixed feelings without anxiety shifting out of the striated muscles. Sometimes, to make things simple, people make up a rule: “Thou shalt pressure to feelings in this way. Repeat after me!” The student, alas, learns to become a clone who follows rules rather than a person who operates according to principles. There are many interventions that could embody the principle of building affect tolerance. And those interventions could be in response to specific words or dynamics the patient has used. They could arise from the therapist’s experience, feelings, and intuition. They could arise from their mutual co-created responsiveness.

In music, the voice leading (how voices related to each other, for instance, in a fugue) was not supposed to have parallel fifths. That was a rule. Suddenly Debussy comes along and he uses all kinds of parallel voice leading to create effects of great beauty. What had been a rule was revealed to be subject to a higher principle. Thus, it could be broken.

Alas, the early phase of ISTDP training often involved people following rules without understanding the overarching principles, to which those rules are subject. If we ritualistically follow rules, therapy is very easy to learn, though robotic. If we follow principles, then we understand the purpose of our interventions, and that allows for creativity in the therapist and responsiveness to the patient.

Good therapy is like jazz. A jazz musician knows the key, the melody, the harmonies, the underlying principles and he improvises based on that underlying structure. He appears to be breaking rules, yet he is guided by underlying principles. A good teacher orients you to principles whether he is teaching you chess, music, or therapy.

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? 

Freud - a balanced view
Sigmund Freud

Jon: As we know from the work of Bion and other group theorists, when humans form groups, groups become irrational. 

Friedrich Nietzche said that earth is the insane asylum of the universe. Every day we see plenty of evidence for this. Idealization of teachers happens in all models to greater and lesser degrees. Think of Freud, Klein, Davanloo, Rogers, or Beck. Every one of them has been idealized, and each of them has been devalued.

There will always be some people who want to idealize their leader and devalue the rest. We have to understand this as not a problem of a given model, but a problem of the human condition. To avoid the anxiety that our knowledge is partial, our theory will be changed and surpassed is the way of all scientific knowledge, and that whatever we create today will be forgotten in the mists of time, we seek magic.

We idealize a model and view it as the final, complete answer. We idealize some figure. Then we devalue other models and teachers. Then we imagine we are part of some secret society of superior therapists in contrast to all those “others.” This pattern has been described in cults, and, sadly, this kind of cult formation is common in the therapy field. All we can do is make ourselves aware of this temptation to idealize and devalue.

Melanie Klein

And we can also step back and realize what makes us anxious: 1) our knowledge is always partial; 2) we will never have all the answers; 3) we will always be flawed and fail with some people; 4) we will never have the final, complete understanding of the human condition in our lifetime; and 5) whatever we achieve, whatever we build is transient and will disappear. This is reality.

When we cannot bear this death anxiety, we engage in the denial of death through the magical claim that we have found the eternal answer, the eternal group, and the theory that has somehow transcended time. Due to death anxiety, this pattern will probably always recur in humanity, including groups of therapists.

OTHER LIMITATIONS AND WEAKNESSES

Do you see other major limitations or weaknesses in ISTDP? 

Jon: My major concern here does not have to do with ISTDP but with the psychotherapy field as a whole. Our understandings all too often are not linked to other areas of knowledge such as sociology, group theory, family studies, and economics. These different fields appear as silos. Take for instance the study of patients who suffer from borderline personality structure or psychotic patients. There is so much good research on the relationship between their psychological difficulties and predictable patterns of family dysfunction.

Yet this research keeps getting forgotten, only to be done again by the next generation. These patients are often examined only from the individual perspective, and we forget the family system that generates these patterns. We look at psychological issues, yet we seem to have forgotten the role of social class and capitalism in character development. Fromm wrote much on that, yet today in the US it is a taboo to recognize the role of class.

Or look at racism in the US or the caste system in India as examples of the transgenerational transmission of trauma. And then there is the tendency to underestimate the role of neurocognitive deficits and brain injury in borderline and psychotic patients. The psychotherapy field has become so focused on the individual, that we easily lose sight of the group and family context, the class context, and the biological context. Then we end up with these different research silos: each reducing the patient to one of these categories, when we need to open up to the interrelationships between them.

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

Jon: It depends on how you define ISTDP. Some describe it as the method. If so, that is ritualism, and, yes, that should be changed. Some describe it as what some teachers do. If so, that is idol worship, and that should be changed. For some, it is a set of rules, and that should be changed.

For me, ISTDP is a set of meta-theoretical principles which allow us to integrate any of a number of techniques. The most important principle is to assess each patient response to intervention to find out if you met the patient’s need in the moment. And these principles are based on a psychoanalytic theory of childhood development and attachment theory. The techniques of cognitive-behavioral therapy, somatic experiencing, gestalt therapy, or internal family systems, you name it, can be incorporated because the key issue, no matter what technique you use in the moment, is: am I meeting the patient’s need in this moment as revealed in her last response to intervention?

In this sense, I am suggesting that we need to move beyond the idea of a model toward an integrative way of thinking and responding. Models can only point toward that. Replication of models does not lead to good outcome. We have to foster a kind of integrative emotional feeling and responsiveness in our work that models and theories can only point toward.

The best therapists in each model look surprisingly alike according to research. This suggests to me that the key factor is not just their model, but a quality of thinking, feeling, responsiveness, and self-reflectiveness that is filtered through their model.

It’s like driving. It doesn’t matter what kind of car we see. It’s the nut behind the wheel.


Jon Frederickson’s latest book Co-Creating Safety: Healing the Fragile Patient came out a couple of weeks ago.

If you liked this article, you might find our other material interesting. Following this link you can find more material in english. Below you’ll find a list of our recent interviews.