Intensive Short-Term Dynamic Psychotherapy (ISTDP)

Core ideas

1. Psychological suffering is maintained by defences that block access to affect

   ISTDP starts from the premise that symptoms and dysfunctional patterns persist because the individual uses automatic defences to avoid conscious contact with intense affects linked to early relational conflicts. These defences momentarily reduce anxiety, but they maintain suffering by preventing direct emotional working through. (Davanloo, 1990).

2. Experiential access to affect is the principal engine of change

   Therapeutic change in ISTDP is not produced mainly through narrative insight, but through direct, lived and sustained access to previously repressed affects. When the patient can experience these affects without defences, a rapid and profound reorganisation of psychic functioning takes place. (Davanloo, 1990; Abbass, 2015).

3. Anxiety is a signal that regulates the therapeutic process

   ISTDP uses anxiety as the central clinical indicator for guiding the intervention. The therapist continuously monitors how anxiety is expressed in the body and adjusts therapeutic pressure so as to keep it within an optimal range that allows affective processing without disorganisation. (Davanloo, 1990).

4. Resistance is an unconscious choice that can be challenged

   In ISTDP, resistance is not interpreted solely as a phenomenon to be understood, but as an active — though unconscious — position taken by the patient with regard to change. The model holds that this resistance can and should be confronted directly when it blocks access to affect, in order to mobilise therapeutic motivation. (Davanloo, 1990; Abbass, 2015).

5. The therapist adopts an active and focused stance

   Unlike more exploratory psychodynamic models, ISTDP assigns the therapist an active role in conducting the process, keeping the focus on the central conflict and avoiding defensive drift. This attitude is not authoritarian, but strategically directed at facilitating access to the emotional core of the problem. (Davanloo, 1990).

6. Unconscious guilt is a central core of the conflict

   ISTDP identifies the unconscious guilt associated with aggressive or loving impulses towards significant figures as a key organiser of defences and symptoms. Therapeutic work seeks to pass through this guilt in order to release the repressed affect and reduce the need for internal punishment or somatisation. (Davanloo, 1990).

7. Unlocking the unconscious produces rapid and profound change

   When defences collapse and the patient tolerates affect without avoidance, what is known as the unlocking of the unconscious can take place, characterised by the spontaneous emergence of memories, emotions and images linked to the core conflict. This process is associated with rapid and stable clinical change. (Davanloo, 1990).

8. Brevity is a consequence of the process, not an aim in itself

   Although ISTDP is defined as a brief therapy, its brevity does not derive from an externally imposed limit on the number of sessions, but from the intensity and effectiveness of the emotional work. When access to affect is achieved directly, change can occur in less time than in more gradual approaches. (Abbass, 2015).

9. Subsequent integration is necessary in order to consolidate change

   Following intense emotional experiences and unlockings, ISTDP stresses the need to integrate the change into the patient's everyday life by reviewing its relational and behavioural implications. Without this integration, there is a risk of defensive relapse despite the emotional access achieved. (Abbass, 2015).

Influences

• Classical psychoanalysis
• The structural model
• Ego psychology (Hartmann)
• Ego psychology (Anna Freud)
• Object relations (Klein)
• Object relations (Fairbairn)
• Brief psychodynamic psychotherapy

Key references

• Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers.
• Abbass, A. (2015). Reaching Through Resistance: Advanced ISTDP.