Mastering the trial therapy in ISTDP – AN online presentation with Patricia Coughlin
At the end of November this year, Patricia Coughlin will give an online presentation on the topic of the ISTDP “trial therapy”. ISTDP often begins with a longer therapy session, usually 2-3 hours, where we assess the patient and the suitability of the treatment model to the patient – the trial therapy. Research has shown that this first session in itself can have long-lasting benefits on mood symptoms and interpersonal problems.
In this video based webinar you will learn how to work effectively with a highly resistant patient with both a character disorder and anxiety and depression. You will observe the process of a trial therapy, in which a specific set of interventions is employed as a vehicle for determining the nature of the unconscious conflicts responsible for the patients symptoms and suffering. We will also discuss suitability for treatment with Intensive Short-Term Dynamic Psychotherapy (ISTDP). The webinar is organized by a group of ISTDP therapists in Oslo, Norway: Psykologvirke
Patricia Coughlin Della Selva, Ph.D., is a licensed Clinical Psychologist with over 35 years of clinical experience. Currently she is Clinical Faculty at the University of New Mexico School of Medicine. Over the past 20 years she has written professionally, given presentations at professional conferences and conducted workshops for mental health professionals internationally. Currently, she is conducting training groups in New York, Australia, Denmark, and Poland. Patricia last presented in Sweden in the fall of 2016.
How does it feel to do yet another Immersion in Sweden? I am very much looking forward to providing another ISTDP immersion to all of the Swedish colleagues and in collaboration with the Swedish ISTDP trainers.
The theme of this year’s Immersion is the initial session, the trial therapy. How come you put so much emphasis on this part of the treatment? The trial therapy is in itself a treatment but also is the basis on which further treatment sessions are built. This first session is the most important part of the treatment. When this process goes well and helps the therapist to understand the patient, and the patient to understand the process, it strongly predicts a good treatment outcome.
How do you prepare for a trial therapy? Do you plan ahead in any way on what you want to aim for? The main preparation for the trial therapy is being knowledgeable on ISTDP psychodiagnosis and treatment processes for different groups of patients. This requires the full ISTDP training including immersions, video review of cases and so on.
As for a specific case, as a general principle I do not want to have too much knowledge about the patient ahead of time. I want to develop my own understanding of the patient and their problems.
The way I currently work is that people are referred and I look at the referral information in case there are some reasons I need more information prior to a trial therapy. Then the patient goes on a long waitlist so that by the time I see the person I don’t recall much of those details I looked at before. This way it is a fresh look at the patient and his problems
How has your understanding of the trial therapy evolved over the years? What are some of the key things you have learned? One of the key things that I’ve come to learn is the issue of how much conscious alliance is required versus how much the process relies on mobilizing the unconscious therapeutic alliance. This balance is different depending on the patient category. For moderate resistant patients, conscious therapeutic alliance is already present so there is no need to spend time building this. For much more complicated patients (eg. fragile patients) more time is required to build a conscious alliance coupled with some focus on unconscious processes and signaling to the patient that the unconscious will be known at some point. It is very important toward developing hope that the more disturbed patients know that their unconscious will eventually become known.
The other issue is how important psychodiagnosis is. In the early years of my work I was often not clear about the psychodiagnosis and that lead to dropouts and misalliances as well as limited treatment effects in some of those cases. With improved psychodiagnostic skills, dropouts and misalliance are less frequent.
What did Davanloo have to say about your trial therapies, if anything? When I was in supervision with Davanloo we typically would study the trial therapy sessions. Of course that feedback varied greatly from patient to patient. Full range of feedback varied from him overly challenging me about things I had done or had not done, all the way up to saying that the treatment trial was great teaching material. It was great to get his feedback and to make adjustments in those cases where I was missing the understanding of the patient’s problems or was not having properly timed interventions.
You’ve said that doing block therapy requires a lot of knowledge about how to proceed through the different stages of therapy, and that it might not be suitable for beginning therapists. In what way does this apply to trial therapy? Should the structure and goals of the trial therapy be different for different levels of trainee development? One thing that varies with therapist experience is how much time it takes for trial therapy. When I started this work in 1990, I would leave the whole afternoon open for a trial therapy starting at 13.00 and sometimes would go into the early evening. When I was in training with Davanloo at McGill University in Montreal, the trial therapies would be all day long on the Monday from 08.30-17.00. He would come out and teach in between segments. Suffice it to say these were not quick trial therapies. As part of my work there, it was my job to analyze videos and produce reports as part of the research. It was quite helpful to take the time to do that.
Over time my trial therapies have shortened substantially. Now I just leave two hours, and if I need another segment of two hours I will go ahead and plan that.
For the new therapist, I do recommend leaving enough time for you to establish a conscious therapeutic alliance, gather history, do the psychodiagnosis, and see if it is possible to mobilize the unconscious therapeutic alliance in the trial. You also need time to recap, review the process, close it up and plan forward.
What do you think other treatment models could adapt from the concept of the trial therapy? There’s no question that the information from the metapsychology of ISTDP is useful in any psychological assessment. Capacity to recognize unconscious emotional processes as well as unconscious anxiety and unconscious behavioral defenses can aid any psychotherapist doing assessment or treatment regardless of the model.
This is simply because attachment occurs in every psychotherapy model and every assessment interview. When attachment related feelings are activated, anxiety and defenses occur within the unconscious of the patient and have quite an effect on the interactional process. At the same time attachment-related feelings can activate in the psychologist and have a dramatic effect on the interactional process from this perspective.
The ISTDP framework allows the therapist to be conscious of what he is doing for his sake and the sake of the patient.
Throughout the years you’ve shown some great trial therapies at your Immersions in Stockholm. I assume these are some of your best work. How does an average or below average trial play out for you? There are a range of responses to the trial therapy. On average there are symptom reductions and interpersonal gains based on some hundreds of trial therapies we have studied. When the trial is less effective or not effective, there are a combination of causes.
These include misreading of the front of the system, inadequate work on defenses, inadequate anxiety reduction which make the process uncomfortable for the patients. In these cases, the patient is too anxious or the process is too flat. Patient factors include heavily syntonic defense systems, conscious obstacles to engagement that the person does not share with therapist and medical factors which interrupt the process. The likelihood of these difficulties reduces after doing 100 or more trial therapies or after 2000 hours of therapy and case reviews.
Do you find you have specific patterns where you consistently find yourself being less effective during the trial therapy? Or did you have such patterns before? In the early work I was doing, there were certain patient styles, including those with significant repression who would disappear from the treatment process and slip into a passive regressive position. With those individuals early in my training I was tending to withdraw rather than to move in and clarify and challenge these defenses. To overcome this pattern it was important for me to self-review videos and try to determine the emotions that were being triggered in me during these processes. Such video self-review is a great tool to help us access our own emotional processes in the patient interactions.
What are you currently working on improving as a therapist right now? The area I am currently working on is that with those patients who have severe personality dysfunction including dissociative identity and psychotic disorders. There are multiple moving challenges with these patient populations.
How are you proceeding on improving your work with this patient group? I’m using the same process I’ve used with each other patient category. Namely the review of videos, reading about these cases, feedback from the patients, trial and evaluation of different interventions at different points in time and on some occasions peer input. I’m convinced that there are some severely ill patient populations that none of us should be working in isolation with. We should all have an opportunity to review cases with someone on an as needed basis.
We’ve previously talked about the different phases in your development as a therapist. There was an early phase in the nineties, a therapist style which you’ve described as “applying a technique”, and over the years a transition to a second phase, which you’ve described as “living the technique”. Can you say something more about the development of your therapeutic style? When I first started to learn this method, I considered myself to be a warm person who liked people and liked to talk to people and learn about them. As a beginning ISTDP therapist, I had to incorporate certain observation skills and procedural skills on top of my personality. At first it felt unnatural in some ways and felt less “warm”. The process felt mechanical. I think I lost some therapeutic efficacy in some ways in the early stages.
This mostly affected the patients who were more resistant or fragile. I found that this did not affect working with more lower resistance patients from the beginning because I was more comfortable and natural in those settings and did not need to use challenge as a therapeutic technique. Working with those low resistance patients mobilized less emotions and anxiety and defense in me as well. As my own underlying feelings started to be mobilized and could be experienced, it was vastly easier to sit and experience the feelings the patient had without resorting to mechanical techniques or other defenses.
As I got comfortable with more resistant patients and fragile patients, it became more and more natural to engage the person with my natural self. In the interviews I will show in the Immersion you will see two older ones and four newer ones that will give you an idea of these changes over time.
Really, some of the keys to becoming a successful therapist include being comfortable, having access to our own feelings and coupled with this, having technical knowledge of timing of interventions.
Anything else you’d like to add ahead of the event? I am looking forward to working with you. It looks like this immersion will be held online. That being the case you’ll have the privacy of your own house, as long as your kids and pets aren’t interrupting you too much, to have a personal experience while studying this trial therapy process. All the best to you in your work.
The 2020 Swedish Immersion in Davanloo’s ISTDP with Dr. Allan Abbasshas been moved online. Se updated information below.
Intensive Short-term Dynamic Psychotherapy (ISTDP) begins with an intensive and comprehensive evaluation and treatment session called the Trial Therapy. The trial therapy seeks to establish both a conscious and unconscious therapeutic alliance, gather a complete history of problem areas, past and present relationships, and related medical and social factors, while testing a client’s response to this therapeutic mobilization of the unconscious. By the end of the interview, therapist and patient should both have information about the suitability of this treatment, and what format of the treatment may be most beneficial. The trial therapy is typically conducted in one session, but sometimes over more than one session.
Based on a study of several hundred trial therapies, we have found that the trial therapy is effective in reducing symptoms and interpersonal problems, and also effective in reducing excess healthcare use. There is evidence that it is beneficial in the hands of new learners, and that is more effective than standard psychiatric intake interviews.
In this 9th Swedish Immersion in ISTDP, Dr. Allan Abbass and colleagues will provide a detailed video–based study of a series of trial therapies from across the two spectra of patients. Hence, we will look at entire trial therapies of patients with low to moderate resistance, high resistance, as well as patients who suffer from repression and significant fragility. The goal of this course is to assist attendees to master the understanding of functions and processes involved in the trial therapy to help build momentum from the very first session of their treatment courses.
ABOUT THE SPEAKER
Dr. Allan Abbass is Professor of Psychiatry and Psychology, Director of Psychiatric Education, and founding Director of the Centre for Emotions and Health at Dalhousie University in Halifax, Canada. He is a leading award-winning teacher and researcher in the area of Short -Term Psychodynamic Psychotherapy, with over 250 publications and 300 invited presentations over the globe. Some of these articles can be viewed at www.allanabbass.com
He is known for simplifying the theory and technical aspects of the ISTDP model, with the use of algorithms, and through highlighting moment-to-moment processes that inform interventions. He has received numerous teaching awards, including two national awards in psychiatry, and has been honored with visiting professorships at several international universities and institutions, holds recurrent intensive training programs in Norway, Sweden, Italy, Switzerland and Canada, and provides internet-based training to professionals and groups around the world.