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In the words of Dr. Allan Abbass: "ISTDP is by definition an integrated treatment model. It includes cognitive work, emotional regulation work, psychic integration or “parts work”, graded exposure, emotional experiencing and processing of trauma nested in a psychodynamic frame".
Seeking out plant medicine is both an ancient and increasingly common contemporary approach to personal growth and healing. Taking such a journey can involve a number of different psychedelic agents. Depending on the agent involved, and the dosage taken, this journey can provide an opportunity to encounter an other, and in so doing, lead to opportunities to encounter yourself - in different, deeper, more meaningful ways.
The therapeutic modality I work with (ISTDP) seems to me to uniquely complement psychedelic therapy processes. This is because it is intensively focused upon the psychodynamic and somatic factors involved in emotional experiencing and therefore on the wounds and responses to those wounds that we all carry within us - which then lead to psychodynamic and somatic issues. That which may be encountered via psychedelic work can assist in engaging with those wounds and subsequent responses within us. When combined with the ISTDP process, we may find ourselves well positioned to not only receive and make sense of what psychedelic work can facilitate a connection to, but also then - to act upon it. From Jon Frederickson, ISTDP Practitioner and Trainer
Where are we going in therapy? Therapists and patients both ask, “Where are we going?” In one sense, we could answer that with one word: nowhere. Why? Because defenses are always designed to take us away from reality and our feelings about it. But no matter where we go, reality shows up. Thus, defenses help us take imaginary “journeys” away from what is, this moment. But we really can’t go anywhere, since we are always here, now. And yet, as we let go of defenses, there is a sense of movement. Even the word emotion comes from the Latin e-movere, to convey the sense of something inside moving outward. We often think of therapy as moving toward an agreed upon conscious goal. And that is true on the conscious level. But a therapy that touches our depths does more. It reaches toward something unknown and unlocatable in space, the inner you. Where are we going? Toward the unknown of the patient and the unknown of the therapist. And because we do not know the unknown, we can’t know in advance where we are going. And even when we touch on the unknown in ourselves or the patient, it remains unnamable, unsayable, never to be captured by a concept or sentence. Just as music cannot be reduced to words, neither can the inner life of you and your patients. (https://istdpinstitute.com/) My macro-level understanding of racial trauma and structural oppression in general integrates well with my micro-level understanding of the ISTDP approach because the modality revolves around the client’s experience of emotion as the mechanism of change, drawing a direct line between experiences of structural oppression and suffering, with the understanding that unprocessed emotions are the primary issue manifesting in all manner of discharging internal and external behaviours.
How a person responds to structural oppression could very well be determined by how they respond to difficult emotional states, something that would have roots in how their attachment system developed, and how they learned to relate to themselves as a result. A potential outcome for working with this issue using this approach could include a greater freedom to experience your own emotions in your own body and therefore to fully experience your grief and rage about the moments of transgression you encounter, allowing you to better understand and communicate your boundaries, and your needs, in such moments in future. The painful events of our lives and the suffering we undergo in response is such that it fully occupies us each, “no matter whether the suffering is great or little” (Frankl, 1984). For people swayed by addictive or compulsive behaviours, that suffering is being responded to in a way that feels like the best possible option available.
One conceptualization of addiction centres around the idea that such behaviour is not so much directly caused by traumatic event(s), but rather stems from the subsequent “frozen residue of energy that has not been resolved and discharged” which “remains trapped in the nervous system” (Levine, 1997) – in other words, that addictive behaviour is an attempt to avoid or soothe this frozen residue of energy, or to put it even more simply, an attempt to avoid or soothe the feelings that resulted from a traumatic event. I believe ISTDP (Intensive Short Term Dynamic Psychotherapy - Davanloo, 1990, 2000) is an extremely valuable intervention in the case of addictive behaviour. It addresses the role of the unconscious in the aforementioned ‘trapping’ and seeks to remove the obstacles to the processing of emotions which are locked in the body – the external and internal behaviours that constitute the “false front, the wall, the dam” which the individual is perhaps unconsciously maintaining, afraid that if they do not, “then everything will be swept away in the violence of their feelings” (Rogers, 1961). This wall might have developed as a protective measure against feelings once learned to be intolerable or unacceptable, but which perhaps then becomes the cage in which an individual finds themselves trapped (Kernberg, 1980). ISTDP aims to explore the unconscious system which fuels compulsivity; it is tailored to an individual’s capacity to tolerate and process the complex emotional states that once overwhelmed them (Johansson et al., 2014) and includes a “Graded Format” that helps to create increased capacity to tolerate, and thus a reduction in, anxiety (Town et al., 2017). This unique modality directly addresses the issue of intolerable emotion that is, for me, at the core of addictive behaviour. It’s also notable that cost effectiveness - a result of lower treatment times - is indicated with ISTDP (Abbass, 2006; Abbass & Katzman, 2013; Town et al., 2013; Abbass et al., 2015; Solbakken & Abbass, 2016; Abbass et al., 2019), another very good reason why this intervention seems appropriate for people with addictive behaviours - a demographic for whom many barriers to therapy exist. Abbass, A. (2006). Intensive short-term dynamic psychotherapy of treatment-resistant depression: A pilot study. Depression and Anxiety. Vol. 23, pp. 449-452. doi: 10.1002/da.20203 Abbass, A. & Katzman, J. (2013). The cost-effectiveness of intensive short-term dynamic psychotherapy. Psychiatric Annals. Vol. 43, pp. 496–501. https://doi.org/10.3928/00485713-20131105-04. Abbass, A., Kisely, S., Rasic, D., Town, J.M. & Johansson, R. (2015). Long-term healthcare cost reduction with Intensive Short-term Dynamic Psychotherapy in a tertiary psychiatric service. Journal of Psychiatric Research. Vol. 64, pp. 114–120. https://doi.org/10.1016/j.jpsychires.2015.03.001. Abbass, A., Town, J., Johansson, R., Lahti, M., Kisely, S. (2019). Sustained reduction in health care service usage after adjunctive treatment of Intensive Short-Term Dynamic Psychotherapy in patients with Bipolar Disorder. Psychodynamic Psychiatry. Vol. 47, pp. 99–112. https://doi.org/10.1521/pdps.2019.47.1.99. Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Frankl, V. E. (1984). Man's Search for Meaning: An Introduction to Logotherapy. Simon & Schuster: New York, NY. Johansson, R., Town, J. M., & Abbass, A. (2014). Davanloo’s Intensive Short-Term Dynamic Psychotherapy in a tertiary psychotherapy service: overall effectiveness and association between unlocking the unconscious and outcome. PeerJ 2, e548. https://doi.org/10.7717/peerj.548. Kernberg, O. (1980). Internal World and External Reality. Aronson: New York, NY. Levine, P. A. (1997). Waking the Tiger: Healing Trauma: the Innate Capacity to Transform Overwhelming Experiences. North Atlantic Books: California, CA. Rogers, C.R. (1961). On Becoming a Person. Houghton Mifflin. Solbakken, O.A. & Abbass, A. (2016). Symptom- and personality disorder changes in intensive short-term dynamic residential treatment for treatment-resistant anxiety and depressive disorders. Acta Neuropsychiatrica. Vol. 28, pp. 57–271. https://doi.org/10.1017/neu.2016.5. Town, J. M., Abbass, A., & Bernier, D. (2013). Effectiveness and cost effectiveness of Davanloo’s intensive short-term dynamic psychotherapy: Does unlocking the unconscious make a difference? American Journal of Psychotherapy. Vol. 67, pp. 89–108. Town, J. M., Falkenström, F., Salvadori, A., Bradley, S., & Hardy, G. (2017). Is affect experiencing therapeutic in major depressive disorder? Examining associations between affect experiencing and changes to the alliance and outcome in intensive short-term dynamic psychotherapy. Psychotherapy. Vol. 54 (2), pp. 148–158. doi: 10.1037/pst0000108 In many contemporary psychodynamic therapy approaches, assessment involves understanding the nature of a client’s attachment trauma, and also the mechanism of their defences. Defences are automatic and unconscious behaviours that work (often by distorting reality) to protect us from feelings we learned were not acceptable or tolerable. They develop as survival mechanisms, enabling us once to survive painful or difficult experiences, but they become problems when they persist as we age despite the absence of what initially required them.
Let’s say you had an insecure attachment, and now you experience anxiety whenever you are about to do something you once learned wasn’t safe to do, such as reaching out for connection, for example. Then, instead of reaching out, you detach. A simple example: you’re at a party, and you want to be with people, but you get anxious and end up staring at your phone all night. Is that a problem for you? Do you wish you didn’t have to react that way? ISTDP interventions are intended to address the unique system of defences which developed in response to your attachment experiences, with the aim of enabling you to feel the feelings you have long denied, and eventually to enable the development of a secure attachment to yourself, and consequently, when in relationship with others. The ISTDP modality requires that client sessions be recorded, and that the therapist review these recordings between sessions. This unique requirement enables a closer appraisal of some of the things that get lost in the heat of the moment (the slight flush of the client's skin, the darting of their eyes, the tension in their shoulders, and equally, the therapist’s own responses that might indicate a reaction occurring they were not conscious of at the time). I know it can be scary to allow your sessions to be recorded, but recordings are kept in line with strict confidentiality regulations (the Personal Information Protection Act), and are destroyed after viewing. From the therapist’s perspective, it can also seem like a lot of work, to review sessions in this way. Personally, I really appreciate the mindset where the practitioner is the one with homework, not the client – we are well paid for our work, and to my mind the nature of what we do necessitates this level of care and attention. It speaks to the sacred nature of the work.
Studies indicate a direct relationship between brief psychodynamic therapy and improvements in a range of symptoms (Barber et al., 1996; Gaston et al., 1998), and also with specific therapist techniques aimed at emotional experiencing (Hilsenroth et al., 2003; Town et al. 2017b).
Intensive Short Term Dynamic Psychotherapy (Davanloo, 1990, 2000) in particular has a strong evidence base as just such an approach to healing (Abbass et al., 2013; Town & Driessen, 2013; Solbakken & Abbass, 2016; Lilliengren et al. 2017; Town et al., 2017a; Town et al. 2017b, for example). This unique therapeutic modality is supported for use with a large range of psychological problems, including (but not limited to) depression (Ajilchi et al., 2016; Ajilchi et al, 2020), major depressive disorders (Abbass et al., 2012), treatment resistant depression (Abbass, 2006; Town et al., 2017a), and other treatment resistant personality disorders (Abbass, Town, & Driessen, 2012; Solbakken & Abbass, 2015). From a client’s perspective, the goals of ISTDP therapy are often symptom elimination, and sometimes even, character change (Abbass, 2015). Target complaints often involve anxiety/depression, relational difficulties, and social role dysfunction (Solbakken & Abbass, 2015). It’s also worth mentioning that this way of working has been proven relatively cost effective as a result of shorter treatment times compared to many other methods of treatment (Abbass, 2006; Abbass & Katzman, 2013; Abbass et al., 2015; Solbakken and Abbass, 2016; Abbass et al., 2019). This is a bonus for me in my desire to bring ISTDP to marginalized populations - demographics for whom many barriers to therapy exist. My own personal experience of ISTDP as a client is what drives my desire to practice this challenging modality and what gives me such confidence in its effectiveness. I became a therapist specifically with the intention of bringing its healing power to others - as was brought to me. Abbass, A. (2006). Intensive short-term dynamic psychotherapy of treatment-resistant depression: A pilot study. Depression and Anxiety, 23, 449-452. doi: 10.1002/da.20203 Abbass, A., Katzman, J. (2013). The cost-effectiveness of intensive short-term dynamic psychotherapy. Psychiatric Annals, 43, 496–501. https://doi.org/10.3928/00485713-20131105-04. Abbass, A., Kisely, S., Rasic, D., Town, J.M., Johansson, R. (2015). Long-term healthcare cost reduction with Intensive Short-term Dynamic Psychotherapy in a tertiary psychiatric service. Journal of Psychiatric Research, 64, 114–120. https://doi.org/10.1016/j.jpsychires.2015.03.001. Abbass, A., Town, J. M., & Bernier, D. C. (2013). Intensive short-term dynamic psychotherapy associated with decreases in electroconvulsive therapy on adult acute care inpatient ward. Psychotherapy and Psychosomatics, 82, 406–407. doi: 10.1159/000350576 Abbass, A., Town, J. M., & Driessen, E. (2012). Intensive short-term dynamic psychotherapy: A systematic review and meta-analysis of outcome research. Harvard Review of Psychiatry, 20 (2), 97-108. doi: 10.3109/10673229.2012.677347 Abbass, A., Town, J., Johansson, R., Lahti, M., Kisely, S. (2019). Sustained reduction in health care service usage after adjunctive treatment of Intensive Short-Term Dynamic Psychotherapy in patients with Bipolar Disorder. Psychodynamic Psychiatry. 47, 99–112. Ajilchi, B., Kisely, S., Nejati, V., & Frederickson, J. (2020). Effects of intensive short-term dynamic psychotherapy on social cognition in major depression. Journal of Mental Health, 29 (1): 40–44. doi: 10.1080/09638237.2018.1466035 Ajilchi, B., Nejati, V., Town, J. M., Wilson, R., & Abbass, A. (2016). Effects of intensive short-term dynamic psychotherapy on depressive symptoms and executive functioning in major depression. The Journal of Nervous and Mental Disease, 204 (7), 500–505. doi: 10.1097/NMD.0000000000000518 Barber, J. P., Crits-Christoph, P. & Luborsky, L. (1996). Effects of therapist adherence and competence on patient outcome in brief dynamic therapy. Journal of Consulting and Clinical Psychology, 64 (3), 619–622. https://doi.org/10.1037/0022-006X.64.3.619 Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Gaston, L., Thompson, L., Gallagher, D., Cournoyer, L.-G. & Gagnon, R. (1998). Alliance, technique, and their interactions in predicting outcome of behavioral, cognitive, and brief dynamic therapy. Psychotherapy Research, 8 (2), 190–209. https://doi.org/10.1093/ptr/8.2.190 Hilsenroth, M. J., Ackerman, S. J., Blagys, M. D., Baity, M. R. & Mooney, M. A. (2003). Short-term psychodynamic psychotherapy for depression: an examination of statistical, clinically significant, and technique-specific change. The Journal of Nervous and Mental Disease. 191 (6): 349-57. doi: 10.1097/01.NMD.0000071582.11781.67. PMID: 12826915. Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J. & Andersson, G., 2016. Efficacy of experiential dynamic therapy for psychiatric conditions: a meta-analysis of randomized controlled trials. Psychotherapy (Chic), 53, pp. 90–104. https://doi.org/10.1037/pst0000024. Solbakken, O. A. & Abbass, A. (2015). Intensive short-term dynamic residential treatment program for patients with treatment-resistant disorders. Journal of Affective Disorders, 181, pp. 67–77. doi: 10.1016/j.jad.2015.04.003 Solbakken, O.A. & Abbass, A. (2016). Symptom- and personality disorder changes in intensive short-term dynamic residential treatment for treatment resistant anxiety and depressive disorders. Acta Neuropsychiatrica, 28, pp. 57–271. https://doi.org/10.1017/neu.2016.5. Town, J. M., Abbass, A., Stride, C. & Bernier, D. (2017a). A randomised controlled trial of intensive short-term dynamic psychotherapy for treatment resistant depression: The Halifax depression study. Journal of Affective Disorders, 214, pp. 15–25. doi: 10.1016/j.jad.2017.02.03 Town, J. M. & Driessen, E. (2013). Emerging evidence for Intensive Short-Term Dynamic Psychotherapy with personality disorders and somatic disorders. Psychiatric Annals, 43, pp. 502–507. http://dx.doi.org/10.3928/00485713-20131105-05 Town, J. M., Falkenström, F., Salvadori, A., Bradley, S. & Hardy, G. (2017b). Is affect experiencing therapeutic in major depressive disorder? Examining associations between affect experiencing and changes to the alliance and outcome in intensive short-term dynamic psychotherapy. Psychotherapy, 54 (2), pp. 148–158. doi: 10.1037/pst0000108 The primary goal of Intensive Short-Term Dynamic Psychotherapy (ISTDP) is to enable change through the mobilization of complex feelings linked to a past attachment bond and trauma that have been displaced and are creating the internal behaviours towards the self and the external behaviours in relationship that have ultimately driven the client to seek counselling (Abbass 2015).
This focus on feeling is for me of particular importance. I view it as leading to the development of a secure attachment to the self, and consequently, in relationship to others. This fits with my own experience of the difficulties that brought me to therapy as a client ultimately being a result of an inability to simply allow myself to feel my own complex feelings. It fits with my own experience of therapy, whereby the identifying and deactivating of my defences and an increase in my awareness of anxiety lead to the unlocking of unconscious complex feelings in me that had resulted from my own attachment trauma and had been negatively active, in many different ways, throughout my adult life. The ISTDP technique may be extremely challenging for both client and therapist alike. It involves the practitioner taking an active stance, and there is potential for their own unconscious activation as well – hence the challenge. Yet, when “resistance is penetrated there is a marked and unmistakable increase in the strength of the therapeutic alliance” (Davanloo, 1990, 2000). Such challenging techniques are, to me and thanks to my experience of them, fully worth the effort. The beauty of this work lies, for me, at the junction of being actively and genuinely caring and compassionate for the client, while tirelessly addressing the resistance to what lies untouched in their heart. The ultimate goal for the psychodynamic practitioner is to assist the client in resolving the core conflicts in their dynamic unconscious (Abbass 2015), and it is my heart’s desire to bring this healing work to marginalized folks, as it was once brought to me. Abbass, A. (2015). Reaching Through Resistance. Seven Leaves Press: Kansas City, MO. Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons: Chichester, England. While there may be a number of traumatic experiences awaiting an adult as they move through their life, the psychodynamic approach first suggests that most of the conflicts of the unconscious have their origins in childhood experience, with early childhood in particular - as Freud suggested - understood as the most important period in establishing individual psychology.
Freud’s suggestion paved the way for attachment theory (Bowlby, 1958, 1969), something that provides the basis for much of modern psychodynamics, and my own understandings of the work my clients and I do together. The “Strange Situation” experiments (Ainsworth & Bell, 1970; Ainsworth, 1973) furthered Bowlby’s ideas, enabling the classification of different attachment styles - secure, insecure-avoidant, insecure-resistant (or ambivalent), and insecure-disorganized - providing containers for the different ways the internalizations and understandings that result from early childhood experience persist into adulthood. Personality provides a window for understanding how we relate to the world around us, and the attachment system reflects our first experience of trying to do so. It is characterized by the drive to bond to a primary caregiver (Kernberg, 1980), something that can be thwarted by attachment trauma, producing anxiety-provoking complex emotional states in the developing individual (Abbass, 2015). With representations of self and other formed in this context (Kernberg, 1980), anything less than a warm, unconditionally loving primary caregiver can be understood as having the effect of a hot stove – a child gets burned by sub-optimal care-giving experiences, causing attachment trauma, learns to close up in one way or another, and thus goes on understanding the stove as being hot forever. Adults bring this early formation of expectation for other people’s behaviour to their relationships; it informs how they view themselves and also the manner of any psychopathology (Kernberg, 1980). Healing, in psychodynamic terms, involves some degree of integration of self-other representations, enabling us to recognize our conscious wish for attachment with others and our conscious expectations of how others will respond to this (Abbass, 2015). Such a perspective provides the therapist and client a consciously accessible framework for collaborating on the work of examining any unconscious feelings behind the difficulties they may be experiencing (Abbass, 2015). Abbass, A. (2015). Reaching Through Resistance. Seven Leaves Press: Kansas City, MO. Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41, 49-67. Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In B. Cardwell & H. Ricciuti (Eds.), Review of child development research (3, 1-94) University of Chicago Press: Chicago. Bowlby, J. (1958). The nature of the child’s tie to his mother. International Journal of Psychoanalysis, 39, 350-371. Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Loss. Basic Books: New York, NY. Kernberg, O. (1980). Internal World and External Reality. Aronson: New York, NY. The emphasis of psychodynamic therapy is on the dynamic forces within the client – on drives they may not be conscious of. The Freudian concept of the unconscious is the foundation of contemporary psychodynamic thought, and what interests me is how unconscious forces are involved in a concept elucidated by thinkers both psychodynamic and otherwise: that of trauma.
Modern day neuroscience and contemporary models of the brain often negate consideration of unconscious drives due to the inability to empirically prove their existence, and many pathologies are increasingly being ascribed to physical causes, but this does not, to my mind at least, satisfactorily account for the issue of trauma and the human response to it. My belief is that all beings experience trauma, even if the worst that one has experienced is the painful separation of birth itself. Traumatic experience is “a pervasive fact of modern life” that can live on in individual bodies long after the event, and even cross “generations in families, communities and countries” – but does not “have to be a life sentence” (Levine, 1997). The role of the unconscious in the response to trauma is something that psychodynamic work seeks to address. A typical psychodynamic aim is the removal of obstacles to the processing of emotions that remain locked in the body as a result of traumatic events. “Emotion, which is suffering, ceases to be suffering as soon as we form a clear and precise picture of it” (Spinoza, as cited in Frankl, 1984). One relevant aspect of this in my own lived experience was that of the painful feelings that arose internally as a result of external, systemic causes. Psychodynamic approaches tend to focus on individual relational experiences and the internal reactions to these, but in my practice I also ensure systemic causes are, at the very least, named as causes - as having a role in individual relational experiences. Structural oppression is the socially mandated experience of being one-down, and the psychological impact of this has been explored through the psychodynamic lens in terms of the adaptations required of us when we experience ourselves as less-than, and the costs of these adaptations (Turner, 2020). This understanding – of the way external systems of oppression can give rise to, or further compound, oppressive internal, unconscious systems – is an important part of my own psychodynamic practice. Frankl, V. E. (1984). Man's Search for Meaning: An Introduction to Logotherapy. Simon & Schuster: New York, NY. Levine, P. A., & Frederick, A. (1997). Waking the tiger: Healing trauma: the innate capacity to transform overwhelming experiences. North Atlantic Books: California, CA. Turner, D. (2020). Fight the power: A heuristic exploration of systemic racism through dreams. Counselling and Psychotherapy Research, 00, 1–6. doi: 10.1002/capr.12329 The contemporary psychodynamic approach to counselling developed from the psychoanalytic tradition begun by Freud and his contemporaries. One of its core tenets is the awareness that the unconscious has a major role to play in internal conflict and pathology, and that resolution of these can be achieved via work performed within the container of a therapeutic relationship.
The way that psychodynamic therapy orients away from Freud’s conception of the psychotherapist as detached observer and the client as object of observation, and toward the concept of the therapeutic relationship instead, particularly appeals to me. Psychodynamic approaches acknowledge that healing, as bell hooks (2004) writes, “does not take place in isolation”. The psychodynamic practitioner understands that therapist and client “are the two major variables in the approach, rather than treatment and disorder” (Sundararajan, 2002), and that “detached following of rules describes the novice rather than the expert, who is affectively involved with the task” (Sundararajan, 2002). The mechanism of change is found in two equally meaningful presences in the room (Laws et al., 2017), the dynamic of transference and counter-transference between them, and a commitment from both to address the anxiety, defences and resistance that may arise during their work together. Studies of practitioner characteristics that can harm the therapeutic alliance highlight inaccurate interpretations (especially those responding to client resistance), inflexible adherence to interventions, and a lack of attention to the repair of ruptures in the relationship (Moyers, Miller, & Hendrickson, 2005). As such, a skilled psychodynamic practitioner seems to me to be one who is always seeking to balance their learning and knowledge of technique with the experience of the relationship in the moment. It is for this reason that in my thinking around psychodynamic counselling, I feel it necessary to also include a passing nod to theorists beyond this particular orientation, such as those of the feminist and client-centred approaches. hooks, b. (2004). The will to change: men, masculinity, and love. Atria Books: Harvard, New York, NY Laws, H. B., Constantino, M. J., Sayer, A. G., Klein, D. N., Kocsis, J. H. Manber, R., ... & Arnow, B. A. (2017). Convergence in patient–therapist therapeutic alliance ratings and its relation to outcome in chronic depression treatment. Psychotherapy Research, 27 (4), 410–424. doi: 10.1080/10503307.2015.1114687 Moyers, T. B., Miller, W. R., & Hendrickson, S. M. (2005). How does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions. Journal of Consulting and Clinical Psychology, 73 (4), 590-598. doi:10.1037/0022-006X.73.4.590 Sundararajan, L. (2002). Humanistic psychotherapy and the scientist-practitioner debate: An “embodied” perspective. The Journal of Humanistic Psychology, 42 (2), 34-47. doi: 10.1177/0022167802422004 “In the modern era, the emergence of the separate rational ego, believing itself to be wholly autonomous, has in some cases led to pathological states of […] alienation” (Le Grice, 2016). In contrast to this, Vine Deloria Jr describes ‘participation mystique’ - the “idea that a strong […] psychic bond exists between […] peoples and various objects in nature” – something perhaps at best “a highly spiritual communication” but at worst, allegedly, an inability in people “to distinguish themselves from their natural environment” (Coppin & Nelson, 2017). It is interesting that western minds – ones borne of societies in which schizophrenia, for example, is most prevalent – consider such a thing as too much connection to the world around them even possible. Could it be, instead, that this arises because of the lack of a satisfactory cognitive framework for that connection? “The original experience of mystery was […] beyond understanding or articulation…” (Hollis, 1995); perhaps now the mind, positioned as the seat of consciousness, sees danger in such connection, and relegates it to a characteristic of the pejorative “primitive peoples” (Coppin & Nelson, 2017). As Camus (1965) said: “Beginning to think is beginning to be undermined […] The worm is in man’s heart. That is where it must be sought. One must follow and understand this fatal game that leads from lucidity in the face of experience to flight from light.”
My position, straddling cultures as I do, is that connection is in - and is nothing more complicated than feeling - the experience which Jung describes as giving “a colorful and fantastic aspect to the […] world” but which people now have perhaps “lost [..] to such a degree that we do not recognize it when we meet it again, and are baffled at its incomprehensibility” (Coppin & Nelson, 2017). Perhaps it has become incomprehensible because of our privileging of the aspects of it we have deemed desirable, and the efforts we each make to avoid the aspects of it we deem undesirable? This may be the essence of the conflict, for “thinking is derivative, a secondary process. We experience phenomenologically, as a felt movement of body and soul” (Hollis, 1995. From “…the ego’s narrow view of the world, the task is security, dominance and the cessation of conflict; from the perspective of depth psychology, however, the proper role of ego is to stand in a dialogic relationship with the Self and the world” (Hollis, 1996) – “to engage in a genuine dialogue with the unconscious” (Le Grice, 2016). For me, this dialogue already exists, in feeling. The ego, the mind, needs to be re-integrated into the activity of feeling – it needs to be used to attend to feeling, and to the nature and course of any systemic evasion of feeling. Most “of life is a flight from the anxiety of being radically present to ourselves and naked before the universe” (Hollis, 1996), and this avoidance of “the dismal states of the soul becomes itself a form of suffering, for one can never relax, never let go of the frantic desire to be happy and untroubled, can never rest easy” (Hollis, 1996). As Camus (1965) wrote, the war “cannot be negated. One must live it or die of it.” Camus, A. (1965). The Myth of Sisyphus, and Other Essays. H. Hamilton, London. Coppin, J. & Nelson, E. (2017). The Art of Inquiry: A Depth-Psychological Perspective. Spring Publications; Thompson, CT. Hollis, J. (1995). Tracking the Gods: the Place of Myth in Modern Life. Inner City Books, Toronto, ON. Hollis, J. (1996). Swamplands of the Soul: New Life in Dismal Places. Inner City Books, Toronto, ON. Le Grice, K. (2016). Archetypal Reflections: Insights and Ideas from Jungian Psychology. Muswell Hill Press; London/NY. The universe is always speaking, they say – we just have to be open to hearing it. “The experience often is characterized by […] guests who come calling, but who swiftly retreat unless they are recognized and greeted” (Coppin & Nelson, 2017). Even in silence, it is speaking. Psyche is the Greek word for “soul”, and it has twin roots - the mysterious “butterfly” and the verb “to breathe” (Hollis, 1996). We breathe it in, that “…breath of life [which] connects us to [the] world, each time we breathe in or out, [enabling] us to be speaking beings” (Downing, 2000).
As Edward Whitmont put it: "one cannot encounter the Self through introversion only. Human fullness requires the actual meeting with a Thou” (Coppin & Nelson, 2017). In the “meeting with a Thou” – in the work of speaking, sharing, relating - of being with – the Self may be experienced, through feeling, and importantly, through all feeling, whether those feelings are desirable, tolerable, or not. The problem has always been that “to know oneself profoundly can be extremely upsetting” (Bettelheim, 1982) – because it means feeling into “the shadow part of the psyche” (Le Grice, 2016), which can mean feeling painful feelings. In this case our task is simply “…to live through them, not repress them or hurtfully project them onto others” (Hollis, 1996). It is here that talk therapy can provide us critical assistance in doing so. To “…experience some healing within ourselves, and to contribute healing to the world, we are summoned to wade through the muck from time to time” (Hollis, 1996), because only “…after the full acknowledgement of the loss […] does there really arise the possibility of turning to other as other” (Downing, 2000). As Rilke said, only one “…who doesn’t exclude any experience, even the most incomprehensible, will live the relationship with another person as something alive and will himself sound the depths of his own being” (Coppin & Nelson, 2017). Therapy can facilitate self-understanding, allowing us to connect to our deeper values, aspirations, and beliefs; it can also bring us closer to the experience of the numinosity of which we are both apart from, and a part of, and which holds us in protection wherever we go - the ocean of which our consciousness is but a drop - though, as Coppin & Nelson (2017) note, even that metaphor is inadequate since, unlike an ocean, it “…is fundamentally immeasurable and therefore impossible to quantify or fully define […it is] a wilderness that cannot be tamed.” As Camus (1965) said, “I don’t know whether this world has a meaning that transcends it. But I know that I do not know that meaning and that it is impossible for me just now to know it. What can a meaning outside my condition mean to me?” One answer might be: nothing, if that condition is restricted to the cognitive. It seems to me that true inquiry cannot “be unyoked from the complex emotional life of the body” (Coppin & Nelson, 2017); for me, the felt sense is the ‘why’ and the ‘what for’ of inquiry itself – my connection to and experience of that which lies beyond my individuality. Psyche, Self, spirit, soul: these are all interchangeable terms to me; their number indicates that what they point at is beyond intellectual comprehension - but not experience. The mind looks for explanations, but the body knows better; it simply receives what is given, and what is given to me - is feeling. It is not one but all feelings that bring such communion. As Nietzsche said, “All feeling suffers in me and is in prison: but my willing always comes to me as my liberator and bringer of joy.” This I understand as meaning: the will to feel - the will to attend to the entirety of the felt sense, no matter how painful. Suffering “is an ineradicable part of life, even as fate and death. Without suffering and death human life cannot be complete” (Frankl, 1984). It seems to me that the felt sense is the live wire through which the current of life travels, that feeling is the immanent experience of the one in all, and that thought is but a shadow cast upon the wall by that singular flame. It follows then that when the mind is not put at service of the heart, but instead learns to dominate it, that many of the difficulties that lead us to seek therapy result. Bettelheim, B. (1982). Freud and Man’s Soul. Vintage Books, Random House, NY. Camus, A. (1965). The Myth of Sisyphus, and Other Essays. H. Hamilton, London. Coppin, J. & Nelson, E. (2017). The Art of Inquiry: A Depth-Psychological Perspective. Spring Publications; Thompson, CT. Downing, C. (2000). Sigmund Freud’s Mythology of Soul; the Body as Dwelling Place of Soul. In: Slattery, D. P. & Corbet, L. (2004). Depth Psychology: Meditations in the Field. Daimon Verlag, Einsiedeln, Switzerland. Frankl, V. E. (1984). Man's Search for Meaning: An Introduction to Logotherapy. Simon & Schuster, NY. Hollis, J. (1995). Tracking the Gods: the Place of Myth in Modern Life. Inner City Books, Toronto, ON. Hollis, J. (1996). Swamplands of the Soul: New Life in Dismal Places. Inner City Books, Toronto, ON. Le Grice, K. (2016). Archetypal Reflections: Insights and Ideas from Jungian Psychology. Muswell Hill Press; London/NY. Nietzsche, F. W. (Translation by Hollingdale, R J., 1977). Thus Spoke Zarathustra: A Book for Everyone and No One. Penguin Books, Harmondsworth, England. Religion is weaponized and used to commit very real harm time and time again, in the name of spirituality. Intersectional issues such as racism, misogyny, sexual and gender expression are all entwined with the subject.
Therapy continues to be contextualized within the dominant patriarchal culture that upholds narratives situating white cis able-bodied men as superior to trans and cis women, trans men, nonbinary persons, racialized folks, neurodivergent folks, disabled folks, and any others deemed outside that narrow, normative circle. This context can result in the spirituality and religiosity of these folks automatically being delegitimized too. And yet it’s possible to argue that psychopathology is, in fact, a result of some degree of absence of spiritual connection to the life and universe around you – as well as, in some instances, even a result of an overwhelming experience of that connection, an experience that takes an individual beyond what their materialist culture provides any kind of framework for, leaving them totally overwhelmed by something they therefore cannot explain or contain. Spirituality and religiosity can be core components of what a person brings to the therapy experience. A lack of understanding of another’s worldview in this sense – a failure, for example, to look beyond mainstream media portrayals of Islam – can be serious barriers to effective therapy. This is where any ignorance on behalf of the practitioner of any of the ways in which a client experiences oppression can lead to all manner of harmful values being imposed upon them. My own experience and journey has highlighted love as the ground from which all other feelings arise. It appears to me that we feel angry because someone has transgressed our boundaries, for example, or that we feel grief because we have lost something or someone, and that none of this would arise if we did not in fact love ourselves and deem ourselves worthy of love, respect, happiness and safety. The thing that appeals to me about psychodynamic therapy is that it arguably centres feeling as the primary unit of experience. Now, this framing may well be rooted in my own bias, but for me the place where psychodynamic therapy and my own eastern spiritual heritage appear to connect is in the understanding that the thing that animates us, the thing that does all things, does them all through feeling.
For me, psychodynamic therapy is the sharpest tool in the therapist's toolbox for cutting through all of the defences we develop to keep ourselves separated from our experience of feeling and therefore our experience of that thing which animates us - ultimately, from our experience of the feeling of love, the feeling of the benevolent universe itself. What does it mean to ‘work with the unconscious’? For me, working with the unconscious in therapy means noticing what is not being attended to but is still manifest, in the room, in the relationship, in the client’s behaviour, in their body - in my own behaviour, and in my own body too. A starting point for doing so is will, or perhaps, openness - to that which is greater than myself and the client, that which holds us both and silently guides us in our work together.
The biggest difference between Freud’s psychoanalytic approach and the modern one can perhaps be generalized as the difference between good science and bad. In bad science the scientist observes the object but never actually accounts for themselves as a variable in the equation. Good science, though, does, and modern psychodynamic therapies do this by pivoting from Freud’s one-directional method of practice - with the therapist as an all-knowing observer, and the client as object of observation - to an awareness of the importance of the therapeutic alliance, where the presence of both people is an equally meaningful part of the process, and the mechanism of change is ultimately found in the relationship between the two.
Freud’s one-directional approach to practice can perhaps be said to reflect the hierarchical, patriarchal model of thought that continues to dominate today - the one-up and one-down - whereas we can but hope that the focus on the therapeutic relationship is indicative of a differently structured future. That’s the direction psychoanalysis seems to me to have taken – a strong therapeutic alliance is widely accepted as being a critical mechanism of action in the psychotherapy, and so much can be learned from our unconscious reactions to being an active participant in one. In therapy there sometimes comes what is called a moment of rupture - a moment in the therapeutic relationship where the connection is threatened, or even damaged. Such challenging moments are quite possibly inevitable, given that out in the world of daily life they occur, relationally, all the time. Our job as a therapist and client dyad, working together, is to be as open and attentive to these moments as we can, because they provide significant opportunities for growth. Such moments can leave us both with no choice but to fall back again on our own resources, and (hopefully) from there to return to one another - having been reconfigured by our individual understanding of what happened, and what it meant, and from this emergent way of being and understanding - rather than backing out - to continue inching forward, toward each other, and ultimately, toward our own selves.
Something good can come from difficult moments; it can almost seem at times as if the unconscious of both therapist and client have colluded to create such an opportunity. If consciousness is a stream, and behaviour and conscious awareness of its determinants are what we see at the surface of the water, well, then - the deep flows just as incessantly. Many clients come to therapists wanting guidance, and tools – ultimately wanting someone to tell them what to do, and how to do it. While I can fully sympathise with this wish, I also can’t help but think this stance arises out of painful experience – that it is a learned response, a reaction in which people shut down their own valid emotional reactions, have an external locus of value and of judgement, lose all sense of their own agency and ultimately lose the knowledge that everything they need is already inside them.
The issue of “wanting tools” is often a barrier to the work a client is there to do. “Wanting tools” often means wanting a shortcut, a way of bypassing the unconscious obstacles between a person and the life they want to live – such as unconscious anxiety, or unconscious, attachment-related behaviours. As a practitioner dealing with this wish requires stepping out of the shoes of an omnipotent, all-knowing expert, and focusing instead on the collaborative effort, the shared effort where the client and I put all our skills together, put our hearts and minds together to try to achieve something good for them. It requires being honest and transparent about the limits of my powers – that I cannot know for sure what the client needs, that I may have some ideas about what might be good for them, but that ultimately only they can know. This means accepting their reactions in response to this, encouraging them to fully embody the feelings that then arise in response to me, and ultimately leaving the space of knowing what they need free for them to step into and claim once again. Transference is perhaps not a widely known term. It can be thought of as when a pattern of interacting with an early attachment figure becomes a blueprint for later relationships. Nat Kuhn, in "Intensive Short Term Dynamic Psychotherapy: A Reference" (2014), describes transference as the tendency to "bring aspects of problematic relationships with early attachment figures into therapy". For example, a client with a highly critical mother may tend to feel that the practitioner is being critical towards them and become hostile in response. Working in the transference, which is a key mechanism of change in psychodynamic work, involves focusing on these feelings towards the practitioner, perhaps in the hope of clarifying their origin and thus allowing the client to work through this unresolved emotional content in the context of a secure attachment. It can be differentiated from projection in that it isn't necessarily something you are disowning from within yourself and then projecting onto another, but more the echo of a learned pattern of interacting. There is overlap between the two - there can perhaps be projection in transference, for example. But what is important here is the willingness and the ability to discern between old feelings about past, painful experiences, and new feelings about present experiences. Without this discernment our reactions in the present will never be just our reactions to the present, but instead be forever clouded by echoes from the past.
My understanding is that this often-confused process involves the outward projection of feelings coming up in me (but which I deny myself the experience of) onto another person. I might be denying myself the experience of these feelings perhaps because I learned that to experience them was intolerable (I never learned to self-soothe and thus regulate these feelings), or that to experience them was unacceptable (a caregiver perhaps never learned to self soothe or regulate themselves in response to me having these feelings when I was a child) – and so now, when this intolerable or unacceptable feeling comes up in me, it causes unconscious anxiety, leading me to the unconscious defensive manoeuvre of projection; instead of feeling my feeling, I believe the person in front of me is feeling it, not me - I "project" it onto them, I believe they are the ones feeling it, and then I behave accordingly in response to my belief about what the other person is feeling. The point here is that I am not interacting with reality, but instead with my belief about reality, and that this whole unconscious manoeuvre is occurring to enable me to not have to feel my own feeling – a feeling experience has taught me to deny myself.
There is an important distinction to be made between feeling something and acting upon it. You can inadvertently communicate so much through your face and your presence when you are just feeling something, but the words you choose to say involve a conscious choice, a path of action. How do you stop the words you say from being a reaction to what you’re feeling, rather than an expression of it? How do you make sure you are being fully congruent and genuine, and not just reacting to the discomfort your feelings or thoughts create inside you? Through integration, I think; through maintaining a connection between your heart and your head, your attachment and your detachment, being clear on what is yours and what is not yours, and ultimately, by ‘doing your work’.
The self-awareness that you will foster by ‘doing your work’ can create enough space inside you to allow you to attend to what is really going on for you before you interact with the world - can allow you to really recognize what your genuine feelings are in response to the events in your life and not just discharge the anxiety you feel because of them. By ‘doing your work’ in this way – by getting closer to who you are and what you really feel – you can begin to step out of the collusion in unreality which we all, it seems, engage in as part of the social contract: the unspoken agreement to all be living inside our own heads and forever interacting primarily with only our own ideas and beliefs about the people around us, instead of being real and authentic with one another. There are legitimate concerns about the medical model and the capitalist logics that have bled into and shaped this area of work over the last century - and the othering potentialities therein. The counselling and psychotherapy industry can, as a result of its inescapable rooting in the capitalist structure of society at large, tend to focus on symptom reduction as a goal rather than exploring causes, with an aim to just get you functioning again – to get you back to work, essentially. And this is why I love psychodynamic work - because it makes space for the question why are these symptoms occurring - what is making them occur?
You can hack away at weeds with all the energy you are able to muster, but unless you get to the roots they will be sure to grow back, time and again, and without getting at those roots you risk being left dealing with the problems they represent for a lifetime. With regards the issue of race and therapy, the overwhelming focus within the industry remains on how to mitigate the issues that arise in the context of racialized clients and White therapists. Here the multicultural competence literature indicates that matching the cultural characteristics of the treatment with those of the client increases treatment effectiveness (Interian & Díaz-Martínez, 2007; La Roche & Lustig, 2013). But this remains a foggy and under researched task, and it is increasingly being shown that matching the cultural characteristics of the therapist themselves to the client also increases treatment effectiveness – due in large part to a greater consequent understanding of the intersections of the client’s complex individual identity (Collins et al., 2010; Ecklund, 2012). There is significant evidence to support this, with clients whose therapists were ethnically similar and/or spoke their native language dropping out of treatment less, staying in treatment longer, and experiencing better treatment outcomes (Wilson & Stith, 1991; Interian & Díaz-Martínez, 2007; Awosan et al., 2011; Hall & Sandberg, 2012; Presely & Day, 2019), highlighting the value of cultural knowledge exercised by ethnically similar therapists. Furthermore, there is strong evidence indicating that this is also the clear preference of racialized clients themselves (Chang & Yoon, 2011; Mofrad & Webster, 2012).
The message here is that racialized therapists are uniquely positioned to serve racialized populations by helping them to recognize their individual and collective strengths; by helping them to define themselves as individuals with unique qualities that can help them overcome individual difficulties; and by being comfortable with and empathic about the impact of skin color differences and associated projections on our lives. (Chen et al., 2008; Chang & Yoon, 2011; Zaharopoulos & Chen, 2018; Sawrik, 2020). A racialized therapist can provide a unique opportunity for racially marginalized folks to better understand their own selves – an opportunity to better learn how to manage the stressors unique to their marginalized status alongside someone who shares the experience of otherness and who can work together with them to understand and shape their experience while highlighting their own agency in doing so (Jones & Pritchett-Johnson, 2018). This opportunity comes at less risk of further traumatization – not at zero risk, as aforementioned, because intersecting and often invisible aspects of identity can still collide – but one that can provide a worthwhile mitigation of a pressure racialized folks otherwise experience every day of their lives. Awosan, C. I., Sandberg, J. G. & Hall, C. A. (2011). Understanding the experience of black clients in marriage and family therapy. Journal of Marital and Family Therapy, 37 (2), pp. 153-168. doi: 10.1111/j.1752-0606.2009.00166.x Chang, D. F. & Yoon, P. (2011). Ethnic minority clients’ perceptions of the significance of race in cross-racial therapy relationships. Psychotherapy Research, 21 (5), pp. 567-582. DOI: 10.1080/10503307.2011.592549 Chen, E. C., Kakkad, D. & Balzan, J. (2008). Multicultural Competence and Evidence-Based Practice in Group Therapy. Journal of Clinical Psychology: In Session, 64 (11), 1261-1278. DOI: 10.1002/jclp.20533 Collins, S., Arthur, N. & Wong-Wylie, G. (2010). Enhancing Reflective Practice in Multicultural Counseling Through Cultural Auditing. Journal of Counseling & Development, 88, pp. 340-347. Ecklund, K. (2012). Intersectionality of Identity in Children: A Case Study. Professional Psychology: Research and Practice, 43 (3), 256–264. DOI: 10.1037/a0028654 Hall, C. A. & Sandberg, J. G. (2012). “We Shall Overcome”: A Qualitative Exploratory Study of the Experiences of African Americans Who Overcame Barriers to Engage in Family Therapy. The American Journal of Family Therapy, 40:445–458. DOI: 10.1080/01926187.2011.637486 Interian, A. & Díaz-Martínez, A. M. (2007). Considerations for Culturally Competent Cognitive-Behavioral Therapy for Depression With Hispanic Patients. Cognitive and Behavioral Practice, 14, pp. 84--97 Jones, M. K. & Pritchett-Johnson, B. (2018). “Invincible Black Women”: Group Therapy for Black College Women. The Journal for Specialists in Group Work, 43 (4), 348-375. DOI: https://doi.org/10.1080/01933922.2018.1484536 La Roche, M. & Lustig, K. (2013). Being Mindful About the Assessment of Culture: A Cultural Analysis of Culturally Adapted Acceptance-Based Behavior Therapy Approaches. Cognitive and Behavioral Practice, 20, pp. 60-63 Mofrad, L. & Webster, L. A. D. (2012). The treatment of depression and simple phobia through an interpreter in the North East of England: a case study. The Cognitive Behaviour Therapist, 5, pp. 102–111. doi:10.1017/S1754470X13000044 Presley, S. & Day, S. X. (2019). Counseling Dropout, Retention, and Ethnic/Language Match for Asian Americans. Psychological Services, 16 (3), pp. 491–497. http://dx.doi.org/10.1037/ser0000223 Sawrik, P. (2020). Service providers’ cultural self-awareness and responsible use of racial power when working with ethnic minority victims/survivors of child sexual abuse: Results from a program evaluation study in Australia. Children and Youth Services Review, 119 (10). https://doi.org/10.1016/j.childyouth.2020.105641 Wilson, L. L. & Stith, S. M. (1991). Culturally Sensitive Therapy With Black Clients. Journal of Multicultural Counseling & Development, Vol. 19, Issue 1, p32-43. DOI: 10.1002/j.2161-1912.1991.tb00455.x. Zaharopoulos, M. & Chen, E. C. (2018). Racial-Cultural Events in Group Therapy as Perceived by Group Therapists. International Journal of Group Psychotherapy, 68:4, 629-653, DOI: 10.1080/00207284.2018.1470899. |
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