Intensive short-term dynamic psychotherapy (ISTDP) is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo.Davanloo, H. "Intensive Short-Term Dynamic Psychotherapy." In Kaplan, H. and Sadock, B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628–2652. Philadelphia: Lippincott Williams & Wilkins, 2005.
The therapy's primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful. The technique is intensive in that it aims to help the patient experience these warded-off feelings to the maximum degree possible; it is short-term in that it tries to achieve this experience as quickly as possible; it is dynamic because it involves working with unconscious forces and transference feelings.Davanloo, H. (1995). Intensive short-term psychotherapy with highly resistant patients. I. Handling resistance. In H. Davanloo, Unlocking the unconscious: Selected papers of Habib Davanloo, MD. New York: Wiley. (pp. 1-27).Malan, D. & Coughlin Della Selva, P. (2006). Lives transformed: A revolutionary method of dynamic psychotherapy (Rev. ed.). London: Karnac Books.
Patients come to therapy because of either symptoms or interpersonal difficulties. Symptoms include traditional psychological problems like anxiety and depression, but they also include physical symptoms without medically identifiable cause, such as headache, shortness of breath, diarrhea, or sudden weakness. The ISTDP model attributes these to the occurrence of distressing situations where painful or forbidden emotions are triggered outside of awareness.Davanloo, H. (1995). The technique of unlocking the unconscious in patients suffering from functional disorders. Part 1. Restructuring Ego's defenses. In H. Davanloo, Unlocking the unconscious: Selected papers of Habib Davanloo, MD. New York: Wiley. (pp. 283-306).Malan, D. & Coughlin Della Selva, P. (2006). Lives transformed: A revolutionary method of dynamic psychotherapy (Rev. ed.). London: Karnac Books. Page 255. Within psychiatry, these phenomena are classified as "Somatoform Disorders" in DSM-IV-TR.American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC American Psychiatric Association, 2000.
The therapy itself was developed during the 1960s to 1990s by Habib Davanloo, a psychiatrist and psychoanalyst from Montreal. He video recorded patient sessions and watched the recordings in minute detail to determine as precisely as possible what sorts of interventions were most effective in overcoming resistance, which he believed was acting to keep painful or frightening feelings out of awareness and prevent interpersonal closeness.Davanloo, H. (2000). Intensive short-term dynamic psychotherapy: Spectrum of psychoneurotic disorders. In H. Davanloo: Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. (pp. 1-35)
ISTDP is taught by Habib Davanloo at McGill University, as well as in other university and post-graduate settings around the world. The ISTDP Institute offers on-line ISTDP training materials, including introductory videos and skill-building exercises.
Origins and theoretical foundation In 1895, Josef Breuer and Sigmund Freud published their Studies on Hysteria, which looked at a series of case studies where patients presented with dramatic neurological symptoms, such as "Anna O" who had headaches, partial paralysis, loss of sensation, and visual disturbances.Freud, S. & Breuer, J. (1957). Studies on Hysteria. In J. Strachey & A. Strachey (Eds. & Trans). New York: Basic Books, Inc. (Original work published 1895) These symptoms did not conform to known patterns of neurological disease, and neurologists were thus unable to account for symptoms in purely anatomical or physiological terms. Breuer's breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives. Experiencing these emotions which had been previously outside of awareness seemed to be the curative factor. This cure became known as catharsis, and the experiencing of the previously forbidden or painful emotion was abreaction.
Freud tried various techniques to deal with the fact that patients generally seemed resistant to experiencing painful feelings. He moved from hypnosis to free association, interpretation of resistance, and dream interpretation.Gay, P. (2006). Freud: A life for our time. USA: W. W. Norton & Company, Ltd. Pages 49-50, 71-73, 107. With each step, therapy became longer. Freud himself was quite open about the possibility that there were many patients for whom analysis could bring little or no relief, and he discusses the factors in his 1937 paper "Analysis Terminable and Interminable."Freud, S. (1937c). Die endliche und die unendliche Analyse. GW, 16; Analysis terminable and interminable. SE, 23: 209-253.
From the 1930s through the 1950s, a number of analysts were researching methods of shortening the course of therapy without sacrificing therapeutic effectiveness. These included Sándor Ferenczi, Franz Alexander, Peter Sifneos, David Malan, and Habib Davanloo. One of the first discoveries was that the patients who appeared to benefit most from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to experience their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered. Clinical research revealed that these "rapid responders" were able to recover quickly with therapy because they were the least traumatised and therefore had the smallest burden of repressed emotion, and so were least resistant to experiencing the emotions related to trauma. However, these patients represented only a small minority of those arriving at psychiatric clinics; the vast majority remained unreachable with the newly developing techniques.Della Selva P. Intensive Short-Term Dynamic Psychotherapy: Theory and Technique. 1996. Wiley and Sons. Cf.: Foreword by David Malan.
A number of psychiatrists began directing their psychotherapeutic research into methods of overcoming resistance. Dr. David Malan popularized a model of resistance, known as the Triangle of Conflict, which had first been proposed by Henry Ezriel.Ezriel, H. (1952). Notes on psychoanalytic Group therapy: II .Interpretation. Research Psychiatry,15,119. At the bottom of the triangle are the patient's true, impulse-laden feelings, outside of conscious awareness. When those emotions rise to a certain degree and threaten to break into conscious awareness, they trigger anxiety. The patient manages this anxiety by deploying defences, which lessen anxiety by pushing emotions back into the unconscious.
The emotions at the bottom of Malan's Triangle of Conflict originate in the patient's past, and Malan's second triangle, the Triangle of Persons, originally proposed by Menninger, explains that old emotions generated from the past are triggered in current relationships and also get triggered in the relationship with the therapist.Menninger, K. (1958). Theory of psychoanalytic technique. New York, Basic Books. The question of how maladaptive patterns of interpersonal behaviour could arise from early childhood experiences in the family of origin was postulated within psychoanalytic theory. Independent empirical support came from Bowlby's newly arising field of Attachment Theory.
Bowlby and attachment trauma John Bowlby, a British psychiatrist and psychoanalyst, was very interested in the impact on a child of adverse experiences in relation to its primary attachment figures (usually the mother, but often the father and others) in early life. He concluded, in opposition to received psychoanalytic dogma of the day, that childhood experience was far more important than unconscious fantasy. He also elucidated the nature of attachment, a system of behaviours exhibited by human and other mammalian infants which are innate and have the goal of physical proximity to the mother. For instance, a child taken out of its mother's arms cries loudly in protest, and it is only quieted by being restored to its mother's arms. Bowlby observed that the innate attachment system would be activated by loss of proximity to the mother, and that long-lasting trauma to the child could result from attachment interruption. Long term consequences included increased propensity to psychiatric disorders, poor relationship function, and decreased life satisfaction.Bowlby J. Separation. Vol II in Attachment and Loss. 1969. Pimlico.
Bowlby conducted numerous studies and noted strong correlations between adverse early-life circumstances—primarily the lack of a consistent and nurturing relationship with the mother—as the source of numerous difficulties, including persistent depression, anxiety, or delinquency in adulthood. Childhood traumatisation to the attachment bond, usually through separation from or loss of the primary mother or mother-substitute, led to adult difficulties. Since Bowlby, the effects of trauma over development have consistently been shown to have a significant detrimental impact on adult psychological functioning.van der Kolk (2005). Developmental Trauma Disorder. Psychiatric Annals
Davanloo's discovery of the unconscious consequences of attachment trauma In the 1960s, while Bowlby was observing children directly, Davanloo was beginning his work with symptomatic and character-disturbed adults. As he began his video-recording work and became progressively successful against higher levels of resistance, he noted that particular themes reappeared with striking consistency in patient after patient.However, Davanloo never considered Bowlby's attachment theory relevant to his work. Davanloo, H. (1995). Intensive short-term psychotherapy with highly resistant patients. I. Handling resistance. In H. Davanloo, Unlocking the unconscious: Selected papers of Habib Davanloo, MD. New York: Wiley. (pp. 1-27).
First, the therapist's efforts to get to know the patient's true feelings often aroused a simultaneous mixed feeling in the patient, composed of deep appreciation for the therapist's relentless efforts to get to know the patient deeply, combined with equally deep irritation at the therapist for challenging the patient to abandon long-held resistances which could thwart the therapeutic effort.
Davanloo noted, in concert with Malan's Triangle of Conflict, that patients would unconsciously resist the therapist's efforts to get to the root of their difficulties. He also observed, from his videotaped sessions, that patients would simultaneously send off signals of their unconscious anxiety. Davanloo carefully monitored these signals of anxiety and saw that they represented the rise of complex mixed feelings with the therapist. The mix represented that part of the patient seeking relief from painful symptoms but also an active desire to avoid painful, repressed feelings.
As Davanloo became more skilled at unlocking the patient's true unconscious feelings, he noted an often very predictable sequence of feelings. The sequence was by no means invariable, but it occurred frequently enough to allow the therapist to hypothesise its existence in a majority of cases.