Intensive Short-Term Dynamic Psychotherapy

Theory and Technique

Patricia C. Della Selva

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429915048
• Subtopic: History & Theory in Psychology
• Index: Psychology

Traditionally, psychoanalytic treatment has been a lengthy endeavour, requiring a long-term commitment from patient and analyst, as well as vast financial resources. More recently, short-term approaches to psychoanalytic treatment have proliferated. One of the most well-known and thoroughly studied is the groundbreaking method of Intensive Short-term Dynamic Psychotherapy, developed by Dr. Habib Davanloo. Having trained directly with Dr. Davenloo, the author has written a clear, concise outline of the method that has come to be regarded as a classic in the field. The book is organised in a systematic fashion, analogous to the process of therapy itself, from initial contact through to termination and follow-up. Detailed clinical examples are presented throughout the text to illustrate how theory is translated into techniques of unparalleled power and effectiveness.

CHAPTER 1

The Integration of Theory and Technique in Davanloo’s Intensive Short-Term Dynamic Psychotherapy

I hear a distant drum beat

A heart beat pulsing low

Is it conning from within

A heart beat I don’t know

A troubled soul knows no peace

A dark and poisoned pool

Of liberty now lost

A pawn, the oppressor’s tool.

Loreeno McKennirr*

In many ways, this songwriter has articulated the plight of neurotics, blind to their own inner world and, as such, destined to live the life of a prisoner. The discovery of such a rich and complex inner life began with Breuer and was elaborated on in great detail by Freud (Breuer & Freud, 1895).

Basic Tenets of Psychoanalytic Theory

Breuer’s (Breuer & Freud, 1895) pioneering work with Anna O. led to the discovery of the dynamic unconscious and laid the foundation for psychoanalysis. He placed the patient under a hypnotic trance and discovered, quite by chance (Schoenewolf, 1990), that her current physical symptoms were connected to traumatic experiences from the past (caring for her sick and dying father). When he was able to get her to verbalize her feelings about these traumatic experiences, the symptoms vanished. Again and again, he found that the recall of memories and reliving of the emotions associated with the memories led to symptom removal. The original forgetting was labeled “repression,” and the remembering, “catharsis” (Fisher & Greenberg, 1977). Although this cathartic treatment led to immediate relief, there were frequent relapses and no lasting cure. An additional problem arose in the treatment relationship when Anna began to have strong loving and sexual feelings toward Breuer. He became frightened and abruptly ended her treatment. In fact, he abandoned this kind of work altogether.

Freud took over where Breuer left off, making changes designed to address the problems encountered with hypnotic treatment. He decided to abandon hypnosis because this technique only provided temporary relief. He felt that the conscious ego must learn to deal directly with the trauma and integrate these memories and feelings into awareness. The task was to develop a treatment that would enable the patient to consciously tolerate what had been previously experienced as unbearable. By encouraging patients to say whatever came to mind and following their associations, Freud found that they would gradually approach previously avoided topics. The technique of free association, designed to enable patients gradually to become aware of unconscious feelings, memories, and fantasies, was the first major change in psychoanalytic technique to follow hypnosis.

As Freud began to encourage patients to say whatever came to mind, he confronted a counterforce working against remembering and reexperiencing painful and anxiety-provoking events. He labeled this force resistance and found it became the greatest obstacle to successful treatment. In many ways, all developers of subsequent technique, including the short-term dynamic psychotherapists such as Malan, Mann, Sifneos, and Davanloo, have tried to find methods for circumventing, reducing, or eliminating resistance so that patients will reach therapeutic goals. The tension between the patient’s desire to get well and the desire to avoid that which is painful by resisting therapeutic intervention, is the essence of psychic conflict. How professionals deal with this conflict in the therapeutic setting is of pivotal importance and will be covered extensively in the present volume.

Another essential change in technique that followed the use of hypnosis involved using, rather than avoiding, the feelings evoked within the treatment relationship. Freud came to realize that the patient’s feelings toward and perceptions of the therapist were not random, but constituted a projection or transference of feelings and perceptions having to do with significant figures from the patient’s past. He called this the phenomenon of transference and used it to bring the patient’s inner conflicts to life in the therapeutic setting.

He combined these changes (i.e., free association, a focus on resistance and analysis of the transference) as he developed the technique of psychoanalysis. He would actively interpret the patient’s defensiveness and resistance to remembering and experiencing painful experiences from the past. These interpretations were designed to release buried feelings. The process itself tended to elicit feelings toward the doctor, which were then associated to prominent figures from the patient’s past. This basic technique of interpreting defense, and releasing buried feelings and memories, enabled patient and therapist to gain insight into links between the forgotten past and current behavior. This remains the essence of psychodynamic psychotherapy.

As Alexander (Alexander & French, 1946) understood it, it was not necessary for patients to remember all the events from their past that caused neurotic reactions. The essential element was the therapist’s ability to reestablish the core conflictual situation in the transference relationship so that “the adult ego has the opportunity to grapple with it in a new attempt at mastery” (Alexander & French, 1946, p. 163). Being able to withstand the full impact of the previously repressed intense feelings and reactions from the past in the current relationship with the therapist, without resorting to regressive defenses, was designed to increase the patient’s ego-adaptive capacity. Thus, the new experience in the transference would restructure the patient’s defensive system. This shift in focus from emotional catharsis to conscious recall was accompanied by a shift in therapeutic goals, from that of mere symptom removal, to a permanent change in the patient’s ego functioning. Dynamic psychotherapy, which had been fairly brief during Freud’s early days, got increasingly protracted as the goals of treatment expanded. Following each extension of therapy, came clinicians attempting to find ways to shorten the process. Contributions of the major theorists in the short-term dynamic psychotherapy movement will be reviewed in subsequent chapters.

The Importance of Theory-Guided Technique

Freud was a theorist, researcher, and clinician who wrote relatively little on technique. In his paper entitled “On the History of the Psychoanalytic Movement” (Freud, 1914), he remained vague about technique, stating that any psychotherapy which recognized the phenomena of transference and resistance as facts and made them central in the work could be considered psychoanalysis. There was little improvement in this regard over time. Analysts as a group have proven unable to agree on theory or technique. A survey of British analysts (Glover, 1958) revealed that half of the respondents reported approaching their analytic work without any theoretical outline in mind. A study conducted in Chicago (Henry, Sims, & Spicey, 1968) revealed that 61% of the analysts there responded in a similar fashion. Given the lack of a cohesive theoretical paradigm for understanding patient material, it should come as no surprise that other surveys were unable to find any agreement on the goals of psychoanalytic treatment (Seward, 1962-1963). In fact, the 65 analysts studied by Seward could only agree on what they did not expect to accomplish, including symptom relief, self-acceptance or expression, and an increase in personal responsibility. These findings have been corroborated by others (Sklansky, Isaacs, Levitor, & Haggard, 1966) who have found that analysts were “highly idiosyncratic” in their interventions.

Davanloo (1980, 1990) has attempted to correct many of these inconsistencies by having a clear grasp on the metapsychology of the unconscious, developing a systematic method of intervention based on theory, closely examining patients’ responses to intervention (asking questions rather than assuming or making interpretations), and using videotapes to study the process. He has labeled this form of treatment Intensive Short-Term Dynamic Psychotherapy (ISTDP). He has repeatedly emphasized that a thorough understanding of the metapsychology of the unconscious is essential to the proper use of the techniques he has developed. Following his suggestion, this chapter will outline the metapsycho-logical assumptions underlying Davanloo’s method and then detail the technical interventions based on this theoretical understanding.

Freud’s Second Theory of Anxiety

The theoretical underpinnings of Davanloo’s model have been derived from Freud’s second theory of anxiety. Originally, Freud viewed anxiety as a reaction to the build-up of instinctual tensions, assuming an “inherent tendency in the nervous system to reduce, or at least keep constant, the amount of excitation present in it” (Freud, 1926, p. 4). This is the essence of drive theory, which hypothesizes a motivation toward the reduction or discharge of instinctual tensions. As early as 1897 (Freud, 1950, Letter 75), Freud expressed doubts about a direct link between accumulated excitation and anxiety. Still, it was not until the publication of Inhibitions, Symptoms and Anxiety in 1926 that he explicitly stated his revised view, that anxiety is a danger signal to the ego, warning of the occurrence of trauma. Trauma, as he defined it, “involves separation from, or loss of, a loved object or a loss of its love” (Freud, 1926, p. 151). That such a separation or loss would constitute trauma is readily explained by the infant and child’s prolonged state of mental and physical helplessness and utter dependence on caretakers for survival and well-being. As such, anxiety serves an indispensable biological function, alerting the ego to the probability of trauma.

This revision implies the central nature of human attachments and is the beginning of an object relations theory (Della Selva, 1992, 1993; Greenberg & Mitchell, 1983). Because of the child’s dependence and the centrality of human attachments, any thought, feeling, or action which has led to unwanted separation from or loss of an attachment figure or their love is experienced as dangerous, evokes anxiety, and is avoided. Symptoms are considered to be compromises between the competing need to express the feeling and to defend against it. Symptoms and defenses keep the anxiety, and the feelings propelling it, out of awareness.

The following example of this theory involves a depressed woman who came for treatment. As she described a recent interaction with her father, she realized that she’d had a stubborn headache ever since the visit with him. After describing the incident, we focused on her feelings toward her father. She began to get in touch with a rage toward him that had mobilized a violent impulse. She imagined smashing his head and poking out his eyes, leaving him dead in a pool of blood. This feeling and the accompanying impulse were experienced as very dangerous and aroused considerable anxiety. There was little love lost with her father, but she imagined her mother would be furious with her. It was her mother’s love and attention she felt she couldn’t afford to lose. The anxiety served as a signal to repress this feeling from consciousness. Still, the feelings and impulses were very strong and were pushing for expression. The compromise between the impulse (smashing his head and poking his eyes) and the defense against it (displacement) was a headache. Following the experience of anger in the therapy session, the headache disappeared, providing compelling evidence that, once the patient was able to consciously tolerate the direct experience and expression affect, the need to defend against it by becoming symptomatic was no longer necessary.

Two Triangles

Menninger (1958) operationalized the notion of intrapsychic conflict by drawing a “triangle of insight” in which impulses and feelings, defenses, and anxiety each occupy one of the three corners. Malan (1979) went one step further by linking the triangle that depicts intrapsychic conflict with another triangle that represents significant others in the patients’s life (called the triangle of conflict and triangle of the person, respectively). The relationship between these two triangles indicates, once again, the central importance of the interpersonal context within which psychic conflict is experienced (Figure 1.1).

Feelings do not exist in a vacuum, but arise both toward and in reaction to others. There is always an interpersonal context to the arousal of emotion, even if only in fantasy. It is hypothesized that those affective states which caretakers did not tolerate will be suffused with anxiety and lead to the operation of a defense. We cannot assume that only certain feelings, such as anger, will be prohibited; for in some families nothing is experienced as more threatening and, therefore, is more heavily prohibited than the expression of tender feelings (Suttie, 1937, 1988). Careful exploration of anxiety as it arises in the dynamic interaction between patient and therapist is the most accurate way to assess this for a given patient.

Figure 1.1 Triangle of Conflict and Triangle of the Person

Operational Definitions of Dynamic Concepts

Davanloo (1980, 1990) has made extensive use of the two triangles as a means for conceptualizing intrapsychic conflict. As such, the triangles serve as both a diagnostic tool and guide to systematic intervention. Since a full and detailed understanding of the two triangles is of such great importance in Davanloo’s system, each element will be specifically and operationally defined.

Feelings and Impulses

Feelings are considered the engine of the intrapsychic system and have been placed at the bottom of the triangle. Primary feelings include joy and happiness, sexual desire and arousal, anger, and sadness or grief. Davanloo has identified three components to feeling that must be present for a patient to be considered “in touch with” the experience of affect (Laikin, Winston, & McCullough, 1991). These three components represent the cognitive, physiological, and motoric elements of emotional experience (Figure 1.2). The cognitive component involves the accurate labeling of the emotion (“I am angry”). The physiological component includes all the physical and visceral sensations that accompany the emotion (“I am feeling hot, like my temperature is up and my blood is pumping. My muscles feel strong”). Finally, the motoric element of the emotion involves mobilization of an impulse (“I feel like punching him in the face”).

Figure 1.2 Components of an Affective Experience

The absence of any one of the components of feelings indicates the operation of defense. This detailed conceptualization of feeling allows the clinician to pinpoint the specific aspect of the feeling that is being defended against and can serve as a guide to specific interventions.

For example, histrionic patients tend to...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Dedication Page
• Preface
• Acknowledgments
• Foreword
• 1 The Integration of Theory and Technique in Davanloo’s Intensive Short-Term Dynamic Psychotherapy
• 2 The Trial Therapy
• 3 Working with Defenses
• 4 Restructuring Regressive Defenses
• 5 Facilitating Grief
• 6 Working with Positive and Erotic Feelings
• 7 Working Through toward Character Change
• 8 Termination and Follow-Up
• References
• Author Index
• Subject Index