I have been reflecting on what constitutes the fingerprint of ISTDP and on explanations for the variability in the application of the model. I will opine, blogpost format, on both of these issues, starting with the latter.
For starters, I assume that all clinicians are sensitive to case specific and contextual factors, but also that everyone still has general tendencies to interpret information through a particular frame of reference and sets of value-laden interpretive-tendencies (Hanson, 1958: 19).
A few years ago I saw someone present the same therapy session for supervision with two different well-known ISTDP supervisors. Their respective assessments of the patient being showcased and their feedback to the supervisee varied a great deal in substance, not just style. I bring this up because though most everything in our field is case-specific and the variability in the application of ISTDP could be explained by pointing to the fact that every patient is different, this event highlighted that there appears to be genuine trends and proclivities in how different people interpret similar data (the exact same data in this case). I imagine that attempts at establishing inter-rater reliability around psychodiagnosis and construct-validity may prove illuminating, but I digress.
It may be useful here to take stock in the idea that all of our empiricism is necessarily steeped in inferences, which are themselves grounded in axioms, fundamental assumptions, and values (Kuhn 1962: 186,186). Nowhere is this clearer than the act of prioritization—the basis for what the therapist selects as priority in any given interaction with a patient—what the therapist perceives to be the most salient and important aspects of the patient-interaction to address (and address towards a particular end). With this idea in mind, it becomes clear that though the call to utilize ‘intervention-response’ is quite correct, this call itself is a fairly low-resolution principle. The many contextual and case-specific variations that determine exactly what part of the patient’s presentation ought to be responded to and the vast variability in the range of immediate clinical objectives do not readily translate to pre-formulations.
Davanloo’s Central Dynamic Sequence, henceforth referred to as the CDS (Davanloo, 1990: 217), with its understandings of how to assess ego-adaptive capacity—and other methods that help us keep an ear to the ground of the unconscious—gives an orienting framework. However, the actual experience of facilitating therapy rarely lends itself to a straight-forward ‘follow the recipe’ approach.
The question in the title of this blog-post invites an answer to the question of how we define ISTDP, and I will make a gesturing attempt in this direction. For now I will introduce the idea of understanding the variability in the application of ISTDP through the lens of polarity scales (captured with great artistic finesse in the featured photo of this blog).
A polarity scale captures two different ideas that exist in tension with a continuum of gradation in-between, connecting the two ideas that reside at each pole of the scale. The ideas may not always be mutually exclusive, though they can be. The scale can be toggled along the continuum, and one may roughly estimate where between the two poles a clinician may be, which would capture information about the clinician’s emphasis-tendencies. We would end up with something approximating a picture of how much stock a given clinician generally tends to place on a given principle.
‘Discipline’ versus ‘flexibility’ could be one such polarity scale. Another is ‘use of self’ versus ‘self-censorship.’ Each pole might have adjacent and clustering ideas and concerns. Adjacent to self-censorship we might place the concern about playing into projective identification, incarnating aspects of experience that the patient wants to disavow, and the idea that therapist activity can usurp healthy patient activity. Adjacent to the pole of ‘use of self’ we might place the idea of ‘the real relationship,’ and ‘modeling congruence and openness,’ for example.
The conscious and unconscious therapeutic alliance could comprise another polarity scale, where concerns about the primacy of accessing the patient’s unconscious are adjacent to the unconscious alliance pole, and adjacent to the conscious alliance pole are concerns about establishing rapport as well as explicit agreements about problem and task. Ultimately there is of course only one alliance with a conscious and unconscious component (Davanloo, 1990: 3) so the poles on this scale are not mutually exclusive, but capture differences in what is emphasized.
Another polarity scale might consist of undoing omnipotent patient expectations on one pole, and meeting the patient where they are and providing some psycho-education on the other pole. Adjacent to and clustered around the first pole are concerns about reinforcing patient passivity and top-down dynamics, whereas concerns in proximity to the latter pole revolve around the therapist being perceived as rigid, withholding, and not lending a helping hand to a patient that needs more clarity and information.
We could reflect on a myriad of polarity scales, from scales that try to pinpoint emphasis-tendencies around different ways to approach resistance as well as capturing greater or lesser concerns about iatrogenic resistance and keeping the therapist “out of the shoes” of past figures, to name just a couple. But I believe that by now the point is clear: polarity scales and differences in emphasis are one way to think about variability in the application of any therapeutic modality, including ISTDP.
My mind goes to the arc of Davanloo’s transcribed cases, from “the case of the teeth-grinding woman” (1978) to “the man with crushing chest pain” (2001, 2005). Though some differences in approach are surely due to the different psychological constitutions of the respective patients, I get the sense (and I believe few would argue against the point) that Davanloo had different emphasis-tendencies at various points in his career (Reher-Langberg, personal communication, 2022).
A picture emerges before my mind’s eye of a fingerprint, where the lines of the print at times are far apart, but nonetheless form a cohesive print. Variations and permutations in how Davanloo worked can represent lines in the print that are far apart, whereas what remained constant throughout represents the outlines of the print itself—the finger print of ISTDP. The CDS may indeed form at least the scaffolding of ISTDP’s fingerprint. As I look over the transcripts from the early to the more contemporary ones, I believe I see differences in emphasis on the different sequences of the CDS.
I have discussed how we can understand variation in the application of ISTDP by looking at different levels of emphasis on the different sequences of the CDS, and also at the use of polarity scales to approximate emphasis-tendencies around various first principles and other important ideas that exist in tension. It seems to me that even small variations in emphasis over a wide range of principles can ultimately result in a great deal of variety when it comes to the application of ISTDP, potentially explaining the differences in assessment and feedback between the two supervisors that observed the same therapy session. Lastly, I proposed that the CDS might approximate something of the fundamental fingerprint of ISTDP.
Hanson, N.R. (1958) Patterns of Discovery, Cambridge: Cambridge
Kuhn, T.S. (1962, 2nd edn 1970) The Structure of Scientific Revolutions,
Chicago: University of Chicago Press.
Davanloo, H. (1990). Unlocking the unconscious: Selected papers of Habib Davanloo, MD.
West Sussex, England: John Wiley & Sons.
Davanloo, H. (1978). The case of the teeth-grinding woman. In H. Davanloo (Ed.) Basic principles and techniques in short-term dynamic psychotherapy (pp. 171-187).
Lanham, MD: Jason Aronson.
Copy of Chapter on ISTDP by Habib Davanloo, MD in:
Editors: Sadock, Benjamin J.; Sadock, Virginia A.
Title: Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 8th Edition
2005 Lippincott Williams & Wilkins Volume II [pp. 2628-2652]