Psychotherapy & Couples Therapy
Adolescent & Family Therapy
Trauma Treatment
Catherine Lockwood, MFT
...for a happier life and more fulfilling relationships

Collaboration is at the heart of all psychotherapy models. Therapists collaborate with their clients to achieve desired outcomes. And therapists often collaborate with other therapists – to coordinate care, provide consultation, and develop their clinical skills. It’s this last form of collaboration that brought the two of us together to solve problems common to our couples work. When we met, Catherine Lockwood was an AACAST accredited Couples and Sex Therapist with over 20 years of experience in the field. I was a relative newcomer to the profession. We met in a course on Intensive Short-Term Dynamic Psychotherapy (ISTDP) held at UCLA. This course began an extremely exciting time of discovery and innovation in our work.

If it’s possible to fall in love with a model of psychotherapy, we both fell hard. ISTDP is a visually and viscerally exciting model. Most ISTDP clinicians videotape their work to improve the timing, dosage, and precision of their interventions, and to review exactly what occurred in a given session. This means that therapists new to the model have a unique opportunity to observe the work of master clinicians achieving in-session results that look (to the novice) like magic, or close to it. In class, we observed clients on video leaning into intensely painful feelings in undefended and deeply moving ways. And we observed clients encountering long-buried memories and images that often emerged in rapid, detailed, and stunning succession. As newcomers, it was thrilling to witness both the artistry of the process and the end results, which when viewed on time-lapse video appeared utterly dramatic. It was undeniable to the viewer that a deep and profound transformation had taken place for these clients.

Shortly after, Catherine and I enrolled in 3-year ISTDP core training programs. We began to consult with each other on cases and collaborate on ways to integrate the most effective elements of ISTDP with couples therapy. As ISTDP was originally designed for work with individuals, we found there was a scarcity of information in the professional literature on the subject of ISTDP and couples therapy (exceptions: Have-de Labije, 2006; Solomon, 2001). We were both excited by the prospect of applying a new metapsychology and set of interventions to a series of common difficulties encountered in our work with couples. This paper is a distillation of our research, refinements, and ongoing experimentation, which culminated in a joint presentation in 2015 to members of the long-running Couples & Sex Training program developed by Dr. Walter Brackelmanns at UCLA’s David Geffen School of Medicine.

In this paper, we aim to share our experience with collaboration, innovation, and the cross-pollination of theoretical models. But first, we thought it useful to provide our readers with a very brief overview of Intensive Short-Term Dynamic Psychotherapy (ISTDP).

A Very Brief Introduction to Intensive Short-Term Dynamic Psychotherapy

Dr. Habib Davanloo’s groundbreaking development of ISTDP in the 1960s has inspired a deeply passionate legacy of researcher-practitioners who continually expand, debate, elucidate, and innovate on Dr. Davanloo’s original model (Abbass, Town & Driessen, 2012; Johansson, Town, & Abbass, 2014; Malan & Coughlin Della Selva, 2006; Neborsky, 2006).

ISTDP operates on the principle that early ruptures in the bond between parent and child lead to intense, complex feelings and impulses that are pushed out of awareness by anxiety and defense mechanisms. Over time, adaptive defenses once necessary for survival become maladaptive to healthy emotional regulation and generalized to all relationships. It’s this intra-psychic conflict between unconscious feelings and impulses and the defenses erected against them (resistance) that leads to symptom formation, including psychiatric disorders, functional and somatic disorders, relational difficulties, and self-defeating behaviors (Abbass, 2015; Davanloo, 1989; Have-De Labije & Neborsky, 2012).

Clinicians trained in ISTDP collaborate with their clients to recognize and relinquish self-defeating patterns of defense, especially defensive barriers against emotional closeness. Treatment often begins with the clinician addressing the tactical defenses clients put into operation to keep the therapist at an emotional distance. The ISTDP clinician encourages intimacy in a direct and honest way, which strengthens both the therapeutic alliance and the client’s emotional capacities (Fredrickson, 2013; Kuhn, 2014).

Equally important is the ISTDP clinician’s ability to help clients healthily regulate their underlying anxiety, which increases when defenses are confronted and relinquished. Working collaboratively in this precise and attuned way quickly builds client capacity, which allows for the breakthrough of long-buried affect and repressed memories in what is termed an “unlocking of the unconscious” (Davanloo, 1990). Once mobilized, these intense feelings, memories, and related attachment ruptures can be deeply processed and healed. This careful restructuring of emotional regulatory capacity together with intense breakthroughs of unconscious affect lead to rapid symptom relief and characterological change, as well as increased self-compassion and improved relationships (Malan & Coughlin Della Selva, 2006).

What Exactly Do We Mean by Anxiety and Defense?

In our opinion, one of the most revolutionary features of ISTDP is its precise understanding and attention to the physical ways in which anxiety manifests in the body and how anxiety functions together with defense to regulate core affect. We’ve observed that most clients are unaware of how anxiety is channeled in their bodies. In ISTDP, clinicians are trained to carefully monitor (and teach their clients to monitor) precise symptoms of anxiety (Fredrickson, 2013) so as to work within the client’s optimal “window of tolerance” (Siegel, 1999; Ogden, 2006).

ISTDP clinicians track anxiety in four major channels. The first and healthiest channel is the patient’s voluntary or striated muscles. Anxiety in this channel frequently manifests as deep sighs, tensing, clenching, and fidgeting. We also monitor anxiety in the sympathetic nervous system, which takes the form of dry mouth and throat, racing heart, sweating, cold hands, or shivering. With the parasympathetic or smooth muscle system, the patient might report dizziness, drowsiness, nausea, diarrhea, urgency to urinate, constipation, acid reflux, and sudden loss of muscle tension (e.g. wobbly legs). Cognitive perceptual disruptions may appear as incoherent, delayed or racing thoughts, or reports of visual disturbances such as tunnel vision or auditory disturbances such as tinnitus. Symptoms in these last two channels – the parasympathetic system and cognitive perceptual functioning – indicate that the client has exceeded his or her window of tolerance and can no longer healthily regulate anxiety. In other words, he or she has gone over a safe anxiety threshold, and the therapist must intervene immediately to reduce anxiety (Fredrickson, 2013; Have-de Labije & Neborsky, 2012).

Why is this important? Because high, unregulated anxiety can exacerbate somatic and depressive symptoms and invite intense projections and misalliance. At lesser levels, it prevents healthy emotional experience and triggers destructive defenses that push others away, including intimate partners and the therapist. The most common defenses we encounter in couples therapy are blaming, criticizing, justification, dismissing, explosive discharge of affect, distancing (also known as withdrawal or stonewalling), sarcasm, intellectualization, rationalization, ignoring, devaluing, dismissal, giving behavioral instructions (e.g. “You shouldn’t feel that way!”), playing the victim and in extreme cases, dissociation. It goes without saying that if both partners are in an anxious, dysregulated state, they cannot contain and metabolize their own feelings let alone the feelings of their partner. In such cases, empathy, healthy co-regulation of affect, and intimacy are impossible.

Why Couples Enter Couples Therapy

In our experience, when couples enter therapy, a great number of them will cite “communication issues” as their presenting problem. Rarely have we observed that couples suffer from an inability to communicate. Rather, they have difficulties in regulating intense feelings, and as a result they become trapped in destructive patterns of dealing with their feelings and each other. Many great couples clinicians, researchers and theorists have observed similar behavioral patterns with couples and have detailed them in evocative terms. For example, Susan Johnson (2004) describes repetitive patterns of relating in terms of “Negative Interactional Cycle,” while John Gottman (1993) describes certain fixed, hostile interactions as “The Four Horsemen of the Apocalypse.” To our mind, all skilled couples therapists seek to apply interventions in a coherent way to interrupt destructive relational patterns and encourage in their place healthy attachment longings and intimacy.

An ISTDP-Based Approach to Increasing Intimacy and Repair in Couples

At its heart, ISTDP can be described as an attachment-system-repair therapy. As ISTDP clinicians who also treat couples, we began to identify the most powerful components of ISTDP that could be applied to interrupt negative interactional patterns while removing barriers to emotional intimacy and facilitating repair between partners. In this paper, we will address two of these components: The first is the systematic restructuring of the couple’s patterns of anxiety and defense, and the second is the positioning of the therapist as a temporary transference figure (Marvin Skorman, personal communication, February 24, 2015).

Restructuring Anxiety and Defense with Couples

One of the advantages of ISTDP is its ability to show clients in real time what is getting in their way. From our perspective, the thing getting in their way is a reciprocal pattern of anxiety and defense that blocks vulnerability and complex feelings, which in turn blocks intimacy.

For example, when Partner A begins to detail her frustrations with Partner B, the therapist can help both partners observe that Partner B’s anxiety is being channeled into his striated muscles and sympathetic nervous system in the form of full body muscle tension and a dry mouth, which then results in the defenses of intellectualization and breaking eye contact, which he deploys in an attempt to regulate both his rising anxiety and his underlying feelings of anger and sadness.

These precise, moment-to-moment interventions work especially well because they keep the focus on what is happening emotionally in the room. The couple’s anxiety and defense patterns can be directly observed by both partners with the help of the therapist and restructured on the spot. If skillfully applied, this approach has the advantage of doing real-time repairs to the couple’s capacity to healthily co-regulate anxiety and complex feelings. Also, helping the couple to observe together their precise emotional and physical responses in vivo also allows them to see their problem from an entirely new, neurobiological perspective, which serves to interrupt their habitual pattern of attacking and then distancing from one another.

Our unique challenge was how to systematically introduce anxiety-defense work into our therapy with couples. The most natural solution was to engage in small blocks of restructuring with one partner at a time in full view of the other partner. This only made sense after establishing a mutual understanding of the couple’s problem, including the specific ways in which each partner contributes to their painful interactional pattern vis-a-vis anxiety and defense. At that point, we could consistently link the partners’ real-time responses back to their presenting problem, while encouraging them to use a healthy alternative.

Finally, we found that asking the observing partner to recap what he or she has just witnessed is a powerful aid in bolstering empathy and consolidating new learning. We then ask the couple to practice co-observing and using their healthy alternatives between sessions.

Taking the Transference Heat

It goes without saying that couples enter therapy with a deep reservoir of feelings toward each other (and usually toward past attachment figures). Often, these feelings are of such intensity that exploring them safely is difficult. One or both partners may lash out, verbally pummel or devalue the other in the therapist’s presence, which usually requires the therapist stepping in to play the role of mediator, interpreter or traffic cop in order to prevent iatrogenic damage.

In our collaborations, we began to adapt ISTDP interventions to draw fire away from the partner under attack by redirecting it into the relationship with the therapist (in psychodynamic terms, “in the transference”). Rather than halt, interpret, or reframe the attack, we would invite the partner to precisely examine the physiological manifestations of the intense feeling under observation, while helping him or her to distinguish between the feeling of anger, anxiety, and defense (e.g. discharging, venting, lashing out, etc.). This shift in focus from interpersonal conflict to intra-psychic exploration invariably leads to the mobilization of feelings toward the therapist, which are subsequently explored in the same manner and then linked back to the couple’s presenting problem. Care is taken to let the other partner know that he or she will have an opportunity to do the same investigation with the therapist.

In our experience, this intervention, if done with skill, offers the following advantages: (1) It prevents in-session damage to the partners and further damage to their attachment bond without diffusing the intensity of feeling. (2) It improves the partners’ capacity for self-observation and emotional regulation. (3) It offers the couple a new, intra-psychic understanding of their interpersonal problems. (4) It interrupts the couple’s repetitive, negative interactional cycle and (5) lets the observing partner see that the problem is not occurring only in relation to him or her.

There are of course many psychodynamic therapies in which the therapist encourages and then interprets the patient’s positive and negative transference feelings, but there are few models in our experience that so vigorously position the therapist in the transference hot seat. The therapist’s willingness to “take the transference heat,” especially when confronting patient barriers to intimacy and engagement, is a key feature of ISTDP that we found highly effective in our work with couples. When combined with anxiety and defense restructuring, transference work can significantly de-escalate negative interactional patterns and accelerate intimacy and healthy co-regulation of affect within the couple.

A Final Word on Collaboration and Sharing Best Practices

We’d like to re-emphasize that our work is an ongoing learning process and that what we have presented here is not a complete therapy. Rather, we view our work as a form of collaboration and cross-pollination in which we seek to apply powerful elements of one modality to improve our work in another. In our efforts to coherently integrate ISTDP into our work with couples, we have discovered areas of enormous potential in addition to certain roadblocks and challenges.

Needless to say, we are excited by the ways ISTDP can add considerable value to couples therapy. Working together on utilizing two different modalities has also increased our awareness of the value of sharing aspects of theoretical modalities and clinical experiences as they might apply to different treatment units, populations or theoretical orientations. We imagine you too are encouraged when therapists from different schools of thought share best practices, and in so doing, work collaboratively to bring the highest value to ourselves and our patients. We would welcome your comments or questions at  CL@CatherineLockwoodMFT.com and ReikoJosephMA@gmail.com.

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References 

Abbass, A., Town, J., & Driessen, E. (2012). Intensive Short-term Dynamic Psychotherapy: A systematic review and meta-analysis of outcome research. Harvard Review of Psychiatry20(2), 97-108. doi: 10.3109/10673229.2012.677347

Abbass, A. (2015). Reaching through resistance. Kansas City, MO: Seven Leaves Press, LLC.

Coughlin Della Selva, P. (2004). Intensive Short-term Dynamic Psychotherapy. London, England: Karnac Books, Ltd.

Davanloo, H. (1989). Central Dynamic Sequence in the unlocking of the unconscious and comprehensive trial therapy. Part I. Major unlocking. International Journal of Short-Term Psychotherapy, 4(1), 1-33.

Davanloo, H. (1990). Unlocking the unconscious: Selected papers of Habib Davanloo, MD. Chichester, England: John Wiley & Sons.

Frederickson, J. (2013). Co-creating change: Effective dynamic therapy techniques. Kansas City, MO: Seven Leaves Press, LLC.

Gottman, J. (1993). A theory of marital dissolution and stability. Journal of Family Psychology 7(1), 57-75.

Have-de Labije, J. ten (2006). ISTDP in couples therapy: Unlocking marital collusion by experiencing the murderous impulse towards the partner and the accompanying guilt, grief and love. Foundation for Intensive Short-Term Dynamic Psychotherapy Ad Hoc Bulletin, 10(2), 34-62.

Have-de Labije, J. ten & Neborsky, R. (2012). Mastering Intensive Short-term Dynamic Psychotherapy: A roadmap to the unconscious. London, England: Karnac Books, Ltd.

Johansson, R., Town, J.M., & Abbass, A. (2014). Davanloo’s Intensive Short-term Dynamic Psychotherapy in a tertiary psychotherapy service: Overall effectiveness and association between unlocking the unconscious and outcome. PeerJ, 2:e548 https://dx.doi.org/10.7717/peerj.548

Johnson, S. (2004). The practice of emotionally focused couple therapy. New York, NY: Brunner-Routledge.

Kuhn, N. (2014). Intensive Short-term Dynamic Psychotherapy: A reference. Belmont, MA: Experient Publications.

Malan, D. & Coughlin Della Selva, P. ( 2006). Lives transformed: A revolutionary method of dynamic psychotherapy. London, England: Karnac Books, Ltd.

Neborsky, R. (2006). Brain, mind, and dyadic change processes. Journal of Clinical Psychology: In Session, 62(5), 523-538. doi: 10.1002/jclp.20246

Ogden, P., Minton, K., and Pain, C. (2006).  Trauma and the body.  New York, NY: W.W. Norton & Company, Inc.

Siegel, D.J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York: Guilford Press.

Solomon, M. F. (2001). Breaking the deadlock of marital collusion. In Solomon, M.F., Neborsky, R., McCullough, L., Alpert, M., Shapiro, F., & Malan, D. Short-term therapy for long-term change (130-154). New York, NY: W.W. Norton & Company, Inc.

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[1]Reprinted with permission from the American Psychological Association, “Psychotherapy Bulletin”, 2015 Vol. 50, # 4, link:  IN THE HOT SEAT: APPLYING INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY (ISTDP) TO COUPLES COUNSELING