Monday, February 2, 2009

Short Term Intensive Dynamic Psychotherapy

Here's yet another interesting therapy style.

A lot of these different styles influenced "my own" style with patients, which I consider to be a flexible and eclectic (and hopefully not too disorganized) mix, parts of which are more helpful in some situations than in others. I think that, in life generally, one must absorb those elements of wisdom or inspiration that resonate in a genuine way with one's nature. Many teachers or mentors may have wonderful kernels of wisdom to share, but perhaps many other aspects to leave aside or reject. I realize that, for my patients too, they may at times find parts of their therapy experience with me to be helpful, other parts less so, other parts not helpful at all.

Anyway, back to the title: "short term intensive dynamic psychotherapy" (STIDP). This style was developed by Habib Davanloo, a Montreal psychiatrist who wished to address the phenomenon of patients whose problems never seemed to change or get better, despite very lengthy courses of psychotherapy.

I consider Davanloo's ideas to be challenging, interesting, sometimes brilliant, often quite eccentric. His technique calls for the therapist to be much more active than in traditional psychodynamic therapy.

Here's my brief summary of what the technique is all about (this is very much my paraphrase, which reflects perhaps those elements of the technique, as I learned it, that have been salient to me over the years):

First of all, in order for the technique to be appropriate, it would be necessary for the patient to be quite stable with respect to symptoms of severe major mental illnesses. So, for example, it would be inappropriate to apply these ideas in situations where the patient is suffering from psychosis or mania.

The technique is based on understanding the dynamics of a patient's situation according to a sort of balance between anxiety, underlying emotion, and defences. In this balance, defences are either conscious or unconscious actions that a person takes in order to cope with anxiety. Both anxiety and defences suppress or distract awareness from underlying "emotion." Defences could include phenomena such as denial or repression, but also such immediate behavioural or conversational phenomena such as intellectualizing, ambivalence, compliance, defiance, passivity, engaging in small-talk, etc. (Here, defences need not be considered "bad" but merely as behavioural tactics that a person uses--often automatically-- to cope with emotion or anxiety). Anxiety could be manifest--again either consciously or unconsciously-- as muscular tension--visible during the therapy session--or through other pathways, including somatization (physical symptoms such as pain).

The technique aims to help a patient "experience underlying emotion" by helping the patient to become more consciously aware--in the moment--of anxiety and defences. With the patient's consent and will, sometimes these defences can be set aside quickly, leading to a strongly emotional experience. I do find it is true that people are often unaware of their defences, and can be unaware of the ways in which anxiety is being manifest.

Often the underlying emotion has to do with anger--the patient's defences being tactics to avoid experiencing or acknowledging anger--and the patient's anxiety being provoked by the magnitude of the underlying anger. If the "underlying anger" is "exerienced" (in a sort of cathartic way), it may be initially directed at the therapist, but upon subsequent dialog, it may be understood that this anger is "transferential", that it originated with an earlier developmental conflict, typically with a parent.

The therapist in this technique can be very active, leading to the patient perhaps feeling criticized or under very close scrutiny. For this reason, the technique only works if there is very clear informed consent, and a very clear and positive therapeutic alliance.

The technique may involve asking the patient to describe a recent problem or conflict in the week, with an emphasis on trying to understand the underlying emotion. The focus may shift to the "here and now" of the session, particularly if defences seem to be very active as the patient recounts the story. Later, the focus may shift again to an early childhood dynamic, perhaps with the idea that such childhood events form core conflicts which keep recurring transferentially.

Another component of the technique involves videotaping the sessions, in order to understand clearly what is helping, and what is not, with a view to considering that the moment-to-moment behaviour of therapist and patient is very significant.

The technique can be used to frame different sorts of problems, ranging from panic attacks, relationship difficulties, anger control problems, past trauma, at least some types of depression, and personality disorders. These different problems could be understood as leading to different forms or styles of defence and different manifestations of anxiety, both of which inhibiting a full expression or ability to experience emotion.

The theoretical lingo in this technique is, in my opinion--just like with so much other therapeutic theory--filled with a lot of overvalued Freudian-style language which is taken as literal truth. So we have dramatic descriptions of "breakthroughs", "unlocking the unconscious", etc. As with other phenomena of this sort, it is a ripe opportunity for some people to adopt the ideas with a sort of dogmatic, quasi-religious fervour; and the "guru effect" may be a factor as well. Yet, perhaps I shouldn't criticize the lingo too much -- it is a truly significant moment when a longstanding psychological truth is discovered, and a new way of experiencing an emotion is discovered -- and perhaps such an experience deserves an impressive-sounding label.

One thing I like about this technique, in a nutshell, is that it encourages the possibility that the therapist can sometimes bravely initiate a discussion about a patient's defences, leading rapidly to positive change. And this dialog may not need to wait for months or years, it could happen during the very first meeting, perhaps minutes after sitting down for the first time. And such a rapid pace could be an immense relief--though perhaps a surprise-- to the patient. In some therapy situations I find that there can be such timidity and passivity on the part of the therapist that very little happens -- not only can this be ineffective, I think it is downright boring sometimes, for patient and therapist!

In some ways it is like a stylistic mixture of cognitive-behavioural therapy and psychoanalytic therapy, but actually with a therapist who is more active than in either of these styles. In some variants of this style, the therapist might view cognitive-behavioural therapy as a sort of subset of the larger, more encompassing dynamic therapy, and might deliberately recommend CBT techniques as a sort of preparatory step.

The risks of the technique, in my opinion, lie in the dogmatism of its theory. Also, the style could be misapplied in such a way as to be offensive, argumentative, or dismissive. It may encourage some therapists to be excessively active, when the patient may need a quiet listener. I also believe it could be seen to aggrandize the role of therapist in a way I'm not particularly comfortable with.

There is a small but positive evidence base for the technique in the mainstream literature.

There is a significant case-series evidence base accumulated by practioners of the technique. Most case series are weak sources of evidence (because there is no control group, it is not prospective, etc.), but because the case series evidence in STIDP is also often accompanied by videotaped sessions demonstrating changes, I feel that this evidence base deserves stronger consideration.


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