An interview with Dr. Allan Abbass on ISTDP and CBT at the ISTDP Immersion in Drammen, Norway 23.05.14

By Vidar M. Husby, Ivar W. Goksoyr and Mangus J. Engen

Few will argue with the fact that good dialogues about psychotherapy facilitates development of the field. Still, I 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 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.

Vidar: How would you go about to introduce ISTDP 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.

Vidar: So how do you bridge it then?

Allan: I’ve done whole segments of presentations using CBT language all the way throughout. This includes the emotional exposure components of the behavioral part, and the cognitive component of clarification and challenge to defenses.

So if you start the conversation by stating that ‘ISTDP 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 what to relate that to”.

In that way, there is no experience of the whole model that they are using is being invalidated as not valuable or not useful in any way.

Ivar: So it really overlaps.

Allan: You can speak to the common factors across the models and how much they overlap in certain ways. These include the common factors in the relationship components, to the interactional component and to the exposure components. 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 going to say ‘ok, let´s see what this model adds to what I already know that makes sense’.

Then you can talk about the unconscious anxiety signaling system, monitoring of physical cues, conscious vs unconscious processes and other ingredients that are not inherent in a traditional CBT model. You can use words that may be common in CBT language like «implicit», «memory processes», and talk about brain bases for psychotherapy processes that bridge therapy models.

You can talk about the ISTDP graded format and graded exposure and different things that overlap between the frames. You can also talk about the emotional experiencing, focus on the bodily experience of the emotions, past-present linkages. Some of this you can refer to as parallel to schema work if you like. There are ways to bridge across.

Magnus: What kind of response do you get presenting like this?

Allan: Overall they are interested. Like any therapist concerned about his clients, they are thinking ‘what else can I put in my toolkit?’.

There are no therapists, none of us, who doesn´t run into resistance and complex processes that defeat therapy and result in treatment stalemates – its universal, no matter what model is used. And that´s where ISTDP can add: handling resistance, to recognize resistance processes, to recognize projections to recognize transference being activated.

A common example is in homework, where the client doesn’t do anything that you ask them to do. So you can think about it as ‘what does this model add to what a therapist knows from their human experience of life, their clinical experience, or whatever they know from common sense?’ So you´ll see the reaction like “ok, what can this add?” rather then “this is a whole new thing”.

Vidar: What about other models?

Allan: For other psychodynamic models i find it easy to bridge – people are familiar with many of the concepts and find the model refreshing because it´s a package that they can understand some of and in many cases can directly help them understand some difficulties and limitations of the impact of resistance and complexity, especially where treatment is extremely prolonged or runs into stalemates.

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 emotions are 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 in some of them: it rattles and scares them almost and it is difficult to understand. Even though the man in the video is just another person feeling a lot of emotions. If you know what you´re looking at, you´ll say ‘wow that’s a very nice, very moving process’. Otherwise you may think that this level of emotions must be harmful to a person, even though he reports huge gains over a relatively short treatment course. So you want to choose what content you show.

I usually start with very intellectual review of material 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 without enough cognitive understanding of the process, as human as it is.

Vidar: When you talk about core concepts like repression, regression, projections, what synonyms can you suggest to make it understandable in CBT-terms?

Allan: Assumptions is a good one for projections. Projection is automatic dysfunctional beliefs and thoughts. For depression and the concept of repression – there are a whole lot of cognitive sets for depression that goes along with that. But you have to talk about unconscious anxiety and uncosncious mechanisms to explain much of this.

For example all the choking that happens 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… Every therapist will see that if they´re working with depression. So they know that there is something happening there, but not what to do with it. But we have a way to understand and conceptualize it and directly address it, so in general this material isa relief to learn and to see on the videos.

So there are ways to present these things in a way for it 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 with a past history that every time that he dealt with authority figures, he was controlled by them. And their experience of control is that they go to defiance. That´s going to be repeated with the therapist. Everybody understands that (for example, defiantly refusing to do homework in CBT therapy).

Transference is a human normal phenomenon that is in the realm of common sense.. That´s when some people in a CBT-audience will say ‘Ok I can do some schema work’. So they end up doing more psychodynamically-informed 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 the CBT concept of schema, 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 section on this. In last year’s Immersion in Stockholm I had a whole section on CBT parallels.

Vidar: From what I´ve learnt about cognitive therapy and related models, there are even more parallels. For example, Josette ten-Have De Labije talks about the importance of model learning and refers to Bandura.

Allan: There are several parallels between ISTDP and CBT: ISTDPs pressure is CBTs focused exploration of 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 efforts to switch 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 has parallels to CBTs graded exposure. ISTDPs challenge resembles CBTs response prevention. And then there are the elements that I mentioned that ISTDP may add to that including the monitoring system , uconscious operations, handling resistance and emotional experiencing to empty the emotions from schema.

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 «pent up emotions are not the problem.

People need to deal with how they reflect on their emotions, thats the key to change». That seems to be hard to bridge sometimes. You know, actual strong experiencing may not look meaningful to some therapists if they have certain beliefs about this.

Allan: Among other theorists, Peter Fonagy and I had conversations about these things. I think I even showed some videos. We were both interested in the parallels and differences between the models. Being mindful of things is a central part of what we´re doing. So it´s not like mindfulness 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 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 to help them be mindful of the emotional experiences underlying stuck patterns.

Magnus: And the experiencing of emotions as a key to change, you also have some process empirical data on that?

Allan: Yes. That is a very 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 0.7. That´s huge. There is no other single factor in psychotherapy that comes anywhere near that. So thats something we are studying further, as a predictive factor. That´s essential for this model but it´s interesting to find such a huge number. This measure of rise in feelings can be used to study the impact of this on outcomes from other models of therapy too, including CBT, and we are looking forward to doing such a study at some point.

Ivar: I think our own experiences tells you what´s possible. And I´ve encountered both in myself and in colleagues, when talking about ISTDP, 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 no rage and no guilt about rage. We don´t assume there is any specific emotion there. We just focus and see how the person responds. The main thing is non-assumption. It´s an open minded 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 are certain typical processes that people have when they are blocking off grief as opposed to when they are blocking off more violent anger or more intense rage and guilt about the rage. So we don´t assume it. In my own psychiatric sample based data there were about ten out of 3000 who only have grief.

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 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 for someone to devalue something when you are not idealizing it. So that keeps it more like a conversation between colleagues, toward a shared understanding of something.


RCTs, metastudies and other studies on treatment effects

Presentation of Dr. Abbass