Intensive Short-Term Dynamic Psychotherapy (ISTDP)
Brief historic overview
Intensive Short-Term Dynamic Psychotherapy is a type of psychodynamic psychotherapeutic technique that was developed during the last fifty years by Dr Habib Davanloo, in Montreal, Canada. Davanloo began working as a psychoanalyst. However, as he experienced and realised the limitations of the psychoanalytic technique he tried to create a psychotherapeutic method that would be more effective in a shorter time. More specifically, his critique to psychoanalysis focused on certain characteristics: the long duration of the treatment process, the doubtful results that could be achieved, the fact that the defenses of the patient many times remained intact due to the passivity of the therapist, and mainly the development of the transference neurosis that creates phenomena like regression, dependence on the therapist, and “analysis interminable” (Davanloo, 1995a, 2).
In the 1970s there appeared various attempts to create a brief psychodynamic technique, based on a more active participation of the therapist in the therapeutic process. Three therapists and researchers, Habib Davanloo, Peter Sifneos and David Malan, decided to work towards that direction and to define the characteristics of a short term model. From this work each one developed his own brief psychodynamic technique (Davanloo, 1992). Some limitations of these efforts were the specific patient selection criteria (high motive, specific psychodynamic focus to work, receptiveness to interpretations), and so these models were applicable to only a small percentage of the psychiatric population (Davanloo, 1995a, 2, Malan, 1992, 15). Trying to address this problem, Davanloo achieved to create a brief psychodynamic technique, that can be applied to the vast majority of the psychiatric patient population (Abbass, 2015, 378).
Davanloo used video-recording of his psychotherapeutic sessions to study which type of intervention is the most appropriate and effective at each moment. Through this process, he found the necessary interventions and actions of the therapist that lead the patient to a direct access to his unconscious feelings, which are the core of his problem and lead to the formation of his symptoms. This access to unconscious feelings can be achieved mostly through the rise of complex feelings towards the therapist, during the psychotherapeutic process. The formation of Davanloo' s technique began in the 1960s, and was at first tried to patients with a high level of functioning and a single psychotherapeutic focus.
During the next twenty years (1970-1990) Davanloo developed the technique so that it could be applied to patients with more severe psychopathology and longstanding characterological problems (personality disorders in ICD-10, DSM) (Davanloo, 1995b, 21).During the last decades psychotherapeutic techniques based on ISTDP principles, though with some modifications, are applied (under some conditions) in the therapy of severe borderline and psychotic patients (Abbass, 2015, 347-376, Abbass, 2002, Frederickson, 2004).
ISTDP can treat a wide range of psychoneurotic disturbances and personality disorders through access and re-experiencing of unconscious feelings. Those feelings come from emotional traumas during childhood concerning patient's main attachments with significant persons. These unconscious feelings and the concurrent unconscious anxiety lead to guilt and to self-punishing actions that can result to the development of symptoms and disturbances in the behavior of the patient.
In ISTDP the therapist works under the concept of the triangle of conflict (the experience of the unconscious feelings lead to the experience of unconscious anxiety and this causes the appearance of defenses) and the triangle of persons (the patient and the therapist work with persons past, of the present and in the transference). Davanllo described that important factor for a successful therapy is the development of the Unconscious Therapeutic Alliance, which develops as the patients experiences Complex Transference Feelings
Davanllo, named the total sequence of the interventions in his therapy Central Dynamic Sequence. This sequence includes the following phases:
Dynamic Inquiry: during this phase there is a search for information that is important to understand the patient's difficulties
Pressure to describe and experience feelings: during this phase the therapist asks the patient to determine his feelings during specific circumstances and then to try to reexperience them
Appearance and clarification of resistance: the pressure towards patient's feelings leads to the appearance of defences, which the therapist clarifies to the patient
Appearance and crystallization of resistance in the transference: all the above process leads to the rise of the patient's feelings towards the therapist and to the appearance of resistances in the transference
Challenge and Head-On-Collision to the Resistance: the therapist describes the resistances to the patient, points to their destructiveness for the therapeutic process and for the patient's life and asks him to leave them
Unlocking of the Unconscious: all the above process leads to even greater rise of the patient's feelings in the transference, to the defeat of resistances and finally to the unlocking of the unconscious and the reexperiencing of the patient's feelings, which are connected with emotional attachment traumas during patient's childhood.
Recapitulation and Consolidation: The objective of this work is a thorough linking of unconscious feelings, anxiety and defence in respect to past and present figures. This collaborative review cements the conscious understanding of the linkages between phenomena but also strengthens the unconscious alliance and weakens the resistance. (Davanloo, 2005).
An important issue in this technique is the assessment of the patient's pattern of unconscious anxiety and the corresponding patterns of unconscious defenses that he uses. The first pattern is striated (voluntary) muscle anxiety when the patient uses as his main defense isolation of affect. The second pathway of unconscious anxiety involves the smooth muscles, something that leads to symptoms like migraine, hypertension, asthma, abdominal pain, nausea etc. This pathway appears when repression is patient's main defense. Finally unconscious anxiety can be expressed as cognitive-perceptual disruption with symptoms like visual blurring, mental confusion, hearing impairment, hallucinations etc. In this case, experiencing of unconscious anxiety may lead to the appearance of more primitive defenses, like projection, projective identification or splitting.
Davanloo firstly developed ISTDP for patients with striated muscle anxiety. In cases of patients with smooth muscle anxiety, and in those with cognitive-perceptual disruption, a modification of the technique is necessary. This is called the graded format of ISTDP where the therapist and the patient work together building the capacity of the patient to tolerate the anxiety, and includes circles of recapitulations and swift of the focus of the process when the unconscious anxiety of the patient is above threshold and it is expressed through smooth muscles or cognitive-perceptual disruption.
OCD Spectrum Disorders
ISTDP has demonstrated efficacy in alleviating symptoms, as well as interpersonal and characterological problems in many studies, including case studies and randomised controlled trials. It is found to be effective in many different psychiatric conditions including anxiety disorders (Rocco et al., 2014), somatic symptom disorders (Abbass, Campbell et al., 2009, Abbass, Lovas and Purdy, 2008), treatment-resistant depression (Abbass, 2006, Cornelissen, Verhuel, 2002), eating disorders (Nowoweiski, Arthey, Bosanac, 2011), personality disorders (Abbass, Sheldon et al., 2008, Town, Driessen, 2013) and psychotic disorders (Abbass, 2001, Abbass, 2002, Frederickson, 2004). In a metaanalysis of all ISTDP studies (Abbass, Town, Driessen, 2012) ISTDP was found to have large effects in long-term follow-up and to be cost-effective.
Comment from an expert
“Dreams are the royal road to the unconscious”
“Working in the Transference with the transference feelings is the royal road to the unconscious”
“Freud discovered the unconscious. Davanloo has discovered how to use it therapeutically.”
David Malan, United Kingdom, 1980
Comment from a trainee
“ When I first saw ISTDP on a video session I got kind of shocked. Not that much because of the unusual high dynamics of the technique, but mostly of its ability to create therapeutic emotional explosions. Huge proportions of unexpressed or suppressed or masqueraded feelings dominating our relations, decisions and lives. And suddenly the thrilling moment after all these years to learn how to apply the emotion on your body and feel it purely and deeply.”
Nikolaos Nikolaou, Sweden, 2019
There are several well-written books about ISTDP ; below are our recommendations:
“Intensive Short-Term Dynamic Psychotherapy” by Habib Davanlo
“Unlocking the Unconscious” by Habib Davanloo
“Reaching through Resistance: Advanced Psychotherapy Technique” by Allan Abbass
“Co-Creating Change: Effective Dynamic Therapy Techniques” by Jon Frederickson
“Lives Transformed” by Patricia Coughlin Della Selva and David Malan
“Intensive Short Term Dynamic Psychotherapy” by Patricia Coughlin Della Selva
“The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice” by Diana Fosha, Daniel Siegel and Marion Solomon
“Individual Psychotherapy and the Science of Psychodynamics” by David Malan
“The Collected Writings of Robert J. Neborsky, MD, and Josette ten Have-de Labije, PsyD.” by Robert J. Neborsky and Josette ten Have-de Labije
“Psychodynamic Psychotherapy: Learning to Listen from Multiple Perspectives” by Jon Frederickson
Video is an essential element of every ISTDP session. So we could not leave our ISTDP chapter without some video recommendations:
Dr Allan Abbas:
Dr Jon Frederickson:
Dr Patricia Coughlin:
Dr Tewfik Said:
International Experiential Dynamic Therapy Association (IEDTA) is devoted to supporting, improving, disseminating, and researching Experiential Dynamic Therapies (EDTs). IEDTA sponsor an international conference every two years, and offer accreditation to EDT training.
Europe IEDTA accredited:
Jerusalem and Tel Aviv
Intensive Short – Term Dynamic Psychotherapy, UK
Core Training in EDT with Jessica Bolton
Core Training in ISTDP with ISTDP-UK
Core Training in ISTDP with Ross Crowther-Green and Mark Stein
Core Training in ISTDP with Susan Hajkowski & Stephen Buller, UK
Europe non IEDTA accredited:
Core Training in ISTDP with Stephen Arthey
Los Angeles - John Rathauser
Los Angeles- DEFT with Susan Warren Warshow
Los Angeles- David Wolff
Los Angeles- Robin Kay
San Francisco, San Diego and Los Angeles- Robert Neborsky
Philadelphia: Patricia Coughlin
Massachusetts: Kristin Osborn
Washington DC: Jon Frederickson
Abbass A. (2001). Modified Intensive Short-Term Dynamic Psychotherapy of a Patient with OCD and Schizophrenia, in Quaderni di Psichiatria Pratica, December: 143-146
Abbass A. (2002). Modified Short-Term Dynamic Psychotherapy in Patients with Bipolar Disorder. Preliminary Report of a Case Series, in Canadian Child Psychiatry- 11(1): p. 19-22
Abbass Allan (2006). Intensive Short-Term Dynamic Psychotherapy of Treatment-resistant Depression: A pilot Study, in Depression and Anxiety 23 (7): 449-452
Abbass A. (2015). Reaching Through Resistance. Advanced Psychotherapy Techniques. Kansas City: Seven Leaves Press
Abbass A., Campbell S., Magee K., Tarzwell R. (2009). ISTDP to Reduce Rates of Emergency Department Return Visits for Patients with Medically Unexplained Symptoms: Preliminary Evidence from a Pre-Post Intervention Study, in Canadian Journal of Emergency Medicine 11 (6): 529-534
Abbass A., Lovas D., Purdy A. (2008). Direct Diagnosis and Management of Emotional Factors in Chronic Headache Patients, in Cephalalgia 28 (12): 1305-1314
Abbass A., Sheldon A.T., Gyra J., Kalpin A. (2008). ISTDP for DSM-IV Personality Disorders: A Randomized Controlled Trial, in Journal of Nervous and Mental Disease 196 (3): 211-216
Abbass A., Town J., Driessen E. (2012). Intensive Short-Term Dynamic Psychotherapy: A Systematic Review and Meta-analysis of Outcome Research, in Harvard Review of Psychiatry 20 (2): 97-108
Cornelissen K., Verhuel R. (2002). Treatment Outcome of Residential Treatment with ISTDP, in Ad Hoc Bulletin of Short-Term Dynamic Psychotherapy- Practice and Theory 6 (2): 14-23
Coughlin Della Selva P. (2006). Intensive Short-Term Dynamic Psychotherapy. Theory and Technique. London: Karnac Books Ltd
Davanloo H. (ed.) (1992). Short-Term Dynamic Psychotherapy. London: Jason Aronson Inc.
Davanloo H. (1995a). Unlocking the Unconscious. Selected Papers of H. Davanloo. Chichester: John Wiley and Sons
Davanloo H. (1995b). Intensive Short-Term Dynamic Psychotherapy. Spectrum of Psychoneurotic Disorders, in International Journal of Short-Term Psychotherapy, vol. 10, p. 121-155
Davanloo H. (2001). Intensive Short-Term Dynamic Psychotherapy. Extended Major Direct Access to the Unconscious, in European Psychotherapy 2(1), p. 25-70
Davanloo H. (2005). Intensive Short-Term Dynamic Psychotherapy, in Kaplan and Sadock's Comprehensive Textbook of Psychiatry, edited by Sadock B.J. And Sadock V.A., p. 2628-2652. Philadelphia: Lippincott Willing and Wilkins
Frederickson J. (2004). A Therapy with a Psychotic Patient: the Incorporation of ISTDP Techniques, in Bulletin of Short-Term Dynamic Psychotherapy- Practice and Theory 8(1), p. 15-27
Frederickson J. (2013). Co- Creating Change: Effective Dynamic Therapy Techniques. Kansas City: Seven Leaves
Malan D. (1992). The Most Important Development since the Discovery of the Unconscious,in Davanloo (ed.), Short-Term Dynamic Psychotherapy. London: Jason Aronson Inc.
Malan D. Coughlin Della Selva P. (2006). Lives Transformed. A Revolutionary Method of Dynamic Psychotherapy. London: Karnac Books Ltd
Nowoweiski D., Arthey S., Bosanac P. (2011). Evaluation of an Australian Day Treatment Program for Eating Disorders, in Behaviour Change 28 (4): 206-220
Rocco D., Abbass A., Agrosi V., Bergomi F., Busetto L.M., Marin S., Pezzetta G., Rossi L., Zuccotti L., Zanelli D. (2014). The Efficacy of ISTDP for Anxiety Disorders when Provided by Psychologists in Training, in Ad Hoc Bulletin of Short-Term Dynamic Psychotherapy- Practice and Theory 18(1): 5-15
Town J., Driessen E. (2013). Emerging Evidence for ISTDP with Personality Disorders and Somatic Disorders, in Psychiatric Annals 43 (11): 503-511
Georgios Kakarinos and Theodoros Koutsomitros, 2nd department of Psychiatry Aristotle University of Thessaloniki, Greece