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Mastering Intensive Short-Term Dynamic Psychotherapy

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Over two decades, on two continents, Josette ten Have-de Labije and Robert J. Neborsky have struggled to define and perfect the therapeutic methods of Habib Davanloo. Between the two of them, they run active training groups in San Diego, Los Angeles, San Francisco, Washington, D.C., London, Amsterdam, Warsaw and Scandinavia. In individual practice, in teaching situations and in partnered study, they have worked carefully to translate the theory and application of the revolutionary clinician's approach. This textbook defines the terms: observing ego, attentive ego, punitive superego, transference, transference resistance, unconscious therapeutic alliance, working alliance, unconscious impulse, in very precise and clinically meaningful ways.David Malan advised that Davanloo's technique needs to be modified and softened if it is to be accepted by the majority of therapists Readers will discover that ten Have-de Labije and Neborsky have surpassed Malan's advice and have taken the practice of Intensive Short-Term Dynamic Psychotherapy to a new plateau. Mastering Intensive Short-Term Dynamic Psychotherapy translates Davanloo's intuitive genius into precise language and operations that students can learn in a systematic and clear way. Thus, applying their methodology fulfills the promise of short term, effective, and safe psychotherapy for a broad spectrum of highly resistant psychoneurotic and characterolgically disturbed patients.

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CHAPTER ONE. Davanloo’s ISTDP, psychoneurosis, and the importance of attachment trauma

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In the early 1960s, Davanloo decided to break away from the traditional psychoanalytic approach. In 1980, in his chapter, “A Method of Short-Term Dynamic Psychotherapy”, Davanloo briefly presented his method of ISTDP which was based on three systematic studies, involving psychotherapy with respectively 130, 24, and 18 clients with psychoneurotic problems.

His work, which from the start was all audiovisually recorded, was received with enthusiasm as well as with scepticism and criticism.

Now, more than thirty years later, we have many clinical studies and outcome research confirming the efficacy of this method.

Davanloo (1990) describes that Freud believed that the superego establishes itself relatively late in developmental history and comes into operation after the resolution of the Oedipus complex. Evidence from his work with patients and from his clinical case studies has led Dav-anloo to modify analytic theory in emphasizing that it is already in the early months of life that the superego may play an active role in the causation and maintenance of neurosis. Neurotic disturbances arise as a result of a variety of possible traumatic experiences, involving damage to or disruption of the affectionate bond between the child and his caretakers. The child unconsciously reacts to this damage/disruption with a sadistic, murderous rage. It is this sadistic, murderous rage and the consequent loss (of the beloved murdered person(s)) which leads to guilt and grief as well as to punitive, sadistic reactions of the superego towards the child’s ego. The traumatic experience(s), murderous rage and its result(s), guilt and grief, are repressed into the unconscious. Various symptom patterns and character pathology develop as the ego of the developing child attempts to keep functioning under the mandate of the punitive/sadistic superego in such a way that it will not be overwhelmed by the impulses and feelings themselves, by anxiety nor by the defences. The earlier, the more intense, and the more frequent the traumatic experiences, the more sadistic the impulses, and the more the ego will be trapped between the sadism of the id and the sadism of the superego, and the more the ego will become paralysed in managing the resistance of repression and the resistance under the mandate of the superego. Davanloo’s view on the development of neurosis is depicted in Figure 1.

 

CHAPTER TWO. The neurobiological regulation of emotion and anxiety

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Any of our functions, be it perception, or thinking, feeling, behaviour, involves the integration of an unknown number of neurons in specific brain areas and in the nervous structures outside our brain. Therefore, we think it will be helpful to the ISTDP therapist to have at least some basic knowledge of the process of neural transmission and of specific brain regions and neuronal network systems that are thought to be involved in the regulation of our feelings and anxiety. Regarding the neuro-anatomy, we base ourselves mainly on Carpenter (1972) and on Netter’s Anatomy of the Nervous System (CIBA, 1994).

The structures of the limbic system are largely interconnected with the rest of the brain, and they are believed to play an important part in the regulation of our feelings and anxiety.

First, however, we want to give you a warning, as in the literature the definitions of structures belonging to the limbic system may vary.

The term “limbic system” is used to include 1) cortical and 2) subcortical parts of the brain:

 

CHAPTER THREE. Emotion regulation and the role of defences

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The road to the patient’s unconscious is in the patient and not in the book (not even in this one!), and establishing a conscious and unconscious working alliance is dependent on the therapist’s expertise to assess the nature and degree of the patient variables that function as red and green traffic lights on this road. Thus, we first want to elaborate on such patient variables as how healthy versus unhealthy is the regulation of the patient’s emotions, and what is the function of the patient’s defences in the patient’s particular emotional regulation process? All of our patients who come for help have a certain degree of unhealthy regulation of emotions.

The consequences of failures in a healthy regulation of emotions range from personal distress and unhappiness to socially maladaptive and self-destructive patterns of behaviour. The more our patients are located on the right side of Davanloo’s spectrum of structural neurosis, the more their emotions and anxiety are regulated in an unhealthy way, the more these patients exert self-destructive patterns of behaviour in their interactions with themselves and with important and unimportant others.

 

CHAPTER FOUR. Assessment of a patient’s anxiety

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When there is anxiety at the onset of the therapeutic encounter, we could say that the patient’s anxiety is somewhere on the continuum between anxiety as a transference reaction and anxiety as a sign of generalized anxiety.

In patients with a high capacity to regulate anxiety, signs of anxiety will be reflected by a pattern of facial muscle behaviour and by tension of other striated skeletal muscles, by a pattern of sympathetic reactivity and sensory vigilance. The proportion of somatomotor manifestations would be higher than the proportion of autonomic manifestations. The rise of the respective manifestations would be slow, and the duration of the manifestations would be relatively short. Such a patient would report various concerns in terms of (subjectively) perceived reality and cognitions, and he would accurately perceive the internal state of his periphery and label it as anxiety.

In practice, we seldom meet such patients at the initial interview. Mostly, we meet patients whose pattern of physiological anxiety manifestations reveals that they are less or not at all capable of adequately regulating their anxiety for their own benefit. In these cases, the proportion of autonomic manifestations is higher than somatomotor manifestations and/or there is cognitive and/or perceptual dysfunctioning. The rise and spread of physiological manifestations is fast and high and the duration of the respective manifestations is relatively long and the velocity of fall of anxiety manifestations is slow. Often, although they suffer from their symptoms, such patients do not report anxiety because they are not (accurately) processing their internal state, and in this way—of course—they maintain their inability to self-regulate their anxiety and, in due time, their anxiety will continue to grow worse and will eventually generalize.

 

CHAPTER FIVE. Resistance, transference, ego-adaptive capacity, and multifoci core neurotic structure

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Davanloo, as well as many ISTDP therapists, often speaks of transference, character resistance, transference resistance, superego resistance, and multifoci core neurotic structure. However, in psychoanalytic and in the ISTDP literature, often the terms are used in a sloppy way. To give some examples: often terms such as defence and resistance or terms such as transference reactions and transference feelings are used interchangeably. Whenever terms can be used interchangeably, this would mean that the terms are completely synonymous (and that one of them could be considered as superfluous). However, terms such as defence and resistance, or transference reactions and transference feelings, are not synonymous. They refer to different descriptive statements, specifying different things. This lack of precision leads to confusion.

Confusion of the therapist is neither of advantage to the therapist nor to the patient, and will undoubtedly influence their working alliance in a negative way. So let us do our best to come to clear definitions of the concepts of character resistance, transference resistance, superego resistance transference, countertransference, and multifoci core neurotic structure.

 

CHAPTER SIX. Observational learning and teaching our patients to overcome their problems

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Whatever the conceptualization of a psychotherapy school, all schools have the common goal of helping their patients to overcome their problems and live a (as-much-as-possible) happy life. So does ISTDP. Although Davanloo based his ISTDP largely on psychoanalytic theory, his therapy method and techniques are structured. The method and techniques have the aim to teach the patient to recognize self-defeating patterns of overt and covert behaviour, to quit these self-defeating patterns, and to replace them by constructive patterns of overt and covert behaviour, thus enabling the patient to access and experience impulses and feelings related to past traumatic experiences, and to express feelings, opinions, and behaviour in a constructive way. One cannot teach patients new ways of looking and expressing themselves, new ways of interacting with themselves and with other persons, by ignoring basic principles of learning theory. Therefore, this chapter will focus on theory and practice of observational or vicarious learning. Why? Because virtually all of our learning occurs on a vicarious basis!

 

CHAPTER SEVEN. The road to the patient’s unconscious and the working alliance

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In psychotherapy, one of the initial concerns of therapist and patient is to understand the nature of the patient’s problems in order to resolve them.

This is specifically true for Davanloo’s trial-therapy model of the initial assessment which he considers the only reliable method to determine if the patient is likely to respond to ISTDP. However, in achieving this twofold task (understanding the nature of patient’s problems and testing patient’s responses), it is at the same time the therapist’s aim to implement Davanloo’s theory to this particular patient and to relate his observations back to the particular theoretical constructs that provided Davanloo’s framework for interpreting data and generating predictions.

This means that in order to assess and understand the patient’s psychodynamics, character structure, ego-defensive organization and (last but not least) genetically structured core-neurotic conflict, the therapist has to implement Davanloo’s set of interventions, which he refers to as the central dynamic sequence (CDS). This CDS can be considered as the treatment protocol for trial therapy.

 

CHAPTER EIGHT. The independent variables: ISTDP techniques to change red traffic lights into green

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Although Davanloo’s intensive short-term dynamic psychotherapy is theoretically based on the psychoanalytic reference realm, his techniques are derived from structured psychotherapy methods such as behaviour therapy or cognitive-behaviour therapy.

The term “structured” refers to the fact that the therapist takes an active and directive stance. It is the therapist who—at each time in the therapeutic process—determines the focus of investigation. Especially in the early phase of the therapeutic process, the therapist also may take the position of a teacher, teaching the patient how to look and to understand his problems.

At each time in the therapeutic process the timing and selection of the specific technique, the dosage of that technique, and its duration are dependent on the momentary state of the patient’s variables and the patient’s reaction to the interventions.

However, a therapist’s clinical judgement can never be fully manualized and, although the therapist’s use of the techniques is prescribed by the therapeutic method, in this case by the ISTDP method, we advise our colleagues not to forget to use their common sense and to apply their interventions with flexibility and creativity.

 

CHAPTER NINE. An initial interview with a transport-phobic patient

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The DSM-IV classifies phobias as agoraphobia (with and without panic attacks), as social phobia and as specific phobia. Agoraphobic persons have an irrational fear of activities outside of the home. They often have anticipatory anxiety of becoming physically unwell/ill. Or they are afraid they will go fainting, thus losing control and thereby causing public disturbance/nuisance. In addition, agoraphobics misapprehend causal antecedents of painful feelings and they develop their symptoms in a climate of notable interpersonal conflict (Goldstein & Chambless, 1978).

Social phobia, or social anxiety disorder, is characterized by extreme anxiety in social and performance situations. A social phobic person is mostly preoccupied with doing something inappropriate and being devalued, judged, or blamed because of that or because others will notice their anxiety symptoms (blushing, sweating, shaking).

A specific phobia is an extreme fear of a specific object or situation that is not in proportion with actual danger or threat. Mostly, five types of specific phobias are defined:

 

CHAPTER TEN. Steps on the roadmap to the unconscious and its application to patients suffering from depressive disorders

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Depression is one of the most common disorders seen in clinical practice. Depression is a complex diagnostic construct that casts a large umbrella over diverse conditions. Some of the varieties of depression as defined by psychiatrists are summarized in Table 5. This chapter cannot do justice to the entire topic of depression, but it is designed to give the reader an organized method to assess whether a depressed patient is suitable for intensive short-term dynamic psychotherapy. Suffice it to say, just as in traditional approaches, all organic causes of depression (thyroid, endocrine, metabolic, drug withdrawal) must be ruled out before undertaking psychotherapy.

Classically depressive neurosis (dysthymia) was seen as responsive to dynamic psychotherapy, but recent research indicates ISTDP can address many forms of depression. The central symptoms of all depression are, of course, a depressed mood and loss of interest in life’s activities. Table 6 illustrates the entire spectrum of depressive symptoms. In contrast to the normal emotional responses to unwanted and stressful events, depression is a mental disorder which, because of its severity, tends to recur and places a high cost on the individual as well as society. It is important to note that up until the present time, no common causes for depressive disorders are known which would allow for aetiological-based valid classification. Despite the current trend in ICD-10 and DSM-IV to pigeonhole depression according to timing and severity, there is little evidence to support that major depression is any more than a syndrome. It is most likely that major depression is a diagnostic construct which we impose upon a continuum of depressive symptoms.

 

CHAPTER ELEVEN. Steps on the roadmap to the unconscious and its application to patients with somatization

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Somatization is both a general and specific term with many definitions. Generally, it is a term used to cover a wide range of clinical disorders. Specifically, it is also a term that describes psychological process wherein an unconscious emotion is expressed through a physical pain or unexplained medical symptom. At other times, it refers to the patients who present clinically with physical symptoms in the face of psychosocial problems or emotional distress. Occasionally, it refers to patients who worry or are convinced that they are physically ill without evidence of disease; and sometimes it refers patients the pattern of frequent unexplained somatic symptoms that cause help seeking and disability (Kirkmayer, 1991).

Somatization and its various guises is an extremely common problem in all areas of medicine and mental health. It creates a major public health and economic problem since functional symptoms are among the leading causes of work and social disability. Frequently, patients with recurrent unexplained somatic symptoms may be extensively investigated with invasive, risky, and expensive medical procedures which can cause morbidity. Patients with high levels of worry about being sick also use healthcare services inappropriately (Abbass, 2009; Ford, 1983; Kellner, 1986).

 

CHAPTER TWELVE. Steps on the roadmap to the unconscious in a patient with transference resistance

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As described in the traffic lights/roadmap diagram, patients present with either anxiety on the forefront or defences. Those patients which present with defence either use verbal and non-verbal defences in the realm of character or of transference resistance. The defences originated in order to protect the ego from some sort of dysregulation when the ego was immature. This dysregulation either represented a cumulative insecurity in the attachment relationship or an acute overwhelming threat (trauma). The ego defends itself when there is no available attachment figure to co-metabolize the trauma. Hence defences are recruited to regulate both emotion and anxiety. The unconscious is a repository of these unprocessed emotions which exist in a space where there is no time and they “sleep” under the veil of the series of defences that make up for the resistance. The art of ISTDP is to help the patient identify these defences and see them as not helpful to the self and for building an alliance with the therapist in order to not utilize them. This, of course, will provoke significant anxiety and the patient must learn to self-regulate the anxiety so it doesn’t compromise the cognitive-perceptual apparatus and thus compromise self-observation. Patients who are less capable to regulate their anxiety are referred to as patients with a low ego-adaptive capacity. Mostly, they do not discriminate between the three poles of the triangle of conflict, they externalize, and they have some regressive defences in their repertoire.

 

CHAPTER THIRTEEN. Exiting the roadmap to the unconscious in the phase of termination

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The end phase of therapy is determined by the beginning. The therapy began as a problem-solving relationship wherein all the treatment goals are agreed upon in the initial interview. Once the ego starts to separate itself from the superego and the resistance is defeated, the unconscious part of the working alliance starts to develop (Davanloo, 1990). The therapist has activated the patient’s attachment longings and they have driven the patient to accept the therapist’s help to explore and revisit the trauma based feelings from the past. The patient has hopefully unmasked the eyes of his internal aggressor(s), understood his/their commands, the ways he submitted to these commands, and declared his freedom from the conditions which were imposed upon the self by his pathological superego. Through internalization of the constructive superego that was modelled by the therapist, the patient gained access to his complex of transference feelings which were associated with past traumatic experiences. In cooperation with the therapist, he has worked these feeling through. The process, as described by Davanloo (1978, 1980, 1984, 1990, 2000), itself, when administered correctly, ignites the termination phase of therapy.

 

APPENDIX. Assessment forms

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