The path of least resistance-arkiv

Mikkel Reher-Langberg: “We all use the same words as Davanloo, but the music is different”

In this interview with Mikkel Reher-Langberg, we discuss his upcoming book on Davanloo and ISTDP and much more. Mikkel is a psychologist and president of the Danish ISTDP Society. In 2018, he published a book on Freud’s concept of the self, Faces of the Freudian ‘I’: The Structure of the Ego in Psychoanalysis. Together with some colleagues, he has been running the private clinic Emotion center in Copenhagen for a few years now.

Dansk version. Svensk version.

What’s on your mind right now?
As you know, I work full-time at a private ISTDP clinic in Copenhagen, and I’m still very busy learning how to work with ISTDP. Alongside the clinical work, I am in the process of writing the book we are going to talk about here. In addition, I have been busy with meditation for the past few years, which I hope to be able to do more of when the book is finished.

Porträtt Mikkel Reher-Langberg — Mikkel Reher-Langberg

You are finishing work on this two-volume book on ISTDP. From hearing you talk about it, I get the impression that you want to contribute to some kind of “back to the roots” process: back to Davanloo’s foundations. What is the background to the book?
The background is that I have been studying with John Rathauser for the past few years. He works in a style that is very close to Davanloo’s technique around 1990. I saw John’s work at the IEDTA congress in Amsterdam in 2016 and was completely sold on his style. I learned the basics of ISTDP through Jon Frederickson’s and Allan Abbass’ formats and styles, and since I started working with John I’ve tried to understand what is unique about his style. Over time, our collaboration has become closer and more of a friendship, and I think after a while John could see that I often understood and articulated his work in a way that he could not. Despite the fact that his clinical intuition is much stronger than my own.

John Rathauser portrait — John Rathauser

At one point, John suggested that we write a book together, drawing on our different strengths. That was in early 2019. I suggested we write the book as an introduction to Davanloo, which we quickly agreed on. I have mainly been concerned with the first volume of the book, which is basically an attempt at a coherent presentation of Davanloo’s theory and methodology. The second volume consists of John’s cases, for which we have written commentaries. For me personally, writing the book has been a way of integrating my understanding of John’s work through a very close reading of Davanloo.

Would you like to share some of the key findings you have made from reading Davanloo in the way you have?
It is difficult to point to individual findings. For me, returning to Davanloo has required a fundamental restructuring of what I thought I knew about ISTDP. What I have been most interested in beyond Davanloo’s conceptual apparatus has been his way of thinking about and orienting himself in his clinical work. I have tried to decode the logic of his clinical thinking by examining the contrasts between his style and later versions of ISTDP. In doing so, I may be placing too much emphasis on the differences between Davanloo and other teachers, rather than the similarities.

Having said that, I do think there is a qualitative difference between the way most of us understand ISTDP today and the way I think Davanloo understood his craft. We all use the same words as Davanloo, but the music is different, and I don’t think that’s just because Davanloo had/has a deeper clinical intuition than most of the rest of us.

One area where I think this is evident is that many people today seem to understand ISTDP as an emotion-focused or experiential therapy. For example, the Swedish ISTDP group on Facebook has a banner that says “the deeper you feel, the more you heal”. This may seem innocuous, but in practice it means that many ISTDP therapists are most interested in “getting to the feelings”, as if experiencing feelings is, in and of itself, important or relevant.

This perspective has its strengths, of course, just as other forms of therapy have their strengths, but I think it is a perspective that is qualitatively different from Davanloo’s – at least the perspective he held until the late 1990s. The emotions he is (or was) interested in are specifically those associated with his work on the resistance, and they are not an end in themselves – they are a means of gaining a deeper understanding of and working through the patient’s unconscious. In this way, Davanloo uses resistance in a different way than most ISTDP therapists do today, which has implications for what the work looks like in practice.

You almost say that this is talking about a new form of therapy developed post Davanloo. Can you go into more detail about what is so different, perhaps with a clinical example? How is Davanloo/Rathauser-ISTDP different from Frederickson/Abbass-ISTDP?
I do think it’s worth considering if it’s the same form of therapy! One specific clinical difference is that many people today have learned to “press through” resistance, choosing what might be called the “path of least resistance”, whereas Davanloo follows the “path of greatest resistance”. But I think the biggest difference is in the deeper conception of the work itself – not in individual technical interventions.

If you change the spirit of a method, is it still the same? It’s hard to give a clinical example, but perhaps we can compare it to yoga. If you use the different postures for the purpose of gymnastics or strength training, are they still “the same” as when used for the purpose of spiritual practice? If you understand ISTDP as a form of exposure to emotional intimacy, where the therapeutic potential lies in facilitating the breakthrough of emotions or corrective emotional experiences with the therapist, as many do, it easily overshadows the part of the work that is about creating insight into the unconscious. We could say that one does not exclude the other, but in practice I still think that many people use the method as if exposure to their own feelings were an end in itself.

There’s a lot of good in that – but I think it’s important to be conscious of where this leads the therapy model as a whole.

You have previously written a book on Freud’s concept of self and taken some interest in philosophy – things that fit well into the psychoanalytic literary tradition. Should we who do ISTDP be more interested in reading original classical texts? Or is it a positive thing that the focus of the ISTDP community is more on craft and watching video recordings?
Both yes and no – I’m not sure that the psychoanalytic literature is relevant to our technique, just as you don’t learn to run a hundred-meter race from a marathon runner. We don’t use the transference neurosis, so it’s hard to compare the methods other than in principle. If there is to be an exchange, I think there is something beautiful, serious and generous about our approach to ISTDP training that I think the psychoanalytic community could benefit from.

One area where I think it would be fruitful to include more psychoanalytic theory is in understanding the psychic levels which run deeper than manifest emotional life. The psychoanalytic tradition has a language for the drives and intersubjective dynamics that give rise to manifest emotions which we do not have at all in the ISTDP community. Incorporating this will have an impact on how we understand the therapeutic process as a whole. I think one of the next things that will be needed in the ISTDP community is for more people to engage in the conceptualization of phase 6/7 of the central dynamic sequence – i.e. working through – which unfortunately we do not have a coherent understanding of at the moment. This phase is closely related to the way in which we view the very purpose of the therapeutic process, as well as the therapeutic mechanisms behind what we are doing. Here I think it is necessary to return to the psychoanalytic tradition for help and to broaden our perspectives.

What do you see as the major challenges for the ISTDP community in the coming years?
I think there are many who started learning ISTDP around the same time when Co-Creating Change came out, who have spent a lot of time on technique, and who are now at a point in their development as therapists where they need something to help them gain a deeper understanding of the therapeutic process itself. I think we need literature and training that focuses on the wider processes so that we can begin to use technique in a more flexible way.

In addition to this, I personally have two things that I would like to see in the near future. First, that someone would develop a phenomenology of ISTDP – a description of the structures of the patient’s and therapist’s inner experiences of the process. Second, that someone wrote in more detail about the therapist’s use of defenses in the process and what they usually look like. Unfortunately, I think that as a community we tend to place more emphasis on the patient’s defenses than on our own, and I think that many of the technical pitfalls of the method, given the recent debate about its harmful effects, could be remedied by focusing more on our own neurotic use of the technique.

What would such a phenomenology describe and contain? Care to speculate?
How does it feel when the therapy process tilts to the transference? How is it experienced when the unconscious therapeutic alliance is high versus when it is low? How is it experienced when the conscious therapeutic alliance is firmly established versus when it is not? How are increases in complex transference feelings experienced before they break through? How is the shift from before to after instant repression experienced? What is the experience of having a projection deactivated? How does it feel to have one’s central resistance properly challenged, and how does it feel when the therapist just hammers away without having made clear what the purpose of it is?

I think this type of descriptions would make it easier, especially for new therapists who have not yet developed their own experience with countertransference, to understand the patient. To be able to fine tune their approach based on the experience expressed by the patient, in addition to using the more crude objective signs such as sighs.

What are you struggling to learn as an ISTDP therapist right now?
I’m mostly working on stabilizing my empathic listening skills. One side of this is that I am trying to find a way to stop using the ISTDP therapist role as a defense against emotional closeness. Another is that I am trying to learn how to have a grip on the method that is neither too tight nor too loose.

This is something that I and many of the readers will recognize – that we use the ISTDP therapist role as a defense. Do you think ISTDP is particularly vulnerable to this kind of problem, given the focus we place on the technical aspects of the work?
Yes, I think that as ISTDP therapists we are vulnerable in at least two areas. One is the high emotional intensity of the contact with the patient that is implicit in the method. The second one is that we have very clear and high quality role models to rely on from the very beginning of our work, both in terms of technical instructions and the work of specific teachers. In this way, we have very big shoes to fill, and most of us who are interested in ISTDP are very ambitious for our own sake and for the sake of our patients.

If we think about it, it’s almost a traumatic situation to put yourself in, especially as a newly trained psychologist. When we sit there and have to navigate a high level of emotional intensity that we don’t fully understand, a very high technical level that we don’t fully master, but that we have to convince ourselves that we have mastered. And which we believe we must convince the patient and our colleagues that we have mastered – then the stage is set for us to have a therapist neurosis, where our therapist personality does not facilitate our personal development, but stands in the way of it because it does not reflect us.

ISTDP assumes that we can go all the way from inquiry to unlocking. We need to have control of the system as a whole before it really works, and so learning the method becomes like putting together a jigsaw puzzle where the motive is constantly changing. In this way, it makes sense that perhaps more than therapists from other therapy disciplines, we acquire a kind of premature therapist identity as part of our development.

If you enjoyed this interview with Mikkel Reher-Langberg, you might be curious about our other interviews:

Mikkel Reher-Langberg: “Vi bruger alle de samme ord som Davanloo, men musikken er en anden”

I dette interview med Mikkel Reher-Langberg taler vi om hans kommende bog om Davanloo og ISTDP og meget mere. Mikkel er psykolog og formand for Dansk selskab for ISTDP. I 2018 udgav han en bog om Freuds begreb om selvet, Faces of the Freudian ‘I’: The Structure of the Ego in Psychoanalysis. Sammen med nogle kolleger har han i nogle år drevet den private klinik Emotion center i København.

Svensk version av texten. Engelsk version.

Hvad optager dig lige nu?
Rent professionelt arbejder jeg, som du ved, fuld tid i en privat ISTDP-klinik i København, og er fortsat meget optaget af at lære at arbejde med metoden. Ved siden af det, er jeg ved at skrive den bog vi skal tale om her. Ud over det, har jeg de sidste par år været optaget af meditation, som jeg håber at kunne dedikere mig mere til, når bogen er færdig.

Du er ved at afslutte arbejdet på en bog i to bind om ISTDP. Da jeg hørte dig tale om bogen, fik jeg det indtryk, at du ønsker at bidrage til en slags “tilbage til rødderne”-proces: tilbage til Davanloos fundament. Hvad er baggrunden for bogen?
Baggrunden for bogen er, for mit vedkommende, at jeg de sidste år har været i træning hos John Rathauser, som arbejder i en stil, der ligger meget tæt op ad Davanloos arbejde omkring 90’erne. Jeg så Johns arbejde på IEDTA-kongressen i Amsterdam i 2016, og var fuldstændigt solgt til hans stil. Oprindeligt har jeg lært ISTDP efter Fredericksons og Abbass’ formater, og siden jeg begyndte at arbejde med John har jeg arbejdet på at forstå, hvad det særlige ved Johns tilgang var. Med tiden blev Johns og mit samarbejde tættere og mere venskabeligt, og jeg tror, John kunne se, at jeg ofte kunne forstå og sætte ord på hans arbejde på måder, han ikke selv kunne, selv om hans kliniske intuition er meget stærkere end min egen.

På et tidspunkt foreslog John, at vi skulle skrive en bog sammen, og gøre brug af vores forskellige styrker – det var tilbage i begyndelsen af 2019. Jeg foreslog at vi skulle skrive den som en introduktion til Davanloo, hvilket vi hurtigt blev enige om. Jeg har primært beskæftiget mig med bogens første bind, som er et forsøg på at fremlægge en sammenhængende præsentation af Davanloos teori og metode. Andet bind består af Johns cases, som vi har skrevet kommentarer til. Kort sagt har det at skrive bogen altså for mig personligt været en måde at integrere min forståelse af Johns arbejde, gennem en meget tæt læsning af Davanloo.

Vil du dele nogle af de vigtigste konklusioner, du har gjort, mens du har læst Davanloo på den måde, du har gjort det i de sidste par år?
Det er svært at sætte finger på enkelte fund – for mig har det at vende tilbage til Davanloo krævet en grundlæggende omstrukturering af, hvad jeg troede, jeg vidste om ISTDP. Det jeg har været mest optaget af, ud over Davanloos begrebsapparat, har været Davanloos måde at orientere sig i det kliniske arbejde, og at forsøge at se det særlige i hans arbejde i kontrast til nyere versioner af ISTDP. På den måde kan jeg komme til at lægge for meget vægt på forskellene mellem Davanloo og andre lærere, frem for lighederne.

Når det er sagt, så oplever jeg, der er en kvalitativ forskel på den måde, de fleste af os forstår ISTDP i dag, og den måde jeg synes, Davanloo orienterer sig i arbejdet. Vi bruger allesammen de samme ord som Davanloo, men musikken er anderledes, og jeg tror ikke kun det handler om at Davanloo havde/har en dybere klinisk intuition end de fleste af os har. Et område, hvor jeg synes, det viser sig, er at mange i dag lader til at forstå ISTDP som en følelsesfokuseret eller oplevelsesorienteret terapiform. Jeres svenske ISTDP-gruppe på facebook har f.eks. et banner med teksten “the deeper you feel, the more you heal”. Det kan virke uskyldigt, men i praksis betyder det, at mange ISTDP-terapeuter mest af alt interesserer sig for at “komme ind til følelserne”, som om det at føle følelser i sig selv var vigtigt eller relevant.

Den orientering har sine styrker, ligesom andre terapiformer også har sine styrker, men jeg synes, den er kvalitativt forskellig fra ånden i Davanloos arbejde – i hvert fald indtil slutningen af 90’erne. De følelser, han interesserer sig for, er specifikt dem, der knytter sig til arbejdet med modstanden, og de er ikke et mål i sig selv – de er et middel til at få en dybere forståelse for og gennemarbejde patientens ubevidste. På den måde bruger Davanloo også modstanden på en anden måde, end de fleste ISTDP-terapeuter gør det i dag, og det har konsekvenser for, hvordan arbejdet ser ud i praksis.

Du siger, at det næsten er som at tale om en ny form for terapi, der er udviklet “post Davanloo”. Kan du gå mere i detaljer om, hvad der er så anderledes, måske med et klinisk eksempel? Hvordan adskiller Davanloo/Rathauser-ISTDP sig fra Frederickson/Abbass-ISTDP?
Jeg synes i hvert fald, det er en overvejelse værd, om det er den samme terapiform! En konkret klinisk forskel er at mange i dag har lært at “presse igennem” modstanden, og tage hvad man kan kalde “the path of least resistance”, mens Davanloo følger “the path of maximum resistance”. Men egentlig synes jeg, den største forskel ligger mere i forståelsen af terapien – ikke i de tekniske interventioner. Hvis man ændrer ånden i en metode, er det så stadig den samme? Det er svært at give et klinisk eksempel på, men vi kan måske sammenligne det med yoga. Hvis man bruger de forskellige positioner som gymnastik eller styrketræning, er det så stadig “det samme” som yoga brugt som spirituel praksis?

Hvis man forstår ISTDP som en form for eksponering for følelsesmæssig nærhed, hvor det terapeutiske potentiale består i at facilitere gennembrud af følelser, eller korrektive emotionelle oplevelser med terapeuten, som mange gør, så overskygger det nemt den del af arbejdet, der handler om at skabe indsigt i det ubevidste. Vi kan sige, at det ene ikke udelukker det andet, men i praksis synes jeg alligevel, mange bruger metoden, som om eksponering for egne følelser udgjorde et mål i sig selv.

Det er der meget godt i – men jeg synes, det er vigtigt at være bevidst om, hvor det bringer terapiformen som helhed hen.

Du har tidligere skrevet en bog om Freuds selvbegreb og har interesseret dig lidt for filosofi – ting, der passer godt ind i den psykoanalytiske litterære tradition. Bør vi, der arbejder med ISTDP, være mere interesserede i at læse klassiske originaltekster? Eller er det en positiv ting, at ISTDP-fællesskabet fokuserer mere på håndværket og på at se videooptagelser?
Både ja og nej – jeg er ikke sikker på, hvordan den psykoanalytiske litteratur er relevant for vores metode, ligesom man ikke lærer 100-meter af en maratonløber. Vi bruger ikke overføringsneurosen, så det er svært at sammenligne metoderne andet end rent principielt. Hvis der skal være en udveksling synes jeg, der er noget smukt, seriøst og generøst i den måde vi i ISTDP-miljøet træner metode på, som det psykoanalytiske miljø måske kunne have gavn af.

Men et område, hvor jeg synes, det ville være oplagt at inddrage psykoanalytisk teori, er i forståelsen af de psykiske niveauer, der er dybere end følelseslivet. Den psykoanalytiske tradition har et sprog for de drifter og intersubjektive dynamikker, de manifeste følelser udspringer af, som vi slet ikke har i ISTDP-miljøet. At inkorporere dét vil være relevant for måden, vi forstår den terapeutiske proces som helhed. Jeg tror, noget af det næste, der kommer til at være nødvendigt i ISTDP-miljøet er, at flere beskæftiger sig med at begrebsliggøre fase 6-7 i den centrale dynamiske sekvens, som vi desværre ikke har en sammenhængende forståelse for på nuværende tidspunkt, men som hænger nært sammen med måden, vi anskuer selve meningen med og forandringsmekanismerne i den terapeutiske proces. Dér tror jeg, det kommer til at være nødvendigt at vende tilbage til den psykoanalytiske tradition efter hjælp.

Hvad ser du som de største udfordringer for ISTDP-fællesskabet i de kommende år?
Jeg tror, der er mange, der begyndte at lære ISTDP omkring det tidspunkt hvor Co-Creating Change udkom, som har brugt meget tid på teknik, og nu er nået til et punkt i deres udvikling som terapeuter, hvor de har brug noget, der kan hjælpe dem med at udvikle en dybere forståelse for selve den terapeutiske proces. Jeg synes, vi mangler litteratur og undervisning der fokuserer på de store bevægelser og meninger med arbejdet, så vi kan begynde at bruge teknikken mere smidigt.

Ud over det, har jeg personligt to ting, jeg gerne så i den nærmeste fremtid. For det første, at nogen ville udvikle en fænomenologi for metoden – en beskrivelse af strukturerne i patientens og terapeutens indre oplevelser af processen. For det andet, at nogen skrev mere udførligt om terapeutens brug af forsvar i processen, og hvordan de typisk ser ud. Jeg synes desværre, vi som miljø kan have en tendens til at tilskrive patientens forsvar større betydning for processen end vores egne, og jeg tror at mange af de tekniske faldgruber metoden har, jf. den debat der på det seneste har været omkring dens skadevirkninger, kunne afhjælpes ved, at vi fokuserede mere på vores egne neurotiske anvendelser af teknikken.

Hvad ville en sådan fænomenologi beskrive og indeholde? Har du lyst til at spekulere?
Hvordan opleves det når processen tilter over i overføringen? Hvordan opleves det når UTA er høj versus når den er lav? Hvordan opleves det når CTA er etableret versus når den ikke er? Hvordan opleves rise i CTF i overføringen, før de bryder igennem? Hvordan opleves skiftet fra før til efter instant repression? Hvordan føles det at få deaktiveret en projektion? Hvordan skal det føles at få sin major resistance udfordret korrekt, og hvordan føles det når terapeuten bare hamrer løs uden at have gjort det klart hvad meningen med det er? Jeg tror, det kunne være nemmere, særligt for nye terapeuter der endnu ikke har udviklet sin egen erfaring i modoverføringen, at finjustere vores metode efter den oplevelse, patienten giver udtryk for, som supplement til de grove objektive tegn som f.eks. suk.

Hvad kæmper du for at lære som ISTDP-terapeut lige nu?
Jeg arbejder mest med at stabilisere min indføling. En side af det er, at jeg er ved at finde ud af at aflære de måder, jeg bruger ISTDP-terapeut-rollen som et forsvar mod følelsesmæssig nærhed, og at lære at have et greb om metoden, der hverken er for fast eller for løst.

Det er noget, som jeg og mange af læserne vil genkende – at vi bruger ISTDP-rollen som et forsvar. Tror du, at ISTDP er særligt sårbar over for den slags problemer, da vi lægger vægt på teknisk håndværk?
Ja, jeg tror, vi som ISTDP-terapeuter er udsatte på i hvert fald to områder. Det ene er den høje følelsesmæssige intensitet i kontakten med patienten, der ligger til metoden. Det andet handler om, at vi har meget klare forbilleder af meget høj kvalitet at forholde os til lige fra starten af vores arbejde, både i form af tekniske anvisninger og konkrete læreres arbejde. Vi har på den måde meget store sko at fylde ud, og de fleste af os, der interesserer os for ISTDP er meget ambitiøse på vores egne og vores patienters vegne. Hvis vi tænker over det, så er det nærmest en traumatisk situation at sætte sig selv i, især som nyuddannet psykolog. Når vi sidder dér og skal navigere i en høj grad af følelsesmæssig intensitet, som vi ikke helt forstår, på et meget højt teknisk niveau, som vi ikke helt mestrer, men skal overbevise os selv om at vi mestrer, og tror vi skal overbevise patienten og vores kolleger om at vi mestrer, så er grunden ligesom lagt for at få sig en terapeut-neurose, hvor vores terapeut-personlighed ikke faciliterer vores personlige udvikling i arbejdet, men står i vejen for den, fordi den ikke afspejler os. Metoden kræver, at vi kan gå hele vejen fra inquiry til unlocking. Vi skal have styr på hele systemet, før det rigtig virker, og på den måde bliver det at lære metoden som at lægge et puslespil, hvor motivet hele tiden ændrer sig. På den måde er det oplagt, at vi måske mere end terapeuter fra andre retninger, andre tilegner os en form for præmatur terapeut-identitet som en bærende søjle for vores udvikling.

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