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.
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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 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.
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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.