My intentions for writing this article are to expose and inform the general community and the professional therapy community to a very effective form of psychotherapy. In Attachment Based/Intensive Short-Term Dynamic Psychotherapy (AB/IS-TDP) we assess the patient’s response moment by moment to develop a clear understanding of the patient’s strengths and weaknesses. This process of assessment is called psycho diagnosis. Diagnosis as we usually refer to it is a phenomenological diagnosis, the therapist finds a number of symptoms and the patient is given a diagnosis. The problem with this process is that although this diagnosis tells us what they have; it does not tell us what causes the problem(s). “Traditionally our diagnostic system does not tell us how to treat the patient. In AB/IS-TDP we diagnose quite differently. We find out what problem the patient has then we explore the problem to find out what conflicts generate those symptoms (Jon Frederickson).”

Most psychotherapy has been designed and focuses on the reduction of symptoms such as depression or anxiety. (AB/IS-TDP) has been shown to give deeper insights and more permanent relief (character change) from neurosis and somatic discomfort and pain. Based on Freud’s theory of psychoanalysis and his discovery of the dynamic unconscious, AB/IS-TDP, under the umbrella of Experiential Dynamic Psychotherapy (EDP), has proven to be more efficient, cover a broader range of problems and give more permanent character change in a shorter period of time.

There have been many attempts to create short term results in therapy. Psychoanalysis itself was developed by Freud as a short term therapy with most of his patients completing treatment within six months. Freud believed that the therapist needed to engage with the patient’s defences and was, initially quite successful in this approach. Unfortunately he became despondent with his theory, partly because of his isolation in his beliefs and because of difficulties in his personal life. He became disheartened and took a more passive position with his therapeutic approach which became known as psychoanalysis. Similarly other therapies take this passive position and without well designed research methodology make claims that patients experience lasting change.

AB/IS-TDP is a form of the original Intensive Short-Term Dynamic Psychotherapy (IS-TDP) discovered and developed by Dr. Habib Davanloo who is still practicing in this field at Montreal General Hospital. Dr. Davanloo’s findings were developed and derived from videotaping over 700 patients sessions. He then reviewed and analyzed the patient’s responses on the videos over and over, observing the physical and emotional responses and developed a very successful methodology which he called Intensive Short-Term Dynamic Psychotherapy. His precise observations of how patients respond to pressure around their defenses and how anxiety and emotions manifest themselves has led to significant breakthroughs in understanding human trauma and its effects on the human psyche. Anxiety and defensive behaviour can be undetected by the individual and the outcome can be negative or ruined relationships, physical symptoms and a long list of psychiatric problems.

Methodology

A large percentage of patients will present to the therapist with anxiety. A smaller percentage will present with a range of defenses. There is also the likelihood that there will be a combination of the two. The most productive assessment would be to determine if the patient is highly defended or do they have anxiety that rises and falls or rises and remains elevated for a long duration. As these phenomena are presented the therapist needs to attend precisely to either defenses and or anxiety moment to moment.

To track defenses accurately the therapist needs to identify and be aware of the types of defenses.

Defenses are categorized as follows:

Repressive Defenses

  • Rationalization (to make excuses)
  • Minimization (to not take seriously)
  • Intellectualization (to block feeling with reasoning)
  • Displacement (to direct feared feelings on to unthreatening object)
  • Reaction Formation (to feel/behave in direct opposition to your truth)

Regressive Defenses

  • Projection (to transfer one’s own feelings to the outside world)
  • Denial (to reject, avoid, an unpleasant truth)
  • Acting Out (to perform rather than bear experiencing of)
  • Dissociation (to disrupt integrated functioning)
  • Somatization (to turn mental pain into physical pain)

Tactical Defenses (Verbal)

  • Sarcasm
  • Argumentativeness
  • Rumination (worrying/brooding)
  • Vagueness/Evasiveness
  • Deflection (changing the subject)
  • Diversification (jumping from one topic to another)
  • Obsessional indecisiveness
  • Being contradictory
  • Helplessness
  • Passive compliance
  • Talking over your feelings (galloping)

Tactical Defenses (Non-Verbal)

  • Avoiding Eye contact
  • Defensive body language (crossed arms and legs…)
  • Smiling or laughing over feelings
  • Weepiness
  • Temper tantrums (having a tantrum rather than setting a healthy boundary)

When these defenses are present they are usually unconscious to the patient or syntonic. If the patient stays in the moment with these defenses it is the job of the therapist to determine the degree of syntonicity (degrees of unconsciousness) and change them to a degree of dystonicity (degree of consciousness). The patients’ recognition of their defenses and their awareness of the cause will make them consciously aware of these phenomena and assists them in defeating their compulsion to use them. By accomplishing this task the anxiety will be reduced and the rise of complex feelings/emotions will occur. As the defenses are made dystonic the patients Ego will become more and more observing and attentive. The therapist will know this is happening when the patient starts to catch themselves in the session attempting to use their old defense system and changes their attention to defeating the defence. They may also return to the next session reporting that they are more aware and caught themselves when they had the urge to use the defense mechanism in the old harmful manner. This conscious awareness allows the patient to now experience the emotion and not have fear of it. This is what Dr.Davanloo calls an “Unconscious Therapeutic Alliance”. This allows for the patient to now better regulate themselves and become more efficient in navigating themselves emotionally in their day to day lives. It reduces anxiety and allows them to be more relational. A fully experienced emotion/feeling has three parts:

  1. Cognitive: What is the feeling/emotion? Be able to name it accurately (anger, love, and anxiety/fear)……

  2. Physiological Response: How do you experience this feeling in your body? What sensations do you notice? (Warm Chest, tight throat, urges to urinate/defecate, dry mouth, tightness in your tummy…….)

  3. Motor Impulse: What does the feeling want to do? How does this feeling/emotion want to be expressed through your body? (I want to strike out at you with my fist, I feel the urge to hug you, I feel like wanting to tear at you with my teeth)……..

— Josette ten Have-de Labije, PsyD

In the IS-TDP methodology the evidence is clear from clinical trial that when the patient can experience all three emotional parts simultaneously the patient experiences satisfaction and relief from previous pathological phenomenon, or destructive behaviour. Research is showing that they gain lasting change to their character. Recent research from New York University shows that by using experiential psychotherapy and precise intervention, the fear response can be substantially reduced. However, this only occurs when the patient/client has experienced the emotion and then a reconsolidation of awareness and connection to the emotion is worked through.

In the AB/ISTDP model, developed by Dr. Robert Neborsky, MD, the therapist continues to increase the pressure on the patient’s defense system creating more Ego Adaptive Capacity or resiliency which in turn reduces less fear of their core emotions:[ guilt, grief, rage and pain,] until there is a breakthrough. The breakthrough will allow the patient to be aware of the emotion, to access their core neurotic structure and experience the emotion cognitively, and somatic matorically (physically in the body). This has been referred to as “dreaming while wide awake”. Deep seated grief may now emerge from the patient’s unconscious. Along with grief, often murderous rage which the patient has always unconsciously been afraid of or felt guilty for experiencing appears from the patients unconscious. This core unlocking when experienced conjointly with emotional, cognitive and somatic motoric will give the patient satisfaction and now ongoing relief from fearing their emotions. Dr. Neborsky, who trained under Dr. Davanloo, sees Davanloo’s theory of psychopathology as a subset of attachment trauma. He references this in the naming of his technique Attachment Based/ Intensive Short-Term Dynamic Psychotherapy. He sees trauma on a continuum and his use of Davanloo’s methodology and the focus of Dr. Mary Ainsworth’s insecure attachment technique has led to a huge expansion of treating a much broader spectrum of patients with symptom reduction, character change, relationship enhancement, and access to creativity from the unconscious. There is not enough room in this article to elaborate how Dr. Neborsky has brought the inclusion of Attachment Theory into the IS-TDP methodology.

Efficacy

This method of psychotherapy is at this time of writing being used in very effective ways to reduce medical expenses. Dr. Allan Abbass et al, has shown scientifically that by treating patients with medically unexplained symptoms by using IS-TDP produced a reduction of sixty nine (69) per cent visits in an emergency department at the Queen Elizabeth ll Health Sciences Centre Emergency Department in Halifax, Nova Scotia, Canada . The cost reduction was $910 per patient. IS-TDP interventions averaged 3.8 sessions (Journal of The Academy of Medical Psychology). Dr. Abbass in another study has shown scientifically that seven sessions of IS-TDP conducted on 890 patients showed an 80% drop in Psychiatric bed use by this population.

AB/IS-TDP demonstrates through the use of videotaping sessions and often transcribing the content word for word moment to moment the scientific outcome not speculated outcome. The actual transformation of the patient from suffering to character change and not just temporary relief is witnessed in and well documented. . Dr. David Malan, who was one of the pioneers of researching the effects of psychoanalysis at the Tavistock Hospital in England, through scientific research showed the effectiveness and ineffectiveness of psychoanalysis says about IS-TDP “In 1980, I referred to Dr. Davanloo’s work as the most important development in psychotherapy since the discovery of the unconscious and he predicted that within 10 years the status of dynamic psychotherapy would change dramatically. Dr. Malan says he stands by the first statement about Dr. Davanloos work but at the time of this statement (1996) the hope in the second part of his prediction he felt had not happened. Dr. Malan strongly feels that the lack of proper training and the unwillingness of practitioners to do the necessary training is a major contributor to the lack of effectiveness of a lot of today’s psychotherapy.

It has been my experience to be witness to the degree of difficulty in learning and applying this form of therapy. From well-trained Medical Psychiatrists, Psychologists, Clinical Social Workers, and Clinical Counsellors there is no easy road to the understanding and successful application of AB/IS-TDP without taking the proper training. Hopefully by arousing the reader’s curiosity and not taking a defensive position they will take the time to investigate the AB/IS-TDP methodology and evidence based research.

Terry maintains a private practice in Vancouver, and specializes in AB/ISTDP incorporating this methodology into his work in Addiction, Couples Therapy and developing programs for Men and Women in assaultive/violent behavior. Terry also has a specialty in Executive Coaching and Life Coaching and will develop programs for workplaces on Emotional Intelligence and Conflict Dissolution not Resolution.

Bibliography

  • Frederickson, Jon, LCSW, ISTDP Institute, Washington, D.C.
  • Coughlin Della Selva, Patricia (1996) Intensive Short-Term Dynamic Psychotherapy. John Wiley & Sons
  • Davanloo, Habib (1990) Unlocking The Unconscious. John Wiley & Sons
  • Davanloo, Habib (2000) Unlocking The Unconscious. John Wiley & Sons
  • Malan, David, & Coughlin Della Selva, Patricia (2006) Lives Transformed: A Revolutionary Method of Dynamic Psychotherapy. H. Karnac (Books) Ltd.