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Book review for Josette ten Have-de Labije and Robert J. Neborsky’s Mastering Intensive Short-Term Dynamic Psychotherapy

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Tony Talevski, Psychodynamic psychotherapist

 

As a psychodynamic psychotherapist who works from a relational framework , I plunged into de Labije and Neborsky’s Mastering Intensive Short-Term Dynamic Psychotherapy with a series of assumptions that didn’t prove true. To my surprise, I encountered terminology in the table of contents that could have been drawn from Freud’s Introductory Lectures such as id, ego, superego, resistance, transference and defence through to the more contemporary and research based psychoanalytic concepts of emotional regulation attachment trauma and neurobiological regulation. Generally one expects to see these terms in a textbooks, rather than being integrated into a framework for contemporary psychotherapy practice.

With my curiosity spiked, I learned that the founder of Intensive Short-term Dynamic Psychotherapy (ISTDP),  Habib Davanloo like many pioneering theorists within the field, broke away from his classical psychoanalytic roots due to his concerns regarding the duration of therapy and the non-specific nature of treatment goals and outcomes. Consequently, Davanloo embarked on a process of video recording and closely examining the micro dynamics of his work with his patients. The subsequent clinical case studies and 3 systematic studies involving psychotherapy with 130, 24 and 18 patients respectively provided Davanloo with the platform from which to launch the ISTDP model, beginning with his seminal book Short-term dynamic psychotherapy in 1980. ISTDP has since generated a small base of researchers and practitioners as well as a number of tertiary courses in both the USA and Europe.

This book consists of 13 chapters, a very helpful glossary and an appendix of ISTPD assessment forms with each chapter closing on a summary of key points that capture the key themes and support the revision and integration of ideas for readers. The clear and pragmatic format of the book mirrors that of the psychotherapy modality it describes. Chapters one to eight lay out the theoretical ground work, blending Freudian analysis, ego psychology, attachment theory, neuroscience, psychopharmacology and, somewhat surprisingly, the outcome focused aspects of CBT, while chapters nine-13 develop the practical application of ISTDP through a series of vivid, verbatim case vignettes. These include: assessment, working with transport phobia, depression, somatization, transference resistance, and the termination phase of therapy.

With Davanloo’s intention being to operationalise psychoanalysis and transform it into a set of constructs that have a practical utility for therapists, it is apparent that Labije and Neborsky have had this pragmatic task as their central guiding principle. They state,

The therapy beg[ins] as a problem solving relationship wherein all the treatment goals are agreed upon in the initial interview. Once the ego starts to separate itself from the superego and the resistance is defeated, the unconscious part of the working alliance starts to develop … The therapist has activated the patient’s attachment longings and they have driven the patient to accept the therapist’s help to explore the patient’s trauma based feelings from the past. The patient has hopefully unmasked the eyes of his internal aggressor(s), understood his/their commands, the ways he submitted to these commands, and declared his freedom from the conditions which were imposed upon the self by his pathological superego. Through internalisation of the constructive superego that was modelled by the therapist, the patient gained access to his complex of transference feelings which were associated with past traumatic experiences. In cooperation with the therapist, he has worked these feelings through … In short, the patient has defrosted from his frozen state and the powers of personal growth are freed … The patient experiences himself in a new and constructive way, from a position of earned secure autonomy. Because of his liberated curiosity and inherent desire to explore the world, his need to build and maintain nurturing and autonomous relationships takes over (2012, p. 355).

There are concise definitions of familiar terms such as id, ego, superego, transference, countertransference, resistance, and anxiety where the authors engage with Davanloo and his effort to sharpen ideas for the purposes of clinical utility. Then there are new terms that have emerged from the ISTDP literature such as “sychoneurotic disorder”, “spectrum of psychoneurotic disorders”, “central dynamic sequence”, “break through of the impulse guilt”, “grief”, “love”, and “unlocking of the unconscious” . de Labije and Neborsky lay out a set of pragmatic techniques to be used in a linear sequence that enable the breakdown of psychological defences in order to access and unravel the core unconscious emotional conflicts within the patient.

Through their conceptual framework de Labije and Neborsky map out a topography of intrapsychic processes and their dynamic interplay within the therapeutic relationship. This topography enables therapists to more clearly comprehend and therapeutically intervene into the whole relational field.  Although as a practitioner, I would not  adopt the whole ISTDP working system, especially the diagnostic “spectrum of disorders” construct, or the overly simplistic and unnecessary metaphor of red and green traffic lights (that signal the rigidity/flexibility of the patient’s defences) because such concepts are reductive and lack the flexibility to interpret more sensitively..

The book does have its shortcomings. It is peppered with typos and some clunky sentence construction, which impeded the flow of reading. Moreover, more in-text referencing where scientific claims are made could also lend it greater intellectual weight. The uninitiated reader could also benefit from a slightly more comprehensive outline of ISTDP’s historical origins and lineage. There are only two short paragraphs at the beginning of chapter one, leaving me slightly intellectually disorientated as I could not locate where this approach was situated within the broader psychoanalytic/psychotherapeutic canon.

The authors admirably demonstrate a rare humility as they acknowledge ISTDP will not be the treatment of choice for all patients recommending other modalities depending on a combination of the nature of issues and patient characteristics. The case vignettes illustrate a confrontational therapeutic posture, using terms such as “confrontation”, “challenging” and “head on collision” that lead me to think that many people might be intimidated by such a forceful approach.  Having a clearer guide for patient selection would be helpful. The therapist-patient exchanges (2012, pp. 182-183, 186) are representative of these forceful dynamics whereby the therapist implores the patient to express their emotions. For example, the following interaction takes place at the conclusion of the first session:

Pt          (Crying)

Th         Just cry, just cry. Don’t Suppress. Don’t Suppress. Follow all the grief. There is a lot of grief.

Pt          So much has been shovelled under. I want to confront it but I can’t. I can’t get hold of it.

Th      There is grief now. And you immediately declare yourself a psychic cripple [“Psychic cripple” is a term the therapist introduced earlier]… There is grief, which is emotion, and immediately you move to the crippled position …” (2012, p. 183).

Despite these limitations, Mastering Intensive Short-Term Dynamic Psychotherapy has something to offer both the purist ISTDP practitioner as well as the clinician who works psychodynamically (or who wishes to).  I suspect I will return to this book when my own therapeutic work with patients is feeling too comfortable or repetitive. de Labije and Neborsky provide a set of powerful techniques to enliven the work enabling a guide through the emotional conflicts that are the site of therapeutic change.

 


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