Intensive Short-Term Dynamic Psychotherapy: Theory and Technique

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Traditionally, psychoanalytic treatment has been a lengthy endeavour, requiring a long-term commitment from patient and analyst, as well as vast financial resources. More recently, short-term approaches to psychoanalytic treatment have proliferated. One of the most well-known and thoroughly studied is the groundbreaking method of Intensive Short-term Dynamic Psychotherapy, developed by Dr. Habib Davanloo. Having trained directly with Dr. Davenloo, the author has written a clear, concise outline of the method that has come to be regarded as a classic in the field. The book is organised in a systematic fashion, analogous to the process of therapy itself, from initial contact through to termination and follow-up. Detailed clinical examples are presented throughout the text to illustrate how theory is translated into techniques of unparalleled power and effectiveness.

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Chapter 1: The Integration of Theory and Technique in Davanloo's Intensive Short-Term Dynamic Psychotherapy

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CHAPTER 1

The Integration of Theory and Technique in Davanloo's Intensive Short-Term Dynamic Psychotherapy

I hear a distant drum beat

A heart beat pulsing low

Is it coming from within

A heart beat I don't know

A troubled soul knows no peace

A dark and poisoned pool

Of liberty now lost

A pawn, the oppressor's tool.

Loreena McKennitt *

In many ways, this songwriter has articulated the plight of neurotics, blind to their own inner world and, as such, destined to live the life of a prisoner. The discovery of such a rich and complex inner life began with Breuer and was elaborated on in great detail by Freud (Breuer & Freud, 1895).

BASIC TENANTS OF PSYCHOANALYTIC THEORY

Breuer's (Breuer & Freud, 1895) pioneering work with Anna O. led to the discovery of the dynamic unconscious and laid the foundation for psychoanalysis. He placed the patient under a hypnotic trance and discovered, quite by chance (Schoenewolf, 1990), that her current physical symptoms were connected to traumatic experiences from the past (caring for her sick and dying father). When he was able to get her to verbalize her feelings about these traumatic experiences, the symptoms vanished. Again and again, he found that the recall of memories and reliving of the emotions associated with the memories led to symptom removal. The original forgetting was labeled “repression,” and the remembering, “catharsis” (Fisher & Greenberg, 1977). Although this cathartic treatment led to immediate relief, there were frequent relapses and no lasting cure. An additional problem arose in the treatment relationship when Anna began to have strong loving and sexual feelings toward Breuer. He became frightened and abruptly ended her treatment. In fact, he abandoned this kind of work altogether.

 

Chapter 2: The Trial Therapy

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CHAPTER 2

The Trial Therapy

You need that rite of passage

before you can continue on,

That great self understanding

you can lean your dreams upon.

Dougie MacLean *

This chapter will outline the process of the trial therapy developed by Dr. Davanloo. The development of this elegant system for assessing suitability for treatment and, when indicated, rapidly entering the unconscious, is surely one of Davanloo's greatest contributions to the field of dynamic psychotherapy. Three cases from my own practice will be used to illustrate some fairly typical responses to the trial therapy. These patients had nearly identical presenting complaints, but the trial therapy revealed different origins to the symptoms and varying capacities for the work at hand, each having distinct implications for treatment.

The trial therapy is a complex and systematic method for assessing the patient's symptomatic and characterological difficulties, determining the unconscious forces behind these difficulties, and evaluating the patient's current ego-adaptive capacity. This extended (2–4 hour) evaluation is, indeed, a rite of passage for both patient and therapist, providing an opportunity for a deep understanding of the unconscious forces responsible for the patient's suffering.

 

Chapter 3: Working with Defenses

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CHAPTER 3

Working with Defenses

Slip sliding away

Slip sliding away

You know the nearer your destination

The more you're slip sliding away

Paul Simon*

Many professionals consider Davanloo's (1980, 1990) technical innovations for handling defense and resistance to be his greatest contribution to the practice of dynamic psychotherapy. The tight focus on defenses from the inception of treatment is also the most controversial aspect of his work. This chapter will review the concepts involved in the mechanisms of defense, will provide a working definition of defense and resistance, and will outline a detailed schema for the conceptualization and handling of these dynamic forces within the treatment setting. The work of those clinicians most directly affecting the development of Intensive Short-Term Dynamic Psychotherapy (ISTDP) will be highlighted.

KEY CONCEPTS IN DEFENSE THEORY

It was during his early work with hysterics that Freud (1894, 1895) first outlined the concepts involved in the notion of intrapsychic conflict—that patients mobilize forces (D) to prevent awareness of painful and anxiety-provoking (A) thoughts and feelings (I/F). He went on to say that the mobilization of these forces, which he called defenses, was a function carried out by the ego.

 

Chapter 4: Restructuring Regressive Defenses

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CHAPTER 4

Restructuring Regressive Defenses

Tell me and I forget

Teach me and I remember

Involve me and I learn

Benjamin Franklin

As has already been demonstrated, many of Davanloo's techniques are employed pre-interpretively, to prepare the patient to withstand and then effectively utilize material from the unconscious. Intensive Short-Term Dynamic Psychotherapy is quite demanding on both cognitive and affective levels and can only be successful if both patient and therapist are deeply involved in the process. In rare cases, patients come for the initial evaluation with the motivation and ability to become freely involved and make use of this focused and intensive approach. More often than not, however, patients arrive in a resistant state or become resistant as painful areas are approached. This resistance prevents the kind of emotional involvement necessary for a successful outcome. Davanloo (1980) has developed a standard technique for handling highly resistant patients, in which “pressure and challenge to the resistance are steadily increased and are not relaxed until the patient directly experiences the complex transference feelings” (Davanloo, 1987, p. 77). Following this experience, there is an outpouring of unconscious material that not only provides a deep understanding of the genesis of the patient's difficulties but dramatically increases the unconscious therapeutic alliance. This process was illustrated in the case of the Detached Observer (see Chapter 3). The patient's resistance was massive and prevented any meaningful contact between patient and therapist, as he was keeping the innermost part of himself sealed off from view. Because all the initial interventions indicated a strong ego, the standard technique of applying unremitting pressure and challenge to the defenses was employed. The outpouring of memories and associations following the breakthrough of complex transference feelings confirmed this assessment.

 

Chapter 5: Facilitating Grief

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CHAPTER 5

Facilitating Grief

It's a necessary condition of human

health to be able to bear what has

to be borne, to be able to think

what has to be thought.

Sernrod (1980) *

Patients come to us because they are suffering and want to get well. For patients to achieve health, they must experience the thoughts and feelings they have considered unbearable and unutterable. That which has been buried in the shadows must come to light. The process through which previously inaccessible feelings, memories, and ideas are de-repressed and made available for re-working will be the focus of the next two chapters.

This chapter describes how to facilitate the experience of grief-laden feelings through specific techniques designed to deepen affect. Chapter 6 will discuss techniques for working with positive and erotic feelings.

THE CENTRALITY OF AFFECT

Wachtel (1993) succinctly summarized the psychodynamic view of the cause and cure of neurotic suffering when he wrote:

The patient's problems are understood as deriving most fundamentally from his having learned early in life to be afraid of his feelings, thoughts and inclinations, and the effort to help him overcome his problems is focused very largely on helping him reappropriate those feelings and incorporating them into a fuller and richer sense of self and of life's possibilities. (p. 32)

 

Chapter 6: Working with Positive and Erotic Feelings

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CHAPTER 6

Working with Positive and Erotic Feelings

Deep oh deep is grief,

but deeper still is joy.

Goethe

One of the central goals of any psychodynamic psychotherapy is to increase patients’ awareness of and tolerance for a mix of strong and conflicting feelings toward significant others. In Intensive Short-Term Dynamic Psychotherapy, the therapeutic process typically proceeds in a kind of spiral from the outer layer of defenses against emotional closeness, to anger, underlying pain and grief, and finally, longings for closeness. The goal of treatment is to enable patients to acknowledge, contain, and integrate the full range of human emotion. All the layers of feeling must be accessed, experienced, and woven together in such a way that patients can see themselves and others clearly. This integration is a pre-requisite for what is sometimes referred to as “whole object” relationships, in which both gratification and frustration are expected and tolerated. Basic needs for attachment and closeness are met without compromising the need for autonomy. Ultimately, an inner sense of personal freedom and a renewed or expanded capacity for joy should be evident.

 

Chapter 7: Working Through toward Character Change

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CHAPTER 7

Working Through toward Character Change

Man's main task in life is to give

birth to himself, to become what

he potentially is. The most

important product of his effort is his

own personality.

Eric Fromm (1947)

Man for Himself

For the therapeutic process to achieve rapid and enduring change in a patient's character, the intrapsychic system must be in a state of disequilibrium. Frequently, an external crisis in the patient's life begins this process. When no such crisis has occurred, or the patient's ego is constricted by the rigid use of character defenses, Davanloo advocates creating an intrapsychic crisis using the techniques of pressure and challenge to the defensive armor. The continual pressure to remain highly emotionally and cognitively involved in the therapeutic process keeps the resistance from returning and the characteristic patterns of adaptation from settling back in once the immediate crisis is over. This, in turn, facilitates the working through of core conflicts and solidifies character change.

 

Chapter 8: Termination and Follow-Up

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CHAPTER 8

Termination and Follow-Up

May the spirit never die

Though a troubled heart feels pain

When this long winter is over

It will blossom once again

Loreena McKennitt *

It seems fitting to approach the subject of termination by coming full circle, ending with the last verse of the song “Breaking the Silence,” quoted at the start of Chapter 1. When psychotherapy comes to a successful end, the painful process undertaken by someone with a troubled heart leaves the person feeling renewed.

The issue of termination involves two basic questions: when and how? The longer and more protracted dynamic psychotherapy has become, the more often innovations tailored to reducing its length have appeared. In fact, in his paper entitled “Analysis Terminable and Interminable,” Freud (1937) lamented that analysis was frequently a protracted affair and advised that we should attempt to shorten its duration. In this spirit, Freud, Ferenzi, Rank, and Alexander all experimented with setting a termination date to accelerate stalled treatments.

 

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