BY KIM BOIVIN-SONOLET, RCC, AND ROBERT BAL, RCC
Originally published in MODALITY CHECK: EXPLORING THERAPEUTIC TOOLS: Insights Magazine, Fall 2023
Intensive Short-Term Dynamic Psychotherapy (ISTDP) was developed by Dr. Habib Davanloo at McGill University in collaboration with David Malan, whose Triangle of Conflict and Triangle of Person are foundational to ISTDP. Davanloo was concerned about the duration of psychoanalysis, reliance on interpretation, and implied omnipotence. He created a modality rooted in the understanding that early childhood experiences lead to internal dynamics that develop as protective measures against feelings and impulses learned to be intolerable or unacceptable, but later become the cage in which a person finds themselves trapped.
Dr. Ange Cooper states: “ISTDP’s primary goal is to help the patient overcome internal conflicts to experiencing ALL of their true feelings about the present and past that 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.”
WHICH CLIENT CONCERNS IS ISTDP ESPECIALLY EFFECTIVE WITH?
ISTDP is effective for anxiety, depression, and relational difficulties, is supported for clients with C-PTSD/ PTSD and treatment-resistant personality disorders, and has a strong evidence base for working with medically unexplained somatic symptoms.
HOW DOES IT WORK?
ISTDP facilitates change via invitations to experience complex emotions connected to past attachments that underlie issues clients seek help with. It involves building tolerance of unconscious anxiety and identifying/ deactivating defenses. We try to not get caught up in thoughts but are more interested in what’s underneath them.
For example, a client says, “I don’t feel good enough.” We invite them to see this as a defense, not a feeling. We don’t try to change or explore the thought; instead, we invite them to get to the bottom of what it is defending against. This is also known as “pressure” in ISTDP. The client shares a specific relational example of when this defensive thought arose and, through a process tailored to their anxiety tolerance, explores whether thinking this is a pattern when they interact with people who don’t meet an attachment need and feelings arise towards that person. “I’m not good enough” may be functioning to defend against such feelings — to cover up that truth.
When anxiety tolerance has increased and defenses have been exhausted enough that truth — those feelings — may show up in the transference, that is welcomed. We express curiosity about the links between those feelings and their original target(s) — the early caregiver(s) — and the bodily experience of grief, rage, guilt, and love the client has been denying themselves.
The process tends to help people become more open and integrated. It’s relieving and freeing to get underneath the anxiety and defenses. It can feel like diving for a treasure chest — it’s hard work but well worth it.
WHAT DO YOU LIKE BEST ABOUT ISTDP?
KBS: I was initially inspired to explore ISTDP first as a client then professionally. I’ve been using ISTDP since 2017. I most appreciate the emphasis on us being attachment-based creatures with needs that create feelings in our bodies. When these needs are not met, especially by people important to us, we may unconsciously engage a combination of bodily anxiety and defensive processes to avoid the powerful mix of feelings and impulses that arise. This way of looking at the human condition and symptoms people come into therapy with is foundational to ISTDP. I find it a grounding, humanizing, and compassionate way to work. I’ve had more moments of deep emotional connection with my clients; I feel more emotionally open and have seen that transformation happen in clients. I also love that clients can apply Malan’s Triangle of Conflict and Triangle of Person to navigate challenges in their life. They don’t need to rely on me — it’s collaborative and empowering.
RB: I became an RCC specifically to practise ISTDP after a significant experience with it as a client. I view it as inherently compassionate — an active attempt to reach the person inside the person, the one who was long ago locked away. What I most love is the way it centres the unconscious. I am continually awed by how the unconscious moves in therapy — how, in this relational work, there is the unconscious of the client, unconscious of the therapist, then, as attachment develops, an unconscious therapeutic alliance, an active healing force leading the dyad forward. This force can perhaps be understood as the sound of that same music at which spirituality and faith the world over is directed.
ARE THERE OTHER MODALITIES IT PAIRS WELL WITH?
ISTDP is inherently trauma-informed and is a good pairing with any modality used with trauma survivors. It has similarities with aspects of CBT, including views of self and other. The Rogerian ground upon which most good therapy stands is also concomitant. ISTDP and EFT have shared emphasis on attachment, emotions, and negative interactional cycles. AEDP was developed by Diana Fosha, who trained with Davanloo. The relative cost-effectiveness of ISTDP, linked with fewer treatment times, means it has potential value for marginalized folks, for whom many barriers to therapy exist, and connecting it to multicultural and feminist modalities.
ARE THERE ANY ISSUES ISTDP SHOULD NOT BE USED WITH?
The ISTDP Institute states: “Other treatment options should be considered for patients suffering from organic syndromes, brain injury, active psychosis, active alcohol and/or drug addiction, severe acting out, antisocial personality disorder, life-threatening active health conditions (i.e., active inflammatory bowel disease)… For some disorders, ISTDP might be considered if the patient condition has stabilized (i.e., bipolar disorder, some psychotic conditions) but these would need be attempted with great care and advanced training.”
WHERE CAN WE LEARN MORE?
There are lots of opportunities to learn ISTDP! Core trainings are offered by instructors who trained with Davanloo, such as Dr. Allan Abbass, Dr. John Rathauser, and Dr. Patricia Coughlin. Many of the following generation have become trainers, such as Dr. Joel Town, Dr. Ange Cooper, Jon Frederickson, and Dr. Jonathan Entis. Shorter trainings with specific areas of focus are also offered. Much ISTDP literature is available, such as Davanloo’s original texts and Abbass’s Reaching Through Resistance and Frederickson’s Co-Creating Change. Finally, it is our heartfelt recommendation that one of the best ways to learn about ISTDP is to experience it first-hand — as a client.
