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Understanding Davanloo's Intensive Short-Term Dynamic Psychotherapy

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The objective of this book is to update dynamic psychotherapists on the latest findings in Davanloo's Intensive Short-term Dynamic Psychotherapy (IS-TDP). Previous authors have sometimes presented a simplistic, reductionist version of the technique to the public, and the current book is important because it offers the broadest and most up-to-date treatment of the subject, written by a psychiatrist who has attended Davanloo's closed circuit training program for the past eight years. Clear and well-organized prose introduces important technical concepts that had not been previously discussed. The book is divided into three main sections. These include sections on basic theoretical principles of Davanloo's work, application of his new principles and research/future directions. The book begins with an opening chapter on Davanloo's metapsychology of the unconscious. Following this chapter, major mobilisation of the unconscious will be explored in detail. This important concept will be reviewed in the context of Davanloo's closed circuit training program which has unique learning and experiential features. A number of important newer topics are also explored. These concepts will be made less abstract and more tangible as they are illustrated through a case study of an individual who was interviewed in the closed circuit training program. These interviews, in their totality, are not available in any other format. The book ends with a section on future directions for research, neuroimaging, and competency-based education.

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Chapter One: A Review of Davanloo's Metapsychology of the Unconscious

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Through the use of video technology, Dr Davanloo has made many discoveries about the human unconscious. He has applied these discoveries to a wide variety of patients, including those who are highly resistant (Davanloo, 2000). These discoveries are based upon empirical evidence, not theory or intuition, and form the basis of his metapsychology of the unconscious (Davanloo, 2001). His work of the early 1980s focused mainly on patients with phobic, obsessional, panic, depressive and functional disorders (Davanloo, 1987a, 1987b, 1989; Zaiden, 1979). Following this, Dr Davanloo began to focus on treating patients with psychosomatic conditions and fragile character pathology. He was able to demonstrate that these patients could be treated successfully with some modifications of the technique (Davanloo, 1999a, 1999b). In this technique, “direct access to the unconscious”, and to all of the pathogenic dynamic forces that contribute to a patient's symptoms and character disturbances, is possible (Augsburger, 2000). The technique of rapid and direct access to the unconscious will be highlighted through a detailed case presentation in this book.

 

Chapter Two: Davanloo's Discoveries: An Overview of the Montreal Closed Circuit Training Programme

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The Montreal closed circuit training programme has been in operation since 2007. Generally, a group of therapists meet with Dr Davanloo in Montreal for three to five blocks per year. Each block consists of about five days of intensive immersion training. Anywhere from five to fifteen therapists may be in attendance at each block. The membership in the programme has fluctuated somewhat over the last nine years. Given the time and financial commitments involved, not all participants can maintain indefinite involvement in the programme.

The therapists assume different roles at different times. Often, one therapist (the interviewer) has a session with another therapist (the interviewee). The session is videotaped and witnessed live. Usually, the session DVD is then viewed. Dr Davanloo watches the entire process and gives formative feedback. This feedback occurs both live and in real time (if the interview is stagnating or at an impasse) and retrospectively (through the viewing of DVDs). Recorded vignettes are watched repeatedly and analysed in depth. While others have commented on the benefits of videotape training in psychotherapy education (Abbass, 2004), it has not been used previously in an immersion setting of this breadth and depth.

 

Chapter Three: Davanloo's Discoveries, 2005–2015: an Overview of Important Terminology and Teachings

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Davanloo's most recent publication was a chapter in the comprehensive Textbook of Psychiatry (Davanloo, 2005). Since then, many other authors have written and published articles and books on Davanloo's technique. However, many of these authors have not attended Davanloo's Montreal closed circuit training programme. As such, their writings reflect Davanloo's older discoveries. While important, Davanloo's earlier discoveries have been greatly elaborated on and refined in his newest programme. In addition, many of these articles do not use the most up-to-date terminology. The purpose of this chapter is to define the most recent conceptual discoveries of Davanloo. This is essential before proceeding to further chapters, which will show these discoveries in operation.

Fusion

The metapsychology of the unconscious is soundly based in attachment theory. Like Bowlby (Bowlby, 1944), Davanloo believes that attachment to important early life figures is essential for normal human development. At the core, or the nucleus, of the unconscious is love and attachment to these important early figures. Davanloo refers to these figures as genetic figures. At some point in human development, the love and attachment to these genetic figures is disrupted. This can be a relatively minor trauma, such as the birth of a younger sibling. Or it can be an extensive trauma, such as repeated and prolonged abuse. This disruption results in a myriad of painful feelings—these include rage (which is often of a murderous quality), guilt, and grief. These feelings are so painful that they remain unconscious in most people. Davanloo refers to this dynamic system as the pathogenic core of the unconscious (see Figure 1). The age at which this love and attachment is disrupted is critical. Like Bowlby (Bowlby, 1951), Davanloo believes that the earlier the disruption occurs, the more damaged the patient becomes. The age span from birth to five years, for example, is a particularly critical period for attachment.

 

Chapter Four: The Initial Evaluative Interview: The Major Mobilisation of the Unconscious and the Total Removal of Resistance

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Now that important metapsychological principles have been reviewed, a recent case will be discussed to visualise these in operation. The case will be reviewed in considerable detail in this and the following chapters. Each chapter will highlight at least one recent major discovery of Davanloo and will explore that particular metapsychological concept or technical consideration in great detail. The subject of this first chapter is the major mobilisation of the unconscious and the removal of resistance.

Case presentation

The patient is a 55-year-old female therapist who presents for evaluation in the closed circuit training programme with Dr Davanloo. Her demographic details will be camouflaged so as not to reveal her identity. She lives in Europe and has four children. She has had lifelong character disturbances that include rigidity, stubbornness, and resistance against emotional closeness. She has also suffered from lifelong migraines and has had the more recent onset of insomnia. There are no malignant character defences and there is an absence of structural character pathology.

 

Chapter Five: The Transference Neurosis: Part I

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In the last chapter, we explored the initial session of a highly resistant therapist who was interviewed by Dr Davanloo in his closed circuit training programme in Montreal. In this next chapter we will continue to focus on this case, reviewing vignettes from the second interview in this programme. This interview is published with the permission of the Association for the Advancement of Psychotherapy and first appeared in the American Journal of Psychotherapy (Hickey, 2015d). What follows is the content of the interview and some updated discussions that have occurred since its original publication.

The focus of this chapter will be the management of the transference neurosis in this patient. The patient had a prior course of therapy, as mentioned in the preceding chapter. It is during this treatment that she developed the transference neurosis towards her therapist. The TCR had been extremely low during that course of treatment and the focus of the therapy had been on the patient's father. Subsequent closed circuit evaluation revealed that this was not the core neurotic disturbance in the patient.

 

Chapter Six: Transference Neurosis: Part II

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The following case is a continuation of the previous chapter with a continued focus on the transference neurosis that had developed in a prior course of therapy. In the first session of the closed circuit training programme, the patient had a massive passage of murderous rage towards the therapist, an impulse to sadistically torture and murder him, and, finally, a massive passage of guilt as she looked into the eyes of the therapist and saw the green eyes of her grandmother. In the second session, she had a similar experience of murderous rage and guilt towards the grandmother.

What follows are vignettes from the third closed circuit training session. This interview was first published in the International Journal of Psychotherapy (Hickey, 2015e). This interview raises a number of important concepts that reflect Dr Davanloo's current-day understanding of the technique. Since this interview has been reviewed in multiple settings (Davanloo, 2013a, 2014a), there have been numerous group discussions on the themes it raises. These will be reviewed in detail at the end of this chapter.

 

Chapter Seven: Multidimensional Unconscious Structural Changes: Part I

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We continue to focus on our case. The first interview focused on the major mobilisation of the patient's unconscious and the total removal of the resistance. The next two interviews focused on the patient's transference neurosis with her previous therapist. A number of important concepts were reviewed in the last chapter. These included the following:

1. The role of the grandmother's sister in her original neurosis.

2. The grandmother's early life orbit and how this impacted the family.

3. The role of projective anxiety and the “court” of the grandmother's unconscious.

4. Fusion.

5. Transference neurosis.

6. Destructive competitive form of the transference neurosis.

7. Unconscious defensive organisation.

8. The protective role of the high TCR.

What follows is the fourth interview in the series, which was previously published as two articles (Hickey, 2015a, 2015f). However, the evaluations and commentaries have been updated since these two publications. There will be a special focus on the use of MUSC as a means of solidifying the therapeutic task, acquainting the patient with her resistance, and highlighting the possibility for change. Simply put, MUSC are any interventions used by the therapist to change various unconscious structures—for example, unconscious defensive organisation, unconscious resistance, unconscious anxiety, and/or unconscious emotion. In doing so, the therapist attempts to help the patient make conscious sense of the unconscious material that comes to the forefront during the interview process.

 

Chapter Eight: The Neurobiological Pathways of Murderous Rage and Guilt

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The first interview focused on the major mobilisation of the patient's unconscious and the total removal of the resistance. The next two interviews focused on the patient's transference neurosis with a previous therapist and the metapsychological and treatment considerations of this. The fourth interview in the series focused on the use of MUSC throughout the interview process and how MUSC are the building blocks for change in the patient's defensive and character structure. This next interview will focus specifically on the neurobiological pathways of murderous rage and guilt.

Vignette I: the phase of enquiry and the therapeutic task

TH: So we are meeting again.

PT: Yes.

TH: And you look forward to it?

PT: Yes.

TH: And again we move to this principle of honesty.

TH: To explore the most painful issues and honesty is the principle. How do you feel right now?

PT: I was anxious in the room.

TH: How do you feel right now?

 

Chapter Nine: The Transference Neurosis: Part III

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We begin with the patient's sixth interview in the closed circuit setting. The focus of this chapter (like the second and third) is the recognition and management of the transference neurosis in IS-TDP. As a result of the syndrome of the “mother turning the daughter against the father” (see Chapter Fifteen), the patient became more distant and detached from her father as a young adolescent. What emerges is that the entire family system was under the controlling influence of the grandmother, who is revealed as “the Queen Bee” of the family. The grandmother, due to her own upbringing and neurosis, could not tolerate anyone in the family getting close to anyone else. This destructive competitiveness was kept alive through means of intergenerational transmission of psychopathology and transmitted to the daughter and then the patient herself. We now focus on how this unconscious system was in operation when the patient sought out therapy with an individual with whom she developed a transference neurosis.

 

Chapter Ten: The Destructive Competitive form of the Transference Neurosis

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We continue with our case. We have reviewed several important new concepts in Davanloo's work. These include:

1. The role of transference neurosis and how it must be avoided at all costs.

2. The use of MUSC throughout the interview process.

3. The neurobiological pathways of murderous rage, guilt, and grief.

Now we will review another new feature of Davanloo's work. Davanloo has identified an important metapsychological concept called the “destructive competitive form of transference neurosis”. This concept must be carefully understood. While it will be reviewed in detail in the case below, it must be briefly defined before we continue on with the case.

Most families contain individual members who have varying degrees of psychopathology. Transference neurosis can develop amongst these family members. The intra-psychic issues of one family member are transferred to another family member—who is often in the next generation and suffers as a result of this transmission. The individual who transfers this material usually does it unconsciously—but the net result is that that the individual who receives the material suffers because of it. In this sense, the entire system is morbid in nature and results in major destructiveness in the family. There is competition for being destructive, rather than competition for being successful. We return to the seventh interview to show this dynamic in operation. Clinical material will make some of these more abstract concepts more tangible.

 

Chapter Eleven: The Transference Neurosis: Part IV

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We continue with our case and will review the eighth interview. The subject of this interview will once again be the transference neurosis and how it leads to destructiveness.

Vignette I: the experience of the neurobiological pathways of murderous rage and guilt

TH: So we are here again. Again I put underline on the principle of honesty but the second issue we have to keep in mind is the destructiveness inherent in the difficulties. So if we keep the destructiveness on one side then honestly we can proceed. Because you are here to remove the destructiveness and be autonomous in your life. This is your own right in this universe. How do you feel towards me? You took a sigh.

PT: I wasn't aware of anxiety until you asked “how do you feel towards me?”

TH: So there is a rage?

PT: I wasn't aware there is a rage.

TH: How do you feel towards me? If honestly…

PT: The axe comes back.

TH: Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. Go on. No interruption. Go on. Go on. Go on. Go on. Go on. Go on.

 

Chapter Twelve: Unconscious Defensive Organisation and Brainwashing

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We continue with the ninth interview in the case. At this point, several chapters of this book have been dedicated to examining the transference neurosis. It has been highlighted as a morbid entity that is to be avoided at all costs. But there remain many unanswered questions about the transference neurosis. For example:

1. Why do some patients develop transference neuroses when others do not?

2. Why are some therapists blind to their propensity towards inflicting transference neuroses on their patients?

3. What are the ethical ramifications for therapists once they have established that a transference neurosis exists in a therapeutic relationship?

4. Is there an element of brainwashing in the development of the transference neurosis?

This chapter will focus very specifically on the effect of the transference neurosis on a patient's unconscious defensive organisation. This chapter will also focus on the link between impairment of the unconscious defensive organisation and brainwashing.

 

Chapter Thirteen: Pathological Mourning and the Mobilised Unconscious

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We continue with the tenth interview in the series. The focus of this interview will be pathological mourning. Specifically, Davanloo's approach to working with and removing pathological mourning will be illustrated through further vignettes. But before we can explore this further, there must be a brief review of the history of pathological mourning.

Freud first explored this concept in “Mourning and Melancholia” (Freud, 1917e). He noted that the deep feelings a patient experienced with the loss of a loved one were very similar to the feelings that a patient with melancholia experienced. Individuals suffering from melancholia shared the same loss of interest in the outside world and were absorbed in their own intra-psychic worlds. However, mourning was seen as a normal phenomenon whereas melancholia was viewed as a medical condition that required active intervention and treatment. Mourning occurred after an actual and apparent loss and was experienced as a conscious emotion. Melancholia did not occur after an actual death and the loss was seen as an unconscious one.

 

Chapter Fourteen: Intergenerational Transmission of Psychopathology

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Following the tenth interview, there was another interview in the closed circuit training programme that was audiovisually recorded. While the visual component of the recording was intact, there was no audio component. As such, the transcript of this interview is not available. For this reason, our next chapter will focus on the twelfth interview in the series. The topic of this chapter will be Davanloo's concept of the intergenerational transmission of psychopathology.

The notion that psychopathology is or can be transmitted or transferred from one generation to the next is not new. Over forty years ago, Guze, 1973 spoke about how the presence of psychiatric illness in one generation often increases the risk of that same illness occurring in members of the next generation. While there are some clear genetic associations for some psychiatric diseases (Alzheimer's and other types of dementia, for example), many would view these illnesses as neurological or brain diseases. Davanloo has formulated that psychoneurotic illness can be directly transmitted from one generation to the next. Davanloo does not see this transmission as a biological one, but rather a psychodynamic one. Children of destructive parents tend to become destructive themselves. Poor attachments in one generation often result in poor attachments in the next. The same relationship and family dynamics tend to be propagated through the generations.

 

Chapter Fifteen: The “Turning Away” Syndrome

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The next two interviews in the series (interviews 13 and 14) were not available for transcription. So what follows is the fifteenth interview in the series. The focus in this particular chapter is a topic that Davanloo has begun to explore only relatively recently (Davanloo, 2015). Specifically, there has been a focus on family members turning other family members against each other. Any member of the family can turn another member away from a third member. We call this the “turning away” syndrome.

Again, while this would intuitively cause major intra-psychic damage to a developing child, no other brief dynamic therapist has focused on it or published on it to date. When one searches the literature on this theme, some information arises from biblical quotes. For example, in Matthew 10:35 (King James Bible) we see the following scripture:

For I am come to set a man at variance against his father, and the daughter against her mother, and the daughter in law against her mother in law.

 

Chapter Sixteen: Following the Trail of the Unconscious

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We continue with the sixteenth interview of the series. By now, the patient is quite familiar with the process. She has been interviewed in the Montreal closed circuit training programme multiple times. She has had multiple breakthroughs of murderous rage and intense guilt. The therapist has applied MUSC throughout the entire process. At this point in the journey we are beginning to see the start of structural change in her unconscious. Simply put, the various components of her unconscious—her defensive organisation, her anxiety, her resistance, and her emotion—are beginning to change.

For example, earlier on in the course of the therapy, she often had projection in relation to the therapist. She had unconscious anxiety in relating to him and this was for a variety of reasons, as reviewed. To summarise, she had unconscious anxiety generated by her murderous impulse. In addition, she had projective anxiety simply because she saw him as her grandmother; and this omnipotent, authoritative, and sometimes explosive figure frequently induced anxiety in her as a small child.

 

Chapter Seventeen: The Neurobiological Destruction of the Uterus

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We move on with the seventeenth interview of the series. By now, many of Davanloo's newer concepts should be familiar to the reader. One concept that has been touched on in previous chapters (albeit in less detail than what is covered in this chapter) is the neurobiological destruction of the uterus.

In some of the patient's previous breakthroughs, she has violently destroyed the uterus of the therapist. The visual image of the murdered body of the therapist and the destroyed uterus transferred to the visual image of the murdered body of an important genetic figure—usually the grandmother. The destruction of the uterus has dramatic psychodynamic implications. In this case, the patient is caught in a destructive competitiveness that triangulates her between her mother and grandmother. She wishes to destroy the grandmother to achieve closeness with the mother and vice versa. So destroying the uterus of the grandmother has extreme significance for her. It accomplishes her intra-psychic goal of achieving the undivided love of her grandmother (in the absence of her mother). But it also creates a tremendous volume of guilt towards the mother and grandmother as well.

 

Chapter Eighteen: The Character Resistance of the Idealisation of Destructiveness

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We now move on to the eighteenth interview in the series. By now, the reader should have basic familiarity with the format of the Montreal closed circuit training programme and just how refined the technique has become over the last several years. It is only through live, experiential interviews that Dr Davanloo and the group participants can see some of these newer concepts and interventions in action. But the group has been met with some controversy in the national and international psychodynamic communities at large. Many psychodynamic psychotherapists reject this model of training. The training is unconventional, immersive, and uniquely experiential. Some therapists have critiqued it as being invasive and as crossing boundaries (Frederickson, 2016).

However, each and every participant gives written, informed consent to engage in this training. No one is coerced to partake by any means. In fact, many therapists seek it out because it is unique. No other training programme offers participants the opportunities to both interview and be interviewed. No other programme allows group members to repeatedly view, dissect and understand this very complicated and precise technique. And few other training programmes (in any modality) allow the founder to teach it precisely using modern day technology. An insightful and prudent reader might ask: is the critique of this programme legitimate? Readers are asked to be mindful of this question throughout the remaining text. We will revisit the question in the last section of the book.

 

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