ISTDP therapy: A practical introduction for anyone who wants to understand the method

Here is the article we received from the Norwegian Psychological Association as our specialist thesis. The article is primarily intended for professionals who want to learn the art of mastering ISTDP. But it can also be relevant to the interested client.

In this article, we provide a thorough practical account of the method's psychodiagnostic and treatment process, with a special focus on how it provides a framework for creating a holistic understanding of and treatment of complex disorders.

The article has a strong conclusion about love from which the driver all springs.

Part 1 provides an overview, part 2 focuses on the psychodiagnostic process, and part three illustrates the capacity-building format through an in-depth case description.

We show that what, according to a formal study, satisfies the criteria for anxiety disorder, depression, irritable bowel syndrome and personality disorder has something to do with each other. The symptoms provide holistic meaning in the context of unprocessed emotional conflicts with associated different types of anxiety manifestations and different types of defense mechanisms.

We try to provide a consistent picture of how, with the help of an attitude of reaching out wholeheartedly to the patient, an intervention system for dealing with resistance, and a concrete signal system for monitoring unconscious processes, the underlying emotional conflicts and the disturbed internalized relational experiences are mobilized (Killingmo , 2008) from which conflicts arise.

This gives a direct insight into what idiosyncratic difficulties with emotion regulation the patient has at different affective mobilization levels.

If necessary, the defense is restructured and anxiety tolerance is built, before the patient within his tolerance window can be brought into direct contact with hitherto closed and unresolved emotional conflicts that have had a driving force for both symptom and character design, and often self-punishing needs. We show here what it is like with unconscious anxious feelings as with the trolls in the fairy tale: they crack in the light.

Happy reading!

Here you can read the assignment in its entirety:

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Should we try to get rid of the unconscious feelings behind the anxiety, the depressive lid, the self-attacks and the withdrawal?

Principles of psychodiagnostics and treatment of complex disorders using intensive short-term dynamic therapy (ISTDP).

Authors: Ivar W. Goksøyr & Hilde W. Goksøyr

ISTDP - Introduction

The proportion of patients who do not respond to treatment is regrettably high, especially in naturalistic studies with improvement rates down to 20-35% (Hansen, Lambert & Forman, 2002). Relapse rates may be above 50% (Steinert et al., 2014). Compound disorders are the rule rather than the exception in the outpatient treatment routine. High comorbidity, often with a mix of personality disorders and symptom disorders is also associated with treatment resistance, with poorer prognosis (approximately double the resistance rate) also for the treatment of the symptom disorder itself (Newton-Howes et al., 2014).

As a therapist, in the complex picture of symptom disorders and character-based ailments, it can be challenging to understand, prioritize and determine how much one can do within the most often limited treatment framework. There is a need for transdiagnostic models that can create a holistic understanding of common underlying psychopathological factors across diagnoses, and there is broad theoretical agreement that difficulties in relating to and regulating emotions are a key common underlying factor (see for example Hagen et al., 2012; Schancke et al., 2013).

Character problems in the patient can also complicate the development of an effective work alliance, where defensive positions such as emotional restraint, docility, defiance, externalization or passivity prevent genuine contact and can be a significant source of treatment resistance (Solbakken & Abbas, 2014).

Intensive short-term psychodynamic therapy (ISTDP) offers a well-developed intervention system to overcome such treatment resistance and work systematically with poorly regulated emotional conflicts. It is an integrative, transdiagnostic and in-depth psychological method which in an increasing number of studies on precisely treatment-resistant and complex conditions has proven to be treatment, time and cost effective in both outpatient clinics (Abbass, 2006; Abbass & Katzmann, 2013; Abbass, Town & Driessen, 2012; Town and Driessen, 2013) as in short-term 24-hour offers (Solbakken & Abbass 2013; 2014; 2015; 2016).

We will account for the method's psychodiagnostic and treatment process, with a special focus on how it provides a framework for creating a holistic understanding of and treatment of seemingly divergent but related symptoms and characteristics.

Part 1: Overview of ISTDP as a treatment method

What is ISTDP

From an overall theoretical perspective, ISTDP is a transdiagnostic, response-driven and integrative therapy model. The model can partly be seen as a form of exposure with response prevention (ERP) where it is exposed to two related conditions: Emotional closeness to the therapist and avoided emotional conflicts. Perhaps even more important than pure exposure effects such as decentralization, less use of problematic avoidance (defense) and better access to adaptive affect, the potential for full mobilization of the patient's inherent healthy power is counted against simultaneous oppressive, life-limiting forces to break through to direct, deep processing. of unresolved emotional conflicts that have driven the patient's ailments and often self-punishing needs.

To this end, ISTDP has developed algorithms for timing and dosing of various interventions based on instantaneous patient response, especially through decoding of bodily signal on mobilization of unconscious anxiety related to unconscious emotional conflicts. This signaling system has been shown to enable safe and effective intervention right up to the upper threshold of the patient's tolerance window for dealing with underlying anxiety and emotions.

The method therefore joins the series of methods that integrate emotion-focused and dynamic perspectives (Binder et al., 2013). Other important characteristics are focus and high initial therapist activity, active challenge of maladaptive thoughts (cognitive therapy), encouragement of behavior change (behavior therapy), active use of the transfer, (psychodynamic therapy) great emphasis on non-judgmental momentary self-observation (mindfulness) and a clear emphasis of conditions such as choice, will, freedom and responsibility (existentialist psychotherapy).

More intuitively, one can say that the therapist's task is to invite the patient's underlying emotions, wholeheartedly reach out to the person who is stuck in suffering and through encouraging active cooperation to re-establish contact with what is at the core of his being: A strong inherent urge to have and give love, and a movement towards growth and wholeness (humanistic psychology). Paradoxically, the way here often goes through the processing of strong negative emotions that have so far been tied up with the self, as primitive rage with associated guilt due to simultaneous love (psychoanalytic theory).

ISTDP - Historical development

ISTDP was first developed by the Iranian-Canadian psychiatrist and psychoanalyst Habib Davanloo. He was one of those who was not satisfied with the treatment results using Freud's hesitant and interpretive technique, especially in people with complex and character-based difficulties with a lot of resistance. He began by systematically testing new techniques to increase the therapeutic benefit in this patient group. Through trial, error and meticulous video analysis of patients' micro-responses to various sets of interventions, he eventually developed a system that made it possible to overcome resistance much faster and more reliably and thus gain direct access to unconscious emotional conflicts.

When the resistance had broken down and the emotions that had hitherto been in conflict broke through and replaced the defenses and the anxiety, Davanloo saw some clear commonalities in the underlying emotional conflicts in a large proportion of the patient population. Based on the content of these, he outlined his metapsychology for the unconscious, or theory of the development of psychopathology.

ISTDP - Metapsychology

When the basic attachment needs are frustrated or traumatized throughout adolescence, not only does sadness arise over the endless loss, as lost or blocked love is, with associated longing and longing. The pain it entails also leads to an impossible reactive rage towards the object of love, which due to the simultaneous love breeds strong guilt. It is in this emotional vice that neuroses, according to ISTDP's metapsychology, are shaped.

Not infrequently, the end result of such internal conflicts is not just that there is a long-term unhealthy adaptation of self-image and behavior, where the child ends up thinking that it is himself there is something wrong with. On another level, anger toward the caregiver creates an unconscious sense of guilt, which is misused for self-punishment and forms of emotional distancing from one's own feelings and those of other people. While the conscious experience of anger and guilt is removed, one often sees strong anxiety in situations where complex emotions approach, with self-destructive responses and often a pathological, overt conscience where underlying latent guilt manifests itself in an unlimited amount of everyday situations (Davanloo 1990).

Frustrated attachment efforts / love needs.

Davanloo uses the term "attachment trauma" as a driving force for the child's emotional conflicts, where guilt over anger in particular drives more serious and complex pathology. Attachment trauma is broadly defined, with disturbances of the establishment and maintenance of the bond, what in Norwegian could be called frustrated attachment efforts, as the central one. In people with higher functioning, less resistance, and more limited problems, Davanloo did not find the same pattern of unconscious guilt over unconscious rage, but rather suppressed grief reactions and other minor emotional conflicts. Underlying guilt rage was increasingly evident in cases of increasing resistance, complexity in symptom design and character disorders.

This knowledge helps to sensitize the therapist to the signal that similar conflicts are on the way. What guides the therapist's interventions, however, are not preconceived answers, but the idea that as long as the invitation to close contact creates anxiety and / or resistance, it is "something" that is inflamed and must be kept away. One works towards a goal of absence of anxiety and resistance, to be able to be together in the innermost thoughts and deepest emotions, and follows the signals from the patient. Generalized effects are expected where processing of the underlying emotional conflicts leads to a marked drop in different symptom design and defensive organization. Put another way: When the individual's needs and feelings are no longer inflamed, but integrated, there is also nothing left on the inside that creates anxiety or drives avoidance.

The Conflict and Person Triangle and ISTDP

In ISTDP, the person and conflict triangle (Malan, 1995) is used as an organizing principle for the listening perspective and intervention focus. The triangles conceptualize the general phenomenon where emotions and impulses that appeared threatening in early attachment relationships created anxiety and drove defense (avoidance / adaptation), and that this pattern is generalized to current relationships, including to the therapist, until awareness and emotional processing enables integration.

When we use the terms emotion, anxiety and defense, these often refer to completely or partially unconscious processes, especially at the beginning of treatment. Anxiety is defined in ISTDP as activation of the biological fear system triggered by an inner stimulus and is in line with Freud's (1926) second anxiety theory where anxiety basically warns of the danger of losing the bond to the object of love.

Fredrickson (2013) defines defense as ways in which we resist reality and our emotional reactions to it. Emotions can be avoided through maladaptive thoughts (cognitive therapy), behaviors (behavioral therapy), relational patterns (psychodynamic, cognitive and behavioral therapy) or through inattention (mindfulness). In some cases, it may make sense to think that an entire character has been designed to keep certain aspects of emotional life at bay. If we do not relate to reality, we can not deal with reality either. We lose touch with life and ourselves. If we avoid our feelings through self-critical thoughts, we become depressed, through evasive behavior, relationships are destroyed (Fredrickson, 2013).

The defense will in many cases be adaptive to ensure the original relationship, but the threatening element can also be a result of the child's imprecise meaning creation or fantasies. Regardless, the pattern is maladaptive when generalized. An overriding idea of what is therapeutic is for the patient to “get to the bottom of both triangles” (Malan, 1995), that is, a direct processing of the conflict-filled emotions, in the original, formative relationship. Or to put it with Neborsky (2006): Feeling past emotions in the present. When the emotions are experienced, the associated anxiety is weakened and hence what drives the avoidance / defense, and thus the patient is released from the neurotic bonds.

The goal is a fundamental change in the structures that create both symptoms and character disorders and achieve full symptom remission and character changes where maladaptive patterns are replaced by healthy ways of relating to oneself and others.

The main principle of ISTDP: Alliance versus resistance

In addition to the conflict between conflicting emotions and between anxiety and emotions, a conflict between a healthy and an oppressive side of the patient is assumed (Kuhn, 2014). Some who want liberation, and others who, out of anxiety, and often guilt, hold back. Patients come to therapy with conscious hope and desire for change. Statements that the patient lacks motivation or does not have sufficient motivation appear within this thinking as at best highly imprecise. As long as the patient is in the room of their own free will, there is a healthy part with motivation for change. The challenge is the simultaneous resistance (for example in the form of defiance, passivity, obedience, externalization, etc.) which often operates completely or partially unconsciously. Resistance is defined here as the use of defense in the therapeutic situation (Davanloo, 2000).

The degree of resistance seems to be related to a number of factors such as the underlying intensity of conflict-filled emotions, total symptom pressure, degree of character-based difficulties and degree of self-destructiveness / masochism (Davanloo, 2005).

In ISTDP, one thinks that the therapist's job in summary is to tip the balance of power between the patient's healthy side and the patient's resistance in favor of the healthy side. In short, it is about creating an intrapsychic conflict in the patient between the two forces, helping the patient to see the costs of the resistance and turn against it, both through weakening of the defenses and appeal to the healthy side. The ultimate goal of this work is to mobilize and release the unconscious therapeutic alliance, a force in the patient's unconscious that has the potential to guide the healing process for both therapist and patient (Lebaux, 2000).

The unconscious therapeutic alliance 

The importance of establishing a conscious alliance is known from psychotherapy research. Davanloo (1990) also referred to the phenomenon of the unconscious therapeutic alliance (UTA). Hansen and colleagues (2013) describe UTA as the implicit, unreflected part of the work alliance that makes the patient spontaneously bring forward important experiences and reactions that need processing. The term covers observations that spontaneous imaging, associations or memories of clear therapeutic significance "emerge" without conscious intentionality on the part of the patient. As if there is a separate unconscious part of the patient who knows how everything is connected, but who operates on an unconscious, intuitive level. The therapist acknowledges the patient's conscious momentary state of not knowing, but at the same time relates to such an imaginary body that knows, which one can ask and have expectations that will contribute to what is necessary for a healing process to take place.

The therapist must be aware of the alliance's "whisper from the unconscious", follow and explore these as UTA is the therapist's "main ally" (Hansen & colleagues, 2013). Kuhn refers to the unconscious therapeutic alliance as “a lively force within the patient, which is inherent in any human being but is often deeply buried” (Kuhn, 2014, pp. 119-120). The activity of the therapist can be kept to a minimum as UTA dominates the resistance and guides the process. With optimal mobilization, the force can almost take the form of a separate state of consciousness "dreaming while awake" (Davanloo, 2000) where the patient is engrossed in the processing of affective material from the past. In its broadest sense, the term is used as a term for the patient's healthy side (Kuhn 2014).

Part 2: The psychodiagnostic and therapeutic process in ISTDP

In part 1, we have given an overall introduction to some of the most important basic elements in the theory. In part 2, we will take a closer look at the dynamic process that guides psychodiagnostics and treatment.

With the exception of some exclusionary diagnoses such as active psychosis and mania, the formal diagnostic assessment is not the basis for treatment, but the patient's responses to the psychodiagnostic process. ISTDP postulates that there are common basic psychopathological phenomena for mental disorders and that this explains comorbidity. More specifically, as mentioned, these are anxiety and guilt associated with often completely or partially unconscious emotional conflicts with associated difficulties in relating to and regulating these emotions.

To find out what specific problems the individual patient has with their emotion regulation, the patient's core conflicts are mobilized by the therapist putting direct pressure on the poorly regulated emotions. Then the therapist and patient together will get a direct look at the type of problematic defense mechanisms that operate, how anxiety tolerance and the ability for self-reflection is when emotions rise, and whether and at what level of emotional activation the patient reaches thresholds where anxiety becomes too high and / or defense mechanisms become primitive. Based on this survey, further treatment is tailored. We will take a closer look at the details of this in the following.

Davanloos diagnostic spectrum

As mentioned, Davanloo did meticulous video analysis of series of cases in which he experimented with techniques to overcome treatment resistance. One of the most important observations he made in this process was that as the underlying emotional conflicts approach, this corresponds to a specific type of (unconscious) anxiety activation in the striated muscles, where the patient takes deep respiratory sighs, rubs his hands and has increased muscle tone. will-controlled muscles. As long as the anxiety outlet comes in the transverse muscles, this is associated with access to affect isolation as a defense mechanism (the patient can talk about the emotions, but not feel them) and the patients can tolerate breakthroughs to full processing of the unconscious emotions.

Some of the typical somatic ailments that correspond to this channeling of unconscious anxiety are tension headaches, fibromyalgia and various musculoskeletal ailments. Based on the degree of resistance before emotional breakthrough, this group is classified as patients with low, moderate or high resistance. These categories predict the intensity and complexity of underlying emotional conflicts and hence the length of treatment for full processing (Abbass, 2015).

Another group of patients reaches a tolerance threshold. At a certain level of mobilization of unconscious emotions, the "signals" from the striated muscles stop (if they have been there at all). Emotions are suppressed in favor of a depressive response and / or the anxiety outlet changes "channel" from the transverse stripe to smooth muscles in the stomach / intestine, blood vessels and bladder that create gastrointestinal symptoms such as nausea, cramps, urogenital symptoms and some forms of migraine. The symptoms often occur reliably and suddenly when certain emotional conflicts are mobilized. This group does not have access to affect isolation. At a certain level of mobilization, they turn anger inward towards the self as a corresponding defense mechanism, which contributes to depressive symptoms (Abbass, 2015).

A third group of patients develop cognitive and perceptual symptoms at a certain level of mobilized emotions. They are unable to think clearly, experience lightheadedness, dizziness, various visual loss or wheezing in the ears. This anxiety outlet channel corresponds with greater fragility in the personality structure and the use of primitive defense mechanisms such as projection, splitting and projective identification. While the two preceding groups fall under what Davanloo referred to as the "psychoneurotic spectrum," this third group falls into the spectrum of persons with "fragile personality structure."

Capacity building format - ISTDP in graded form

Common to both the second and third group of patients is that they need a capacity-building format, called the graded format, where anxiety channeling and the main type of defense mechanisms must be restructured before one can continue with the "standard format" where one puts pressure and challenge defense to affect breakthroughs. The graded format involves alternating cycles with the mobilization of emotions and associated anxiety up to the tolerance threshold, in order to regulate anxiety, and build self-observing capacity. This is done especially through visualization of the patient's movements in the conflict triangle; between emotions, anxiety and defense. And how the same patterns behave predictably across relationships from the past to the present and to the therapist (the person triangle).

When repression and primitive defense mechanisms are gradually replaced by the ability to intellectualize, or isolate affect, this means that the anxiety channel also shifts to cross-striped muscles. When sighs, increased muscle tone and the ability to think clearly about the process return, this is the "green light" (ten Have-de Labije & Neborsky, 2012) to mobilize further. Thus, this becomes a graded exposure that raises tolerance gradually through increased self-observing capacity that brings structural changes of anxiety channeling and defense structures. The thresholds for symptom design are raised and eventually the patient can withstand full mobilization of underlying emotions without problematic anxiety channeling, primitive defenses or self-attacks.

The latter two groups are diagnosed as mild moderate and severe displacement / fragility, respectively, depending on the level of mobilization (of unconscious emotions) at which they occur. Severe fragility corresponds to Kernberg's conceptualization of borderline personality organization (Abbass, 2015). At the mild end of the fragility scale, we find patients who do not experience cognitive / perceptual disturbance and / or have to resort to primitive defenses before reaching a high level of mobilization.

Summary

In ISTDP, the described psychodiagnostic process is the basis for predicting treatment duration and main content. Two people with the same formal diagnosis may have different structures and thus require different treatment strategies and vice versa. The treatment consists of continuing the psychodiagnostic process, with the goal of breakthrough to conscious processing of underlying core conflicts until there is no longer material in the patient that triggers anxiety and drives defense.

In summary, the unconscious emotional conflicts are mobilized through the therapist stretching towards the patient and his or her emotions, while the defenses that emerge are continuously clarified, put under pressure and challenged. In this process, one either achieves affect breakthroughs, or encounters thresholds where the defenses and anxiety channeling must be restructured and the ability for self-observation strengthened to create "structural capacity" to later withstand breakthroughs to the underlying emotions. Once the underlying emotions have broken through, they are available for processing, they no longer trigger anxiety, do not defend themselves and there is no longer any guilt attached to them. The emotions are tolerated, integrated and the source of psychopathology, the mentioned difficulties with emotion regulation, disappears. If the work is deep enough, they will not return either.

How to mobilize the unconscious core conflicts in ISTDP?

We have seen that in order to be able to do psychodiagnostics and effective treatment, it is crucial to be able to mobilize the patient's core conflicts in a safe and effective way. The mobilization of the core conflicts creates an effective focus in the divergent symptom picture, and it also makes it easier to see how the patient's difficulties are due to movements in the conflict and personal triangle. All this is difficult if one just follows the patient's history, especially in the early stages where the history will be colored by resistance and have blind areas. Adherence to important core focus is also considered important for outcomes within short-term psychodynamic therapies.

Before looking at the various main interventions available to the therapist to mobilize the unconscious core conflicts, we will focus on the various parameters the therapist monitors to determine the timing and dosage of these interventions.

Response to intervention

To ensure safe and effective mobilization of the unconscious emotional conflicts, the therapist's task is constantly to tailor the next intervention based on the patient's response to the previous one. The therapist monitors a total of five parameters to select the type, timing and dosage of intervention. These are anxiety channeling, active defenses and how ego-synchronous they are, degree of mobilization of complex transference emotions (mobilization or degree of mobilization) and presence of thresholds (Abbass 2015).

The same intervention may have opposite effects depending on the combination of factors. For example, challenging defenses when these are ego-syntonic (the patient is identified with them) will lead to misalliance, if the patient is above the threshold, to an increase in symptoms, and at a low degree of mobilization to stagnation. While when defense is dystone, the degree of mobilization is high and the patient is below the threshold, challenging defense can lead to an affect breakthrough where conflict-filled emotions come to the surface and are directly experienced.

The signal system in ISTDP

The most important single factor that is monitored to determine the next intervention is the presence or absence of "signaling", here defined as anxiety outbreaks through the striated muscles, especially in the form of respiratory sighs.

The signaling occurs when unconscious emotions approach. After the therapist's intervention, unconscious bodily signs of anxiety will signal an increase in unconscious emotions immediately. When the intervention does not trigger signaling, it is simply described because the focus is wrong, the patient is over the threshold so the anxiety outlet goes to smooth muscle or cognitive / perceptual disorder, or active defenses operate and do a good job of keeping emotions at a proper distance. Absence of an unconscious problem, such as when it comes to only external cumulative loads, or organic factors, can be other reasons for lack of signaling.

In the absence of signals, the therapist can shift focus, regulate anxiety or do defense work. When the signaling starts again, it is known that the previous intervention hit and the buttocks burn again (Fredrickson 2013). The ISTDP therapist listens as much with the eyes as the ears and responds to the signals from the unconscious and can give this signaling priority over the patient's verbal utterances.

Main intervention: «Pressure»

The therapist's starting position is a type of intervention that Davanloo called "pressure", or pressure. A better word could have been encouragement or encouragement, because in its essence it is about the therapist wholeheartedly reaching out to the depths of the patient and encouraging him to cooperate actively, step forward clearly and seek towards the core of his own emotional conflicts. By continuing the relentless encouragement to approach your own emotions and be fully present in the room with you and try to overcome the defenses, conflicting emotions towards the therapist will eventually begin to mobilize: Positive emotions, such as gratitude for the genuine attempts to reach in, as well as frustration over the degree of challenge inherent in the work. This increase in the “complex transference feelings” will create anxiety and increase resistance further as they on an unconscious level begin to reason with and mobilize the unresolved emotional conflicts from previous relationship experiences and thus trigger transference reactions in the traditional sense of the term (Kuhn 2014).

Paradoxically, this increase in unconscious anxiety and resistance is welcomed as a sign that not only underlying emotional conflicts are approaching, and that effective work with the patient's most important defense mechanisms is made possible, but also that the unconscious therapeutic alliance is promoted.

Mobilization of the "healing trinity" 

Davanloo called the complex feelings of transference and resistance the two "twin factors". He discovered that the development and intensification of both of these factors was crucial for the simultaneous mobilization of the inherent healing power necessary for the full "unlocking of the unconscious", namely the unconscious therapeutic alliance (UTA). Davanloo called the direct experience of the complex transference emotions (the emotions as they arise above the therapist) the "trigger mechanism" for unlocking the unconscious, and the degree of activation of these is in direct proportion to the degree of mobilization of UTA. In practice, this means that to the extent that the patient can afford to directly experience the conflicting feelings that build up above the therapist, a spontaneous link to the original figure will come from the unconscious therapeutic alliance, rather than being delivered in traditional packaging as interpretation from therapists.

Principles for defense work in ISTDP

Another significant factor that makes one want to bring the resistance into the room, or as Davanloo formulates it "tilting the patient's character-defenses in the transference" (Davanloo, 2000) is that both the therapist and the patient get a "live" demonstration of the patient's character defense. The character defenses can be said to be the patient's way of entering into the relationship in an unhealthy way and the behavior will place exactly the same limitations on the therapeutic relationship as in the patient's other relationships, unless the therapist and patient work together to identify and overcome the defenses.

When the defenses come up and play out in the relationship, the defense work is not based on interpretations or an intellectual exercise, but an experience that the patient and the therapist share, which makes the work with the resistance more effective. The apparent obstacle that character defenders usually create becomes a source of being able to work effectively with character change within this system.

In Davanloos' own words: “The therapist welcomes the resistance and he knows that the resistance can be reliably overcome and that the very act of overcoming it has far reaching beneficial effect. It is an actual therapeutic tool to help break into the patients unconscious (Davanloo, 2000 p. 10) ”.

Clarification of the defense

The first principle for working effectively with the patient's resistance is "clarification" or clarification of the defenses. Clarification is an absolutely essential part of the treatment because it involves identifying when defenses come in, what functions they serve and the costs they have for the patient. Becoming aware of the defenses as automatons that destroy rather than help, makes the defenses less ego-syntonic and it becomes easier to turn to them and see them as something worth fighting to overcome. Clarification helps patients understand, but as in all other ISTDP interventions, all psychoeducational elements should be done “live” while they are happening and it should be done briefly, where one quickly returns to pressure or challenge. Otherwise, clarification of the defenses can contribute to intellectualization, curb mobilization and / or strengthen or create transfer resistance where the therapist places himself in the expert position and the patient can step out of the active collaboration, and the further mobilization of own feelings / core conflicts is stopped.

When the destructive avoidance the resistance represents acts unconsciously and automatically, one is in the violence of one's own forces. When they are identified and both the function and the cost are clarified, you have a choice. It is the therapist's task to convey to the patient how he or she still has little choice between moving towards anxiety-provoking material or following habitual destructive patterns of avoidance, and that the benefits of therapy are proportional to how much one chooses the former (Kuhn, 2014).

Challenge of defense and "Head on Collision"

When the patient's defenses are sufficiently clarified and the resistance has “crystallized” in the transference, the phase of systematic challenge of the patient's defenses begins, to exacerbate the intrapsychic conflict mentioned earlier between the healthy side (UTA) and the destructive side (resistance).

From clarifying the defenses and putting pressure on (or encouraging) to move towards the emotions, the interventions are now beginning to take on a more confrontational style, where the degree of challenge increases. This further mobilizes complex transference emotions. The amount of challenge needed to break through is different. For those with the highest resistance, the challenge will lead to further crystallization of resistance in the transmission, ie the patient sets up a wall where not only their own emotions but also the therapist must be kept at a distance, as to prevent the mobilized transmission emotions from penetrating.

The most powerful intervention in the therapist's toolbox, which must be used on those with the highest degree of resistance, is called "head on collision" - a frontal collision against the resistance. This type of intervention can be delivered short-term, comprehensive or as a related chain. Some aim to remove obstacles to further mobilization of higher levels of transference and resistance, while others aim for a direct breakthrough into the unconscious (Abbass, 2015). Timing is essential for the use of all interventions in ISTDP and is determined on the basis of signaling and where the patient is otherwise on the five parameters previously mentioned. Challenge of defense, and especially head on collision, is used only when the patient is not identified with the defense, sees the cost, the anxiety outlet is in the striated muscles and the degree of mobilization of the underlying emotional conflicts is high.

The purpose is to bring the patient face to face with the consequences of their own resistance, or "meet the resistance head on and win the internal battle against it" (Davanloo, 2000). The intervention must be tailored to the patient in question at the relevant time, but contains up to 16 elements that pose a direct challenge to all forces that maintain self-destructiveness and self-sabotaging patterns. Abbass (2015) summarizes that it is about putting the destructiveness of resistance against the alliance's possibilities, emphasizing the therapist's limitations, the necessary reciprocity in the collaboration and disabling all forms of projective processes so that the therapist is not in "someone else's shoes".

All this intensifies the complex transference feelings and will at some point bring the patient to a tipping point where the balance between the resistance and the alliance is "tilted", where the psychic system loosens, the resistance gives way, and there is a marked drop in anxiety as the transference feelings are activated emotionally in the body.

Direct processing of the emotions and unlocking the unconscious

The patient now receives help to process the activated emotions. For many, the first partial breakthrough will be grief over their own defenses and associated self-compassion. In those with the highest resistance, anger will often be the first emotion to break through. UTA will then provide relevant links and clarify the original address of the feelings. This can happen in several ways. In the slightly changed state of consciousness, the "memory bank" wants to open up and shed light on the nature of the problems.

For example, in the midst of experiencing the complex emotions of the therapist, the patient may be associated with the mother's passivity, instead of the father's aggression, which has always been the focus. Quite surprisingly, the patient may come into contact with unrecognized rage with accompanying guilt over her. Suddenly, the excessive everyday anger towards the spouse becomes understandable to the patient in light of the fact that the feelings have been transferred, which resolves the couple's conflicts in the area in question.

In the phase after the patient has had a direct experience of strong emotions in the room with you, the condition is often markedly changed. Initially in a therapy class, patients often fill the room in very different ways. In this "unlocked" phase of therapy, where the resistance and anxiety are gone and the patient processes emotions related to attachment efforts, the attitude is open, the condition receptive and thoughtful. The patient acts on his own, and is present fully as himself with the therapist. Here we are struck by how similarly the patients fill the room, when the character one has built up around the core needs ends up in the background.

It is with this condition as a contrast fluid that it is easier to see how much resistance and tension the patient usually encounters invitations to close contact with. Ways the organism contracts, adapts, searches for the right thing, hides, or rises. As one could call all the ways the organism has learned to do alone to be able to be together.

Therapeutic mechanism in ISTDP

As we see from the text above, the method has the potential to make unconscious conflicts visible and provide increased emotional insight. The direct processing of all the complex emotions weakens the link between underlying emotions and anxiety (as well as pain), which in addition to being positive in itself, means that problematic defenses are no longer necessary. In addition, the supply of adaptive affect increases, which in itself is associated with better health (see Schancke et al., 2013).

One may ask what triggers the sometimes violent self-hatred, the irrational self-accusations, the self-destructive maneuvers, the morbid conscience, the feeling of being "evil" or the common fear of becoming a "monster" if emotions are allowed to escape (McWilliams , 1999), which many of our fellow travelers, nice people, have bothered with for years. There are obviously some strong irrational forces at play. Some may have insight into the irrational, but still fail to override the emotional firing. Interpretations, "tools", insights or attempts at new behavior are not always enough. For Davanloo, among others, the answer to this question was that a pathological superego structure gives punishment for the aggressive impulses the person may have had in the emotional conflicts with their loved ones.

The deepest therapeutic potential, especially in those with the most self-destructiveness, therefore lies in the actual processing of unconscious guilt over the anger component in the conflicting emotions above important others. This is because the actual experience of guilt over anger in the highly ambivalent mix of emotions has the potential to remove the self-punishing need that is increasingly seen in many of the more serious cases. When the rage takes place, this facilitates the processing of the simultaneous love, sorrow and longing and guilt. By fully acknowledging the negative aspects of the caregivers and allowing their own protest fully, it seems as if something that has been in the way of the good in the relationship is pushed aside and not infrequently there is an improvement in the relationship, or at least in the patient's relationship. to himself.

The shadow that one's own rage and guilt has cast over the relationship eases. It is not uncommon for patients to report marked changes in the ways they can relate to their loved ones, after first acknowledging and processing the deepest layers of negative emotions. "I could be present and nurture her with genuine care, rather than mechanically and distantly as I usually do." Patients often report being able to feel much more nuanced and love deeper.

Emotional conflicts with caregivers, where the child often "loses out", and the therapeutic potential that lies in resolving parental bonds, brings us to a brief discussion of character defense, defense through identification and superegopathology, before we illustrate the most important treatment principles as they come to expression in our clinical practice through a case description in part 3.

Character defense - a royal path to character change

A key point in the healing principles we find in the way ISTDP works systematically with character defense. Each character defense that comes up in the room with you as resistance in the transfer, reveals a part of the patient's suffering history. Fredrickson (2013) summarizes character defenses as when one treats oneself in the same way as he was treated by some early important ones (e.g., devaluation or ignorance). In other words, defense via identification. Emotions related to being devalued or ignored are kept away when one takes in a parent's neglectful or critical attitude as one's own (Whittemore, 1999). This criticism or neglect eventually affects oneself, but can also be directed at and affect others. Or the attitude of criticism or neglect can be projected onto others (not least the therapist) and then met with fear, defiance or obedience (Fredricksson, 2013).

Getting help to process assertive, protest-filled emotions related to this way of being treated is in itself a therapeutic event. To actually feel a strength, assertiveness and protest against oppressive forces, shadowy sides that have come from the other. An adjustment of the parental images is often necessary for an adjustment of the self-image.

Understanding identifications also helps to separate the patient from the identifications. The patient most often dislikes the way they have been treated badly. Acknowledging that you treat yourself (or others you love, such as your own children) in the same way is a powerful insight that helps them turn to the defenses (Kuhn, 2014). Seeing the self-destructive nature of identification also helps prevent externalization in the form of blaming parents or others. While acknowledging that the pattern arose for a reason, that one was once a victim of circumstances, one can take ownership of the responsibility for one's own life and take on a more selective, active role in one's own life.

An important principle here is that the ISTDP therapist does not compensate for the resistance, or allow it to develop into a so-called transmission neurosis. If a patient takes a helpless position, it is important not to step into the role of omnipotent helper and reinforce an addiction dynamic. If a patient is passive, it is important not to be so active that the patient can remain passive, but put pressure on the defense. Otherwise, the patient's invitation to a sick relationship will be accepted (Fredrickson, 2013), and the patient's own underlying capacity will remain unavailable. Instead, it is about holding the patient responsible for their own helplessness or passivity, helping them to see the consequences of these positions in therapy and in life in general, and encouraging them to enter the relationship in a more active and constructive way. We will take a closer look at some of these principles in the last part of the thesis.

Part 3: ISTDP in practice - illustration through case

We have outlined the most important dynamic principles in ISTDP as a treatment method in part 2. The presentation has been characterized by our condensed understanding of the method through our own practice, guidance, courses and literature that describes the model. We have highlighted the need for individual adaptation through a detailed description of the psychodiagnostic process, where the therapist monitors the patient's instantaneous responses on five parameters to determine the choice of the next intervention. While some patients are in need of building a structural capacity, others can be mobilized for direct breakthroughs to emotions. We have briefly described how this capacity can be built up, before we have concentrated on showing the various principles in order to arrive at an emotional breakthrough where the unconscious is "unlocked". We have also emphasized how the degree of resistance and difficulties are related to the intensity and complexity of underlying emotional conflicts.

In the following, we will illustrate some of these central treatment principles through a presentation of a case that is close to actual experienced cases from our own practice. The vignettes are intended to illustrate principles and take the form of condensed dialogues. With this presentation, we will show how we understand and apply the theory in practice through a concretization of the process. We will also use the case to illustrate how complex symptoms and character disorders give holistic meaning as an expression of underlying unprocessed emotional conflicts.

Background information about cases

The case presented here is, as stated, intended as a prototypical presentation in a certain group of patients with whom both authors have experience. The patient is a woman who comes to therapy with a wait-and-see attitude characterized by passivity, anxiety that rises rapidly and with defensive tears that flow when she talks about herself and her difficulties. The patient has a somewhat externalizing style, talks about how difficult she is, how other people fail her and with a little pressure she quickly takes a desperate and helpless attitude. She does not have many ideas even about what she wants to focus on or what the ailments may be.

The patient has a recurrent depressive disorder and satisfies criteria for avoidant personality disorder and also has irritable bowel syndrome with seizures and diarrhea. She is characterized by widespread anxiety and panic attacks on a rare occasion. She has significant self-esteem and relationship difficulties. She has some friends from school that she occasionally meets, but does not form new relationships, with a typical pattern of pushing people away. She quickly experiences that others fail her, do not care and can become passive aggressive. A couple of times she has made scenes in front of friends where she has become angry about feeling overlooked and stormed out of the room crying. Overall, we can say that she is characterized by complex symptom and character disorders, with extensive use of regressive (immature) character defenses.

Beginning collaboration in ISTDP

ISTDP is often based on specific symptom-intensifying episodes in order to obtain the underlying mechanisms. What inner emotional problem do you want us to focus on now? Can we look at a specific event where the problem unfolded? And then we try to get a picture of the underlying mechanisms from there? What event do you want to watch? (pressure against the patient's will, pressure against being specific)

The patient in our case declares an inner problem, to which she replies that she wants to look at the anxiety and depression, but quickly states that she is unable to come up with specific episodes. This initiates a dialogue in which the patient's tendency to habitually underestimate herself, give up herself before she has tried and become helpless in relation to challenges is thematised. The therapist points out what is happening and wonders if it is only in this slightly special situation that it happens, or if it is more general. She recognizes those patterns from her life and can see that they are limiting for her and that they want to limit the therapy. The focus here is on removing obstacles for the patient to get involved in their own project at all and actively build a conscious alliance, where it is especially emphasized that it is only with each other's help that the positive goals can be achieved, an intrapsychic focus on underlying emotions will be crucial and change may be possible if both parties reach their utmost capacity, with the patient's liberation from life - limiting inner forces as the overriding goal.

The beginning work with the character defenses (passivity, helplessness) and the focus on the alliance mobilizes her more (she begins to sigh and have a more active posture) and comes up with a concrete example. The therapist is satisfied with seeing the signaling and can be sure that the process is on a good track. We enter the dialogue after she has told about an episode where she experienced that her boyfriend rejected her when she tried to record something that bothered her, whereupon she felt a real discomfort in the body, became quiet the rest of the evening and felt heavy. When asked what she thinks about what he did, she can eventually say that she thinks it was unfair.

Restructuring of regressive character defenses: externalization and helplessness

In the following, we will illustrate the dialogue using vignettes where T refers to the therapist's reply and P to the patient's.

So when he treats you unfairly, is there something inside that makes you anxious and heavy? And that makes you shut up and retire? Shall we find out what it was inside that triggered it all? (pressure on inner focus and will)

P: It's typically he, he never listens to me, I'm so tired of it so, I do not say anything (defensive tears, no signal of unconscious anxiety activation, externalization ("blaming and complaining") as a defense)

The therapist's job here is to help the patient to establish an inner focus and thus be able to get more agents, and take responsibility for themselves and their own feelings and needs. She does not see that his behavior triggers unconscious emotions in her, which she unconsciously gets anxious about, and which she avoids in the situation by withdrawing and down into something heavy. She also does not see that in the therapy situation she keeps her own feelings away by taking an accusing position where she underestimates herself, and makes herself more of a victim than she really is. In therapy, these regressive defenses of externalization and helplessness prevent further mobilization of their own core conflicts. In her life, they help push people away (her friends will not listen to her) and she gets a passive way of overcoming challenges. The goal is to form an alliance with the patient against the defenses, and help her endure the underlying anxiety-creating emotions instead of getting anxious and using these character defenses.

Do you see that now, even if he is not here, the body becomes anxious and then you are pulled down into something heavy just by approaching the subject?

P: Yes, so far

So it may seem as if something inside is creating unrest and then these heavy tears?

P: Yes, I guess so

Okay, and can you see that even though you really wanted to be heard, you withdraw as soon as you meet resistance? (Clarification of internal conflict, defense)

P: I have not thought about it like that before

Is there a pattern in you? That you get anxious about having to stand up for yourself? And end up ignoring yourself by withdrawing? And then you make yourself a hostage for others to meet you? (The conflict triangle is summarized, emotions create anxiety that drives defense. Establishes inner focus, builds self-observing capacity, shows causality in problem design)

P: (sighs) Yes, it happens all the time

What does it do to your relationships with others? And to yourself? (focus on the cost of the defense, separate the patient from the defense)

P: (sighs) I think it makes me lonely and bitter, and I think my boyfriend is starting to get tired of me, because I kind of just get quiet and say nothing, and overhear him when he asks what it is.

The patient shows insight into how her own defenses create the problems she comes up with. If we can help her endure the conflicting emotions that have been triggered in her relationship with her boyfriend, she does not need these defenses that keep her down and other people away. The therapist puts new pressure on emotions, knowing that when you hit the defense in front and the patient has turned to it, as now, underlying emotions will rise, with that anxiety, and a new defense will be mobilized (Fredrickson, 2013). This is how the lids are "lured forward", and make themselves available for restructuring.

Restructuring of regressive character defenses: Habitual self-attack

Shall we try to look at the emotions that lie beneath, so we can free it from that automaticity there? What feelings were whirled up in you in front of your boyfriend for not listening to you?

P: I just think I was stupid

Instead of getting a reaction against him, does a mechanism come in and attack you?

P: That's just the way I am

Is it a pattern? That the negative emotions are coming towards you?

P: I've always been like that

We see that self-blame is synton, that is, the patient is identified with the defense. Think about it, for this person this has become normal. The therapist's job is to respond to this, separate the person from the defense, see the consequences and mobilize the healthy free person she was meant to be, and who is still lying there waiting to be found. The therapist must keep the focus here until the patient sees the defense and has turned towards it. Examples of interventions can be: But you were hardly born that way, were you? Is it really you or an automaton that keeps you down / an automatic way of treating yourself / dealing with emotions? What did that do to you? How does it affect you when you blame yourself when you experience that others are treating you unfairly? Or when others frustrate your attachment needs?

P: (sigh) I never thought about it like that… it's pretty bad… I think I get a bad self-esteem from it, because it happens all the time. 

We see how it becomes clear in the dialogue that the patient's habitual pattern of self-attack helps to create the patient's difficulties. Gilbert & colleagues (2004) found that 80 percent of people with depression had a pattern of reversing anger. In addition to that there may be one possible etiological factor in a subgroup of depressed, there is also a pattern that contributes to damage self-esteem. Often this is the result of adaptation to the caregiver, that the patient takes the blame himself. It can also be a result of guilt. Anger is reversed due to the need for self-punishment over anger.

If we can help her endure the underlying emotions when someone she loves and seeks closeness to rejects her, she will not have to attack herself. We see that three major regressive character defenses (helplessness, externalization and self-attack) have been activated, but made (more) egodystone. We therefore go further and try to continue to mobilize the patient's will, feelings of transference, resistance and unconscious therapeutic alliance through further pressure on underlying emotions.

The resistance crystallizes in the transmission

Should we try to get hold of the unconscious feelings behind the anxiety, the depressive lure, the self-attacks and the withdrawal? What emotions are there just below the threshold of consciousness that make you anxious, pull you down and away and attack yourself? What feelings come up during that if the organism is released?

P: (sugar) I do not know.

Do you notice that something in you went into a position of not knowing right away? Before you got to know after? Is not that the mechanism that underestimates you? (Identifies the defense that she has already become acquainted with)

P: Yes it is.

Which comes automatically. But what can we do with it now, because as long as it is left unchallenged, it will stop you? (points to the cost of the defense, puts pressure on the defense, degree of challenge increases)

P: (sugar)

P: (starts to break the contact, becomes quiet and looks at the wall)

Do you notice that even though you have obviously come here to form a healing relationship with me, is there something else in you that begins to become quiet and pull you away with your eyes? Just like you're putting up a wall between us here now? That you withdraw into yourself and make yourself alone?

P: (Sugar) yes, when you say it like that I can see it.

Is not this the automatic that makes you lonely and bitter? Who pushes people away? Should we rather look at the feelings that come up in you above me here now? So you do not have to retire?

P: (The signaling ends, there is a physical change)

What are you noticing on the inside right now?

P: I'm starting to get a stomach ache, just like those cramps are on their way.

The patient reaches the threshold, emotions are displaced 

Here the patient reaches her threshold for the degree of mobilization of underlying emotions she can tolerate before the emotions are transformed into symptoms in the body. So far in the conversation, she has alternated between having character defenses in front that have been clarified, which has given her anxiety outbursts in transverse stripes manifested as sighs. It means green light, so the therapist has put further pressure on emotions and defenses as they have come up. This process causes the complex transfer sensations to rise and the resistance to crystallize in the transfer. A clarification of this and further pressure on the emotions in the transfer further mobilizes the emotions, to a level she still does not have the structural capacity to withstand. She therefore needs the graded format (see for example Abbass & Bechard, 2007) to build capacity.

We see that the somatic ailments associated with irritable bowel syndrome occur in parallel with an increase in emotional activation with an associated anxiety outlet channel that shifts from the transverse stripe to smooth muscle. This gives a strong indication that the problems with irritable bowel are at least aggravated by unconscious anxiety channeling to the gastrointestinal system, especially if this connection is reliable. This is the red light (ten Have-de Labije & Neborsky, 2012) for further mobilization of the unconscious emotions, which would now only aggravate the somatic ailments, and probably made her more heavy and depressed, since she tends to turn anger inward towards the self. Here we must stop and help the patient to regulate anxiety. If it is sufficient, preferably by helping her to reflect on the process and see causality in the symptom variation.

More specifically, the therapist's job is to help her see the movements in the conflict triangle through a summary. This strengthens self-understanding and the ability to self-observe capacity and raises anxiety tolerance. One exposes up to threshold. When the nausea is gone and the anxiety is back in the transverse muscles (the "signals" come back), you can continue the pressure on emotions, but then preferably at another pole in the person triangle. One principle here is to regulate firing in the limbic system (anxiety) by seeking to activate prefrontal functions (intellectualization). In an intervention type called "bracing", one seeks to make these areas fire simultaneously, through a combination of pressure on self-reflection and emotions.

When we reach the threshold at this point, the patient will be described as having high resistance with a moderate degree of displacement, as displacement occurs at a medium high level of mobilization of complex emotions (as indicated by the defenses beginning to crystallize slightly in the transmission). Abbass (2015) describes how many in this psychodiagnostic category have elevated thresholds for symptom design related to displacement and anxiety activation in smooth muscle during the first four to five hours when treatment is going well, while total treatment duration for full symptom remission and character changes is estimated at up to 30-40 hours (Kuhn, 2014).

Capacity building through reflection and summary.

Okay, so the cramps are now a sign of anxiety settling in my stomach. Then we'll just calm down and understand what's going on for a while, okay? We first saw that when your boyfriend frustrates your needs, you do not know the feelings above him to do so, but you become anxious, pull yourself down into something heavy, may go on a self-attack and withdraw. Is it precise?

P: yes, I'm in.

And when I ask these important but frustrating questions about what lies beneath, does it seem like you're getting some mixed feelings about me? Is that correct?

P: Yes

And a bit of the same automation comes here with me? You put a lid of silence and retreat over? And when we try to remove those lids, the fear of those feelings increases a lot? Anxiety settles in your stomach and your cramps are triggered? Do you see what I mean?

P: (sugar - the anxiety outlet is back in the transverse muscles, the acknowledgment that the intervention hit and the patient is again within the tour window) Hm .. I who did not think it was like that… what do you call it, psychosomatic? (sees the link, demonstrates good self-observing capacity. This plus anxiety in the crossbar gives the green light for further mobilization)

So there is something about others frustrating you that makes you end up being self-blaming and withdrawn, do you recognize that there?

P: I think it started very early (UTA)

What comes up (follows UTA)

P: Mom has always been more concerned with my little sister than me, I tried to say something about it, but then she just sent me to the room. And eventually I was almost not in the living room when my sister was home (UTA, mixed with resistance: defensive tears, regression).

It sounds important, so let's stop for a moment and think about this. This must be whirling up some emotions in you towards your mother. But instead of feeling the different emotions there, do you notice that those tears will pull you down into something heavy now? Because those are the kind of tears you get stuck in there, aren't they? That is right? Should we rather look at what feelings come up in you towards your mother? (clarification of defensive tears as defense, quickly puts pressure to mobilize underlying nuclear conflict).

The unconscious therapeutic alliance is coming

As a result of the therapist's pressure on emotions, and at the same time clarifying the character defenses, complex transference emotions are mobilized, increased resistance (the patient begins to break contact) and with it the unconscious therapeutic alliance is mobilized which at this point clearly emerges through resistance for the first time spontaneously. to bring up the underlying conflict. The therapist works with the patient's healthy side to understand how the episode when the boyfriend did not listen to her whirls up unprocessed conflict-filled feelings related to the mother (and sister) who did not listen to her either.

Pretty quickly the patterns become clear: Old conflicting emotions are triggered, and with it the anxiety and the old defenses of withdrawal and the heavy, depressive lid where emotions are repressed and anger is turned in the form of self-attack (the conflict triangle). The patient can begin to see how she handles her needs and feelings in the same way towards her boyfriend and therapist as she did at the time (the person triangle). This insight increases the patient's capacity to observe herself and understand herself dramatically, which builds anxiety tolerance, and it gives her a sense of agent that "boosts" the alliance and the positive component of the complex transference emotions. She becomes acquainted with and turns to the regressive character defenses.

The therapist puts pressure on the feelings towards the mother, works with the defenses that come up, until the patient again reaches the threshold by starting to flatten out and get hurt, immediately takes off the pressure, regulates anxiety and summarizes the process cognitively. When the anxiety is back in the transverse muscles and the patient clearly thinks about what is happening, immediate pressure is put on emotions again, in another corner of the person triangle. This is how the signal system helps us to work in the patient's upper part of the tolerance window.

This work gradually gives the patient other structures to deal with emotions without being overwhelmed by anxiety or having to resort to harmful defenses. The body tolerates the activation better and the patient understands more. We will now look at how this process has gradually led to structural changes in the patient as shown in the following sections. We return to the same situation and the same questions as initially, after spending 4-5 hours with graded exposure as shown above.

What feelings come up in you towards your boyfriend for not listening to you?

The patient sighs and rubs his hands - a signal that unconscious emotions have been mobilized. Anxiety is channeled through will-controlled muscles. The butt is burning and what we expect is mature defense

P: I do not think I got any special feelings (mature defense rather than regressive)

(Communicates with the unconscious signals, they take precedence) You took a sigh, do you notice that something is building up? What feelings are in you there, under the anxiety?

The patient takes a new, deeper sigh and rubs his hands - the mobilization increases, a confirmation that the previous intervention hit. The therapist knows that we are closer to breakthrough to the feeling than ever, and the work is going in the right direction.

P: I actually get a little angry, because I think it was really badly done

The patient can recognize anger instead of turning it in, attacking themselves and becoming depressed and insecure about themselves. The anxiety channel is still in the transverse stripe, she can tolerate the anxiety instead of the anxiety going to smooth muscles and creating cramps and ailments with the intestine. The anxiety outlet channel and the defensive structures have been restructured. The therapist continues to put pressure on the same place, since mobilization increases and the patient is within the tolerance window.

How do you feel the mind physically inside?

P: I just feel it tightening in my chest but I think I'm angry about what he did

The patient only feels anxiety, isolation of affect as a defense (can talk about it without knowing it) there is still a green light and the therapist can continue to put pressure on the physical experience of anger and on the way there continue to put increasing pressure on and eventually challenge to defense. This in turn will bring an increase in the complex transfer sensations, the resistance in the transfer and UTA.

At this point in treatment, the patient has already experienced significant symptom relief due to increased anxiety tolerance (less diarrhea and seizure problem) and raised threshold for need for displacement / self-attack (less depressed). They feel better, without fully understanding what the reason is, and the GP may be surprised as the patient has often had the same health problems for years, despite medical follow-up (Abbass, 2015 p. 212). Improvement in self-esteem, depression and relational functioning due to restructured defenses (does not push people away in the same way, be more active and responsible in their own lives, attack themselves less and with it less depressed, improved self-esteem) is also incipient, and will cement itself more and more outwards in the process as underlying anxiety and guilt-laden emotions break through and are processed.

The task is to continue the cycle of mobilization up to the threshold, bring anxiety down and see your own conflict and personal triangle and mobilize again. The patient tolerates first the idea about own conflicting emotions, including anger, and gradually stronger and stronger physical activation of anger in the body before thresholds for anxiety channeling and regressive defenses strike. Finally, the patient endures full mobilization and breakthrough to the emotions and all the underlying conflicts they are a part of can come to the surface for review. When guilt is processed and with the "engine" in the self-destructive system turned off, or the fuel burns up, the last "plug in the system" is removed so that the patient can embrace himself and his life with the people in it completely. The process involves a deep experience that even if the body reacts as if one has done something very wrong by having these conflicting feelings, they are not signs of actual crimes, but rather a basic humanity and a confirmation of deep love needs.

Is it justifiable to initiate such deep processes within a short-term framework?

The demonstration of the application of the graded format in the case above emphasizes that ISTDP is primarily a capacity-building method. When you recognize thresholds, you help the patient immediately with anxiety regulation and building self-observing capacity. This principle makes it a safe method to use, where the therapist does not have to worry about "opening wounds and leaving the bleeding". A fear that makes many therapists refuse to go in to work with deeper problems.

An important aspect in this respect is that within this thinking one does not assume anything regarding the patient's capacity to be able to profit from treatment based on diagnoses or trauma history. We mobilize core conflicts and measure responses. Where and when we meet thresholds tells us where the patient is placed on the psychoneurotic spectrum and approximate duration of treatment. As the anxiety outlet channel begins to change, or regressive defenses occur, we know we have reached the threshold and are working systematically to raise thresholds for symptom design. Once the anxiety outlet is back in the transverse muscles and the patient thinks clearly, we mobilize further. Although ISTDP is an emotion-focused method, the focus is not on the breakthrough of emotions, it is on working from the patient's last response and intervening from there. Clarifying one's own movements in conflict and the personal triangle leads to dramatically increased self-understanding and choices. For each defense that is clarified, the patient comes one step closer to his or her own core, and for each exposure to the underlying emotions, the associated anxiety and pain will be relieved. And if you work precisely in this process, the emotional breakthroughs will eventually come, which requires even deeper healing.

Another important point in the discussion about whether it is safe to initiate deep processes within limited limits is that the establishment of unhealthy dependencies is averted through continuous clarification of such defensive positions before they have time to develop. The focus is not on getting the patient to open up and "tell everything", but to gradually work on increasing the ability to tolerate and regulate anxiety related to underlying emotional conflicts, use more mature defenses, understand oneself and eventually process emotions within one's own tolerance window. .

However, it should also be added that precise maneuvering in this landscape requires a certain level of expertise. It is the responsibility of everyone who learns a new method to, as far as possible, work within one's own skill level. Continuous video guidance and gradual implementation of the method in more and more complex cases is considered imperative to reduce the chance of misalliance, dropout and worsening of symptoms. A rule of thumb here is to initially only apply the method to patients with low, moderate or high degree of resistance without displacement or fragility in the personality structure.

Concluding about the case

With knowledge of metapsychology at its core, the therapist will expect that the patient's emotional conflict consists of both strong love with longing for attachment to mother, grief over the element of loss that lies here, anger over rejection and guilt over anger. Similarly, one would expect similar emotional conflicts in relation to sister. Difficulties with triangular situations (acting out when several girlfriends are together) are also thought to be attributable here. One can also sense traces of character defense through identification with the mother (ignoring oneself, criticizing oneself). The therapist's job is to help the patient to endure full mobilization of the underlying emotional conflicts so that she no longer needs life-limiting defenses, and as the most curative one is considered to be able to actually feel guilt over the anger component of the ambivalent emotions, instead of continuing to punish oneself. have had these impulses in them. All steps on the way here will have a symptom-reducing effect on the patient, but to a greater degree of mobilization of emotions, to greater character changes and less risk of relapse (Abbass, 2015).

ISTDP - Summary

Aided by an attitude of reaching out wholeheartedly to the patient, an intervention system for dealing with resistance, and a concrete signaling system for monitoring unconscious processes, the underlying emotional conflicts and the disturbed internalized relational experiences are mobilized (Killingmo, 2008) from which the conflicts spring. This provides direct insight into the idiosyncratic difficulties with emotion regulation the patient has at different affective mobilization levels. If necessary, the defense is restructured and anxiety tolerance is built, before the patient within his tolerance window can be brought into direct contact with hitherto closed and unresolved emotional conflicts that have had a driving effect on both symptom and character design. The goal is full symptom remission and character change as quickly as the patient's structural capacity allows.

For the ISTDP therapist, as mentioned, the formal diagnosis is not decisive for the treatment strategy, but how the patient responds to the psychodiagnostic process. We have tried to show how complex symptoms make sense in light of ISTDP's metapsychology, which focuses on the basic transdiagnostic phenomena that underlie psychopathology, namely difficulties in relating to and regulating emotions. Within this theoretical framework, it can be said that the problems with emotion regulation are operationalized as the use of maladaptive defense mechanisms, and for some also difficulties with self-observing capacity and anxiety tolerance. In addition, there is often a problem with guilt with associated self-punishment over the anger component of the conflicting emotions.

Effective work to improve emotion regulation first presupposes mobilization of the difficult-to-regulate emotions. The therapist mobilizes the unconscious core conflicts and puts pressure on the experience of the avoided emotions that are difficult to regulate. Then the individual patient's specific problematic defense mechanisms and any difficulties with anxiety tolerance and self-observing capacity will be directly visible and one can work systematically with these.

In the above case, we see a person who comes in with recurrent depression, elusive personality disorder, irritable bowel syndrome with cramps and loose stomach with significant character-based problems with relationships and self-esteem.

We saw how organizing contact by putting direct pressure on the patient's emotions in symptom-intensifying situations brought up the various character difficulties and symptoms almost like pearls on a string.First the regressive character defenses, simplified the sources of depression, low self-esteem and relationship difficulties (helplessness, externalization and self-attack as the most important). These were stable structures the patient looked at as parts of himself. When she began to turn to the defense, anxiety rose within the tolerance window. Upon further pressure, a threshold is reached for the displacement of the mixed emotions, where the gastrointestinal symptoms occur.

Through a capacity-building format, we gradually saw signs of structural change. The patient no longer had stomach ailments or became flat / depressed with massive self-complaints when she approached conflicting emotions involving anger, but could talk about it, and have anxiety in striated muscles. In this way, thresholds for symptom design are raised with gradual exposure, which ultimately gives full access to breakthroughs to unconscious emotional conflicts. In this process, character changes occur.

The way of organizing the contact close to work in the two triangles, as well as well-developed systems for dealing with resistance, monitoring the degree of mobilization of unconscious material and clear guidelines for timing and dosing of interventions make it possible to work clearly and effectively with complex symptoms and character disorders in the upper part of the patient's tolerance window. Dosing of active elements counts more than the number of hours for change processes to take place, so it is hoped that more studies can confirm the growing trend towards complex, grade-based and often treatment-resistant difficulties being treated successfully within the short-term framework that is most often available. .

Afinal discussion

Theoretical discussion or assessment of ISTDP as a method is outside the purpose of the thesis. We will nevertheless briefly mention some insights. Although the method has been shown to produce large effect sizes that last (or increase) over time for a wide range of conditions such as mood disorders, anxiety disorders, personality disorders and somatic conditions (see Abbass, Town and Driessen, 2012, Solbakken & Abbass 2013; 2014; 2015; 2016, Town and Driessen, 2013), such outcome data are of course not sufficient to say anything about the validity of psychotherapy theory. There are only a few process / outcome studies that help to validate certain parts of underlying assumptions such as direct connection between degree of intensity in emotional experience, unlocking the unconscious and outcome (among others Abass 2002, Town, Abbass & Bernier 2013; Johansson, Town & Abbass 2014). It is conceivable, for example, that this way of working potentiates common factors, or that there are other specific factors than the postulated ones that lead to a positive outcome.

Another point we will mention is about the large element of interpretation of non-measurable phenomena, as unproven processes, on which the model is based. One could, for example, ask to what extent the experience of emotions in the therapy situation is an awareness of hitherto unconscious emotions that have been there all along or to what extent the emotions are generated in the dynamic process between therapist and patient (McWilliams, 1999). For a discussion of the scientific status of unconscious cognitive, affective and motivational processes, we refer to Westen (1998) and Kihlstrom (2015) as two different voices in the debate.

A strength in this respect is the extensive use of audiovisual recordings during the development of the model, in research, training, guidance and daily practice, which makes the basis for interpretation transparent and contributes to clear operationalisations and concretisation of phenomena.

If you look at the specific content of the vignettes above, there are of course other ways of interpreting the material and other models you can use, which presuppose other mechanisms of action and causality principles that can also be effective.

ISTDP conclusion

There is a need for ways to understand complex character and symptom disorders and to have ways of working with these within short-term frameworks. ISTDP has a theoretical framework, operationalized principles and a nascent evidence base to be a good alternative for a subgroup of these patients. We have accounted for psychodiagnostics and treatment using the method, with a special focus on complex disorders.

We have seen that what, after a formal study, satisfies both criteria for anxiety disorder, depression, irritable bowel syndrome and personality disorder has something to do with each other. The symptoms provide holistic meaning in the context of unprocessed emotional conflicts with associated different types of anxiety manifestations and different types of defense mechanisms. The path to the release of symptoms, physical ailments and character problems goes via restructuring of self-observing capacity, anxiety tolerance and defense structures in those cases where this is necessary, to direct processing of underlying emotional conflicts. When the emotions are experienced, they no longer trigger anxiety and then neither do problem-creating defenses, or drive a self-sabotaging need. It is with the illusion that emotions should be dangerous and must be avoided, as with the trolls in the fairy tale, they burst into the light.

In summary, ISTDP postulates that attachment trauma, or frustrated attachment efforts, initiates a chain reaction in which the patient's self-punishing way of dealing with the intense conflicting emotions leads to symptoms, relationship, and self-esteem difficulties. With the help of dealing with these feelings in healthy ways, one will be able to free oneself completely from the impact of the trauma. The patient does not have to be held hostage by someone else to change. Although it is common consequences of an ISTDP treatment, it is not primarily through interpersonal events such as self-assertion and confrontation and / or repair of broken ligaments that healing occurs.

Through the therapeutic process, the patient's intrapsychic conflicts are resolved and the patient is again able to see himself as a loving person, where the primitive aggression is understandable expression of deeply frustrated love needs. The guilt of the primitive rage, when it comes to consciousness, becomes a confirmation of profound love, rather than a source of psychological warfare against oneself. The patient, who is now not anxious about these feelings on the inside, also does not need defense to keep them away. She no longer has to distance herself from others or be afraid of the closeness she seeks. With this, her natural urge for connection, growth and wholeness will unfold and she can live the rest of her life with natural freedom from neurotic obstacles. She we could enter into relationships with others in new ways, and with that set in motion further good circles. The often generation-bound baton of pain associated with frustrated love needs is broken with ripple effects far into the future. More love, more security, more freedom, more growth and more joy for those living now and future generations. It is these "ideal outcomes", which in step with our own development occur more and more often, that make it so rewarding to work with this form of intensive depth therapy.

As a formerly highly self-critical and emotionally distant patient of one of us, it said after repeated breakthroughs to all the conflict-filled emotions: «Its hard to have so much promise and nowhere to put it ». 

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If you want to read the entire specialist thesis as a download, do it here:

Should we try to grasp the unconscious emotions behind the anxiety, the self-attacks and the withdrawal? Principles of psychodiagnostics and treatment of complex disorders using intensive short-term psychodynamic therapy (ISTDP)