ISTDP: Overview and Brief History
A Focus on Feelings, Defenses, and Anxieties
ISTDP aims to harness the healing power of emotions to accelerate therapeutic change. Our feelings are our hard-wired emotional GPS system that tells us what we like and don’t like, how to protect ourselves when under threat, and who we feel close to and love.
But if emotions are there to guide us, why do we struggle with them in so many ways? Why do we learn to be afraid of our feelings?
The ways we adapt emotionally to our environment allow us to cope with traumatic events or difficult relationships with caregivers. As children, we are dependent on our parents: Our survival depends on our parents keeping us safe and secure. If a parent is depressed or overwhelmed, we may learn to hide our needs and depend only on ourselves. If a parent overvalues achievement, we may come to feel that we are not okay the way we are — that performing is the only way to feel safe and loved.
If self-sacrifice or being unobtrusive (“not making demands”) is more highly valued than self-fulfillment in our families, we may learn to ignore what we feel or want: to meet disappointment or losses with a “stiff upper lip,” to hide our sadness in order to make our caregivers comfortable. Just as a baby bear or tiger has the instinct to stay close to its parents for safety and protection, we adapt to parents’ behaviors and emotional capacities to stay in their good graces. These strategies, necessary at the time, later can cause difficulties. (Sometimes these adaptations are also the source of enormous resilience.)
It should be noted that 90% of this learning is unconscious, well below the radar of conscious thought.Therapy aims to bring such automatic mental habits into awareness so we can have more control over our actions and emotional responses.
Because of the adaptations we learn from caregivers, our emotions can become charged with anxiety. We develop defense mechanisms, usually unconscious, to ward off or minimize this anxiety.
In truth, it is never our emotions that cause the problem, but defenses against these emotions. Grieving a loss is as normal as breathing; but when you learn to avoid sadness, depression is a common outcome. Feeling anger and asserting ourselves are also perfectly normal parts of living; but when we feel anxious about advocating for ourselves, we can lapse into a passivity and neglect our basic needs.
As your ISTDP therapist, I will take an active role in pointing out these mechanisms as they occur. I will encourage you to do the same, and we will collaborate to figure out what you can do about them, and thereby alleviate the suffering they cause.
Once these mechanisms become conscious, we can help you break their stranglehold to have more choice and control in your life. This active therapeutic approach is quite different from almost every other therapy, and is probably a major reason why ISTDP tends to be shorter term than other therapies.
The collaboration and commitment necessary to achieve these goals in a shorter time frame demands more of both therapist and patient.
While we are doing this work we will be working together to closely monitor your anxiety.
The body processes anxiety in several ways. Some anxiety is actually a positive sign, telling us we are touching on important issues for you, and that you have the capacity to tolerate the feelings being activated. Other types of anxiety can be an indication that your level of anxiety is getting too high, and that we need to slow down.
My goal in working with you is not to eliminate anxiety altogether, since avoiding difficult experiences is a prescription for stagnation and ineffective therapy. Rather, we want to work to keep anxiety at a moderate level that is best for learning new skills so you can develop greater capacity to tolerate feelings. Anxiety will become less and less of an impediment in your life.
How Will I Know When It’s Time to End Therapy?
Session by session, we will together monitor the changes you experience from therapy, both verbally and at times with symptom checklists. We will also be assessing whether you have accomplished the goals you set for yourself (which are often defined within the first few hours of therapy). It is not uncommon in the later stages of treatment to decrease the frequency of visits before eventually phasing them out altogether.
The length of therapy varies tremendously based on what we are addressing, and on your goals for yourself. While ISTDP sometimes results in dramatic changes in a few sessions, the emotional learning usually takes place through a more-gradual process. As your therapist, my goal is to make your therapy as brief as possible without shortchanging the core emotional and cognitive work that will allow you to function at your highest possible level. After all, our goal in ISTDP is not merely to mute your symptoms or provide temporary relief, but to get to the heart of the problem so the issues do not return once therapy ends. ISTDP challenges the traditional view that good therapies stretch on for years and years. However, there are certainly situations in which longer-term supportive therapy is more appropriate and beneficial.
A Brief History of ISTDP
ISTDP was first developed in the 1960s and 1970s as a response to frustrations with the growing length and limited success of psychoanalysis. Theoreticians such as David Malan and Habib Davanloo began video recording patient sessions and analyzing moment-by-moment patient/therapist interactions to determine what interventions were most effective. They spent several decades testing hypotheses to learn which interventions worked with which patients.
In the 1980s, psychotherapy researchers such as Leigh McCullough began in-depth studies on ISTDP. Research over the past 50 years has shown that ISTDP is an effective treatment for a very broad range of issues, including depression, anxiety, somatic disorders such as fibromyalgia, and relationship difficulties such as lack of emotional closeness and intimacy. Unlike most therapies, in which the goal is short-term symptom reduction, the goal in ISTDP is to achieve deep and lasting change of longstanding emotional and personality difficulties. Relapse rates are high for therapies (such as cognitive behavioral therapy, CBT) that use only conscious, rational approaches without also seeking to create changes in emotional processing. In contrast, patients who have completed ISTDP tend to continue to improve even after the therapy has ended. Moreover, many patients who complete this therapy experience changes that go way beyond the issues that brought them to treatment — reporting increases in creativity, productivity, and leadership, as well as a greater ability to experience joy and closeness.
 McCullough Vaillant, L. (1997). Changing Character. New York: Basic Books.
 Abbass, A., Kisely, S.R., Town, J.M., Leichsenring, F., Drissen, E., De Maat, S., Gerber, A., Dekker, J., Rabung S. Russalovska, S., Crowe, E. (2014). Short-term psychodynamic psychotherapies for common mental disorders (Review). The Cochrane Collaboration. New York: John Wiley & Sons.
 Grawe, K. (2007). Neuropsychotherapy: How the neurosciences inform effective psychotherapy. New York: Psychology Press.
For more information about ISTDP, visit the ISTDP Institute.
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