«The main thing is to try to stay out of over-idealizing or devaluating models»
An interview with Dr. Allan Abbass about bridging ISTDP concepts at the Immersion in Drammen, Norway 23.05.14
Few will argue with the fact that good dialogues about psychotherapy facilitates development of the field. Still, we experience frequently that good dialogues turn into a clash of ideologies. At that stage of the conversation, no meaningful exchange of information can occur. Magnificent psychology gets labeled “too oldschool, too analytic, too simplistic and too superficial”, and tossed away on the junkyard of misconceptions.
Dr. Allan Abbass has held numerous presentations, immersions and coregrops on intensive short-term dynamic psychotherapy (ISTDP) over the last decades. Doing this, he´s had to bridge istdp concepts to make the model understandable to people from different orientations. Hoping to learn some useful synonyms between ISTDP and other models, we took the opportunity for a short interview with him to share with the readers of the Favne-blog.
Av: PsykologspesialistVidar M. Husby – Favne Voksenklinikken, Ivar W. Goksoyr and Mangus J. Engen
Vidar: How would you go about to introduce ISTDP concepts to collegues with other theoretical orientations?
Allan: There are different ways to go about that and it depends on your audience. Most psychology programs emphasize cognitive behavioral therapy (CBT). I find it relatively easy to bridge the languages between that model and ISTDP.
Bridging ISTDP concepts with CBT
Vidar: So how do you bridge ISTDP concepts with CBT for example?
Allan: I`ve done whole segments of presentations using CBT language all the way across, right up to the exposure components of the behavioral part, and the cognitive component of clarification and challenge to defenses and the differentating parts. So if you start the conversation with that «this is a very highly specialized exposure model with response prevention» – which it is – then people say «oh, ok! I know where to put that in my head, i know where to relate that to». In that way, there is no experience of the whole model that they are using is invalidated as sort of not valuable or not useful in any way.
Ivar: So it really overlaps.
Allan: You can speak to the common factors over across them and how much they overlap in certain ways, to the common factors in the relationship component, to the interactional component and to the exposure component. At that point they won´t be thinking that you say that what they do is bad, wrong or anything like that. Instead they´re gonna say «ok, let´s see what this model adds to what I already know that makes sense?». Then you can talk about the unconscious signaling system, monitoring system, conscious vs unconscious processes. You can use words that may be common in CBT language like «implicit», «memory processes», and talk about brain bases for these things. You can talk about graded format and graded exposure and different things that overlap enough.
You can also talk about the monitor system and the emotional experiencing, interest in the bodily experience of the emotions, past-present linkages, so.. you know… you can call that schemawork if you like. There are ways to bridge across.
Magnus: What kind of response do you get presenting ISTDP concepts like this?
Allan: They´ll be interested: «What else is this gonna give me, that I can put in my toolkit?». Because, you know: There are no therapist out there who doesn´t run into resistance, complexity, and projective processes. These are treatment stalemates – its universal, no matter what models. And that´s where this can add on: To handling resistance, to recognize resisting processes, to recognize projections, recognize transference being activated. A common example is in homework, where the patient doesn´t do anything that you ask them to do. So you can think about it as «what does this add» to what someone knows from their human experience of life, their clinical experience, or whatever makes sense in the common sense-frame. So you´ll see the reaction «ok, what can I add?» rather then «this is an new old thing».
Bridging ISTDP concepts with other models
Vidar: What about bridging ISTDP concepts with other models?
Allan: For other dynamic models i find it easy to bridge – people are familier with the concepts and find the model refreshing because it´s a package that they can understand some of and they understand more of what they´re doing.
Ivar: In my experience some of the clinical material, the videos showing ISTDP-work, they evoke feelings in the audience.
Allan: You´ll run into the issue of people getting anxious when this stuff is activated. When showing videos, that happens. I mean, the video I showed yesterday for example, is very evocative. Usually when I show that kind of video to new people, it causes fear and projective stuff, it rattles and scares them almost. Even though the guy in the video is just a guy feeling a lot of emotions. If you know what you´re looking at, you´ll say «wow thats a very nice, very moving process». Otherwise it´s frightening, you know! So you want to choose what content you show. I start with very intellectual review of stuff and evidence, and then I try to ease into it. That helps for some people. You grade the presentation – rather that burst things on them and shake up things too much.
Bridging ISTDP core concepts with CBT
Vidar: When you talk about core ISTDP concepts like repression, regression, projections, what synonyms can you suggest to make it understandable in CBT-terms?
Allan: Assumptions. Assumptions is a good one for projections. It is automatic dysfunctional beliefs and thoughts. And the concept of repression – theres a whole lot of cognitive sets for depression that goes along with that. But you got to talk about when the unconscious anxiety and all the choking thats happening when a person goes to regressive defenses. So I´d explain the physiology of what is happening; emotions coming up and then getting blocked in the body with a lot of tightening… I mean every therapist will see that, if they´re working with depression. So they know that theres something happening there, but not what to do with it. But we have a way to understand and conceptualize it. So it´s a way for it usually to be understandable and acceptable in a context that somebody already has.
Vidar: What about tranference resistance?
Allan: You can talk about schema. For example: A person has a past history of that everytime that he dealt with authority figures, he got controlled by them. And their experience of control is that they go to defiance. And that´s gonna be repeated, everybody understands that (for example, not doing homework in cbt therapy). It´s a human normal phenomenon that they are going to repeat that. That´s when a some people in a CBT-audience will say «ok I can do some schema work». So they end up doing more dynamic work, saying to their patient «how can we deal with what happens between us, so that you can get the most out of this therapy?». So you can bridge it with this schemastuff, understanding it as just a human reaction. This makes sense for them. I´m writing a book right now and I´m considering having a chapter on this. In last years Immersion in Stockholm I had a whole chunk on CBT parallels.
Vidar: From what I´ve learnt about CBT and related models, there´s even more parallels. For example, Josette ten-Have De Labije talks about the importance of model learning and refers to Bandura.
Allan: There´s several parallels between ISTDP and CBT: ISTDPs pressure is CBTs identifying dysfunctional beliefs, schema and behaviors. ISTDPs clarification is CBTs exploring of cognition and behavior, cost-benefit analysis, and reality testing. ISTDPs challenge is similar to CBTs swiching thoughts. ISTDPs recapitulations of links between past relationships, present relationships and the transference and links between impulse, feeling, anxiety and defenses is CBTs behavior analysis. Exposure in both models can mobilize the unconscious and lead to breakthroughs. ISTDPs graded format is CBTs graded exposure. ISTDPs challenge resembles CBTs exposure. And then there´s the stuff that I mentioned that ISTDP adds to that.
The understanding of pathology and key to change
Magnus: When it comes to understanding what´s keeping the pathology there, and the experiencing of emotion as a key to deep change. Often I get into entaglements there when people talk about how you handle and talk about the emotions. This will even be in dynamic approaches such as mentalization-based therapy. They will be like «there are no pent up emotions, people need to deal with how they reflect on their emotions, that’s the key to change». That seems to be hard to bridge sometimes. You know, actual strong experiencing will not look meaningful to some of these people when they have rigid ideas about this.
Allan: Peter Fonagy and I had a skype-conversation about these things, I think I even showed some videos. He was quite interested. This makes sense to people. You know, being mindful of things, is a central part of what we´re doing. So it´s not like it doesn´t exist in this frame. But the next step is the somatic experiencing, being aware of the bodily reactions and adding that into the equation. I haven´t found that being in conflict with people interested in the mindfulness-model. There´s a case I showed you the other day – a treatment-resistant person who had been treated by a mindfulness-based therapist. She had even trained with Jon Kabat-Zinn. That model helps the person get a certain distance. And it doesn´t help them to get any further than that, it stops. Some people need more.
Magnus: And the experiencing of emotions as a key to change, you also have some process empirical data on that?
Allan: Yeah. That is a strong outcome-factor. There´s a sample we did on trial therapies, where the amount of variance due to degree of rise in the complex feelings was half the variance in outcome! It is huge. The correlation-coefficent was .7. That´s huge. Theres no other single factor in psycohtherapy that comes anywhere near that. So thats something we are studying further, as a predictive factor. That´s essential for this model, right, that mobilization. But it´s interesting to find such a huge number.
The centrality of repressed anger and guilt
Ivar: I think our own experiences tells you what´s possible. And I´ve enocuntered both in myself and in collegues, when talking about ISTDP concepts, that the centrality of repressed anger and guilt about the anger like a driving force is quite a controversial idea. I get comments that it´s a narrow focus.
Allan: Here´s how I respond to that one: Some patients don´t have any buried rage. They just don´t. You have low-resistant people who´s had later life losses. They have grief but not much rage and guilt. We don´t assume there´s anything there. We just focus and see how the person respond. The main thing is non-assumption. It´s an evaluation. And we can focus and see how they react as they identify feelings. And see what kind of mechanisms and barriers they put up. We see repeatedly on thousands of hours of videotaped sessions that there´s certain typical prototype processes that people have when they are blocking off grief as supposed to when they are blocking off more violent anger or more intense rage and guilt about the rage. So I´d go that way with that kind of question. You don´t assume it. The people in my data… there´s like ten out of 3000 only have grief. But they exist.
The concept of feedback
Ivar: The model is very feedback-oriented. It is traditional to review sessions by self-report after the actual session, but here you monitor responses from moment to moment.
Allan: There´s no substitute for showing video. Then people can see what they would do and this helps them tie to what they already do. The main thing is to try to stay out of over-idealizing or devaluating models, like a splitting of some kind. Some people have a devauled split of the model as a start point. But if you neither idealize or devaule it, this neutralizes the devaluation. Its hard to devaule something when you are not idealizing it. So that keeps it more like a conversation between collegues, toward a shared understanding of something.
RCTs, metastudies and other studies on treatment effects: http://www.istdp.ca/media.htm#publications