(Review originally published 28 May 2006) Intensive Short-Term Dynamic Psychotherapy: Theory and Practice, by Patricia Coughlin Della Selva. London: Karnac Books, 1996.

Reviewed by Jon Frederickson

This book is considered by many to be the best introduction to Davanloo’s version of short term therapy. Based on Freud’s second theory of anxiety, Davanloo holds that any feeling, thought, or action which could lead to separation from a loved one is dangerous, arouses anxiety, and is avoided. Symptoms arise as compromises between the wish to express a feeling to a loved one and the defense against doing so. Symptoms and defenses keep the anxiety, and feelings propelling it, out of awareness. Defenses against feeling create the symptoms and presenting problems which bring the patient to therapy.

Thus, we focus on the underlying feeling. To do so, we ask the patient to discuss a problem area. Then we identify the triangle of conflict: the impulse/feeling, anxiety, and defense. Then we show the patient how defenses create the presenting problem and invite the patient to join us in the therapeutic task. The therapeutic task can be summarized as follows: help the patient see this conflict, tolerate the anxiety, turn against the defenses, and face and experience as much of the warded off feeling as possible. The goal is to help the patient experience her feelings and desires rather than avoid them and to substitute for each defense an adaptive response. This leads to symptom elimination, greater self-empathy and intimacy with others.

Coughlin then defines the concepts of impulse/feeling, anxiety, and defense. Impulse/feeling has three components: the cognitive label [e.g. sadness], the physiological experience [heaviness in the chest], and the motoric impulse [the urge to cry]. All three components must be activated to access the unconscious. Anxiety does not refer to a conscious fantasy. Anxiety refers to unconscious pathways of discharge in the body: striated muscle, smooth muscle, and cognitive/perceptual disruption. Each pathway of anxiety discharge has important implications for treatment. Defenses are also categorized and examined for sytonicity.

Coughlin describes the central dynamic sequence: 1) inquiry into the patient’s difficulties; 2) defense analysis; 3) rise and breakthrough of complex transference feelings; 4) de-repression of important memories and feelings; and 5) interpretation and consolidation of insights.

Key elements receive emphasis: maintaining a consistent treatment focus in spite of the patient’s defenses; identifying defenses systematically; helping the patient distinguish feelings from defense; turning the ego against the defense; eradicating defense and resistance through pressure to feeling and challenge to defense. The goals of defense work are to de-sensitize the ego to previously toxic affects, allow de-repression of key memories and feelings, and use this information to make meaningful interpretations which link conflicts in the past, present, and transference relationships.

A separate chapter is devoted to restructuring regressive defenses. Here, the goals are to undo regressive defenses, re-direct the pathway of impulse/feeling into awareness, and build the ego so that impulse/feelings can be experienced directly. Separate chapters are devoted to grief work, positive and erotic feelings, working through, and termination. Each section is filled with numerous clinical examples.

Available for purchase at Amazon.com.

Reaching through Resistance: Advanced Psychotherapy Techniques, by Allan Abbass, MD. Kansas City: Seven Leaves Press, 2015.

Reviewed by Nat Kuhn, MD

First, I know that nobody has a very long attention span these days, so the executive summary of this review is: if you are interested in Habib Davanloo’s Intensive Short-Term Dynamic Psychotherapy (ISTDP), whatever your level of experience, buy this book and read it. If you are starting out with ISTDP and trying to figure out which book to read first, this is the one.

After years of training with Davanloo, Allan Abbass has gone on to devote his life and career to practicing, researching, and disseminating ISTDP. He is currently Professor of Psychiatry at Dalhousie University in Halifax, Nova Scotia, where he is the founding director of the Centre for Emotions and Health, which he has built into what is arguably the world’s leading center for ISTDP teaching and research.

I first saw him present at an IEDTA conference in 2003, and I have attended his annual immersion in Halifax pretty much every year since 2008. What is it about his approach that keeps me and others coming back, year after year? First, he has an enormous wealth of clinical experience, which I believe has enabled him to boil ISTDP therapy down to its absolute essentials. At the same time, he preserves a deep humanity in dealing with patients. Finally, he has a gift for clear exposition, a rare quality in the world of dynamic psychotherapy, in my opinion.

Those of us who follow him knew he was writing a book, and of course we were looking forward to it eagerly. We knew it would be really, really good. We knew we would learn a lot from it, and others would as well. We knew he would pour his enormous experience, humanity, and clarity into it. What we didn’t know was that it would exceed our already high expectations: that it would be a masterpiece. It is.

Allan’s writing is like his speaking: clear, direct, and always connected to the reality of the therapy encounter. It is simple but never simplistic, allowing him to approach the ideal attributed to Einstein that “everything should be made as simple as possible, but not simpler.” Beginners can—and should—embrace this book, but there is enormous value here for experienced therapists as well. I cannot summarize the book adequately in this review, but I will try to give an overview emphasizing aspects of the book that may be less familiar to therapists who have trained with other ISTDP teachers.

The book has two main parts. In Part 1, “A New Metapsychology of the Unconscious,” Abbass spends 5 chapters outlining Davanloo’s underlying theory, including: attachment trauma; Malan’s two triangles, and unconscious feeling, anxiety, and defense; transference, and complex transference feelings; the unconscious therapeutic alliance; and Davanloo’s spectra of patients suitable for ISTDP.

Part 2, “Clinical Application,” consists of 12 additional chapters showing how the theory of Part 1 underpins a coherent, powerfully effective, rapid psychotherapy that is appropriate for a very broad variety of patients. Built around the interventions of pressure, clarification, and challenge (including head-on collision), Part 2 demonstrates the simultaneous use of these interventions as diagnostic and therapeutic instruments. The first chapter of Part 2, “Initiating Treatment,” discusses how to start treatment in ISTDP, but in addition it outlines a key aspect of Abbass’s distillation of Davanloo’s teachings: 5 main parameters to monitor as treatment proceeds (more on these below), and an algorithm to help sort patients into broad psychodiagnostic categories that guide treatment (low, medium, and high resistance, high resistance with repression, and fragile). Chapters 7-11 flesh out the details of these interventions and concepts, and the remaining chapters, 12-17, focus on how to do therapy with each of the psychodiagnostic categories. The book closes with an appendix ably summarizing the research base for short-term dynamic psychotherapy (STDP) in general, and ISTDP in particular.

In many ways, the book mirrors Abbass’s therapeutic minimalism: if it’s essential, it’s there, and almost everything else is boiled away. The theory, and basics of the technique, are presented in a condensed way: the first 12 chapters average just 8 pages each. The remaining 5 chapters, focusing on clinical cases with extensive transcripts, average 55 pages. Even so, there is something here for everyone: in addition to the graphs and diagrams that Abbass has used for years to clarify ISTDP theory and technique, in this volume he expands ten Have-de Labije’s “front door/cellar door” metaphor to include a punitive king (superego) who keeps a prisoner (the patient’s true self) trapped in a dungeon (resistance). In his hands, this becomes an allegory that organizes the psychodiagnostic categories in an affectively memorable way. And while Abbass generally attributes his teaching directly to Davanloo, in this volume he does introduce the term “bracing”: an intervention which combines pressure with intellectual recap, used in the graded format when the patient’s anxiety is hovering around a threshold.

*

Proficiency in ISTDP, perhaps more than any other therapy, demands an intimate integration of theory and practice. A central principle of ISTDP technique is “response to intervention,” which means that attention to what the patient says, and what the therapist says in response, is absolutely essential. For this reason, the primary focus in teaching ISTDP is on video recordings. That is as it should be: I believe that it is impossible to learn ISTDP without close attention to video recordings of actual therapy.

However, the therapist’s next intervention is informed not just by the patient’s last response, but also by the overall arc of the therapy session and, to some extent, the therapy as a whole. Focusing on specific interactions without a way of understanding their context within the session can lead to an overemphasis on individual interventions while losing track of the “big picture” of the therapy process. One of the great strengths of Reaching through Resistance is that it always maintains the balance between moment-to-moment interaction and an understanding of that big picture.

There have been various approaches to the big picture, starting of course with Davanloo’s “central dynamic sequence” (CDS), which he called the “roadmap to the unconscious.” In the CDS, a therapy session is divided into a series of phases: the phase of inquiry, phase of pressure, phase of challenge and so on. Davanloo repeatedly acknowledges that this approach has its limitations, for example noting that “not all therapies proceed in exactly this sequence. The phases tend to overlap and proceed in a spiral rather than in a straight line (2000, p. 40).” A complementary approach is offered by ten Have de Labije and Neborsky with their own “Roadmap to the Unconscious” (2012, Fig. 20).

Abbass, based on his training as Davanloo continued to refine his technique, emphasizes careful tracking of 5 parameters which vary from moment to moment during a therapy session. The result is less like a driver consulting a roadmap to turn left at a certain point, and more like a pilot continuously adjusting controls based on constant feedback from her senses and from instrument readings. The 5 parameters are:

• the active unconscious anxiety discharge pathways (striated muscle, smooth muscle, cognitive-perceptual disruption);

• the presence and height of thresholds (transitions from one anxiety pathway to another);

• the active major defense patterns (isolation of affect, repression, projection, etc.);

• the degree to which resistances are syntonic versus dystonic; and

• the degree of “rise in the transference” (that is, the mobilization of the “triple factors” of complex transference feelings, the transference component of the resistance, and the unconscious therapeutic alliance).

These parameters, along with an assessment of whether the patient is currently exhibiting feeling, defense, or over-threshold anxiety, guide both the choice and the vigor of the therapist’s next intervention.

Of these 5 parameters, the trickiest to assess—and the one that is least familiar to those who have trained with other teachers—is undoubtedly the rise in the transference, or more simply “rise.” The therapist gauges the degree of rise (low-, mid-, or high-rise) primarily by observing the transference component of the resistance (the degree to which the patient is erecting an interpersonal “wall” with the therapist) and the observable degree of intrapsychic conflict, as discussed in Chapter 8.

When anxiety is in the striated system, interventions are to be guided primarily by the degree of rise. In general, the appropriate interventions are:

• low rise: pressure only;

• mid-rise: pressure, clarification, some challenge;

• high rise: a high degree of pressure, clarification, and challenge (head-on collision).

While Abbass does not ignore the CDS, monitoring of the parameters is what enables the therapist to weave the phases of the CDS into a coherent and effective spiral. The CDS is a general map, but it is the parameters that help the therapist negotiate the particulars of the terrain.

Reading the book has given me an opportunity to reflect on Abbass’s discipline as a therapist, and to see that what he teaches is truly what guides him as a master therapist. For example, despite perhaps half a dozen viewings of Abbass treating moderate-resistance patients similar to the one presented in Chapter 13, I was amazed, reading the transcript, at the amount of pressure relative to the sparing use of clarification and challenge. To convey a sense of this, I decided to count. In the section on “Initial Phase and Psychodiagnostic Evaluation” (pp. 105-7), the therapist has 23 speaking turns; I counted 17 pressures, 6 clarifications, and zero challenges. On the next 5 pages (108-112), after the process gets to mid-rise, I counted 23 pressures, 16 clarifications, and only 5 challenges in the therapist’s 34 speaking turns. At that point the session turns to the somatic pathway of rage.

*

Not every ISTDP practitioner or teacher will want to adopt Abbass’s therapeutic and expository minimalism, any more than every Buddhist wants to adopt Zen minimalism. After reading this book, ISTDP trainees will have many gaps, which will need to be filled by clinical experience, supervision, studying video, and other reading. But to the extent to which they absorb this book, they will have a solid foundation for organizing their subsequent ISTDP experience. And even if minimalism is not to your taste, Abbass’s work is always a towering reminder of what is essential, and what is possible. This book, and the work it chronicles, are gifts to our field.

Davanloo, Habib (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD. John Wiley & Sons.

ten Have-de Labije, Josette & Neborsky, Robert (2012). Mastering Intensive Short-term Dynamic Psychotherapy: A Roadmap to the Unconscious. Karnac.

Co-Creating Change: Effective Dynamic Therapy Techniques, by Jon Frederickson.  Kansas City: Seven Leaves Press, 2013.

Reviewed by Tony Rousmaniere, PsyD

(Originally posted 19 November 2013)

The theory and practice of Intensive Short-Term Dynamic Psychotherapy (ISTDP) has been described well in multiple publications.  Through these books, practitioners can gain an accurate and impressive picture of what ISTDP looks like in actual practice.  What has been lacking, however, is a textbook on ISTDP that provides guidance on specific techniques to match the theory; in other words, a “how-to” book.  Co-Creating Change: Effective Dynamic Therapy Techniques, by Jon Frederickson, aims to be the first textbook that comprehensively covers the full breadth of ISTDP theory: working with low-resistance to fragile cases; anxiety regulation; superego pathology; and the subtle nuances of addressing character and transference resistance.  Given the complexity of ISTDP, this is an ambitious undertaking.  However, Co-Creating Change succeeds admirably.

The book is organized in a series of logical steps that guide the reader progressively from more basic ISTDP concepts (e.g., the working alliance) up to the most advanced topics (e.g., transference resistance).   Each step is illustrated with simple diagrams, akin to flow-charts, helping the reader conceptualize the progress of therapy.  As is customary in ISTDP publications, every topic and point is illustrated via transcripts of real ISTDP cases.  Although the book was clearly written as a practical guide to ISTDP, it also includes a host of academic references to notable and timely topics, including neuroscience, attachment theory, and psychoanalytic theory.

Crucially, the writing style throughout Co-Creating Change is very clear, consistent, and coherent, which is crucial for the learning of ISTDP.  Along with the transcripts, learning points are repeated from multiple perspectives, so readers can better learn both the underlying theories and techniques for practical applications.  The book frames each ISTDP topic in terms of the underlying theory (e.g., how defenses operate, from a neuroscience perspective, and the attachment theory underlying why people develop character resistance.)

Co-Creating Change does have some omissions, such as a discussion of various methods for ISTDP learning and training.  As founder and faculty of the ISTDP Institute, Jon Frederickson has developed an innovative toolbox of ISTDP training materials, such as webinars, technique “drills,” and audio skill-building exercises.  A description (with examples) of these methods would have been a valuable addition to this book, and hopefully will be included in follow-up volumes.

One last feature of Co-Creating Change worth noting is its attempt to reach out to the much larger community of psychodynamic psychotherapists.  The theory and techniques described in the book are presented as “Dynamic Therapy” techniques—not just ISTDP techniques.  By doing this, Frederickson breaks down the false wall separating ISTDP from the larger psychodynamic community, and helps frame ISTDP in more accessible terms.  It is hoped that future publications will follow this path.

Restructuring Personality Disorders: A Short Term Dynamic Approach, by Jeffrey J. Magnavita.  New York: Guilford Press, 1997.

Reviewed by Jon Frederickson

(Originally posted 29 May 2006)

The goal of short term restructuring therapy is to provide a new structure to the patient’s personality and to resume ego development. Whereas many EDT books focus on rapid access to unconscious emotion, this book focuses on developing the ego capacities which are missing in a fragile patient population. In this book, one learns how to help develop the following ego capacities in the patient: 1) ability to see his defenses; 2) ability to see how his defenses interfere with his goals; 3) how his defenses arise in response to feelings and anxiety; 4) ability to turn against his defenses; and 5) ability to face previously warded off emotions and experiences. We can take these ego capacities for granted with the high functioning neurotic patient. However, with the personality disordered patient these ego capacities are often absent and must be developed through personality restructuring. To do so requires the following steps:

1. Help patient see a maladaptive personality trait, pattern, or style, and how it interferes with his goals and creates his symptoms.

2. Use past, current, and transference relationships to highlight these patterns.

3. Assess whether to pursue comprehensive restructuring or a graded approach. Then select which methods to use: defensive, affective, or cognitive restructuring.

4. Bring feelings from core difficulties to the surface and help the patient metabolize them.

5. Encourage more adaptive patterns and activities which were previously avoided.

6. Process patient’s experience and reaction.

The book includes sections on assessment, diagnosis, typical problems and issues with the personality disordered patient, and flexibility of treatment. But where it makes a unique contribution is on the process and technique of treating personality disordered patients. Separate chapters are devoted to the process and unique difficulties one can encounter with cluster C (treatment refractory), B (mixed results), and A (treatment responsive) patients. Whereas many EDT books focus on the intense experience of affect, this book focuses on helping patients gradually develop the ego capacity for more intense affective experience without channeling their anxiety into cognitive perceptual disruption, somatic pathways, or the smooth muscle system. The book is also unique in its flexibility of approach, its recognition that no one single way or working will be ideal for each patient. Many examples are given of how to make treatment focused, short term, and directive, but flexible and responsive to patient needs and vulnerabilities. For readers accustomed to dramatic cases such as those of Davanloo, you may find these cases bland. This would be a mistaken judgement. There is much subtlety in this smooth, collaborative approach with hard to reach patients, a subtlety which is often more apparent after several readings.

(Originally posted 16 November 2014) The Collected Writings of Josette ten Have-de Labije, PsyD and The Collected Writings of Robert J. Neborsky, MD.  Del Mar, CA: Unlocking Press, 2010.

Reviewed by Arno Goudsmit, PhD

Reading this double volume of the collected writings of Josette ten Have-de Labije and Rob Neborsky, one comes to be impressed. The books offer a wide variety of reflections on, and interpretations of, Davanloo’s teachings. They are full of wonderful ideas and, even more importantly, full of the authors’ personal interpretations and wisdom on how to bring these ideas into fruitful therapeutic praxis.

Let’s start with some critical remarks and let’s end with the good news. While reading, one inevitably comes across topics that have been covered already in a previous chapter, or that will be elaborated in more detail in a later chapter. These repetitions are unavoidable in a straightforward compilation of papers written over more than a decade. It is pointless to enumerate the second and third times one comes across passages already met elsewhere. This is a drawback of the books. They would have deserved a rewritten presentation as a twin monograph, a digraph. And they would at least have deserved more rigorous editing. For instance, on p. R-10, we find a real Dutch “nee” left to itself, a justified correction memo apparently not elaborated, by oversight.

But there are better things to note. The project of co-publishing the two authors’ collected writings emphasizes their close collaboration and kinship. Nevertheless there are also differences of scope. Josette and Rob differ in their emphases and priorities. For Josette the major goal seems to be the elaboration of Davanloo’s work in terms of more specific criteria for recognizing behavioral cues and in terms of more specific descriptions of therapeutic technique. For Rob the major goal seems to be a theoretical reflection on issues of attachment and loss. This is not just a theoretical hobby; it is a way of founding and justifying his attachment-based approach to ISTDP.

Rob’s emphasis is upon attachment and object relations. His theoretical remarks on the Klein-Bowlby issues are of particular importance. Take the “re-united Klein-Bowlby camp” (p. R-121). It is that current events and persons on the one hand, and on the other hand the archetypical unconscious phantasies and psychological needs of the infants may meet and mix up in the etiology of neurosis. Such meeting enables real life to become a locus of truly new and truly deep experiences that affect old objects and old relationships, and, vice versa, a locus where old issues may influence current experiences and affects. If this has been Davanloo’s original idea, it is at least Rob’s focus: “[Davanloo] has unknowingly healed the split between Klein and Bowlby by integrating the role of actual relationship into the pathology of the superego” (p. R-121). These ideas help the therapist to move freely between current, past and transferential issues, link and allude to them together, and weave metaphorical relations between them. And this is what Rob is demonstrating in his vignettes and what makes up the fluidity of mind that constitutes the core of his craft.

Another important contribution Rob makes is the differentiation between shame and guilt. This text, I think, is among the best of original theorizing presented in our field of EDT. As a result of pointing out that shame originates from a developmental stage earlier than guilt, we may come to deal with a patient’s shame differently, as an anticipation of (projected) social expulsion (p. R-92), rather than as the regular superego issue.

Josette’s emphasis and scope are different from Rob’s. She presents herself as a true disciple of the Master, elucidating and expanding his ideas, whereas her own creative additions and valuable elaborations are modestly not announced explicitly as new work. But in fact that’s what they are, offering fresh emphases, combinations and insights.

Josette’s project is to offer a practical way of applying Davanloo’s concepts, to add empirical criteria, both for diagnosis and for therapeutic technique, so that the practitioner’s work may be guided by more and easier empirical tokens and by concepts that are defined more in detail. She uses the term “maintaining Davanloo’s discovery” in the title of several papers. Her major commitment is to describe executable steps for the various aspects of his technique, and to describe observation criteria (“operationalizations”) for the theoretical concepts, so that theory and technique can be practiced better and taught better. This culminates in a variety of schemas and schedules, the most famous of which is known as the “red and green traffic lights” (p. J-105), a detailed flow chart of decision criteria and feedback loops of action steps.

However, it is not always clear which purpose (practicability of the technique, concreteness of the observation criteria, or both) is being served by a particular schema. A listing of observation criteria may be in need of some inner structure. For instance, the various criteria for a patient’s full experience of emotions (e.g., p. J-182) have more interdependence than an enumeration may convey. How are these criteria interrelated and how can these interrelations be expressed with maximum parsimony? Likewise, which of the steps that a therapist has to perform (pp. J-183ff) are meant to be consecutive in time, and which steps are logical derivations? The relations between terms may be missing, as in the extensive table on verbal versus nonverbal defense mechanisms at the levels of stimulus and response (pp. J-92ff). Without a detailed elaboration this lengthy table is not maximally effective for teaching.

A pitfall of her didactic approach, I feel, is that the reader may become immersed in rules and details that make up a certain codification of the technique, whereas the practicing therapist would also have been helped by tools for simplifying things, such as to learn how Josette manages to apply her astounding clarity of mind in complex situations. Accordingly, the application of codified technique may suffer from some static qualities, so that, for those mastering the technique, what matters is to preserve one’s freedom, that is, one’s capacity to vary and to experiment with this technique and not be overrun by it.

On the other hand, her writings and teachings, her vignettes and theoretical reflections have shown her clarity of mind and the precision of her craft. She is capable of integrating so many of the details she describes, of finding creative modes for addressing a patient’s healthy and adaptive parts, and of joining with these and empowering them for a joint effort against superego pathology. Her recommendations for making sharp distinctions between ego and superego are most helpful for a therapist who finds himself lost in a labyrinth of resistances. Likewise, the idea that a benevolent superego may come to replace the punitive one is self-evident only due to her lucid clarifications, and it helps the therapist distinguish pathological from healthy superego issues.

I would have liked to see more about her personal style of intimidating the patient’s superego. Though not described in these terms, it deserves recognition and serious study in itself, as a valuable technique. The therapist may say:
“Yes, that’s what you do. Then you behave self-negligent. I ask you whether you understand my language.” (p. J- 61)
or:
“You think so too, you agree with that, not because I say so but because you see the sense of it?” (p. J-118)
These lines do not sound very nice, but the truly reassuring effect they may have when addressed to a patient with a vindictive superego is not to be underestimated. This way of dealing with superego pathology deserves serious study and recognition. It demands from the therapist a capacity to make an exact distinction between superego and adaptive ego, so that the patient will feel supported rather than attacked. It demands an exactness of timing and strength, so that confusion is avoided. It demands courage.

In conclusion, in this twin volume these two major proponents of ISTDP allow us to enter into their workplaces and have us watch the thoughts, the tools, and the instruments as they are using them. Thank you, Josette and Rob!

(Originally posted 16 November 2014) Intensive Short-Term Dynamic Psychotherapy: A Reference, by Nat Kuhn.  Experient Publications, 2014.

Reviewed by Maurice Joseph, MPsy

Nat Kuhn’s Intensive Short-Term Dynamic Psychotherapy: A Reference is enjoyable and relatable in a way that I never imagined a dictionary could be. It is a massive contribution to the ISTDP community. Relevant for beginners and veterans of ISTDP, it is also a welcome bridge to the larger psychotherapy world.

Beginning with his introductory comments, Nat’s book includes one of the best representations yet available of the attitudes necessary to provide effective psychotherapy, and in that sense it is a major ethical and philosophical contribution to our field (see, for example, entries on Neutrality, Support, Omnipotence, Disrespect, Advice). Nat models a position of striving for expertise and openness to new information that is essential to the mastery and application of any model of psychotherapy.

Another powerful contribution of the book is the inclusion of personal communications with leading teachers in the field, especially Abbass and Frederickson, and references to immersions and supervisions with them. This allows readers access to information that is not yet published elsewhere. Nat also provides detailed definitions of concepts such as Working Through, Termination, Crystallization, Phase of Consolidation, Complex Transference Feelings, Head-On Collision, Projection, and Portrayal; introduces new ideas (e.g., Externalism, Incrementalism); and has moments that are beautifully poetic (see Sadness).

ISTDP purists will appreciate that Nat integrates recent developments in the model while ultimately staying true to Davanloo’s metapsychology. By linking these concepts to psychoanalytic theory, Nat makes the model more accessible to people with a psychodynamic background. His thoroughness and clarity of thought and language will also make the model more accessible for cognitive-behavioral therapists. Comparisons to other models (e.g. “supportive” psychotherapy, Tomkins’ affect theory, psychoanalysis) showcase the advances made in Davanloo’s new metapsychology of the unconscious.

Fortunately, Nat is turning the Reference book into a living document by creating a website (http://www.istdp-reference.org/) where we can submit or suggest edits, critiques, or additions. I look forward to watching this text grow and change, and will certainly recommend it to fellow students of ISTDP for years to come.

Archeology of Mind: Neuroevolutionary Origins of Human Emotions, by Jaak Panksepp and Lucy Biven.  Norton Series on Interpersonal Neurobiology, 2012.

Reviewed by Kai MacDonald, MD

1. Introduction

I AM A REVIEWER, AND THOU SHALT READ NO REVIEWS OTHER THAN THIS.

In some of the (slightly different) iterations of the Bible’s Ten Commandments, the solemnity of the first few injunctions is emphasized by their being cast in ALL CAPITAL LETTERS. 2000-plus years later, this all-caps scheme is considered bad form in many email forums (it’s the electronic equivalent of YELLING), and often signals an eruption of what in that medium is called “toxic disinhibition” or “flaming” behavior. Before reading Jaak Panksepp’s seismic 1998 masterwork “Affective Neuroscience”–in which he denotes his 7 core emotional systems in this larger-than-life format (i.e. RAGE, LUST) – I had never seen this capitalization tendency outside of the Decalogue and blog rants. Certainly never in scientific writing. In many ways, this perhaps quirky, and perhaps presumptuous (why not italics? or underline?) bending of conventional punctuation is both an apt signature for his work and symbolic of its chiseled-in-stone portent.

In this review of “Archeology of Mind: Neuroevolutionary Origins of Human Emotions (Part of the Norton Series on Interpersonal Neurobiology)”, Jaak’s most recent book (co-authored by Lucy Biven), I will address three questions. First, does Panksepp’s oeuvre, captured in Archeology, warrant this use of the LARGER THAN NORMAL disconvention? Second, what are the main theories that are rediscovered in Archeology? Third and perhaps most importantly for the helping professions and the psychotherapeutic community (for whom the book is supposedly written): is Archeology the best summary of his work?

The answer to the first question―whether Panksepp’s ideas warrant a bending of standard punctuation for time immemorial―is a conditional YES. Taking the conditional first, if you have an attachment to reading standard sentences, take a vantage 100 years hence and imagine what other earth-shaking, fundamental things may be discovered that need similar typological setting-off: “This paper will undertake a comparison between Panksepp’s RAGE system, Dr. Smiths MESOLIMBIC THETA SYSTEM and Professor Penguin’s !*#SUBSTANCE P-SENSITIVE CIRCUIT#*! “. A scientific arms race of emphasis could ensue. Furthermore, why not capitalize other scientific categories or words that could be confused with their more pedestrian variations, for example defense mechanisms like SUBLIMATION (the really important defense mechanism, not the petty transition from solid to gas), and REPRESSION. Of course, 100 years hence, a broad swath of the scientific community will be largely illiterate anyway, driven by micro-tweets and iTube, so we needn’t worry.

To justify the capital YES, we may wryly note that the import of “capitalize” comes from the Latin caput (head), where these emotion circuits lie, and that the verb form capitalize signals one will “take the chance to gain advantage from”. Capital letters (weirdly called “Tall Man” letters in some publications) have been empirically demonstrated to help with lexical confusion, at least in part by influencing eye movements (Filik, 2004). My biased belief―which Jaak has helped solidify–is that if any set of things in the world of mammalian neuroscience deserve to be set off with CAPS, the core emotion systems in the brain would fit the bill. Knowing about these systems gives significant theoretical advantage, especially to emotion-informed, evolution-endorsing therapists. Six years ago, in 2006, I first wrote to the ISTDP listserve discussing Jaak’s first book “Affective Neuroscience: The Foundations of Human and Animal Emotions (Series in Affective Science)”. At that time, it seemed to me a watershed: specifically, it was the only neuroscientific source I had seen discussing RAGE―the fireworks part of Davanloo’s ISTDP–in any depth, and in a larger context of emotional systems. At the time, it was my impression that few in the therapeutic ISTDP/STDP/IEDTA community had heard of this maverick scientist, or his scientific discoveries. Since then, Jaak has been much more widely read, has spoken at therapeutic conferences, and has branched into several psychotherapeutic forays.

In “Archeology”, Panksepp takes on a large project, albeit one that many or most ambitious, career scientist-philosophers undertake: the theory of all things. In this case, Jaak attempts to plumb the source of mammalian consciousness and mental function. Starting from first principles―(i.e. materialism and evolution)–he takes us to what he considers the bedrock of the human and mammalian mind: the subcortical and brainstem loci which are the root of what Panksepp calls primary affective consciousness. From this root, according to Jaak, the whole civilization of higher forms of consciousness spring. Anatomically, in the brain, these foundations are old, deep, centralized: vital. This journey, this delving to the ancient, buried radix affectorum, justifies the Archeology of the title.

2. The Man

A brief biopic informs a review of Panksepp’s work and Archeology. The Estonian-born Jaak began as a somewhat itinerant child, his family escaping from that country to Germany during World War Two; Jaak landing in the US in 1949. Though the majority of his research is in animals, Jaak started his training in clinical psychology at the University of Massachusetts, at a time when behaviorism was the zeitgeist. After spending time in an electroencephalography lab, Jaak became intently interested in the neuroscience of mind: his 1969 thesis is on “the Neural Basis of Aggression in the Albino Rat”. Even in this first published work, which explored the neural basis of the mouse-killing behavior of rats, we can hear the pangs of Jaak’s fellow-feeling conscience:

Since live, unanesthetized mice were used as attack victims in the present research, justifications are in order. The procedure of using live victims seemed necessitated for lack of . . . alternatives . . . it may be questioned whether the information reported here was worth obtaining at all. The author’s opinion is that research into the neural basis of aggressive behavior is presently of direct psychiatric and social concern . . . Distress to mice was minimized as much as experimental aims could allow in these experiments . . . At most, any mouse felt pain for 30 sec . . . if wounded but not immediately killed, mice were immediately sacrificed by the experimenter.”

Jaak’s empathic soul-searching and suffering-sparing evokes Burns’ “To a Mouse . . .” (which Jaak quotes in Archeology), and is emblematic of the refined sentiments he has for his “poor, earth-born companions”; these sentiments, one can see, have informed the last 4 decades of his work.

Since this telling, germinal publication, which blends empathy, compassion and implicit guilt (in the experimenter) with aggression and neurobiology (in the rats), Jaak has been obscenely prolific, with greater than 300 scientific papers on emotion, several field-spawning textbooks, and an ever-broadening spread of interests. Still early in his career, Jaak designed and published a large number of truly seminal basic-science studies on the basis of mammalian emotion. Like other giants of natural science (Darwin, Wilson, Kandel), observations from these experiments became the primordial soup from which Jaak’s later theories evolve. Included in his groundbreaking initial works are seminal discoveries about decortication (surgical removal of an animal’s cortex); electrical brain stimulation; oxytocin and its relation to separation distress; the connection between opiates and social bonding; and the role of too-high-pitched-to-hear rat vocalizations as an expression of rat’s titillation at being tickled. These vocalizations are thought to be an expression of the core PLAY circuit (see a must-see video at youTube ). As a scientist, then, Jaak’s theories about emotions do not spring–rough-clad and unanchored–from his own personal experience or ruminations. Instead, they grow out of the terra firma of peer-reviewed, published research with our animate (and, he argues, fellow-feeling) cousins.

Notably, Archeology is more personal and closer to the heart than Panksepp’s former works. In these pages–using the standard scientific metric of complete authorial anonymity–Panksepp bares all. Here, we read about the selfish lush whose drunken drive clumsily snuffed the flame of Panksepp’s daughter, Tiina Alexandra Panksepp (1975-1991). Though he dedicated “Affective Neuroscience” to her, in Archeology he shares many more details of this painful rent in his paternal life. Here also we read about his emotional reaction to that loss, his use of antidepressants, the benefits he received from psychotherapy. Here also, we read about his (and his wife(s) recent chemotherapy for lymphoma, its nearly-fatal complications, his experience with EMDR. In many ways, these personal revelations, neither mawkish nor maudlin, complement and humanize his science. In fact, I distinctly remember that this “humanization” of himself―specifically the foreword to his daughter in Affective Neuroscience–drew this reader into its pages. In his discussions of core emotions, Jaak is speaking both for the species and for himself: “archeological dig” has been deeply informed by the personal pain of loss, the experience of depression, and existential dread. Jaak, we sense, feels: like we do.

3. The Theories

In Archeology, Jaak highlights all of the ideas he has developed over his career―most which have roots in his own research. The majority of these theories are extraordinarily informative―in a general way–for people interested in human mental function, behavior and brain-based suffering. Their deep resonance with emotion-focused therapy in general and ISTDP in particular–as well as their consilience with the phenomenology seen in deep emotional psychotherapeutic work―justifies a review.

The first theory (which he develops a long, detailed, and oft-repeated proof for) is that an overwhelming majority of the available evidence suggests that mammals have primary emotional consciousness. That is, they experience emotions. Specifically, animals experience subjective states which are similar in their essence to our own unprocessed, unexamined, unverbalized, unthought-about core emotional states, the felt states of mind that occur 100-300 milliseconds after a stimulus. In ISTDP, these are the emotional responses at the bottom of the triangle of conflict. In Archeology, a great deal of ink is spent on “animals feel” blandishments, and many, many passages are spent buttressing his argument against agnostics (“how can we know . . . animals can’t talk”) and anti-anthropomorphists (”its natural―and wrongheaded―to extrapolate from your own introspection to animals”). Three key sets of facts support his “animals feel” claim, which seems obvious to the pet-loving layperson and also philosophically problematic, even dangerous, to many scientists. First, animals clearly exhibit likes and dislikes when we electrically stimulate the same brain areas that―when stimulated in humans―produce subjective feelings. If those brain areas are not creating subjectively valued experiences, what are they creating? Second, though humans have large cortexes, the cortex is not necessary―based on the behavior of animals and humans without cortexes–for what Jaak calls primary process emotional experience (that first 100-300 milliseconds). Third, given the clear homology between emotional feelings and emotional behavior, it is infinitely reasonable to infer that emotional behaviors exhibited by animals reflect the simultaneous activation of emotional feeling states.

Tracing back through this argument, we can see the three points which anchor the second of Jaak’s seminal ideas: the triangle of affective neuroscience (yes, he has a triangle, too). These points anchor a naturalistic, brain-based perspective on emotions: 1) subjectively-experienced mind (which includes the primary process affective experiences of animals), 2) brain, and 3) behavior. Thinking like a neuroscientist who experiments on animals, this triangle justifies the claim that animal experimentation can illuminate the emotional lives and ailments of humans.

A third fundamental tenet of affective archeology is that of nested layers of anatomy and experience, which draws on the principle of the layered evolution of the brain ala Paul McLean’s “triune brain” theory. This theory suggests that there are three different levels of brain function which create three different levels of emotional experience: 1. Sub-neocortical (i.e. brainstem)-based primary process emotions; 2: Basal ganglia (subcortical)-based secondary-process emotions; 3. Cortically/frontally-based tertiary affects and neocortical awareness functions. Important for ISTDP and emotion-focused therapies in general is that #1―if you allow some conceptual wiggle room―can be moored at the bottom of the triangle of conflict, #2 at the anxiety pole, and #3 in defenses. Said differently, a careful examination of the micro-phenomenology of affective experience (i.e. videotapes of emotion-focused therapy) also supports the existence of these levels, and their recursive (looping back on themselves) influences. See the free article referenced below for details and illustrations.

A fourth major part of Panksepp’s worldview identifies 7 primary affective systems, anchored in subcortical brain circuits and present in all mammals. These are (roll out the capitals . . .)

1. SEEKING (expectancy)
2. FEAR (anxiety)
3. RAGE (anger)
4. LUST (sexuality)
5. CARE (nurturance)
6. PANIC/GRIEF (separation)
7. PLAY (joy)

Each of these systems emanates from a core set of brain regions and is influenced by a cadre of contributory neurochemistries (see article, again). A large part of Archeology goes into the scientific background behind these seven systems, their implication for human ailments, and their impact in larger society and human life.

In developing and explicating these theories, and therefore in Archeology, Panksepp straddles several chasms that bedevil all attempts to describe an unbroken materialist causality from molecules to mind. First, there is the gap between homo sapiens and all the other mammalian species we currently breed and use for scientific experiments: largely, rodents, but throw in chicks and dogs and pigs and primates. The second gap is actually a series of similar gaps between different levels of understanding of the central nervous system: between neurochemistry (i.e. opiates, oxytocin, and dopamine); separable brain circuits; affective states with their embodied felt-ness; behavior; and complex, multilayered states of mind. To straddle the latter gap–between organ and experience–Jaak takes another lexical liberty and mints a mirror-image neologism: BrainMind/MindBrain. Like something plucked out of Lewis Carroll’s Through the Looking Glass, you can flip the two sides of the term as needs demand: BrainMind emphasizes the organ aspect; MindBrain the subjective. This term (terms?) captures Panksepp’s belief in what is called dual-aspect monism: an essentially materialist worldview that sees mind and brain activity as two perspectives on the same natural phenomena.

4. Archeology: The Book

One of the best parts of Archeology, at least for this “return reader”, was re-finding veins of linguistic jewels which flash brightly in all Panksepp’s work. As a writer, Jaak is a master of crafting lapidary phrases that add sparkle to the science of affect. The seven emotional brain circuits are “ancestral tools for living”, “ancestral memories of how effectively we play the game of survival and reproduction . . . passed down through the collected mindless ‘wisdom’ of our genetic code”. “Affective consciousness”, the bedrock of our conscious lives, is “an energetic form of consciousness”. A section on the RAGE circuit is given the Macbeth-inspired heading “The Rageful Furies of the Mind”. Describing the SEEKING system, Jaak notes that “these highly energized, euphoric-foraging engagements with the world” are”what some might call joyous aliveness”. Though stern scientists might rankle at these emotion-tinged descriptions and their implications, from the perspective of a scientist-author, I find them both descriptive and fetching, both here and in his earlier Affective Neuroscience. Despite these sparklings, and despite the clear relevance of Jaak’s ideas and research, Archeology’s numerous flaws too often divert the dig. Specifically, though Archeology has some advantages over the earlier Affective Neuroscience (a freshet of new illustrations, novel ideas about PLAY and LUST, the role of time in experience), I think his core themes are expressed more concisely in his former work. For the educated lay reader, Archeology had a few too many flaws, and a few too many pages. A one-sitting precis of his recent work and key ideas can be found at plosone.org .

5. Blind Spots, Rough Spots

The largest, most glaring flaw in Archeology is that it created an at-times vertiginous sensation that–though welcomed when one visits the deep “layers of history” buried in Rome–was not welcome in a more casual read. Specifically, I found myself asking again and again: who is/are he/they (more on this in #2) addressing? Novitiates to Jaak’s work may find themselves either annoyed or befuddled–or both at different times–by passages recounting details of the often-spirited neo-Talmudic infighting between the cognoscenti of neuroscience, psychology and emotion. In some of these passages, Jaak seems to be grinding a personal axe with some of his more prominent detractors, and showering us with distracting sparks. Indeed, though the preeminence of a neuroscientific perspective on our identities makes these theoretical issues important, and though the history of science informs our current state, gossipy details of the “infighting” were too frequent and too detailed.

In the same vein, but at a different level, I often found the technical writing buried in many passages too byzantine for a “layperson read”. These passages caused this reader―admittedly familiar with the language–to glaze over. For example, a section discussing a variety of small proteins (neuropeptides) that may be used as drug treatments details a variety of animal experiments using agonists (stimulators of a receptor) and antagonists (receptor blockers) contained twists and turns like this “these episodes can be inhibited by glutamate receptor antagonists… However, it is unlikely that its direct pharmacological manipulation would yield a useful antianxiety agent . . . milder stimulation through a glycine receptor “side-knob” on glutamate receptors may be a very safe and useful treatment.” Is there an expectation that lay-readers, most of whom presumably do not have a degree in neuropharmacology, will hold the thread through this labyrinth of changing acronyms and chemistries? Perhaps if the faint-of-heart reader struggles, they may benefit from taking an agonist–or was it an antagonist–of CRF . . . or was it MSH? Yet another mind-numbing section goes too deeply into the details of Pavlovian conditioning experiments, with their UCS’s, UCR’s, CS’s and CR’s: which is the bell again? The meat? The saliva? Reading these “conditioning” sections (the CS), I found myself experiencing very light nausea: my CR (conditioned response) to multistep causality and a profusion of abbreviations. Amidst this technical material, we get Twitter-ready clunkers like the revelation that when animals press a lever to electrically stimulate parts of their brain’s SEEKING system, rats get “super excited”.

A second flaw, in a work that aims to explicate Panksepp’s ideas for a lay readership, is that several of Jaak’s pet (ok, animal companion) projects are given much too thorough treatment. As discussed above, Jaak is nobly and transcendently committed to the enterprise of raising human consciousness of consciousness in animals. As highlighted by the above quotation from his thesis, he has a bodhisattva-like awareness of the suffering of sentient beings. All this is a supremely enlightened stance. Many of readers have read Singer’s “Animal Liberation” or one of its more modern variants. Many have been happy, I suspect, with the common-sense idea that their canine companions feel. Add to this project the oft-repeated flailing against the hackneyed ‘affect versus cognition’ canard, and you have a book that appears to be trying to both 1. educate and entertain the public; and 2. take detailed issue with his staunch critics. In striving too much for latter, Archeology is too long―and labyrinthine–for the former.

Panksepp wisely flew solo in Affective Neuroscience. In Archeology, his often-clumsy co-authorship with the psychoanalyst Lucy Biven creates a third, jarring flaw. Certainly, the authorial duo of a therapist and neuroscientist is a clever pairing and might leaven the work for the large “lay” readership of therapists, teachers and healers. Certainly, this two-gendered duo could be seen as representing each part of the MindBrain, like two halves of the cortex. The problems created by the partnership, however, surpass its benefits. Though we are mercifully spared the worst-case authorial Jabberwocky that could have resulted (the use of BivenPanksepp/PankseppBiven), several sections of this book are annoyingly author-aware. In different chapters, we may hear from our authors that “we have intentionally not dwelled” on this or that topic, whereas later–speaking for himself–Jaak discusses “his” ideas with the personal “I”. Delightful in an opera, I found the solo-pair-solo dynamic too distracting amidst often-challenging conceptual material. On top of this, Biven’s theoretical leanings often mean that “psychotherapy” equals “traditional psychodynamic psychotherapy”. For example: “when affects maintain the upper hand, the talking cure is apt to fail because the interpretive method, the cardinal psychotherapeutic tool, can frequently be ineffective in the face of our primal passions.” Later, Jaak (I assume here he is speaking for himself) seems to displays a subtly supercilious attitude toward analysis and perhaps even psychotherapists when he says that “neuroscientists are the only tribe of scientists that will ever be able to clarify the mechanisms of mind”. Sadly, Jaak, when he takes up the job of discussing some “new ways to help establish affective well being”―the work of Diana Fosha and Les Greenberg―he must go it alone. In this section, Biven explicitly opts out, for “the junior author did not wish to be affiliated with those views”. Though one respects her commitment to ideological purity, one wishes her affiliation with the unity of the work–and the experience of the reader–had surpassed her personal affiliation with her views.

Besides these specific shortcomings, several aspects of affective neuroscience specifically relevant to the psychotherapies are excluded. The role of attachment―the human crucible for affective learning–in the process of human emotional development is underplayed. Regarding the latter, though basic-emotion-demonstrating humans can survive without a cortex (an oft-cited argument against the “emotional processes are cortical” argument), few actually do. The anticonnectionist (here, I mean the complex, dynamic, and evolving connections between different brain areas, which actually change as the result of therapy), antidevelopmental implications of a cortex-minimizing model flatten the nuances of the complex neurobiological process of real human development. The cross-level process between midbrain, subcortex, and cortex includes the development of vital mental attributes: emotion regulation, theory of mind, the complex self. Specific to psychotherapy, the important topics of guilt and shame are barely mentioned. Finally, experienced psychotherapists may find some of the well-meant psychotherapeutic suggestions alternatively too Chicken Soup for the Soul–“two major ways to restore your composure are taking a few deep breaths and reflecting on who you want to be”–and too preachy: catharsis is “not good for you”, and “you should want, in the long term: . . . ‘mindfulness and wisdom’ ”. Amen.

As a psychiatric clinician, I often use the divining rod question “how might this help the next the person in front of me?” as a yardstick. Using this metric, I find an affective neuroscience classification model often falls short. As illuminated by our financial support of at least two of classification schemes (the DSM system and RDoC―the NIH’s new tax-supported Research Domain Criteria), brain-based human ailments are currently not able to be illuminated, studied or treated within any single explanatory model. Schizophrenia, substance-use disorders and social phobia―just to stay in “S”, are informed by an affective neuroscience model, but certainly not encompassed or explained by one. During our short lifetimes, our classification schemes may always vaguely resemble Jorge Luis Borge’s fanciful Celestial Emporium of Benevolent Knowledge, which divides animals into ramshackle categories like “embalmed ones”, “those that are trained”, “those that tremble as if they were mad”, and “those that, at a distance resemble flies”. Though Panksepp’s theories are important tools in our understanding of mammals, humanity and some of humanity’s ills, the “theory to treatment” arc of the affective neuroscience worldview is sometimes hard to traverse.

If, in spite of this work’s shortcomings, the SEEKING reader chooses to plunge into Archeology, take CARE to go armed with a spade of patience, a map of the blind alleys, and an understanding of the project’s history. Do not FEAR; you will certainly emerge with more than a handful of treasures.

Resources

PLOS ONE. Cross-Species Affective Neuroscience Decoding of the Primal Affective Experiences of Humans and Related Animals by Jaak Panksepp.

YouTube: Rats Laugh When You Tickle Them.

Amazon.com: The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions (Norton Series on Interpersonal Neurobiology)

Mastering Intensive Short-Term Dynamic Psychotherapy: A Roadmap to the Unconscious, by Josette ten Have-de Labije and Robert J. Neborsky. London: Karnac, 2012.

Reviewed by Robert Tarzwell, MD, FRCPC

This is the newest entry in the very small group of textbooks of brief psychodynamic psychotherapies, and it is welcome. With careful editing, it could become great book, showing potential to be recommendable as the mandatory text for the field.

Its 13 chapters review Davanloo’s discoveries, attachment theory, developmental psychopathology, the neurobiology of anxiety and affect, and their regulation via defences, framing the chapters on clinical application. MISTDP’s worthwhile ambition appears to be greater than simply imparting technique. Intellectual rigour is sustained through the book, with frequent discussions invoking psychology, neurophysiology, receptor pharmacology, comprehensive use of DSM and ICD nosology–and frequent reference to situations where ISTDP may, crucially, not be the treatment of choice–a refreshing scientific humility. The clinical techniques are rich and clear. Transcripts appear carefully selected as paradigmatic examples of specific clinical phenomena. As ISTDP apprentices soon learn, and journeymen regularly attest, the beguiling simplicity of Davanloo’s Central Dynamic Sequence frequently feels much more like attempting to lasso and ride a scared horse in a thunderstorm. Transcripts of this clarity are a crucial foundation to trainees regarding how therapy can proceed with a strong alliance, and I freely admit to having already incorporated many of the authors’ phrasings and techniques, with good effect.

The book is not perfect. Its innovative “Red and green traffic lights on Davanloo’s road to the unconscious,” found on the colour plate, is poorly introduced and wielded. To the good, it guides ISTDP interventions from patient responses, a unique addition to the pedagogy. However, it is not adequately explained within the text, and I had to brute-force my way through it and its uses in the clinical application chapters. This useful device risks being ignored by many students. The diagram needs to be right at the start of the technique chapters, interwoven with the CDS, and thoroughly explained. This would make the cryptic traffic-light figures accompanying each transcript much clearer. This single investment, though it demands a significant reworking of the text, would make this good book a great book.

ISTDP deserves a textbook as great as MISTDP could be. The traffic-light caveat aside, I recommend this text. I hope its example of rigour becomes an implied challenge to other authors in brief dynamic therapy to avoid shortcuts and fully embrace the rich complexity this field deserves. This is precisely the kind of intellectual calibre, which has the potential to move our field out of the psychotherapeutic shadows and into the full light of day.

Psychotherapie dynamisch intensiv direkt: Lehrbuch zur Intensiven Dynamischen Kurzpsychotherapie, by Paul Troendle. Psychosozial Verlag, 2005. Regretably, not available in English at this time.

Reviewed by Esther Rosen, PhD

Everything you ever wanted to know about ISTDP, – “Intensive Short Term Dynamic Psychotherapy” – the” ins and outs” of this fascinating psychotherapeutic treatment approach, you find in this very comprehensive book. In this German text Troendle provides a rich foundation of philosophical thought and scientific findings from areas such as anthropology, Freud´s psychoanalysis, developmental psychology as well as Neurosciences. His rendition of theory and technique of this captivating paradigm of psychotherapy is rich, precise, and clear. Troendle´s vast and detailed knowledge of the classical as well as the contemporary psychoanalytic thinking provides a strong context in which he presents us with the ideas of Habib Davanloo, the founding theorist and clinician of ISTDP.

The goals of ISTDP are identical to the goals of the psychoanalytic treatment: The therapist aims to change the character pathology of the patient by resolving the core neurotic conflict. Cornerstone of ISTDP is a conceptualization of emotional processes based on Freud’s original understanding yet crystallized in two simple models which were formulated originally by Menninger, Malan and then Davanloo; the triangles of conflict in connection with the triangle of person. This conceptualization serves the ISTDP therapist as an understanding of the state of the patient at any moment. Is the patient engaging in defense, experiencing anxiety or is he experiencing a feeling or impulse?

In following a carefully developed sequence of interventions and techniques, the “Central Dynamic Sequence”(CDS), the ISTDP therapist is aiming for a break through to the unconscious. By way of applying several well defined techniques such as pressure to feeling as well as challenging the resistance the therapist seeks to develop an alliance with the patient that goes beyond conscious cooperation. The patient’s repressed emotions pushing toward a conscious experience the “unconscious therapeutic alliance” (UTA ) constitute an important therapeutic factor in Davenloo´s understanding of the therapeutic process. A “major unlocking” of the unconscious enables the patient to experience the whole spectrum of the complex emotions. The experience of the murderous rage, guilt, pain and grief is the precondition for real forgiveness and deeply felt exoneration. Now the channels are free for the capacity of love. The most important therapeutic element is the patient´s insight into his unconscious guilt related to his murderous rage. The psychopathology of the patient is directly linked with the patient´s tendency to punish himself as a means to deal with his unconscious guilt. The more intensely the patient is experiencing his guilt, the more the patient´s resistance will decrease.

Troendle´s presentation of the central dynamic sequence offers the student of ISTDP a rich palette of examples of interventions as well as their rationale, detailed explanations, practical suggestions and caveats about the likely mistakes of a beginner. The reader will also find a diverse array of vignettes based mostly on Troendle’s own clinical work.

While Davanloo originally saw patients with low anxiety tolerance, high fragility, and superego pathology as inappropriate candidates for ISTDP, Troendle describes modifications of the original process of therapy – the graded technique which allow a much larger patient population to benefit from ISTDP. Troendle offers lists of patient characteristics that would still lead to the exclusion of a patient from the treatment of ISTDP, which include patients with severe cognitive disruptions such as psychotic processes as well as patients with endogenous depressions, chronic alcohol and drug dependency.

Paul Troendle`s book might well assume the place of a bible within the community of ISTDP therapists. It is by far the most comprehensive textbook of ISTDP theory and technique available today. The student of ISTDP will not just read it once and then put it aside. This book will serve as a critical reference book in the understanding of theoretical concepts and their application to the therapeutic work. One can only hope that it is eventually translated into English to be available to a wider readership.

The Transforming Power Of Affect: A Model For Accelerated Change, by Diana Fosha. New York: Basic Books, 2000.

Reviewed by Jon Frederickson

Accelerated Experiential Dynamic Psychotherapy (AEDP) is a model of treatment which holds that what heals is not so much the de-repression of buried feelings, but the transformative experience of powerful affects within a secure attachment with the therapist. This transformative experience “unlocks” the patient’s adaptive strivings and deep motivation for change. Psychopathology is understood as the product of a compromised capacity to process affect—a result of a poor attachment in which the patient had to bear an experience alone. Hence, undoing aloneness is at the center of the therapeutic process.

AEDP moves from an intrapsychic to a relational perspective. For instance, an entire chapter is devoted to relational strategies. The therapist will explicitly track how the patient is taking her in, how the patient experiences her support, how the patient reacts to her empathy, her disclosures of affect, her disclosures of how the patient has affected the therapist. The therapist may ask, “what do you see in my eyes?” In all these ways, an AEDP therapist explicitly focuses on non-verbal, relational adaptive action tendencies, what Fonagy refers to as “the present unconscious.”

AEDP therapists also do restructuring. However, this term has an entirely different meaning. They do not mean a restructuring of the ego (Davanloo) or of the defenses (McCullough). Instead they restructure defensive affective and relational patterns through an experiential focus on the visceral experience of “open” and “defensive” relational patterns. Defenses are understood as adaptive ways of maintaining attachments to troubled caretakers. The therapist will track aversive affects such as anxiety and shame which trigger defenses, outline the costs and benefits of defenses, and reassure patients that they need not approach feared situations until they feel ready to do so. At the same time the therapist encourages the patient to persist in facing what they have feared. In AEDP the therapist explicitly explores the patient’s cognitions and fantasies related to their experiences of shame and anxiety in the here-and-now to find meaning and make sense of them. This clears the way for more adaptive strivings, “green signal affects”, to emerge more freely.

The therapist focuses a great deal on helping patients experience positive affects, particularly within the context of the therapeutic relationship. The emphasis is not only intrapsychic: “What are you feeling inside?”, but, equally important, relational: “What is that like for you to feel that feeling here with me?”, or “What is that like for both of us to experience this emotion together?”

In AEDP, the core belief is that offering unconditional acceptance of the patient where she is will trigger core affects and inhibiting affects based on the attachment history. Working through of inhibiting affects within the climate of affirmation facilitates the emergence of core affects. The experience of core affects leads to the patients’ experience of the core self and the experience of that core self changing in the context of a secure attachment with the therapist.

Changing Character: Short-term Anxiety Regulating Psychotherapy for Restructuring Defenses, Affects, by Leigh McCullough. New York: Basic Books, 1997.

Reviewed by Jon Frederickson

Theoretically, this is an integrative approach. McCullough replaces Freud’s drive theory with Tomkins’ theory affect. Affects, the primary movers of human motivation, amplify the drives. However, due to attachment failures, patients develop affect phobias. Therefore, the therapist must expose the patient to the avoided affects within an anxiety regulating therapeutic alliance. To do so the therapist must engage in defense restructuring: identify defensive behaviors and inhibitory affects, then show the relationship between the warded off affect, the inhibitory affects, and defensive behaviors, then help the patient relinquish the defense to experience the avoided affect. Affect restructuring involves helping the patient separate adaptive affects and inhibitory affects through repeated exposure to the adaptive affects so that the inhibitory affects lose their power. Self-other restructuring involves working with the patient’s representation of herself and of others and the aversive affects which are triggered.

The book is designed as a teaching text, hence for the beginning student it is quite useful since specific chapters are devoted to the triangle of conflict, how to formulate the core conflicts in a given case, how to help patients identify defenses, how to help patients turn against defenses, how to help patients face and experience previously warded off affects, how to help patients integrate the experiential insights which result from deep affective experience, and how to help patients restructure their inner representations of self and others. McCullough clearly links her theoretical premises to each kind of intervention. Each intervention is illustrated with numerous examples which are analyzed to show how the triangle of conflict is the organizing principle for generating interventions.

McCullough focuses on preconscious affect knowing that unconscious affect will rise with the continual weakening of the defenses. Also, her emphasis on adaptive and defensive behaviors allows her to address implicit procedural knowledge, thereby accessing the unconscious through another avenue than breakthroughs to unconscious murderous fantasies. Theoretically, she integrates: 1) the psychoanalytic concept of conflict with Tomkin’s revamping of drive theory; 2) cognitive therapy as an anxiety regulating technique; 3) behavior therapy as part of defense identification and affect experiencing; and 4) the psychoanalytic relational school as part of affect restructuring and self-other restructuring. Character change occurs through relinquishing defensive behaviors then facing and feeling previously avoided emotions with others. Cognitive, behavioral, and relational techniques are merely means to serve these basic goals. This attempt at a theoretical synthesis is unique in EDT for she is able to show how these theories operate actually at different logical levels. For instance, the conflicts which generate defensive behaviors are at a different logical level than cognitions which are merely a single dimension of the resulting character structure.

Students wanting to learn about the triangle of conflict, how to formulate conflict, and how to generate interventions will find this a very practical and easy to understand book.

Healing Trauma: Attachment, Mind, Body, and Brain, edited by Daniel Siegel and Marion Solomon. Norton Series on Interpersonal Neurobiology, W. W. Norton, 2003.

Reviewed by Peter C. van Tricht, MD (published in Ad Hoc Bulletin for STDP: Practice and Theory, 2005, Vol 9, No 2, pp 80-86)

The book “Healing trauma, attachment, mind, body, and brain” is an ambitious plan to make transparent the processes, occurring when a human being is traumatized, when he is cured from his trauma, and what processes can be followed in his brain when all this takes place.

I started reading this book with a certain dose of skepticism. Of course it is interesting, and scientifically important, to find the correlation between what happens in the brain and what happens in an interpersonal contact, but it remains to be seen, I thought, if neurobiology can add anything of value to our knowledge of psychotherapy and metapsychology.

Can we use the findings of neurobiology to understand mental processes and to improve or refine the working alliance with our patients? Can we use these findings for an actual mental health prevention program? With this premise in mind I started reading “Healing Trauma” and right away, on the second page of chapter 1, Daniel Siegel invited me to take “this seeming conceptual leap”.
In eight chapters, all of them written by different authors, we are guided through this interdisciplinary field, where three specialisms are exposed, each with its own scope, and with one purpose in common: to understand how human beings are traumatized and how they can be healed. And we soon discover (at least I did) it is a fascinating field. It’s like driving a tunnel from three sides: neurobiology, attachment theory and psychotherapy. The moment seems to have come that from each of the tunnels we can hear the other two.

Chapter 1, Daniel J. Siegel: An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and the Resolution of Trauma.

One could say that when e.g. patient and therapist are sharing emotions one mind becomes (often non-verbally) connected to another. Neurobiological research findings suggest that such a sharing of non-verbal signals may be one way in which the right hemisphere of one person “joins” with the right hemisphere of the other.

Thus a right-to-right-hemisphere communication between therapist and patient might become a well attuned successful therapy session. Or it might become a thunderous speech. Herewith the Orbitofrontal cortex (part of the limbic association cortex) plays a decisive role. Our orbitofrontal cortex is involved in the neural integration of all information from the external (what we hear, see, smell) and internal environment and has an important function in the regulation of e.g. our emotions and their motor planning.

Siegel pilots us into the really complex world of brain activity. He gives us an introduction, to mention a few things, to the development of our brain, the cortical and subcortical structures of the brain, the functioning of some brain structures (and their interconnections), the processing and regulation of e.g. information and emotions, the anatomical asymmetry in the human brain, specific functions of the left and the right hemisphere.

It’s a world, the greater part of which we only learn to know by the facilities of high tech examinations, like PET- and MRI-scans: pictures on a screen. At the same time it is at the core of our own being alive, thinking feeling and behaving and it is as far away and difficult to reach, and as fascinating, as, say, the pictures of Titan, Saturn’s moon, more than a billion kilometers from here. These bizarre pictures and colors, do they tell what happens in my head? Siegel makes us feel at home in this world (unless, of course you already are at home with the grey and the white matter).

To give you some idea of what Siegel explains: The developing brain, during the first years of life, has many neurons and relatively few synapses and is relatively undifferentiated. The basic circuits of the brain are formed that are needed for processes as emotional and behavioral regulation, interpersonal relatedness, language and memory. Genetic information is important in this development, but so is a proper experiential stimulation. Experiences with the caregiver, and especially the kind of interaction, determine to a high degree how the synapses develop. The nurturing should be good, literally and emotionally.

And he introduces some principles of chaos theory or complexity theory into his working definition of mental health, which leads him to the conclusion: “A human being is a complex system, striving to complexity”. According to Siegel, mental health can be defined as a “self-organized process that enables a person, or a relationship or a group to continually move toward maximal complexity. Unresolved trauma creates impairment to this striving and leads to either chaos or rigidity”. To give an indication, I think chaos is associated with borderline structure, rigidity with character neurosis. (So – to make things clear – an unresolved Oedipus complex, being impairment to our striving to complexity, makes us less complex, in the sense of this theory). Psychotherapy is meant to help restore the potential to complexity and thus to greater adaptive capacity, flexibility and stability.

Chapter 2, Erik Hesse, Mary Main, Kelley Yost Abrams, and Anne Rifkin: Unresolved states regarding loss or abuse can have “second generation” effects: Disorganization, role-inversion, and frightening ideation in the offspring of traumatized, non-maltreating parents.

These authors lead us into quite a different world: the world of early attachment patterns, the role of fear in early attachment and all that can go wrong with it. They are building on Bowlby’s theory. They focus on “Second Generation” effects: what happens to the children as a result of their patterns of interaction with their traumatized parents, parents with unresolved states regarding loss or abuse. These parents may exhibit frightened, dissociative or threatening behavior (“FR behavior”). Examination of children has been made at different ages: one year, six year and at about eighteen years old. The behavior of the observed children shows a differentiation in two categories:

1. organized attachment patterns, the majority, the low-risk samples

2. disorganized/disoriented attachment pattern (D)

The organized attachment patterns are either secure (B) or insecure. The insecure attachment patterns are avoidant (A) or resistant/ambivalent (C). Fear of the parent, be it the result of FR behavior or of the parent being abusive leads to a situation in which the child, being afraid, has no one else to run to but the parent with FR behavior. This leads to “fright without solution” for the child, resulting in a D pattern of attachment. This is a diagnosis that easily can be overlooked, if and when only the parent him/herself seems to be the victim. The child is well off with a parent who is at home with his/her own life history, cognitively and emotionally. That is to say with a parent with a cohesive and coherent autobiographical narrative, which appears to be characteristic of mental health.

Chapter 3, Allan N. Schore: Early Relational Trauma, Disorganized Attachment, and the Development of a Predisposition to Violence.

In the first two years of our life, from three months before birth on, a spectacular growth spurt of the brain takes place, especially of the right hemisphere. In this period the creation of a secure attachment is an essential task, which occurs in a dyadic interaction. Learning to regulate the intensity of affects takes place in these early years of our life, in the contact with a caregiver who is a “good enough mother”. The maturation of the right hemisphere’s prefrontal area (one of the three major association cortices), the development of function of cortical and subcortical structures in the regulation of emotions and behavior is highly experience-dependent. Effects of early abuse and/or neglect are reflected in an enduring developmental impairment of the right brain hemisphere. When the learning process to regulate anxiety and/or aggression has not succeeded, the harm has been done in these early years of one’s life. Strong indications have been found that severe early trauma, be it abuse or neglect (the combination is worst), is at the root of later violent behavior. We then meet “The ghosts from our nursery”. Decisive to the extent of the developmental impairment is the presence or absence of one person in that nursery, not the primary caregiver, with whom the child can develop a better attachment.
Strikingly we are looking here at the period of the life cycle in which according to Davanloo, superego pathology finds its origin. Schore suggests that aggression can become dysregulated by early relational trauma. He argues that the psychopathic personality is susceptible to “cold blooded” predatory rage, while the borderline personality to “hot blooded” impulsive rage. Schore elaborates on the development of an aggression regulation system in the orbitofrontal cortex.

Allan Schore pleads strongly for a prevention program, of which I think it is at the same time very difficult to realize (to actively intervene in families where children are abused/neglected) and highly necessary. How to track these families down? How to enter their system? How to create a working alliance? How to make a PET scan of an intractable child?

In several chapters the theme of Attunement – Disruption – Repair is at stake. In the process – first year of life – of learning to regulate the intensity of feelings, when the attunement between child and caregiver is all-important, there inevitably are moments of disharmony. The experience that a disruption of the harmony can be repaired is essential for this learning process. This theme comes back in the psychotherapeutic context (Diana Fosha, Robert J Neborsky, Marion F Solomon) as an important controlled intervention.
Allan Schore made us look at the brain in depth.

Chapter 4, Bessel A. van der Kolk,: Posttraumatic Stress disorder and the nature of trauma, offers the broad vision (+ statistics).

His chapter tells about PTSD and the nature of trauma. And he reminds us that already at the end of the 19th century Charcot, Janet and Freud understood the essence of psychotrauma, and its treatment. He states that, although many people who are traumatized by horrendous events do not seem to develop lasting effects, the human response to psychological trauma is one of the most important public health problems in the world. This concerns not only PTSD, but also depression, increased (self-) aggression, compulsive behavioral repetition of traumatic scenarios, etc. Dissociation during a traumatic event is an important predictor of the development of subsequent PTSD.

MRI scans and PET scans have revealed abnormal brain activity when PTSD sufferers have a traumatic recall: heightened activity of structures in the right hemisphere, especially in the structures, involved in emotional regulation such as the amygdala, the insula and the medial temporal lobe and under-activity of the left hemispheric cortical structures, mediating verbal communication. This corresponds with the finding that a traumatic recall makes the person feel, see or hear the sensory elements of the traumatic experience, not susceptible of correction by experience, but don’t have words to tell about this experience; may even suffer from speechless terror.

Effective treatment should focus on self-regulatory deficits. Should help the PTSD patient to find a language in which he can come to understand and communicate his experiences. Needed are: 1. a safe place to recover, 2. anxiety management and 3. emotional processing, which means, in a nutshell: creating the narrative of what has traumatized the patient. The narrative should emerge without eventual dissociation or avoidance. Bessel van der Kolk ends his chapter with the promise that the studies of trauma and neuroscience are beginning to open up entirely new perspectives on how traumatized individuals can be helped. As for me, these perspectives have not been opened up, yet. Regarding the study of trauma: yes; regarding the contribution of neuroscience: what’s really new in terms of therapeutic working alliance?

Chapter 5, Francine Shapiro and Louise Maxfield: EMDR and information processing in psychotherapy treatment: personal development and global implications.

EMDR: A peculiar technique. It may give one an idea of hocus-pocus: the eliciting of the eye-movement. But it isn’t! And how it originated also is a peculiar story, but this I suppose is well known. It was a nice case of serendipity.

The adaptive information processing (AIP) model was developed to explain and predict EMDR treatment effects. We read: The AIP model states that all memory is associated, and learning occurs through the creation of new associations. When an incident is not fully processed, the perceptions, thoughts, and emotions that were experienced during the traumatic event are generally stored in state-dependent form. This storage may be in an isolated memory network where the information cannot link up with more appropriate information and learning cannot take place. And, to jump to a conclusion, what EMDR does is linking, forging new connections between the unprocessed memory and more adaptive information that is contained in other memory networks, while the simultaneous eye-movement decreases the intense and painful emotions that are recalled. Again: creating the narrative, cognitively and emotionally.

EMDR, provided it is well indicated and correctly applied, seems to be a very useful technique, a real tool, without pretension. It provides what it offers if… the results last (do they?). The case studies described in this chapter are convincing, one of them with a 5 year old child with a D attachment pattern (disorganized/disoriented attachment pattern, see also chapter 2). Both mother and child treated with EMDR. What happens in the brain when we move our eyes from left to right to left while recalling a traumatic incident is not explained.

In chapters 6-8 we can read about the psychotherapy of traumatized people.

Chapter 6, Diana Fosha: Dyadic Regulation and Experiential Work with Emotion and Relatedness in Trauma and Disorganized Attachment.

What’s this? Diana, we’ve never met. But your chapter invites me to write in dyadic format and to say something personal. Even with your writing you seem to activate my right hemisphere. How do you do that? When I started my own learning process in the psychotherapeutic field, Carl Rogers (his writings) was there. Wandering through psychoanalysis, psychodrama and ISTDP (I’m an ISTDP-adherent) I’ve always kept him with me, like a compass in my pocket. And now I have a hunch that you, Diana, are his reincarnation, evolved and adapted to this era. So it’s back to the cradle.

But now back to business, back to the third person. Diana Fosha gives an introduction, which, in case you had to plough your way through the mound of the first half of this book, and your left hemisphere has become over-active, is a welcome integrative summary of chapters 1-4. It is followed by an introduction of her (A)ccelerated (E)xperiential-(D)ynamic (P)sychotherapy, and she reports of two sessions that illustrate the dyadic regulation of affective states. Both introductions are clear. The case is called “Fright without solution”, referring to the second chapter.

In the description of the two successive sessions the theme of: attunement – disruption – repair, so important in the first year of life, in the working alliance, and in life, is central. Clarifying for me was the differentiation of pathogenic versus core anxiety and shame. Where Diana Fosha describes how she makes a therapeutic disruption I’m not surprised that the disruption is not severe: it is obvious that her anger is meant to defend the patient’s ego, directed to the self-destructive tendency of the patient. We might call this ‘empathic anger of the therapist’ (well-known of Davanloo too). There is empathy throughout the sessions. We get the opportunity to follow a deeply felt and moving therapeutic process.

Chapter 7, Robert J. Neborsky: A Clinical Model for the Comprehensive Treatment of Trauma Using an Affect Experiencing-Attachment Theory Approach.

Most people who have been exposed to a major trauma do not develop PTSD. The “tendency to experience negative affects when exposed to a new event”, we read on the first page of this chapter, is a powerful predictor for PTSD. In each of us, Robert Neborsky says, there is an unconscious negative affect processing system that protects us from developing anxiety disorder and/or depression. This system is called the attachment system. In a preview first is outlined how trauma is processed with an integrated attachment system, and next how and why chronic disorders of stress happen. This is illustrated, with clinical know-how, by an appealing example.

Chapter 8, Marion F. Solomon: Connection, Disruption, Repair: Treating the Effects of Attachment Trauma on Intimate Relationships.

Marion Solomon gives us an exposé of couple’s therapy. In her pithy formulation: “To be in any relationship where one feels unrecognized, disconnected, and helpless to change things is deflating, and is the most salient feature of unhappy marriages”. And: “A defining factor in relationships that last is the ability to reconnect emotionally after an argument”.

She gives an example of therapy with two early traumatized partners, and explains: the internal model of attachment of each partner is used as the guideline for the therapeutic process. When both partners are traumatized to help the partners acknowledge their sense of vulnerability is an important (first) step. The regressive pull toward old, familiar (egosyntonic) interactional dynamics has to be tracked down. Marion Solomon elaborates on this topic in an inspiring way and gives a clear illustration. (But, contrary to what Marion Solomon does: I, myself, will not point out to my patients that “traumatic experiences are often processed in the non-verbal right hemisphere”).

There are several themes we encounter in every chapter of this book. To start at the beginning:

To acquire a secure attachment in the contact with a caregiver during the first year of life is of lifelong importance. An insecure attachment may be changed into an earned security (e.g. as a result of psychotherapy, or when the partner has a secure attachment). A disorganized attachment may result in an irreversible hot- or cold-blooded violent character.

During the process when the attachment is getting shape the sequence of attunement-disruption-repair is decisive for the outcome. When repair doesn’t take place, the evoked negative emotions cannot be “metabolized”, integrated.

A person with insecure/disorganized attachment doesn’t have a cohesive and coherent biographical narrative and if she/he is also a caregiver.
This has an impact for the development of the attachment of the next generation.
In these cases there might be an impaired functioning of the orbitofrontal structures of the right hemisphere and their interconnections with other cortical and subcortical structures.
The essence of trauma therapy is integration of defended emotions, which were elicited by the trauma.
The evolution of attachment theory is of direct value for the daily practice of psychotherapy.

Regarding the coherent narrative of traumatic events it is interesting what Freud wrote (in 1893):

…We must presume rather that the psychical trauma – or more precisely the memory of the trauma – acts like a foreign body which long after its entry must continue to be regarded as an agent that is still at work; and we find the evidence for this in a highly remarkable phenomenon which at the same time lends an important practical interest to our findings. For we found, to our great surprise at first, that each individual hysterical symptom immediately and permanently disappeared when we had succeeded bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affects into words. Recollections without affect almost invariably produce no result. The physical process which originally took place must be repeated as vividly as possible; it must be brought back into its status nascendi and then given verbal utterance. Where what we are dealing with are phenomena involving stimuli (spasms, neuralgias and hallucinations) these re-appear once again with the fullest intensity and then vanish forever”.

This book, Healing Trauma, could well serve as an introduction to neuroscience and to some principles of attachment theory. Resolution of trauma is amongst others rooted in neural integration, and from a viewpoint of pure science it is of great importance that we know which cortical and subcortical structures and their interconnections are involved in specific aspects of the regulation of our emotions, cognitions, behaviors and learning processes. And of course it is of great importance when the results of neuroscienctific research may lead to more effective psychotherapy.

But, when a therapist is “only” an expert at carrying out the dynamic diagnostic interview, therapist and certainly the patient, are very well off, I’m sure.

In neuroscience a lot of brainy work has been done. But the concrete contribution of neuroscience as an instrument to enhance effective psychotherapy is still in a process of growth, I think.

Short-Term Therapy for Long-Term Change, by Marion F. Solomon, Robert J. Neborsky, Leigh McCullough, Michael Alpert, Francine Shapiro, and David Malan. W. W. Norton & Company, 2001.

Reviewed by Donn Warshow, PhD

In Short Term Therapy for Long Term Change, six master therapists discuss their diverse, dynamic techniques to uncover core affect. Their work aims focuses on buried and blocked emotions that lay beneath anxiety and defense, to free patients to experience secure and loving attachments, the outgrowth of emotional intimacy and collaborative communication.

Robert Neborsky. M.D., begins by summarizing Dr. Habib Davanloo’s method of Intensive, Short-Term Dynamic Psychotherapy. He illustrates the approach with a transcript from an18 hour treatment with a patient with PTSD, chronic depression, substance abuse and character pathology. He describes Davanloo’s Central Dynamic Sequence, a series of interventions using carefully applied pressure and challenge to overcome the self-sabotaging defenses. The defenses are superego-driven: the patient self-attacks with guilt/shame, anxiety and self-punishment to spare the love object from the force of her rage and complex emotions. This is a succinct and clear introduction to IST-DP.

Leigh McCullough illustrates how she desensitizes patients to anxiety-provoking affects (“affect phobias”) in order to free up emotional responding. She views these “affect phobias” as the driving force behind neurosis. She finds evidence that lowering defenses against affective expression improves outcome. Restructuring defenses, affects and relationships by regulating anxiety or conflicted affects will have the greatest staying power in promoting positive change.

Michael Alpert’s Accelerated Empathic Therapy helps patients to feel deeply understood in a way that many have never experienced in their lifetimes. The cornerstone of his work is a shared affective, deeply intimate emotional experience with open communication between therapist and patient. Alpert helps the patient to see and feel when the therapist is genuinely moved and truly cares, thus providing a corrective emotional experience. Dr. Alpert concludes that defenses are more readily transcended by increasing more overt expressions of compassion and caring and by minimizing pressure and challenge, i.e. by creating the safest possible relational environment.

Francine Shapiro, the creator of EMDR (Eye Movement Desensitization Reprocessing), elucidates her discoveries that anxiety associated with large- T and small- T traumas can be reduced through the use of eye movements, tapping or tones, which are applied as the patient holds in mind the most disturbing parts of the traumas. Thus, the images, cognitions, affects and body sensations associated with trauma and stored in the memory network can be reprocessed, seen in a new light, and therefore become manageable. Shapiro has stated that all of us have an internal, physiological mechanism that activates emotional healing when appropriately accessed and directed.

In the next chapter, “Breaking the Deadlock of Marital Collusion,” Marion Solomon describes how treatment helps patients become aware of childhood traumas which lead to anxiety and defense, perpetuating emotional distance in the relationship. She “uses empathic resonance to enhance each partner’s contact with the unconscious system at play in the dyad.” Dr. Solomon emphasizes the importance of integrity and the willingness for partners to explore their own projections, self-sabotaging behaviors and underlying feelings in order for a secure attachment to be achieved.

In Chapter 7, “Attachment Bonds and Intimacy,” Neborsky and Solomon offer an overview of attachment theory and research, primitive aggressive self-organization (the PASO), the spectrum of trauma (Small-t to Big-T), and defenses as neurobiology promulgating psychopathology. Short-term therapy with three insecure attachment styles is explored, with case discussions illustrating how the PASO is overcome. This refers to complex core feelings that have been repressed in the service of attachment longings and have changed into self-punishment. The therapist models secure attachment for the patient, in which the full spectrum of emotions underlying the defenses are encouraged and invited into the relationship. Thus, the defensive system can be released so that love can be experienced.

David Malan, one of the great pioneers and contributors to the development of Short-Term Dynamic Therapy, offers an overview of how it developed. He reveals how therapists can adapt the basic principles of STDP to their personal styles while maintaining efficacy. For him, research reveals three pivotal principles: addressing the resistance; illuminating the unfolding transference; and effectively facilitating the experiencing of the patient’s buried feelings. Malan describes positive outcome as “inhibition or compulsiveness replaced by emotional freedom, intensity or depth.” Malan also states that the best results “possess qualities that are specific to dynamic therapy and are superior to those of other methods.” However, this is underreported because these individual results do not show up in the statistical averages of large group outcome studies.

The Working Alliance in ISTDP: Whose Intrapsychic Crisis?, edited by Josette ten Have-de Labije.  Dutch Association for Short Term Dynamic Psychotherapy (VKDP), 2001.

Reviewed by Jon Frederickson

This is a book of essays based on a summer training offered by VDKP. The first article, Dynamic Assessment of Ego Functioning in Davanloo’s ISTDP by Patricia Coughlin shows how to conduct a psychodiagnosis of ego functioning using Davanloo’s central dynamic sequence: evaluation of symptom disturbances, assessment of unconscious anxiety discharge patterns, components of affective experience necessary for a breakthrough into the unconscious, defense work, affect facilitation, turning the ego against the superego, and access to the unconscious. The most succinct summary of Davanloo’s metapsychology available.

Red and Green Traffic Lights on Davanloo’s Road to the Unconscious by Josette ten Have-de Labije is the most detailed case study illustrating how to develop the ego capacities necessary for a breakthrough to the unconscious. Absence of an ego capacity equals a “red light.” Ten Have-de Labije shows how patient responses to intervention allow the therapist to assess for the following ego functions: 1) capacity to bear feeling; 2) capacity to identify anxiety, the triggering event and emotion, and the channel of discharge; and 3) capacity to see a defense, its price, and to turn against it. The article is accompanied by a diagram of the pathway to the unconscious, along with its “green” and “red” lights.

Facilitating the Development of Therapeutic Alliance by Jan Bass and A. Marjanne Rondaij-de Jong shows how Davanloo’s central dynamic sequence develops both the conscious and unconscious therapeutic alliances. In particular, they emphasize specific interventions which will mobilize the therapeutic alliance.

The Integration of Cognitive and Dynamic Approaches in the Short Term Treatment of Depression by Allen Kalpin shows how both approaches can be useful in ISTDP. Specifically, cognitive therapy can help undo projection. When a patient can recognize that his thought is a belief rather than reality, only then is it possible to begin to examine the defensive functions of that belief. An excellent case example illustrates how Kalpin undoes projection with a depressed patient in preparation for experience of the aggressive impulse.

With Davanloo under your Pillow: The ISTDP of Dr. H. Davanloo in a Residential Setting by Kees Cornelissen describes the use of ISTDP on a six month inpatient unit designed for patients with fragile character structure and low ego adaptive capacity. This article is unique, as is all of Cornelissen’s work, for its emphasis on working with severely disturbed patients, helping them relinquish their primitive defenses, and develop their ego adaptive capacity.

Short-Term Therapy for Long-Term Change, by Marion F. Solomon, Robert J. Neborsky, Leigh McCullough, Michael Alpert, Francine Shapiro, and David Malan. W. W. Norton & Company, 2001.

Reviewed by Donn Warshow, PhD

In Short Term Therapy for Long Term Change, six master therapists discuss their diverse, dynamic techniques to uncover core affect. Their work aims focuses on buried and blocked emotions that lay beneath anxiety and defense, to free patients to experience secure and loving attachments, the outgrowth of emotional intimacy and collaborative communication.

Robert Neborsky. M.D., begins by summarizing Dr. Habib Davanloo’s method of Intensive, Short-Term Dynamic Psychotherapy. He illustrates the approach with a transcript from an 18 hour treatment with a patient with PTSD, chronic depression, substance abuse and character pathology. He describes Davanloo’s Central Dynamic Sequence, a series of interventions using carefully applied pressure and challenge to overcome the self-sabotaging defenses. The defenses are superego-driven: the patient self-attacks with guilt/shame, anxiety and self-punishment to spare the love object from the force of her rage and complex emotions. This is a succinct and clear introduction to ISTDP.

Leigh McCullough illustrates how she desensitizes patients to anxiety-provoking affects (“affect phobias”) in order to free up emotional responding. She views these “affect phobias” as the driving force behind neurosis. She finds evidence that lowering defenses against affective expression improves outcome. Restructuring defenses, affects and relationships by regulating anxiety or conflicted affects will have the greatest staying power in promoting positive change.

Michael Alpert’s Accelerated Empathic Therapy helps patients to feel deeply understood in a way that many have never experienced in their lifetimes. The cornerstone of his work is a shared affective, deeply intimate emotional experience with open communication between therapist and patient. Alpert helps the patient to see and feel when the therapist is genuinely moved and truly cares, thus providing a corrective emotional experience. Dr. Alpert concludes that defenses are more readily transcended by increasing more overt expressions of compassion and caring and by minimizing pressure and challenge, i.e. by creating the safest possible relational environment.

Francine Shapiro, the creator of EMDR (Eye Movement Desensitization Reprocessing), elucidates her discoveries that anxiety associated with large- T and small- T traumas can be reduced through the use of eye movements, tapping or tones, which are applied as the patient holds in mind the most disturbing parts of the traumas. Thus, the images, cognitions, affects and body sensations associated with trauma and stored in the memory network can be reprocessed, seen in a new light, and therefore become manageable. Shapiro has stated that all of us have an internal, physiological mechanism that activates emotional healing when appropriately accessed and directed.

In the next chapter, “Breaking the Deadlock of Marital Collusion,” Marion Solomon describes how treatment helps patients become aware of childhood traumas which lead to anxiety and defense, perpetuating emotional distance in the relationship. She “uses empathic resonance to enhance each partner’s contact with the unconscious system at play in the dyad.” Dr. Solomon emphasizes the importance of integrity and the willingness for partners to explore their own projections, self-sabotaging behaviors and underlying feelings in order for a secure attachment to be achieved.

In Chapter 7, “Attachment Bonds and Intimacy,” Neborsky and Solomon offer an overview of attachment theory and research, primitive aggressive self-organization (the PASO), the spectrum of trauma (Small-t to Big-T), and defenses as neurobiology promulgating psychopathology. Short-term therapy with three insecure attachment styles is explored, with case discussions illustrating how the PASO is overcome. This refers to complex core feelings that have been repressed in the service of attachment longings and have changed into self-punishment. The therapist models secure attachment for the patient, in which the full spectrum of emotions underlying the defenses are encouraged and invited into the relationship. Thus, the defensive system can be released so that love can be experienced.

David Malan, one of the great pioneers and contributors to the development of Short-Term Dynamic Therapy, offers an overview of how it developed. He reveals how therapists can adapt the basic principles of STDP to their personal styles while maintaining efficacy. For him, research reveals three pivotal principles: addressing the resistance; illuminating the unfolding transference; and effectively facilitating the experiencing of the patient’s buried feelings. Malan describes positive outcome as “inhibition or compulsiveness replaced by emotional freedom, intensity or depth.” Malan also states that the best results “possess qualities that are specific to dynamic therapy and are superior to those of other methods.” However, this is underreported because these individual results do not show up in the statistical averages of large group outcome studies.

Experiential Short-Term Dynamic Psychotherapy, by Ferruccio Osimo. AnchorHouse, 2003.

Reviewed by Ronald J. Frederick, PhD, LP

With Experiential Short-Term Dynamic Psychotherapy: A Manual, Ferruccio Osimo, MD, makes a substantial contribution to the field of Experiential Dynamic Therapy (EDT) detailing with refreshing clarity and humanity the theory and technique of his particular model of psychotherapy: E-STDP.

Dr. Osimo begins by introducing the reader to the basics of the experiential-dynamic paradigm with an illustration of Malan’s Two Triangles followed by a brief history and theory of the acceleration of the therapeutic process. He then goes on to delineate in detail an array of clinical interventions for dealing with each of the three corners of the triangles with a particular emphasis on therapeutic activity, that is, what the therapist does or can do to affect change. Grounded in the quest for deep emotional experiencing and working through common to the different EDTs, the clinical methods essential to E-STDP focus on the active management of defenses, affects and anxiety, and constitute what Osimo refers to as the Dynamic Activities: Defense Restructuring, Emotional Maieutics, and Anxiety Regulation.

Of the three dynamic activities set forth, it is in his conceptualization and discussion of “emotional maieutics” where Dr. Osimo makes what may be his most significant contribution. He astutely finds a way to delineate and articulate therapeutic activities that heretofore had not been adequately given their due. “Maieutic Activity” applies the concept of maieutics (derived from the ancient Greek for midwife) to E-STD and the experiencing of emotions. Here, the therapist acts as a midwife of sorts, helping the person to fully bare and give birth to emotions present in him/herself. Through a “maieutic attitude” the therapist (1) makes himself emotionally available to the patient providing a sense of being connected and not alone, (2) actively attunes to the experiencing of emotion, and (3) supports the verbal and bodily expression of such emotion. Above all, the main purpose in this activity is to attenuate an “intense, primordial” fear of emotional expression so that feelings can coalesce and then be expressed.

All of the three main activities rely on the accurate mirroring of defenses and can flexibly be adapted to the therapist’s own personality, the individual patient, and the specific issue being addressed. Never dogmatic, Osimo emphasizes being realistic about the influence of the therapist’s personality, gender, culture, life experience and training on the work with clients and encourages an individualistic approach that honors the clinician’s strengths as well as his/her authenticity. He contends that the best results will occur when the therapist makes use of the dynamic activities that are most aligned with his or her personality saying, “a therapist’s effectiveness primarily descends from coherence with his/her own way of being, and willingness to make oneself emotionally available to the patient” (p. 140). Osimo highlights the essential interpersonal nature of the therapy relationship, in which both the therapist and client come together as real, as the “basis on which cure can be built” (p. 165). The challenge to doing transformational work lies in not only being able to master and apply these approaches, but to do so in a manner that honors both the uniqueness of both the client and the therapist. Osimo illustrates the different approaches of E-STDP and demonstrates his own flexibility in applying relevant interventions in two lengthy case descriptions of two very different clients. The reader is thus afforded two wonderfully detailed examples of the application of this model and the remarkable therapeutic that are possible.

Clinical and Research Issues in Short-Term Dynamic Psychotherapy, by Arnold Winston. Washington, DC: American Psychiatric Press, 1985.

Reviewed by Jon Frederickson

This monograph contains collected articles by STDP practitioners.

Transference in Short-Term Dynamic Psychotherapy by Harold Been and Isabel Sklar is one of the clearest papers ever written to illustrate the differences between psychoanalysis and short term dynamic psychotherapy in their understandings of, and approaches to, transference. They illustrate how the transference neurosis and regressive transferences are avoided in short term dynamic psychotherapy by the early, systematic analysis of characterological defenses and negative transference. Pathological Mourning in Short-Term Dynamic Psychotherapy by A. Winston and V. Goldin describe the phases in changing pathological mourning into normal grief. Case examples illustrate the importance of deep affective experience of complex feelings for lost figures through the use of imagery.

The Impact of Short-Term Dynamic Psychotherapy on Psychoanalytic Psychotherapy by V. Goldin and A. Winston describes what happens to psychoanalytically oriented therapists who encounter STDP for the first time. Initially, therapists find the approach “aggressive” and “badgering”, but this impression fades over time as they see a number of interviews, see that the therapist is challenging defenses not the patient, and as they begin to see how the therapist will shift to a less challenging stance if there is any indication of patient fragility. Therapists learn to become more active and focused; they shift from analyzing the transference cognitively to helping the patient experience the transference emotionally in the here and now. They begin to thwart regression rather than foster it. In short, they found that exposure to STDP changed the ways therapists conducted their psychoanalytic psychotherapy.

Research Issues in Short-Term Dynamic Psychotherapies: and Overview by M. Trujillo and L. McCullough summarizes the state of research into STDP in 1985 and describes a pilot project which was not completed at that time.

Book is out of print, but may be ordered through www.abebooks.com and other on-line used book stores.