My work as a psychotherapist has always been strongly influenced by psychodynamic theory. As my years in practice progressed, I found myself reflecting on my work and wondering if I was being as effective as possible. I had seen some patients for many years and saw many of them improve in significant ways. However, I was struck by the fact that some still seemed to suffer with painful feelings or relationship conflicts despite the valuable work that we had done.

In 2005, I attended a conference on Intensive Short Term Dynamic Psychotherapy (ISTDP) and was powerfully impacted by observing on videotape the work of colleagues who were using psychodynamic theory but applying it in ways that I had never before seen. Their experience was that the ISTDP method often led to meaningful, and sometimes dramatic, progress in relatively short periods of time. These therapists would maintain contact with their patients long after the therapy had ended in order to verify that the gains made in therapy had been maintained.

This experience motivated me to become involved in a rigorous training program to learn how to incorporate ISTDP into my own practice. I now approach the psychotherapy work I do from the vantage point of ISTDP. I have prepared the following description of ISTDP in order to help prospective patients evaluate whether they might want to investigate this form of psychotherapy. If you prefer to read it as a pdf file, click here.

Intensive Short Term Dynamic Psychotherapy: An Introduction

Human beings have an innate need to connect in loving, secure relationships. From infancy onward, we are profoundly impacted by those experiences that foster a sense that we are known and cherished for who we are. We are as impacted, if not more so, by those experiences that fail to provide this essential validation and nurturing. When we reveal ourselves to important people in our life and are met with disinterest or rejection or punishment, we try to protect ourselves from letting this happen again. If we have encountered this kind of pain often enough, we tend to put up barriers to allowing others access to our authentic nature. Our potential for healthy connection is then compromised.

Intensive short term dynamic psychotherapy (ISTDP) is an approach to psychotherapy that is based on the belief that most emotional suffering results from difficulty facing the complex painful feelings that result from broken attachments. These painful feelings may be triggered by a recent experience so that it seems that what just happened in our lives is the cause of our pain. However, upon careful examination in therapy, it usually becomes clear that the recent event is so painful because of the unresolved and often unknown feelings resulting from earlier painful experiences. When these underlying feelings can be understood and directly experienced in therapy, powerful change can occur. In turn, this change leads to significant relief from symptoms like anxiety and depression, improvement in intimate relationships, and an end to self defeating behaviors. This work can help build the capacity to bring our healthiest and most vital self to all of our endeavors in life. ISTDP attempts to achieve this by creating an alliance between therapist and patient that encourages and supports a deep, honest look at core emotions that are being kept from full awareness.

Painful feelings result in anxiety when they come close to our conscious awareness. Even if we believe that we are anxious because of a specific circumstance in our lives, the true source of anxiety will be painful feelings that are generating internal conflict. In order to cope with anxiety, we use defense mechanisms to ward off the anxiety and the underlying painful feelings. While some defense mechanisms can work well for us and even allow us to be successful (e.g. managing anxiety and emotional pain by being very hardworking, organized, and ambitious), there is usually a cost to us emotionally as a result of relying upon these defenses. When someone seeks therapy, it is generally because habitual defense mechanisms are no longer effective in dealing with a current crisis or else we have become aware that our defenses are exacting a cost that is no longer acceptable (e.g. a lack of intimacy due to defenses that cause us to maintain an emotional distance from others).

Most forms of psychodynamic therapy attempt to help us understand how our current suffering is due to painful and often unconscious feelings; to show us how defense mechanisms are getting in the way of a healthy life; and how to link the current difficulties to past painful experiences in life, especially those that involve significant figures such as our parents and siblings. Unfortunately, developing insight into ourselves is valuable, but often insufficient, to bring about the kinds of changes that most seek from therapy. Many people find that even after significant periods of time in therapy, they are still struggling with the issues that led them to seek help in the first place. Those of us who practice ISTDP have found that this approach has the potential to be more effective than other therapies. It appears that the majority of patients in need of psychotherapy prove to be good candidates for ISTDP. How to find out if you might be helped by this approach can only be determined by a consultation that will likely be different from previous therapy experiences you may have had.

What makes ISTDP different from other therapies?

There are two characteristics that immediately distinguish it from most other therapies: the first session is usually 2 or 3 hours long and, with your consent, the sessions are videotaped. Videotaping sessions allows me to carefully review what has happened so that I can identify ways to better understand the process and be more effective. The interaction between a patient and a therapist is complex and I believe that being able to review the session on tape can make a very positive difference for the patient. The first session is called a "trial therapy" because it is possible in a few hours to get to a very deep level of understanding of a patient's problems and to offer to the patient the very elements that are part of the ISTDP process. This can lead to breakthroughs in the first session that can clarify how the therapy can be helpful, instill hope, and provide powerful motivation for the work ahead.

At the heart of ISTDP is the belief that it is not enough just to have insight into our feelings. Rather, we believe that the way to change the most is to have a direct experience of feelings in the therapy session itself. This leads the therapist to take a very active stance in helping patients experience deep and essential feelings. The therapist works to identify defenses that are preventing a patient from having direct access to feelings. Patients are helped to face the defenses they use so that they can begin to make the choice to relinquish defenses in order to face their feelings honestly and fully. This process usually triggers anxiety which is understandable given that feelings are being brought closer to the surface that are associated with pain and a sense of danger.

In ISTDP, anxiety is addressed throughout the session to help the patient regulate anxiety so that feelings can emerge and not be overwhelming. Patients are helped to see the various ways that feelings are being avoided even when it appears that meaningful issues are being addressed in the session. For example, talking about other people in your life may be a diversion from facing your own feelings towards them. Tendencies to speak from an intellectual and rational standpoint are identified and actively challenged so that underlying feelings can be revealed and faced directly. Angry feelings are often perceived as threatening and, therefore, strongly avoided. This must be addressed since anger which is suppressed often leads to depression and self-defeating patterns of behavior.

In short, a serious collaboration takes place between therapist and patient to get to the heart of the matter and not waste time talking around the issues. Sometimes the experience may feel very challenging and intense, especially when patients are accustomed to having wide latitude to talk about whatever comes to their minds in therapy. However, patients generally appreciate that the therapist is making a serious effort to help them get to a point of mental health that is consistent with their stated goals and which will prove to be enduring. While the approach is called short term, this does not mean that a specific number of sessions is predetermined. Instead, the therapist is committed to working with the patient to make each session be a meaningful step towards addressing the core issues that led to the decision to seek help in therapy.

How long are the sessions in ISTDP?

The intensive nature of this kind of therapy is such that the traditional model of 50 minute sessions occurring on a weekly basis may not be the optimal approach for all patients. While some patients do see me for weekly sessions, I have found that the work can be more effective if done in longer sessions (e.g. 90 minutes to 2 hours) that may occur less than once a week.

To learn more about ISTDP, consider these resources:

A book by Ronald Frederick Ph.D. titled Living Like You Mean It (2009) can help the layperson understand many of the principles underlying ISTDP. It is a self help book that provides valuable exercises useful to anyone interested in learning more about the relationship between feelings, anxiety, and defense mechanisms.

The website www.istdp.ca provides links to many articles about ISTDP including a number of important research studies documenting the effectiveness of ISTDP.

For psychotherapists interested in studying ISTDP please go to the Supervision and Training page.