Author s : Alan R. DOI : Background: Short-term dynamic psychotherapy is a well-established treatment modality. Habib Davanloo, MD was a pioneer in bringing it to the forefront of psychotherapy. Method: The origin and development of dynamic psychiatry, from the early work of Mesmer through classical psychoanalysis and contemporary theories will be reviewed.
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Intensive short-term dynamic psychotherapy ISTDP is a form of short-term psychotherapy developed through empirical, video-recorded research by Habib Davanloo. The therapy's primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful.
The technique is intensive in that it aims to help the patient experience these warded-off feelings to the maximum degree possible; it is short-term in that it tries to achieve this experience as quickly as possible; it is dynamic because it involves working with unconscious forces and transference feelings. Patients come to therapy because of either symptoms or interpersonal difficulties.
Symptoms include traditional psychological problems like anxiety and depression , but they also include physical symptoms without medically identifiable cause, such as headache, shortness of breath, diarrhea, or sudden weakness. The ISTDP model attributes these to the occurrence of distressing situations where painful or forbidden emotions are triggered outside of awareness.
The therapy itself was developed during the s to s by Habib Davanloo, a psychiatrist and psychoanalyst from Montreal. He video recorded patient sessions and watched the recordings in minute detail to determine as precisely as possible what sorts of interventions were most effective in overcoming resistance , which he believed was acting to keep painful or frightening feelings out of awareness and prevent interpersonal closeness.
In , Josef Breuer and Sigmund Freud published their Studies on Hysteria , which looked at a series of case studies where patients presented with dramatic neurological symptoms, such as "Anna O" who suffered headaches, partial paralysis, loss of sensation, and visual disturbances.
Breuer's breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives.
Experiencing these emotions which had been previously outside of awareness seemed to be the curative factor. This cure became known as catharsis , and the experiencing of the previously forbidden or painful emotion was abreaction.
Freud tried various techniques to deal with the fact that patients generally seemed resistant to experiencing painful feelings. He moved from hypnosis to free association , interpretation of resistance, and dream interpretation. Freud himself was quite open about the possibility that there were many patients for whom analysis could bring little or no relief, and he discusses the factors in his paper "Analysis Terminable and Interminable. From the s through the s, a number of analysts were researching methods of shortening the course of therapy without sacrificing therapeutic effectiveness.
One of the first discoveries was that the patients who appeared to benefit most from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to experience their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered.
Clinical research revealed that these "rapid responders" were able to recover quickly with therapy because they were the least traumatised and therefore had the smallest burden of repressed emotion, and so were least resistant to experiencing the emotions related to trauma. However, these patients represented only a small minority of those arriving at psychiatric clinics; the vast majority remained unreachable with the newly developing techniques.
A number of psychiatrists began directing their psychotherapeutic research into methods of overcoming resistance. David Malan popularized a model of resistance, known as the Triangle of Conflict , which had first been proposed by Henry Ezriel. When those emotions rise to a certain degree and threaten to break into conscious awareness, they trigger anxiety. The patient manages this anxiety by deploying defences, which lessen anxiety by pushing emotions back into the unconscious.
The emotions at the bottom of Malan's Triangle of Conflict originate in the patient's past, and Malan's second triangle , the Triangle of Persons , originally proposed by Menninger, explains that old emotions generated from the past are triggered in current relationships and also get triggered in the relationship with the therapist. Independent empirical support came from Bowlby's newly arising field of Attachment Theory.
John Bowlby , a British psychiatrist and psychoanalyst, was very interested in the impact on a child of adverse experiences in relation to its primary attachment figures usually the mother, but often the father and others in early life.
He concluded, in opposition to received psychoanalytic dogma of the day, that childhood experience was far more important than unconscious fantasy. He also elucidated the nature of attachment, a system of behaviours exhibited by human and other mammalian infants which are innate and have the goal of physical proximity to the mother.
For instance, a child taken out of its mother's arms cries loudly in protest, and it is only quieted by being restored to its mother's arms. Bowlby observed that the innate attachment system would be activated by loss of proximity to the mother, and that long-lasting trauma to the child could result from attachment interruption. Long term consequences included increased propensity to psychiatric disorders, poor relationship function, and decreased life satisfaction.
Bowlby conducted numerous studies and noted strong correlations between adverse early-life circumstances—primarily the lack of a consistent and nurturing relationship with the mother—as the source of numerous difficulties, including persistent depression, anxiety, or delinquency in adulthood. Childhood traumatisation to the attachment bond, usually through separation from or loss of the primary mother or mother-substitute, led to adult difficulties. Since Bowlby, the effects of trauma over development have consistently been shown to have a significant detrimental impact on adult psychological functioning.
In the s, while Bowlby was observing children directly, Davanloo was beginning his work with symptomatic and character-disturbed adults.
As he began his video-recording work and became progressively successful against higher levels of resistance, he noted that particular themes reappeared with striking consistency in patient after patient. First, the therapist's efforts to get to know the patient's true feelings often aroused a simultaneous mixed feeling in the patient, composed of deep appreciation for the therapist's relentless efforts to get to know the patient deeply, combined with equally deep irritation at the therapist for challenging the patient to abandon long-held resistances which could thwart the therapeutic effort.
Davanloo noted, in concert with Malan's Triangle of Conflict, that patients would unconsciously resist the therapist's efforts to get to the root of their difficulties. He also observed, from his videotaped sessions, that patients would simultaneously send off signals of their unconscious anxiety.
Davanloo carefully monitored these signals of anxiety and saw that they represented the rise of complex mixed feelings with the therapist.
The mix represented that part of the patient seeking relief from painful symptoms but also an active desire to avoid painful, repressed feelings. As Davanloo became more skilled at unlocking the patient's true unconscious feelings, he noted an often very predictable sequence of feelings.
The sequence was by no means invariable, but it occurred frequently enough to allow the therapist to hypothesise its existence in a majority of cases. First, after a high rise of mixed feeling with the therapist, manifested as signals of intense anxiety tension in skeletal muscle, often manifested as wringing of the hands, accompanied with deep, sighing respirations , there would often be a breakthrough of rage, accompanied by an immediate drop in anxiety. This rage, Davanloo discovered, is intensely felt.
It often has a violent impulse associated with it, sometimes even a murderous impulse. Once patients feel this rage, they are able to describe vividly detailed fantasies of what the rage would do if it were to take on a life of its own.
The rage is a product of thwarted efforts to attach from the past. Those thwarted efforts to love and be loved yield pain, in the form of what Bowlby described as protest. The pain yields a reactive rage at the loved person who thwarted attachment efforts. Complete experiencing of the rageful impulse is typically accompanied by a tremendous relief at finally getting something out which has yearned for release.
However, the relief is typically short lived. Next, Davanloo almost invariably noted that patients then experience a tremendous wave of guilt about the rage. The guilt is a product of the fact that the old rageful feelings were with a person who was also loved.
It is this guilt, Davanloo discovered, which is the key ingredient in symptom formation and character difficulties. Symptoms and interpersonal difficulties usually unconscious efforts to ward off intimacy and closeness are the product of guilt, which turns the rage back on the self. For instance, the rage of a two-year-old toward a mother who dies may be experienced in the present as suicidal feelings self-directed murderous rage.
Beneath the guilty feelings from the past, Davanloo almost invariably noted painful feelings about thwarted efforts at emotional closeness to parents and others in childhood. Finally, at the deepest layer of feelings are the still powerful yearnings for closeness, attachment, and love. The goal of the ISTDP therapist is, as rapidly as possible, to help the patient overcome resistance, and then experience all the waves of mixed, genuine feeling, previously unconscious, triggered by the intense therapeutic process.
Those feelings are traced back to their origins in the past, and then both therapist and patient come to understand how the patient came to be the "consciously confused, unconsciously driven" person in the present. Old pockets of emotion are drained, the patient has a clearer self-narrative, and self-destructive symptoms and defences are renounced. The understanding gained is not just cognitive, but goes to the fundamental, emotional core. The influence of Freud's early trauma theory is evident.
Davanloo discovered the layers of the dynamic unconscious through a process of developing specific interventions which allow the therapist to reach those layers. Those interventions, applied in a specific fashion at specific times in the therapeutic process, are all calculated to overcome the patient's resistance as quickly and completely as possible, to allow the earliest and fullest experience of true feelings about the present and past as quickly as possible. Those interventions are known as pressure , challenge , and head-on collision.
Initially, pressure takes the form of encouraging the patient to describe symptoms and interpersonal difficulties as specifically as possible, so both patient and therapist get the clearest picture possible of the precise difficulties. It starts from the moment the patient walks into the room, in the form of the question, "Are there some difficulties you are experiencing which you would like us to have a look at?
The primary form of pressure is pressure toward feeling. Again, this is exerted mainly in the form of questions, such as, "How did you feel toward your boss for humiliating you in front of your staff? We see that you got anxious and depressed, but how did you feel? Pressure can be toward the patient's will : "Can we look to your feelings? Do you want us to look to your feelings? Pressure is also exerted toward the therapeutic task : "Our goal here, if you want, is to get to the root, the engine, driving your difficulties.
So, can we look at a specific time when you experienced anxiety? This will give us a clear picture of the problem which we can use to get to the engine. In its essence, pressure is encouragement from the therapist to the patient. It is encouragement to renounce defences, tolerate anxiety, and walk, with the therapist, into those places which have previously been off-limits. It is a way of saying, "There's nothing in there we cannot face together, and we do so in your service, to relieve you of painful difficulties.
Patients with low resistance are often quite responsive to pressure alone. However, as explained above, those are the patients who are healthiest to begin with. For patients with higher levels of resistance, usually the product of a more traumatised early phase of life, pressure quickly leads to the patient erecting barriers with the therapist.
Those barriers are the patient's habitual defences against avoided feelings. The combination of intentional conscious and unintentional unconscious defences is called the resistance.
The therapist is constantly monitoring for both the rise in anxiety and the appearance of resistance. When resistance does make its appearance, new interventions, in addition to pressure, are called for. Challenge is a two-stage process. The first stage is clarification , which is the therapist's effort to confirm that resistance is operating, and also to acquaint the patient with the specific defense being deployed.
Patients are often quite unaware of their own defenses. Clarification takes the form of a question, meant to clarify the defense to both patient and therapist: "Do you notice that when you speak of being angry with your boss that you smile and giggle?
Is a smile something you sometimes do to cover up a deeper feeling? When a defense is properly clarified, both patient and therapist can work together against it, because it represents an obstacle to the therapeutic task of getting to the patient's true feelings.
A defense which has not been clarified is still invisible to the patient. It is also important to note that in childhood, defenses can be a useful tool in emotionally overwhelming or traumatic situations. However as we grow up, this shielding cuts us off from our full range of feelings, even when we are now emotionally able to handle the feelings. Challenge to the defenses represents an exhortation to the patient to abandon the defense: "Again you smile when I ask you about feelings in relation to being humiliated by your husband.
If you don't smile, how were you truly feeling?
Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, M.D.
Davanloo was a psychiatric resident under Erich Lindemann, a German psychiatrist who specialized in the treatment of bereaved and traumatized patients. He later gave seminars about his research and made the videotapes available. Davanloo's methods, which according to some authors were based on resolving Oedipal conflicts,  were widely discussed in psychiatric literature and  successfully used by many other therapists. From Wikipedia, the free encyclopedia.
A Brief History of Davanloo’s Intensive Short-Term Dynamic Psychotherapy
Intensive short-term dynamic psychotherapy