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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".
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. 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. |
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