The Background Of ISTDP

Source: www.istdp.com

ISTDP is an evidence based, brief term psychotherapy shown to be effective for a broad spectrum of emotional difficulties, including anxiety, medically unexplained symptoms and treatment resistant depression.

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The Challenge of

Short-term Psychotherapy

Robert J. Neborsky and Marion F Solomon

An Ideal Therapy
IN 1980, DAVID MALAN wrote about a wish fulfillment fantasy of brief psy-
chotherapy based entirely on psychodynamic principles. He stated:
1. It would be applicable to a high proportion of the psychotherapeutic
population.
2. Therapeutic effects would begin to appear within the first few sessions.
3. At termination no traces of the original disturbances would remain,
and this position would be maintained at follow-up.
4. Adverse phenomena that complicate ordinary therapy—sexualized or
dependent transference, acting out, and difficulties over termination—
would not appear.
The purpose of this book is to describe the work of six short-term clini-
cians who aspire to these lofty outcome goals. The authors of this book have
dedicated their careers to the goal of delivering to their patients the promised
results of dynamic psychotherapy in as effective a way as humanly possible.

A Definition of Short-term Dynamic Psychotherapy
Short-term dynamic psychotherapy (STDP) has its theoretical origins in psy-
choanalysis but at the same time has a mutually ambivalent relationship with
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psychoanalysis. The major conflict between the two treatment modalities
revolves around the issue of time and efficacy. STDP ambitiously purports to
treat the same disorders as psychoanalysis but in a shorter period of time.
STDP uses the scientific method to evaluate outcome whereas psychoanaly-
sis rarely does. Naturally, many psychoanalytic practitioners feel threatened
by the emergence of STDP—a treatment that can comprehensively treat neu-
rotic patients in less than 40 hours of therapy compared to between 250 and
600 hours for a “complete” psychoanalysis. Traditionally, psychoanalysis has
ignored the findings of the short-term group, hiding from the implications
of the research behind the superficiality hypothesis.
Technically, psychoanalysis requires the establishment of a transference
neurosis between the patient and the analyst. This means that the analyst be-
comes the parent to the patient and the patient develops symptoms in order to
deal with unconscious feelings toward the analyst. The analyst uses resistance
interpretation and dream symbol analysis to uncover the patient’s repressed
feelings and impulses. Eventually, the unconscious transfer ends, and the pa-
tient ideally terminates analysis with a reconstructed personality. Outcome
research by Malan and others questions whether, in fact, this really occurs.
Short-term dynamic therapy also uses the transference to a great extent.
However, the development of a transference neurosis is discouraged by the
intense focus on the affective relationship between patient and therapist in the
session, and all emotions are identified and acknowledged before the patient
leaves the session. The therapist is more a catalyst or guide to help the patient
face unacceptable feelings, rather than a figure to attach to in order to slowly
emerge from the suffering of symptoms. Transference is seen as a ubiquitous
phenomenon that occurs in all intimate relationships. It is explored on an
affective level in the first session and all subsequent sessions until the neuro-
sis is resolved by discovery of genuine feelings, affect desensitization, correc-
tive emotional experience, and insight into one’s unconscious process. The
specific techniques of short-term dynamic psychotherapy have been developed
to accelerate the working through process in order to restructure psychic bal-
ance between id, ego, and superego (dynamic) forces in an attempt to (1) re-
duce symptoms, (.2) change character, and (3) improve the relational capacity.
Now, within this camp there are emerging schools represented by each of
the authors, as well as active debate among the practitioners of each sub-
group. Those in the Davanloo group, represented by Neborsky, Patricia Della
Selva, Allan Kaplain, Allen Abbass, and others, work along the lines in which
they were trained and largely adhere to the central dynamic sequence as the
key to their approach. For this reason, they place heavy emphasis on bring-
ing self-punishment trends into consciousness in the initial moments of the

THE CHALLENGE OF SHORT-TERM PSYCHOTHERAPY 3

first therapeutic contact. McCullough and her followers organize their treat-
ment around a flexible approach, which includes psychoeducation about de-
fenses, mild pressure to feeling, persistent pressure not to self-punish, and
encouragement to feel emotion in the session. McCullough believes that the
experience of affect is essential to character transformation, but she goes one
step further and adds what she calls “self-other restructuring,” wherein she
explores the transference-countertransference distortions that occur in treat-
ment of patients with low self-esteem and negative self-images. She actively
encourages “self-directed compassion” when patients are self-critical. Michael
Alpert, Isabel Sklar, and Diana Fosha (2000) represent a school of short-term
dynamic psychotherapy centered in the New York area that emphasizes the
healing aspects of affect and empathy. They work exclusively in the area of
self and other by focusing in minute detail on what the patient experiences
in the moment between the patient and therapist. This approach evolved
when Alpert noticed the affect of one of Davanloo’s patients deepen when
Davanloo commented on the patient’s courage. In the process of the relational
work, remarkable associations to the patient’s past spontaneously appear and
past traumas are worked through in a short time.
In summary, short-term dynamic psychotherapy takes place in three to
forty hours of therapy. The initial contact is two to three hours. The length
of the therapy within the range is defined by the degree of psychopathology
that the patient demonstrates: low resistant neurotics with one focal conflict
(e.g., Oedipal focus) can be treated in three hours; patients with diffuse
pathology and multiple foci may need closer to forty hours.

Confusion About Short-term Dynamic Psychotherapy
There is considerable confusion about “short-term” in the term short-term
dynamic psychotherapy. The term originated because psychoanalysis and
long-term, open-ended therapy was the gold standard of treatment from the
post World War II years until the 1960s. This was the form of therapy that
was taught in academic centers throughout the country. In fact, most chair-
men of academic departments of psychiatry from 1946 to 1960 were psy-
choanalysts. Thus, the curriculum presented their biases to generations of
psychiatrists and psychotherapists. So the term “short-term” was an attempt
by Malan, Sifneos, Davanloo, and others to distinguish their efforts from the
traditional therapies of the time. Ironically, in our age of managed care, and
with the authorized treatment of complex problems with the “three-session
limit,” short-term therapy of up to forty sessions seems like a luxury!

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In addition to the time distinction there is also confusion about the term
“dynamic.” Dynamic has both general and specific meanings. The term dy-
namic has its roots in the Victorian concept of the mind as a closed system
in which psychic energy flows were generated by human libido. The new sci-
ence of psychoanalysis hoped to influence these energy flows away from path-
ogenic foci that created anxiety, depression, conversion disorders, etc. The
force of libido was, of course, infantile sexual drive, which was influenced by
early childhood events, which were later repressed into the unconscious. Dis-
tinct from this formulation is the structural theory of the mind, that is, the
tripartite organization of the psyche into id, ego, and superego. In this con-
text “dynamic” refers to the interplay of these three sections of experience,
part of which may be unconscious. So, dynamic has multiple meanings from
history and metapsychology. It is also used in one other important way. In
the late 1950s and early 1960s there was considerable controversy between
the schools of analytic treatment and the behavioral therapists. The behav-
iorists were entering territory that was the exclusive domain of psychoanalysis:
phobias, compulsions, anxiety disorders, and ultimately depression. They
were getting documented results and challenging the stranglehold analytic
therapy had on the academic and professional training centers. Plus the treat-
ments were scientifically conducted and results—outcomes—were measured
and published in refereed journals. So the term dynamic became a modifier
that distinguished treatment from the behavioral approach. Finally, a new and
important meaning has become attached to the term dynamic psychotherapy: it
refers to the deeply therapeutic process of accessing repressed feelings. This
is a newer usage of the phrase, but it has become synonymous with STDP.
Let’s now explore the development of this specific approach from a histori-
cal perspective.

The Evolution of Dynamic Short-term Psychotherapy
Early History
Psychoanalysis began with Breuer’s “talking cure” of Anna 0 (Freud, 1893).
Soon thereafter, Freud struggled with the hysterical symptoms of Emmy Von
M, Lucy R, Katharina, Elisabeth von R, and lastly Dora (1900). As Breuer’s
young associate, he was given cases of hysterical psychopathology to treat.
Intrigued, Freud began to investigate the psychological causes of these
women’s symptoms. To do so he had to invent a technique. He first gravitated
to hypnosis but became disenchanted with its results. Later, he discovered

THE CHALLENGE OF SHORT-TERM PSYCHOTHERAPY 5

free association as a technique, and this led to the discovery of transference
and then resistance. Each of these cases was treated in months, not years.
Soon Freud became enamored with dream analysis. This change in interest
naturally caused the process to lengthen. Freud’s initial concept of psy-
chopathology was that of direct or actual molestation trauma as the origin of
hysterical pathology. He later revised this idea concurrently with his inter-
est in dreams. This led to his discovery of the Oedipus complex. Simply
stated, he concluded that neurosis was a result of the castration complex in
men and of penis envy in women. Consequently, the process of psychoana-
lytic treatment lengthened as theories of pathogenesis became more complex.
It is known that Freud orchestrated a number of short-term therapies. In
his autobiography, the conductor Bruno Walter (1940) describes a successful
six-session therapy with Freud in 1906. Ernest Jones (1957) reports that Freud
successfully treated Gustav Mahler’s psychogenic impotence in a single
four-hour session! However, as psychoanalysis developed a more complex
theoretical superstructure, treatments grew to such a length that they became
interminable. Freud wrote Analysis, Terminable and Interminable to express these
concerns in 1937.

The Pioneers
Around 1918, Sandor Ferenczi began to systematically experiment with new
techniques. He called his work “active therapy.” He used techniques to over-
come stalemates, introduced desensitization for phobias, and tried some of
the restrictive techniques that are used today to treat compulsive symptoms.
He also experimented with reparative efforts of hugging, kissing, and
nonerotic fondling. So he can he considered the father of both active thera-
peutic approaches and boundary violations in dynamic psychotherapy. Freud
wrote Ferenczi a not so friendly letter putting Ferenczi’s treatment technique
down with humor and irony. Predicting further, more severe boundary vio-
lations by followers, Freud (Jones 1957, Vol. 3, pp. 163-164) predicts that
someday Ferenczi will lament to himself, “Maybe after all I should have halted
in my technique of motherly affection before the kiss.”
Interestingly, Otto Rank collaborated with Ferenczi. Reading their work,
The Development of Psychoanalysis, is like reading a contemporary discussion of
the issues surrounding short-term/long-term therapy. They also anticipated
later concepts like Alexander’s “corrective emotional experience” and Davanloo’s
heavy emphasis on affective experience in the here and now. They asserted
that psychoanalytic treatment should not remain tied to the free associative
technique out of which it evolved. They criticized the preoccupation with

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investigating the past and stressed the essential importance of focusing on
the transference in the present treatment situation. In discussing the factors
of effective therapy, they stated, like Davanloo, that the analyst should “sub-
stitute by means of the technique, affective factors of experience for intel-
lectual processes” (1925, p. 62).
Rank (1924), known as a proponent of birth trauma, actually began to play
that down later in his career and recognized that separation and individua-
tion were core processes for the work of psychotherapy. He was the first an-
alytic therapist to set a time limit on therapy to accentuate the separation and
individuation aspects during termination phase. Rank (1947) also predated
Davanloo in his focus on the concept of the patient’s “will.” Like Davanloo,
he emphasized the importance of mobilizing the patient’s “will” during the
course of the therapy to facilitate the process. We now have evidence from
Davanloo’s and others’ recorded cases that he was on the right track.
Twenty years (1946) after Rank and Ferenczi’s publication, Alexander and
French, at the Chicago Institute of Psychoanalysis, wrote in Psychoanalytic
Therapy about the “baffling discrepancy” between length and intensity of psy-
choanalytic treatment and the degree of therapeutic success. This finding was
to be confirmed in later studies by David Malan at the Tavistock Clinic and
eventually by the Menninger Foundation Study in Topeka. So, nearly 70 years
after the discovery of psychoanalysis, in the first systematic study of its re-
sults, the validity of the technique as a therapy was disproved. However, the
theory behind the technique seemed to be shown valid. Alexander stressed
three important variables in the treatment process that predicted successful
outcome: (1) understanding of the patient’s psychodynamics, (2) under-
standing the genetic development of the patient’s difficulties, and (3) once 1
and 2 were established, structuring the therapist’s reactions to the patient in
such a way as to create a “corrective emotional experience.” Alexander’s work
was a watershed in the history of psychotherapy. Suddenly the process of
psychoanalytic psychotherapy had the potential of being helpful to large pop-
ulations of people suffering from neurotic and characterologic difficulties.
The 1960s saw an upsurge in research into the process of short-term
dynamic therapy, fueled in part by the Federal government’s funding of men-
tal health. Malan, Wolherg, Bellak and Small, Sifneos, Halint, Mann, and
Davanloo worked on this problem and interacted scientifically with each
other. Somewhat separate but extremely important is the work of Aaron Beck
(1970, 1976) in the cognitive behavioral realm, where the therapist attempts
to correct the patient’s cognitive distortions and acts as a “coach.” Under rig-
orous scrutiny in its application to depression, this therapy has demonstrated
comparable if not superior efficacy to drug therapies for depression.

THE CHALLENGE OF SHORT-TERM PSYCHOTHERAPY 7

Malan (1963), a continent away, scientifically confirmed Alexander and
French’s counterintuitive finding that long-term therapy (psychoanalysis)
shows no greater—and perhaps less change than short-term approaches.
Malan standardized the Triangle of Conflict* as well as the Triangle of People±
and invented a short-term therapy for patients whose concerns were oedipal
and who could work with interpretation. Malan’s approach has been com-
pared with that of Sifneos (1972), which also applied to a narrow spectrum
of patients. Mann (1973) focused on patients whose difficulties centered on
loss, separation, and differentiation and so was similarly limited. Bellak and
Small (1965) kept their horizon narrowly focused on symptom alleviation.
They went so far as to declare that character change was not a goal of short-
term therapy.
Michael Balint and his wife Enid Balint, along with Paul Ornstein (1972),
began to get impressive results with their focal psychotherapy, in which the ther-
apist insisted that the patient focus on a central core conflictual disturbance.
They studied 39 patients and struggled to create outcome measurements for
dynamic therapies. In 1975, Malan summarized what he thought the Tavistock
Clinic Study by Balint and his colleagues established as a standard for psy-
chotherapy evaluation:
1. Clear-cut results, based on statistical methods, the essence of which
has been cross-validated.
2. Strong evidence about specific factors in technique that are thera-
peutically effective.
3. Some degree of validation of scientific principles.
4. Some evidence on the validity of psychotherapy.

The Revolution
In March 1975, Davanloo set up the first of three International Symposia on
Short-term Dynamic Psychotherapy. Around 1976 Malan began collaborat-
ing with Davanloo, which resulted in the publication of his “wish-fulfillment”
chapter in 1980. By that time Davanloo had turned from full-time research
to disseminating his findings and teaching his technique around the world.
Eventually, in the 1980s, Malan and Davanloo parted ways. Interestingly, in
recent years Davanloo has spent much of his time modifying his intensive
short-term dynamic psychotherapy technique, which he calls “analysis.” This

*This concept has its origin in Ezriel (1952).
‘This concept has its origin in Menninger’s Triangle of Insight (1958).

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technique is designed to induce rapid and dramatic character change in ap-
propriate patients. Malan in Davanloo, 1980) writes:
He was a true researcher in the field of psychotherapy who had become
profoundly guilty and dissatisfied at the way in which, under the classical
psychoanalytic technique, his patients went on year after year without sub-
stantial improvement. in consequence he began a twenty-year series of ex-
periments, working single-handed …during this time, like Freud in the
1890s, he was secure in the knowledge that what he was doing was so orig-
inal that there was not the slightest possibility that anybody else in the
world might anticipate him.
He began to videotape every session, playing the tapes over and over
in the evenings in order to see which ingredients of his technique seemed
to lead to progress and which to failure. When he thought he identified
an important factor, he would systematically employ it in his next half
dozen cases.
Davanloo for the first time in the history of psychotherapy applied the scientific
method to the development of specific techniques. Out of his courageous
and painstaking efforts he developed a cascade of interventions, which he
called the central dynamic. sequence. Davanloo did not want short-term dynamic
psychotherapy to be limited in its scope to a narrow population of patients,
like the therapies of Mann, Malan, Sifneos„ and Bellak and Small. He wanted
this treatment model to have as broad applicability to patients as psycho-
analysis. In fact, he viewed it as an alternative to psychoanalysis. Hence the
therapy included a heavy emphasis on character and character change.
Davanloo also did something else unique in the history of short-term ther-
apy. He went about systematically training therapists in his technique. With
the zeal of a missionary he traveled about the world demonstrating his
method. As a direct result of these efforts, short-term dynamic psychother-
apy has an international presence. Now, it is perceived as a discipline of
its own with devoted practitioners. At the present time Davanloo has func-
tioning teaching centers in Montreal, Toronto, New York, Los Angeles,
Amsterdam, Paris, Florence, and Nuremberg.

Modern History
Davanloo had a profound influence on current practitioners of short-term
therapy. Among the authors, Alpert, McCullough, and Neborsky have studied
under Davanloo, and McCullough actually studied with Malan before
Davanloo. What is important here is that most of the authors of this book

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