LIVES TRANSFORMED
The Art and Science of Experiential
Dynamic Psychotherapy
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Stockholm
August 2010
Patricia Coughlin, Ph.D.
Sullivan
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If you do not feel equal to the
headaches that Psychiatry induces, you
are in the wrong business.
Skill in psychotherapy consists of doing
as much with as little as possible.
Scientific Approach
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1 – Must have a theoretical basis of
understanding human functioning and
unconscious processes
2 – develop skills/techniques that
clinically effective and
3 - are consonant with theory and
supported by empirical research
Today’s Program
Introduce you to Davanloo’s method of
Intensive Short Term Dynamic
Psychotherapy:
By laying a theoretical foundation
Describing the method in detail
Acquainting you with the research
support
Illustrating the method with videotape
DAVANLOO’S ISTDP
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Based on his understanding of psychoanalytic
theory of neurosis
Developed new techniques designed to
accelerate and condense the process by
precipitating an intrapsychic crisis, creating
an opening into the unconscious
Taped sessions and conducted follow to study
outcome and bring scientific method to bear
PSYCHODYNAMIC PRINCIPLES
Based on Freud’s Second Theory of
Anxiety: Anxiety is a signal that some
threatening feeling or impulse is on the rise.
Defenses reduce anxiety and keep
threatening feelings out of consciousness BUT
Excessive reliance on these defenses causes
the symptoms and difficulties the patient
wants help with
This creates conflict: patient wants help for
relief of symptoms but doesn’t want to face
feelings they have been avoiding
Attachment/Emotion Theory
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This is an attachment theory
Feelings that are thwarted or punished become
associated with anxiety and are avoided
If there is significant or repeated rupture to the
attachment, the child is overwhelmed with pain and
reactive rage
Rage toward loved one stimulates guilt
Guilt drives self punishment and protects loved one
BOND
With
Parents
BOND
With
Parents
BOND
With
Parents
PAIN
Rage, Guilt
about the Rage
BOND
With
Parents
PAIN
Rage, Guilt
about the Rage
Feelings
avoided
Self-destruct
Symptoms
THE TWO TRIANGLES
A
D
I/F
Triangle of Conflict
A= Anxiety
D= Defense
I/F= Impulse/Feeling
T
P
Triangle of the Person
T= Transference
C= Current Figures
P= Past Genetic Figures
C
Same theory, new technique
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Only 20% respond to interpretation
Developed techniques designed to
create/intensify internal conflict
Shift from defense and resistance to
activation and alliance
Experience of avoided feelings is key to
unlocking the unconscious
De-repressed material makes sense of
patient’s suffering
Awareness create choice
Central Dynamic Sequence
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Phase I: INQUIRY
Phenomenological approach
Survey of difficulties/symptoms
Get example, usually regarding precipitant
Focus on feelings
Phase II: DEFENSE WORK
Identify and clarify defenses
Focus on negative consequences
Pressure and challenge
Turn the ego against defenses
Central Dynamic Sequence
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Phase III: BREAKTHROUGH OF FEELINGS
Rise in complex feelings in C or T
Signal from the unconscious that impulse is pre-cs
Passing of the impulse with portrait
De-repression of memories
Obtain relevant history
Phase IV: INTERPRETIVE PHASE
Cognitive re-analysis of process
Make T-C-P links
Get consensus and form contract
Psychodianostic Procedure
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1- Pressure to feelings toward
significant other
2 - Monitor anxiety
3 - Block defense
Only 3 responses possible
Patient’s response to intervention is
diagnostic and guides next step
Each treatment tailor made
Two Forces within Psyche
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As Davanloo developed techniques to block
defense and resistance and got to buried
feelings he discovered
There is a healing force within the
unconscious
This is our ally: unconscious therapeutic
alliance
Work to activate and strengthen healing
capacity while blocking defenses that prevent
growth and perpetuate suffering
Basic Human Feelings
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Love, fear, anger, sadness/grief, sexual
desire
Components of Affect
1 - cognitive label
2 - physiological activation
3 - impulse/action tendency
CHANNELS OF ANXIETY
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STRIATED MUSCLE
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SMOOTH MUSCLE
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COGNITIVE DISRUPTION
FORMAL DEFENSES
REPRESSIVE
REGRESSIVE
Intellectualization
Rationalization
Minimization
Displacement
Reaction
formation
Projection
Denial
Dissociation
Acting out
Somatization
TACTICAL DEFENSES
VERBAL
Vague and general
Diversification
Sarcasm
Argumentative
Contradictory
Rate of speech
NON-VERBAL
Avoiding eye contact
Arms and legs crossed
Smiling
Laughing
Weepiness
Temper tantrums
RESULTS OF WORKING THROUGH
Reduction in anxiety/increased tolerance for conscious
experience of anxiety
Decreased reliance on defenses
Increased emotional activation and expression
Enhanced understanding of inner self with coherent life
narrative
Increasing tolerance for ambivalence and complexity
Early Research Efforts
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Alexander and French
David Malan
Davanloo
Winston and Beth Israel Group
Allan Abbass
Leigh Mc Cullough & the Norwegians
Davanloo
Amassed N=1 studies, all recorded on video tape
Demonstrated that it is possible to expose core conflicts
within first contact
The emotional and visceral experience of feelings is key
to cure
Developed techniques to create an intrapsychic crisis,
creating a therapeutic “emergency”, allowing for
rapid re-organization of personality
Long term follow-up revealing the sustained nature of
changes achieved in therapy
Empirical Basis of ISTDP
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1960-Present: Davanloo’s case studies
Controlled Clinical Trials – 60 published
studies finding strong evidence for efficacy in
broad range of conditions
Effective with treatment resistant depressives
Effective with personality disorders
Effective with somatic patients, movement
disorders and fragile patients
Huge cost savings to the health care system
Empirical Basis of ISTDP II
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Superior to wait list
Superior to medication in long run
Clinically effective in real world
Cost effective
One ISTDP session outperforms
standard intake interview
ABBASS, 2002
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89 consecutively referred patients
treated on an average of 15 sessions
Average age of 40
25% unemployed and on disability
46% on multiple meds
83% treatment resistant
Abbass Results
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71% stopped all meds
18 of 22 back to work
17 of 18 off disability insurance
Combined savings from prescriptions,
disability, hospital and physician costs
of $402,523 per year for three years
following treatment
Process Research
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Weinberger’s Meta-analysis revealed:
1 – development of strong therapeutic
alliance
2 – helping patient confront what they tend
to avoid
3 – revival of hope
4 – increased sense of mastery & competence
5 – attribution of success to patient
Case Studies
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Possible for patients to serve as their own
controls
Lay down criteria for cure following the trial
therapy
Make predictions about issues to be dealt
with and compare those to actual results at
end of treatment
Follow-up to assess whether changes hold
over time
Neuroscientific evidence
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Our brains are wired interpersonally
Neurons that fire together, wire
together
The brain is plastic and changes as the
result of experience
Psychotherapy changes the brain
How to change the brain
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Establish trust and collaborative alliance
Focus, intensity and repetition
Induce moderate levels of anxiety, alternate
with periods of calm
Activate multiple levels of
experience:cogntive, emotional, somatic and
interpersonal
Facilitate profound moments of meeting
Create meaning and coherence
The most vital element:YOU
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The person of the therapist is the most
potent but understudied variable
Top 15% do better than all the rest combined
Passionate and enthusiastic
Open and flexible/adaptable/approachable
Masters at handling relationship
Humble, life long learners
Pressure themselves and patients to get
extraordinary results
Reflective - they ARE the change they want
to promote
Take home message
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It is possible to become far more
effective and efficient
Self development
Study
Practice, Practice, Practice
10,000 hours to become a master