Intensive Short-Term Dynamic Psychotherapy is a psychodynamic/psychoanalytic treatment model that, unlike traditional insight-oriented treatment (which could last indefinitely), was conceived out of a need to treat a wide range of patient complaints faster due to limited resources, a modern-day concern.
It is intense because the treatment seeks to involve the patient and uncover the core issue as quickly as possible, short-term with the aspirational intent of not letting the patient needlessly suffer or languish with symptoms, and (psycho)dynamic in that it works with the unconscious and transference feelings.
How are mental health symptoms understood?
In this treatment model, and in psychodynamic work in general, symptoms are seen as compromise formations. They are a compromise between a defense used to keep emotions out of awareness and the emotion itself. For example, depression [defense] is the result of internalizing rage [emotion] and the neurovegetative signs of depression are the compromise formation – they both hide and express the conflicted emotion. In this case, depression is treatable by the patient undoing the internalization once this is well understood - not by medication, symptom management or self-soothing skills.
Why the Symptoms Exist Now
Patients will often present with an onset of acute anxiety, depression, chronic worry, etc., without knowing why. There is always a precipitant that triggers an intrapsychic crisis. This is first assessed and made clear. Then, feelings about that situation and the person involved are explored and defense, anxiety and emotions are drawn out to see how they interact and create symptoms. After a breakthrough of emotion (where true feelings overtake all defense and resistance), often a spontaneous link by the patient is made to a genetic figure from early on where the true unresolved conflict lies. This is a deep, emotionally felt understanding, not merely cognitive and intellectual.
The Purpose of Anxiety
Another contribution that ISTDP has made to treatment is understanding the function of anxiety and how it is discharged in the body. Anxiety is not a life-long affliction to be managed by medication, but a mediator between defense and emotion. For example, upon approach of anger towards a loved one, the patient becomes quite anxious about their anger and uses depression to alleviate the anxiety and avoid the anger. Once the patient has sufficient tolerance for the anger, the depression and anxiety dissipate.
Three Types of Anxiety Discharge
Most patients will discharge their anxiety into striated muscle – that is, tension in the upper shoulders, neck, lower back, tightness in the intercostal muscles, and often accompanied by sighing respiration on approach of emotion. This level of anxiety is a positive sign that the treatment is approaching these warded off and conflicted feelings and a green light for continued work.
Some patients will discharge into smooth muscle – that is, vascular constriction, gastrointestinal complaints, and can experience bouts of nausea, headaches, diarrhea and constipation. Once the patient can tolerate anxiety and emotion, the patient will typically return to a striated level of discharge.
A small percentage of patients will discharge anxiety into cognitive perceptual disruption – that is, sudden forgetfulness, fuzzy thinking, difficulty with cognition, tunnel vision and ringing ears. Patients with these symptoms need a graded approach to treatment until anxiety is discharged into striated muscle. Emotions can then be safely approached.
Medically Unexplained Symptoms
ISTDP can be a useful treatment for people who have medically unexplained symptoms. A case example - a patient presents to their doctor with headaches, there is a suspicion of trigeminal neuralgia, an MRI is ordered, and a referral made to the headache clinic in Burlington. However, a psychological component is suspected and the patient seeks out psychotherapy. The patient concurrently enters psychotherapy and within the first hour, the rage towards a person is explored, then experienced with an impulse in the body to forcibly strike the person with their right open hand against the person’s left temple. This is the intrapsychic defense of projective identification – doing to oneself what they wish to do to the other out of guilt over their rage. The patient’s symptoms remit almost immediately once the patient has seen the connection, with no further medical follow-up needed.
Why haven’t I heard of ISTDP before?
ISTDP is more widely known in Europe, largely because most industrialized European countries have nationalized healthcare systems where an evidence-based psychotherapy is important in controlling costs and improving outcomes. The model was developed in Canada for the same reason, where long-term treatment at unending costs was unacceptable to taxpayers, providers and most importantly, patients. In one study conducted at Dalhousie University in Halifax, Canada, it was determined that for every dollar spent on ISTDP treatment, seven dollars were saved in costs to the healthcare system (Abbass & Katzman, 2013).
It's also a very technical treatment, requiring significant training, the video recording of patient sessions for training and supervision and a therapist’s willingness to tolerate and understand their own conflicts, defenses and anxiety.
If you’re interested in further information, the Wikipedia entry for ISTDP provides a good overview.
Abbass, A., & Katzman, J. W. (2013). The cost-effectiveness of intensive short-term dynamic psychotherapy. Psychiatric Annals, 43(11), 496-501. doi:10.3928/00485713-20131105-04