November 14, 2022

ISTDP: Intensive Short-Term Dynamic Psychotherapy

ISTDP (intensive short-term dynamic psychotherapy) is a specific type of evidence-based psychodynamic therapy focused on resolving emotional disorders. ISTDP therapy can be used to treat:

ISTDP has similar features to psychoanalysis. Both models pay close attention to unconscious mental processes (which can be thoughts, memories, perceptions, and distorted beliefs). However, psychoanalysis is notoriously a complex, long-term treatment. ISTDP practitioners believe in rapid resolution, and the treatment typically takes fewer than 40 sessions to remove symptoms.

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History of ISTDP

Although it is not as popular as other evidence-based therapy models, ISTDP has been practiced by clinicians around the world for a half-century. Dr. Habib Davanloo, MD developed the framework for ISTDP in the 1960s. The model was fully refined in the early 2000s. 

Davanloo, like many of his colleagues, initially felt stumped and frustrated by the resistance many of his clients showed in therapy. He would watch as they came for help- while simultaneously resisting self-awareness or efforts to grow. 

Drawing upon his own research and clinical experience, Davanloo began creating a more compassionate, humane approach to managing resistance. He saw how it was essential for people to confront their past to achieve a sense of present freedom. ISTDP, in its current form, is a method intended to release oneself from inner bondage. In doing this, people can achieve their full potential and live with high levels of self-confidence and resilience. 

What are the Main Goals of ISTDP?

ISTDP helps people overcome their internal battles between past experiences and present distress. This entails examining unconscious material and bringing it to the surface. 

This exposure is intense, and it can be painful. While insight is always important for growth, learning about your patterns often feels uncomfortable and shameful. That said, clients undergoing ISTDP learn how to use their unconscious as an ally- by working with it, they can resolve some of their internal struggles.

Other coinciding goals of ISTDP include:

  • Building confidence to handle life’s adversities
  • Reducing or eliminating excessive anxiety
  • Improving personality traits that enhance emotional turmoil
  • Strengthening interpersonal relationships
  • Removing symptoms that the client finds distressing

Understanding Intrapsychic Conflict 

Intrapsychic conflict acts as a defense against painful, suppressed feelings. This phenomenon leads to and exacerbates anxiety, particularly once someone raises these feelings to the surface. 

In an ISTDP framework, ‘hidden feelings’ can be conceptualized as the ambivalent emotions towards caregivers due to attachment bond ruptures. There is a desire for love and connection, but there is also a sense of grief, guilt, and sadness. 

Subsequently, the individual experiences an extraordinary conflict within themselves. One part of them desperately wants to cope and work through their anxiety. Another part works hard to suppress this discomfort. The therapist aims to cultivate the part that wants to work and heal. They move toward the emotion instead of against it, and they strive to promote a safe, supportive space for feeling and regulating emotions. Over time, this enables them to feel more empowered over their intrapsychic state. 

What to Expect in ISTDP Therapy

ISTDP is so emotionally intense because it literally requires clients to face and feel their emotions as fully as possible. One of the defining features of this therapy is labeling an emotion and then feeling it physically. After doing that, the client explores how these emotions act out as an impulse or fantasy. 

In this video, watch psychiatrist Dr. Kristy Lamb utilize elements of ITSDP through a conversation with MedCircle Host, Kyle Kittleson about his life long struggle with depression.

It’s important to be aware of this emotional labor ahead of time. People often enter therapy because something (or many things) in their life isn’t working. They desperately want change. Yet, many obstacles prevent them from making those important changes.

An ISTDP therapist calmly and thoughtfully works with their clients to understand these obstacles. They don’t act as a teacher- rather, they are a collaborator walking alongside their clients. They work together to access strengths and cope with difficult moments.

Central Dynamic Sequence

Davanloo conceptualized the Central Dynamic Sequence to help clients identify their defense mechanisms and access suppressed emotions. This sequence follows a set structure that goes as follows: 

Inquiry: Inquiry is part of the initial intake process. During this time, the therapist asks thoughtful questions about the client’s inner experiences and the frequency and intensity of certain symptoms. They will collaboratively develop the goal of deepening emotional insight.

Establish the triangle of person: This intervention encourages the client to identify a specific time when emotional difficulties were experienced. They can use either past or present examples.

Working triangle of conflict: This intervention enables the client to experience their feelings without their usual defense mechanisms. Anxiety is regulated and faced head-on (making this an emotionally-intense experience for most people).

De-repression: Since the unconscious is now unlocked, it is imperative that the client has time to experience and share freely-associated feelings, memories, or experiences. These images are not always entirely unconscious. However, the client likely has new interpretations about their meanings and relevance.

Interpretation: The interpretation stage entails linking the de-repressed content into a more realistic, healthy narrative. Ideally, this narrative paints a better picture of the client’s internal world (without as much conflict or anxiety). This linking allows them to feel more confident and build new insight into making changes in the future.

Other Relevant ISTDP Techniques

ISTDP interventions focus on the therapeutic relationship and facilitating the client in uncovering unconscious material. The work is largely experiential, meaning that clients focus on what’s happening in the present moment when they are involved in therapy. 

Working alliance: Working alliance refers to the relationship between therapist and client. Therapy is a vulnerable, intimate relationship. It’s normal for clients to experience feelings of anger, sadness, or love toward their providers (known as transference). Likewise, therapists have their own feelings about their clients (known as countertransference). A working alliance strives to build a safe dynamic where both parties are mutually trusting of one another. 

Complex transference feelings: Many clients in ISTDP experience mixed feelings toward the therapist (they may feel grateful for the support, but angry they can’t have a personal relationship). It’s important to discuss and resolve these emotions as they arise in real-time.

Cognitive recapitulation: This refers to clarifying a client’s statement to reduce pressure while also linking emotions. For example, a therapist might say, When you just told me about how sad you felt, you became cold and folded into yourself. Is this where your sadness goes? 

Pressure: Pressure refers to the intentional efforts to facilitate a client to emotionally engage with both themselves and the therapist. A therapist might ask, What does your body feel right now? How are you physically feeling towards me in talking about this topic? 

De-conditioning: De-conditioning refers to actively helping a client desensitize from trauma-based emotional experiences. This is achieved through learning important self-regulation skills. 

Awareness: Clients are supported in being in the here and now with the present moment. Awareness helps them attune to their inner needs. It also helps improve the ability to identify feelings. 

Head-on collusion: This is the reflection and challenge stage of treatment-resistant defenses. There is a combined, collaborative effort to overcome potential stagnation. For example, a therapist might say, We both see how challenging this issue is to talk about. You find it hard to be open, causing you to become angry and defensive. Let’s better look at these feelings so we can face the situation together. 

Activation of latent capabilities for secure attachment: In attachment-based ISTDP (an off-shoot of ISTDP), this intervention refers to building a sense of safety and security. When someone has a secure attachment, they feel generally supported by others. As a result, they tend to have healthier self-esteem and are more likely to have meaningful relationships. 

Visualization: Visualization is a broad term, but it may mean imagining certain situations or practicing specific grounding skills that promote a sense of calmness. Visualization can also help clients with goal-setting. 

Verbalization of feeling: This technique refers to articulating feelings within the therapy room. Identifying feelings can help people feel more in control of their bodies and needs. By recognizing how you feel, you can take steps to cope effectively (without automatically acting out). 

Evidence for ISTDP

ISTDP is evidence-based, meaning its practices were developed and tested against rigorous standards. There is scientific data supporting its efficacy in clinical practice.

Over 20 outcome studies have examined the role of ISTDP in treating somatic disorders, mood and anxiety disorders, and personality disorders. Over half of those studies met the criteria for meta-analysis. And across all mental health symptoms, research found greater improvement in both the short and medium-term relative to control samples.

Of course, it’s always important to be mindful of potential research limitations. Data can, at times, be attributed to correlation instead of causation. Even the best researchers cannot always distinguish what does and doesn’t work when it comes to establishing results.

How to Find an ISTDP Therapist

Interested and prospective clients can search for ISTDP therapists through the ISTDP Institute. They have a directory with local providers. All providers are either actively completing or already have completed core training in ISTDP. The institute requires this advanced level of training.

All therapies can be beneficial, but it’s important to evaluate various pros and cons of a treatment model before starting the process. Knowing what to expect ahead of time can avoid wasting excess time or money.

ISTDP may be worth considering if you:

  • Feel like you haven’t been able to go “deep enough” in therapy in the past
  • Have been labeled as treatment-resistant by other providers 
  • Have childhood trauma that continues interfering with the quality of your life
  • Value in-depth work that requires rigorous self-evaluation
  • Want to commit to the emotional intensity associated with this type of therapy 
  • Have spent years in mental health treatment without obtaining the results you want

Final Thoughts

ISTDP is a practical, depth-oriented therapy that provides effective results in a brief amount of time. Many clients report significant improvements in their emotional well-being after completing treatment. 

If you’re considering ISTDP, you can begin searching for a therapist through the ISTDP Institute’s directory. Even if you’re not sure if it’s the right approach for you, you can always seek clarification about the process from your provider ahead of time.

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Disclaimer: This information is not specific medical advice and does not replace information you receive from your healthcare provider. This is only a brief summary of general information. It does NOT include all information about conditions, illnesses, injuries, tests, procedures, treatments, therapies, discharge instructions or lifestyle choices that may apply to you. You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider’s advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

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