Intensive Short-term Dynamic Psychotherapy - Origins and Theoretical Foundation of ISTDP

Origins and Theoretical Foundation of ISTDP

In 1895, Josef Breuer and Sigmund Freud published their Studies on Hysteria, which looked at a series of case studies where patients presented with dramatic neurological symptoms, such as "Anna O" who suffered headaches, partial paralysis, loss of sensation, and visual disturbances. These symptoms did not conform to known patterns of neurological disease, and neurologists were thus unable to account for symptoms in purely anatomical or physiological terms. Breuer's breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives. Experiencing these emotions which had been previously outside of awareness seemed to be the curative factor. This cure became known as catharsis, and the experiencing of the previously forbidden or painful emotion was abreaction.

Freud tried various techniques to deal with the fact that patients generally seemed resistant to experiencing painful feelings. He moved from hypnosis to free association, interpretation of resistance, and dream interpretation. With each step, therapy became longer. Freud himself was quite open about the possibility that there were many patients for whom analysis could bring little or no relief, and he discusses the factors in his 1937 paper "Analysis Terminable and Interminable."

From the 1930s through the 1950s, numerous analysts were engaged with the question of how to shorten the course of therapy but still achieve therapeutic effectiveness. These included Sándor Ferenczi, Franz Alexander, Peter Sifneos, David Malan, and Habib Davanloo. One of the first discoveries was that the patients who tended to benefit the most greatly from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to an experience of their previously warded-off feelings. These also happened to represent those patients who were the healthiest to begin with and therefore had the least need for the therapy being offered. Clinical research revealed that these patients were able to benefit because they were the least resistant. They were the least resistant because they were the least traumatised and therefore had the smallest burden of repressed emotion. However, among the patients coming to the clinic for various problems, the rapid responders represented only a small minority. The vast bulk of patients coming for treatment remained unreachable with the newly developing techniques.

It became commonly recognised among the short-term dynamic researchers that overcoming resistance was the chief task of psychotherapeutic research. Toward this end, Dr. David Malan promulgated a model of resistance, known as the Triangle of Conflict first proposed by Ezriel. At the bottom of the triangle are the patient's true, impulse-laden feelings, outside of conscious awareness. When those emotions rise to a certain degree and threaten to break into conscious awareness, they trigger anxiety. The patient manages this anxiety by deploying defences, which lessen anxiety by pushing emotions back into the unconscious.

• Triangle Of Conflict

The emotions at the bottom of Malan's Triangle of Conflict originate in the patient's past, and Malan's second triangle, the Triangle of Persons, originally proposed by Menninger, explains that old emotions generated from the past are triggered in current relationships and also get triggered in the relationship with the therapist. The question of how maladaptive patterns of interpersonal behaviour could arise from early childhood experiences in the family of origin was postulated within psychoanalytic theory. Independent empirical support came from Bowlby's newly arising field of Attachment Theory.

• Triangle Of Persons