ISTDP: Overview and Brief History
A Focus on Feelings, Defenses, and Anxieties
ISTDP is an emotion-focused therapy that 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?
Actually, the ways we adapt emotionally to our environment are also part of our survival system, allowing us to cope with traumatic events or difficult relationships with caregivers. As children, we humans are dependent on our parents for much longer than most species. Our survival depends on making sure we are safe and secure with them. 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 is higher on the “emotional food chain” in our families than self fulfillment, we may learn to ignore what we feel or want. If we learn that we should meet disappointment or losses with a stiff upper lip and stoicism, we learn to hide our sadness to make our caregivers comfortable. Just as a baby bear or tiger has the instinct to stay close to her parents for safety and protection, we have to make sure we adapt to a parent’s behaviors and emotional capacities so that we stay in his or her good graces. These strategies are necessary in the climate in which we are raised, but later can become the cause of our difficulties. (Sometimes these adaptations are also the source of enormous resilience, even though they may limit us or cause problems in other areas.)
It should be noted that 90% of this learning is unconscious, falling well below the radar of conscious thought. Part of what therapy attempts to do is to bring these automatic mental habits into awareness so that 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. Since humans usually seek to avoid anxiety, we develop defense mechanisms to ward off or minimize this anxiety. Because these defense mechanisms are also based on implicit, unconscious learning, they usually operate on automatic pilot.
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 your sadness, depression is a common outcome. Feeling anger and having the capacity to assert our will are also a perfectly normal part of living, but when we feel anxious about advocating for ourselves, we can lapse into a passive approach to life that neglects 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 then collaborate in figuring out what you can do about them.
Why do we take such an active stance in addressing the defenses against feelings? Because these mechanisms are often the root cause of the symptoms or problems people want to address in therapy. Thus, we need to address them as quickly as possible to alleviate suffering.
Once these unconscious mechanisms become conscious, we can help you break their stranglehold so that you can have more choice and control in your life. This active therapeutic approach is quite different from almost every other therapy, and is probably why, along with the emotional component, 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 the therapist and patient.
While we are doing this work we will also be working together to monitor your anxiety very closely. Just as we are interested in how you experience emotions in the body, we also want to learn about how you experience anxiety.
The body processes anxiety in several different ways. Some anxiety is actually a positive sign because it tells 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. However, we do want to work to keep anxiety at the moderate level that is best for learning new skills. Through this learning you can develop a greater capacity to tolerate feelings, which means that anxiety will be less and less an impediment in your daily life.
How Will I Know When It’s Time to End Therapy?
Together, session by session, we will 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 that 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 working on and what your goals are 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 you from doing 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 that the issues for which you are seeking help do not return once therapy ends. ISTDP does offer a challenge to the traditional view that the only good therapies are ones that stretch on for years and years. However, there are certainly situations in which a longer-term, supportive therapy is more appropriate and beneficial.
Once we have completed therapy, I typically follow up with people twice in the first year to check in about whether the changes have been sustained (of course with your permission). These are generally quick check-ins by phone or e-mail, but sometimes you may find it helpful to have follow-up or booster sessions if your symptoms have returned or there is some indication that continued therapy is needed. Interestingly, research has shown that patients who complete a course of ISTDP tend to continue to improve after ending therapy.
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 emotional closeness and intimacy. Unlike most therapies in which the goal is short-term symptom reduction, the goals in ISTDP are 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 reasons 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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