(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.