Like all therapy modalities, ISTDP has its critics. In this article, experienced ISTDP therapists examine and address some of the most common criticisms of ISTDP.
“ISTDP uses an authoritarian approach – forcing patients to comply, lack of patient autonomy.”
- ISTDP therapists are trained to create collaborative and empathic relationship with clients. There is a strong focus on the conscious and unconscious therapeutic alliances, with the goal in mind of empowering the patient, not trying to control them. Patients are encouraged to take an active role in therapy and a heavy emphasis is placed on their will and in making their own decisions. As part of this process the therapist aims to help clients notice and realise how their life is controlled by unhelpful avoidance mechanisms (defences) and anxiety, to empower them to make meaningful change in line with their values.
- In other words, A lot of the focus of ISTDP is in helping the patient actualise their autonomy and empowering them to make their own decisions based on their own core values. Part of the process is helping them develop self-awareness so they can take responsibility for their thoughts, emotions, and anxiety rather than being ruled by pathology.
- In ISTDP, patients are not forced to comply with the therapist. Rather, therapists are trained to monitor for compliance and facilitate client autonomy. If compliance is suspected, it is often addressed, and focus is made on helping the patient build their capacity towards being autonomous. Autonomy and self-expression are encouraged so that the therapy can focus on the clients will and goals. Interventions are utilised to build patients capacity to know and actualise their own will.
“ISTDP provokes anger in the patient.”
- Anger is just one of the many emotions likely to be explored in ISTDP. ISTDP does not aim to provoke anger or any other emotion just for the sake of that emotion.
- It’s true that ISTDP therapists may use techniques like confrontation or challenge (e.g., bringing client awareness to self-destructive avoidance strategies and offering a choice to retain or challenge the avoidance themselves) to help people access avoided feelings. However, the intention is not to ‘provoke’ anger, rather that anger can be a natural response when avoided feelings are mobilised, when the avoided feelings trigger anxiety, or when the maladaptive ways of avoiding emotion and anxiety, the defences, are challenged.
- Current emotional experiences tend to use similar neural pathways to previously experienced emotions.8 As such, emotional experiencing encouraged in the present can also activate unprocessed emotions experienced in the past and bring them to the forefront. Sometimes the emotions triggered can be anger.
- So rather than “provoking anger”, the goal of ISTDP is to help patients access and understand the avoided emotions in the present, whatever they may be. While also helping them face and understand any past unprocessed emotions that arise. ISTDP therapists aim to provide a competing more accepting and non-traumatic environment to do the processing.
- To this effect, patients are guided throughout the process and levels of anxiety and discomfort are monitored collaboratively to ensure a safe and therapeutic experience.
“ISTDP has research quality issues and limited generalisability”
- The ISTDP research base may have methodological limitations, however there is a strong drive within the research community to continue engaging in quality research such as RCT’s which are gold standard for demonstrating efficacy. Ongoing research continues to refine our understanding of ISTDP, intervention protocols, and our understanding of mechanisms of change and effectiveness.
- There are also a large and growing number of randomised control trials that already exist and are in the process of being conducted or written up.
- ISTDP has demonstrated promising effectiveness in treating most common mental health conditions such as depressive and anxiety disorders. Efficacy has also been demonstrated for personality disorders and somatic and symptom related disorders 1,3,4,5,6,7.
Lack of consensus definition on “unlocking the unconscious”
- A recent meta-analysis conducted by Hooviadoost et al. (2020)2 have found that in the research literature there is an inconsistent definition used for “unlocking of the unconscious”. Most studies treated unlocking as a “binary” event (occurred or did not occur) and only assessed for “major” unlocking, despite ISTDP theory suggesting there are various levels of unlocking the unconscious.
- Hooviadoost et al. propose that future research could consider investigating if treating unlocking as a continuous variable and/or differentiate between “levels of unlocking” is a viable way to start to address this issue in the literature.
References
1 Abbass, A., Town, J., Holmes, H., Luyten, P., Cooper, A., Russell, L., … & Kisely, S. (2020). Short-term psychodynamic psychotherapy for functional somatic disorders: A meta-analysis of randomized controlled trials. Psychotherapy and Psychosomatics, 89(6), 363-370. https://doi.org/10.1159/000507738
2 Hoviatdoost, P., Schweitzer, R. D., Bandarian, S., & Arthey, S. (2020). Mechanisms of change in intensive short-term dynamic psychotherapy: Systematized review. American Journal of Psychotherapy, 73(3), 95-106. https://doi.org/10.1176/appi.psychotherapy.20190025
3 Kia, M. S., Hashemian, K., & Abolmaali, K. (2023). Comparison of Effectiveness of Transactional Analysis, Exposure and Response Prevention and Intensive Short Term Dynamic Psychotherapy on Students’ Academic Anxiety. International Journal of Applied Behavioral Sciences, 10(2), 1-8.
4 Nowoweiski, D., Abbass, A., Town, J., Keshen, A., & Kisely, S. (2020). An observational study of the treatment and cost effectiveness of intensive short-term dynamic psychotherapy on a cohort of eating disorder patients. Psychiatry, 3(1), 1030.
5 Rahmani, F., Abbass, A., Hemmati, A., Mirghaed, S. R., & Ghaffari, N. (2020). The efficacy of intensive short-term dynamic psychotherapy for social anxiety disorder: randomized trial and substudy of emphasizing feeling versus defense work. The Journal of nervous and mental disease, 208(3), 245-251. https://doi.org/10.1097/NMD.0000000000001097
6 Town , J. M., & Driessen, E. (2013). Emerging evidence for intensive short-term dynamic psychotherapy with personality disorders and somatic disorders. Psychiatric Annals, 43(11), 502-507.
7 Town , J. M., Abbass, A., Stride, C., Nunes, A., Bernier, D., & Berrigan, P. (2020). Efficacy and cost-effectiveness of intensive short-term dynamic psychotherapy for treatment resistant depression: 18-Month follow-up of the Halifax depression trial. Journal of Affective Disorders, 273, 194-202. https://doi.org/10.1016/j.jad.2020.04.035
8 Weinberger, J., & Stoycheva, V. (2019). The unconscious: Theory, research, and clinical implications. Guilford Publications.
