If you’ve never been in treatment, you probably have a lot of questions about how it works and what to expect.
Patient (P): So, I’ve never been in therapy before and wonder what it’s like and how it works.
Therapist (T): Great question, do you have a couple of hours? So, psychotherapy is the therapy of one’s own psychology, that is, their internal world. That means people come to therapy with problems that reflect a conflict they have internally. That conflict may not be immediately known to them, but it’s my job to highlight the conflict for them so they can see why they have problems.
It’s important to also say what psychotherapy isn’t. It isn’t giving advice, the therapist talking about how they solved their own problems or trying to persuade someone else who isn’t the patient to act in a way the patient approves of.
P: Okay, so there’s a conflict. But let’s say I have a problem with depression, or anxiety, or my girlfriend or my boyfriend is pissing me off. What’s the conflict?
T: Right, so we don’t know what the conflict is until we explore the person’s symptoms, when they started, etc. It’s not like people who have depression have X conflict, and people with anxiety have Y conflict. An analogy might help – you go to the doctor with a headache that happens every day and doesn’t get better with over-the-counter pain meds. The doctor examines you, asks a few questions, and says, “Aha! You have a Headache Disorder! I’ll prescribe some medication for it, call me in two weeks if it continues.” You might wonder why a symptom is now a diagnosis and become angry that the doctor isn’t exploring why the headache is there in the first place. And so, the same thing happens with mental health symptoms. We explore why they’re occurring in the first place and address the underlying conflict that gives rise to the symptoms.
P: That sounds good. Do you have an example of symptoms that speak to an underlying conflict?
P: Sure. One example might be that a person comes in with depression. You know, no motivation, feeling hopeless, low energy, not eating, not sleeping, the whole bit. If you’re a pharmaceutical company, you would think it’s a chemical imbalance which requires the medication for a chemical re-balance. Some therapists who would deal only with the conscious mind might see depression as a mental health issue that is chronic and is to only be managed. But if you work with the unconscious like I do, you get specific with the patient and trace it down to find out when the depression started. Perhaps the depression started in college after a breakup. The breakup led the person to internalize their rage about how they were treated, giving rise to depressive symptoms. In other words, they turned their anger inward. A careful inquiry can help us run this down and then take a look at what happened.
P: So, you get specific, run it down, and you see this person has a conflict about anger?
T: Yes, exactly. We don’t know why yet. But pressing on the feeling, in this case anger, to be experienced by the patient will flush out all the defenses a person uses, which I point out to them. It’s the defenses, not the anger, that gives rise to the symptoms. When a person gets in touch with how they really felt, without using all of their defenses, usually they have some insight into why this was the chosen method of coping with feelings.
P: And then that’s it?
T: Often not. Usually the current issue is linked back to the family earlier in life where the original feelings weren’t processed either. Left untouched, any situation in current life that leads to feelings similar to the original can result in the same set of symptoms.
P: Ah, so it is all about your mother and father! Daddy issues.
T: Not always. Sometimes its other figures, rivalries with siblings, etc. In some cases, it has nothing to do with the childhood family.
P: So, you’re saying, find out when the symptoms started, find out what the conflict is, help the patient see what their defenses are, and have feelings about it and that’s it?
T: It can be. Sometimes people have a lot of guilt about their rage towards others, so we have to work through all the complicated feelings towards that person and see how the guilt has been used to punish them in current life.
P: This sounds intense. What kind of person wants to do this?
T: Any person who finds the symptoms are worse than looking at unresolved feelings about people in their life. But it’s tough work and takes both of us.
P: Huh, so I’ve wondered about this, what is my role in all of this? You’re the expert of course, so do I sit back and let it happen?
T: That’s the hard part about therapy. Unlike any other medical profession where you just sit back and let the professional take over and follow all of their advice, therapy is different. It’s actually very important that the agent of change in this process isn’t me – it’s them. Once we get really clear on what’s happening, only the patient can make those changes. And that’s a good thing, because we want to work me out of a job. You would like to leave therapy, wouldn’t you?
P: Oh definitely! But if I already know what the problem is, couldn’t I just do it myself, then I wouldn’t need you?
T: Yes, and if you can do that, good for you! Sometimes you can’t because some of these defenses are “ego-syntonic”, fancy talk for saying that it’s a defense you use but you can’t see it. So, I help you see it.
P: Okay, then we get to the emotion underneath and all of the other stuff we talked about.
T: Exactly, and then you start to have a different perspective and hopefully symptoms get better.
P: Yes, I was wondering about that – how long are we talking about here, to start feeling better?
T: That’s a hard question. Largely that depends on the types of defenses a patient uses, how long they have been in play, the significance and/or duration of trauma and how old the person was, their motivation, level of insight and how well they develop an alliance with me. Some people notice substantial changes in the week after the first trial therapy. More often people really start to see changes in the first month. If after six weeks of therapy we’re not seeing anything move, it’s time to reassess.
P: Six sessions? But people are in therapy for years!
T: Yes, that’s true. People are in therapy for years because either the issues that brought the patient to therapy were hugely significant, or the therapist isn’t doing their job, or only dealing with conscious material.
P: So, in essence, therapy shouldn’t take forever? I mean, that’s what I worry about, that it becomes this never-ending process.
T: No, and I try to ask every session with every patient, “Are we on the right track? Is this making sense to you?” And if they don’t volunteer, I ask about symptom improvement. There’s been this longstanding belief that deep treatment has to be long treatment. Deep and short treatment is possible.
P: So how do people know if they’re getting better?
T: At the start of treatment, I hear about what specific symptoms they’re having. And I also ask about what this prevents them from doing. So, a person might say they’re having panic symptoms (racing heart, clammy skin, shortness of breath, fear of dying) and that it prevents them from completing an application to graduate school. I ask along the way, and patients will begin to notice, “Yeah, that would have given me a panic attack, but I didn’t get nervous about it. Oh, and I put in my grad school application.” I reflect back the progress. Often patients will report that important people in their life will also notice positive changes in them, which of course is hugely gratifying to know that the hard work in therapy is paying off. And we continue to tie it back to the internal conflict.
P: This sounds great. But it sounds intense too. Is it?
T: Yes, both for therapist and patient. But my focus is to get real specific real fast with people. Although people initially are surprised by this, especially if they’ve been in much slower therapy before, they are appreciative because they’ve been suffering for quite some time.
P: Do patients ever not like it?
T: Yes, all of the time. But it’s important to make a distinction here – patients are often appreciative that someone is trying to help them and simultaneously they can easily become angry that I am calling their defenses into question. We address that in session as well.
P: So, you address it like “Hey, I’m just trying to help you – what’s with the anger?”
T: No, any feeling experienced is to be welcomed and processed. It may be the first time anyone in their life has been able to tolerate their intense feelings. For example, if a person turned their anger inward to preserve important relationships as a child, to be angry with me and I don’t kick them out can be hugely therapeutic.
P: It’s weird that people would be angry at you for trying to help.
T: Well, remember the conflict. If their defenses were so easily addressed and cast aside, the conflict isn’t huge. But if you have a huge conflict – that is, to be angry at someone means the potential for abandonment then a conflict ensues. Do I look at this anger and threaten the loss of my therapist who tries to help me, or do I cover up in defenses, stay depressed and have panic attacks?
P: Okay, I guess that makes sense. Have you ever had people choose to keep using their defenses?
T: Yes. Sometimes I end therapy with people who choose to use their defenses over getting better. But at this point it’s well established what the problem is, what the solution is, and what their responsibility is in making change. Some people want me to be powerful, wave a magic wand, and I can’t do that. And when we reach that point, and they don’t want responsibility for their share, we end. Otherwise, I am invited into yet another dysfunctional relationship the patient has.
P: You keep using the word defenses. I know I use it – “You’re being defensive.” What does this really mean?
T: Defenses are things we do to protect against painful feelings and there are different categories of them. But to keep it simple, examples of defenses might be intellectualization or projection or my favorite, negation.
P: Do you have an example of how these defenses work, like how you see it?
T: I might hear that the depression started at the start of a new job, and most specifically, a particularly bad interaction with a boss. Once I hear this, I test to see if there is more here. I might ask, “What’s the feeling you’re having towards your boss right now?” I know I’m not going to get a feeling from them – I will get a defense first. They might say, “Well, I would certainly have a great deal of anger towards him if he were to do that again.” Here the tense of the sentence and the future orientation is a way of avoiding it right now. Or the person might say, “Well, it’s not like I want to punch him in the face or anything.” When a person says this, and I didn’t ask about an action, only a feeling, it’s negation. It’s the unconscious way of saying that I’m so angry I could hit him, but the conscious mind puts in the negative. This is the unconscious helping us out.
P: Do you say, “hey you’re using negation”?
T: No, no one knows what negation means. But I do point out that they seem to have some real anger at the person. I then ask if they experience it in the body, where they located the angry feelings physically. Most often, the body responds with anxiety, not anger. But the defense of negation, or any defense for that matter, are bread crumbs on the trail. It means we’re headed in the right direction.
P: Okay, so I also gather that you have a particular way of working. I’ve read about so many types of therapy that I get confused with what I need and what works.
T: Our profession is full of alphabet soup. Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Experiential Dynamic Therapy (EDT), Intensive Short-Term Dynamic Psychotherapy (ISTDP), Emotionally Focused Therapy (EFT), and others that people are naturally confused. Our profession doesn’t do a good job of helping the general audience understand the differences, if they matter, and what works.
P: So, how does the general patient in need of therapy to help with anxiety or depression know what they need?
T: It’s helpful to remember that although there are hundreds if not thousands of types of therapy out there, they are, pardon the analogy, like food. There are thousands of dishes out there, but the ingredients can be summed up in about 4 groups – vegetables, meat, dairy, and grain. The same with therapy. There are main groups of therapies that are either psychodynamic or behavioral with elaborations that are cognitive and based upon learning. Some of those models are then tweaked to cater to a certain type of diagnosis. Like DBT is a re-working of CBT for people with personality disorders.
P: Right, so what do I need?
T: Okay, well here’s my bias. Only psychodynamic theory deals with the unconscious in addition to the conscious mind. Because the metapsychology behind ISTDP is that symptoms are compromise formations and indicate a conflict, we would seek to understand the symptoms of anxiety not as an anxiety disorder listed by the DSM, but symptomatic of an underlying conflict which when brought to light, can be resolved, leading to symptom reduction.
P: Okay, so Freud.
T: Yeah, but…with 120 years of innovation and neuro research. It’s like you saying that you bought a car, and I say, “Yeah, like the Model T.”
P: But most of the stuff I read says “CBT is the gold standard.” You don’t think so?
T: Yes, and Chevy trucks are the most dependable, longest lasting trucks on the road. Or at least so says the commercial. Sometimes the best is what is marketed as the best but doesn’t hold up as well in research.
P: So, CBT is pitched as the type of therapy that’s most helpful but it’s not.
T: What people don’t know is that earlier on CBT was pretty effective. The person who started CBT was a trained psychoanalyst, Aaron Beck. Was his treatment effective in spite of his psychodynamic training or because of it? As later generations of CBT therapists were trained, it turns out that they were less effective, maybe because they didn’t have a psychodynamic background. And that leads to another interesting issue with what works – when therapists report what type of treatment they use, they might say CBT. And then we see they get good results. But it’s important to listen to their session transcripts and see if that’s actually the case. One study looked at this and the interventions were psychodynamic.
P: So, you’re in the psychodynamic camp. What’s that called?
T: If psychodynamic is the food group, Intensive Short-Term Dynamic Psychotherapy is the dish. Put another way, psychodynamic theory can be used as an intervention in various way, analysis being one way like the person on the couch, or ISTDP being another.
P: So, what makes ISTDP different, and if I hear you right, more effective?
T: Two issues here. The first issue is fidelity to a treatment model. Habib Davanloo was a psychiatrist in Montreal who wanted to develop a shorter model of treatment, which everyone since Freud has wanted to do. He started recording patient’s sessions on a reel-to-reel camera, and if you’re a Vermonter, will appreciate that he could take 40 gallons of sap and make a gallon of syrup therapeutically. By watching tapes, he found ways to increase the intensity and decrease the treatment time. Because this is how ISTDP got started, using tapes is also how it is taught and supervised. Now that we have a set of interventions based upon theory, we supervise our tapes using real patient videos. That allows the person who teaches us how to treat patients with ISTDP the ability to know if we’re implementing the treatment with fidelity. Many times, people learn a new treatment method from a book or a training, but no one watches them implement it. If they’re not successful, it’s easy to blame the method and forget that maybe we’re not adhering to the model.
P: So, you get more success because the tape shows where you screw up?
T: Yes. Then I learn, fix it, and I know what to do next time for every patient with a similar issue. I think that the psychodynamic theory is also important too, that being the second issue, because it adds a real depth to treatment that other models lack. And people who tend to do ISTDP tend to be people who can tolerate their own conflicts, feelings, and high anxiety because when we initially train in this model, we show our own tapes in front of someone who has been doing it for decades, and with our training colleagues in the room watching it with us.
P: No thanks. What do patients think about this?
T: Patients tend to mirror the therapist. If the therapist is unsure about it, the patient will protest. If the therapist is confident that this is the standard of care, the patient doesn’t care. That’s been my experience. And I think it’s also that some patients, who have been through so many failed therapies, are interested in doing work with someone they see as very invested in being competent.
P: Do you watch all of the tapes?
T: No, I don’t have time. But I run the video recorder all of the time anyway. One, that helps me not focus on being recorded, and two, should something go wrong, or I just have a general sense that I’m missing something, I’ll review a section of the tape to see if I can figure it out. I learn a half dozen new things every time I watch a tape.
P: Why do you think other models are less effective? Is it the model or the fidelity to the model?
T: Perhaps both. ISTDP isn’t the only model that uses videotaping, but it’s the only model that seems to use videotaping as the standard throughout a therapist’s career. Others might use it to learn and then stop, but most ISTDP therapists have tripods and camcorders in their office and record even when they’ve been doing it for 30 years.
P: What else should I know?
T: Really, it’s about the experience. If you’re not sure, it’s worth a try. Once you have a good sense of what you need and are ready to make change, set up a time to meet.