- The felt sense of connection, the two tiers of mobilization, and openness to going outside the ISTDP roadmap
- Troubling trends
- An element of non-gushing warmth and support, but confrontation is far from dead
- The central role of the head-on collision
- Premature pressure is problematic
- Supervision and Teaching
- In closing
As Mr. Skorman’s time as a teacher draws to a close (after nearly 42 years in the field), I am reflecting back on the years we have had together. I met him in 2007, learned informally from him till 2012, at which point I began weekly audio-visual supervision as well as core training with him.
As far as I can tell, his perspective and approach to ISTDP is unique. I use the term “approach” to suggest a particular flavor and emphasis, and as an acknowledgment that there are likely differences in degree, if not in kind, between how Mr. Skorman has adapted ISTDP to fit with his personality and intuitions and what may be termed orthodox ISTDP. I imagine that most practitioners and teachers, even those who aim to adhere rather strictly to a Davanloo-esque approach, adapt the model to some degree or another to fit with their own temperaments.
Mr. Skorman was one of Dr. Davanloo’s right-hand men in the 1980s, had a falling out with Dr. Davanloo in 1991, and the two reconnected in 2012. Mr. Skorman worked briefly with Dr. Davanloo again in 2015. Since the 1980s Mr. Skorman remained in close collegial contact and collaboration with James Schubmehl, MD and Deborah J. Lebeaux, CSW, both students of Dr. Davanloo.
He has eschewed the limelight, felt repelled by some of the “seeking and finding religion” culture that can be connected with ISTDP, and besides the little professional association in Rochester, NY with Schubmehl and Lebeaux, he has not wanted to be associated with any institutions or associations. He coined the term “ISTDP attachment disorder,” cementing his strong emphasis on flexibility and concern around formulaic treatment.
Filtered through my own interpretations and proclivities, here are my observations on the distilled essence, the signature, as well as stand-out items of the Skorman approach:
The felt sense of connection, the two tiers of mobilization, and openness to going outside the ISTDP roadmap
“Therapy is about two imperfect human beings working out a relationship” is a phrase Mr. Skorman will sometimes use. Nothing supersedes maintaining this felt sense of connection to the patient, which includes factoring in who we are and who the patient is at any given moment in time. This includes being connected to ourselves as therapists in the session — aware of what is happening inside of us, helping the patient be aware and convey to us of what is happening inside of them, and directly addressing any barriers that eclipse this awareness and emotional closeness. What maintains this connection can vary a great deal: for some it may look very supportive, for others it may look like heavy pressure and systematic challenge.
When this is accomplished, not perfectly but sufficiently, the treatment outcome will be positive, no matter which therapeutic modality is used, Mr. Skorman maintains (personal communication, 2021). Making and maintaining this emotional connection typically involves frequent recapping and clarification work, always making sure that the therapist can picture precisely what the patient is saying, to the point where the therapy session takes on the sensation of patient and therapist “sharing the same dream” (M. Skorman, personal communication, 2013). Dynamic inquiry and exploration are typically strongly emphasized in this approach. I see what this looks like repeatedly in a host of Davanloo’s transcripts (H. Davanloo, Unlocking the Unconscious, 1990, and Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, 2000).
A sign that this connection is happening is that therapist and patient nod along together, sometimes even finishing each other’s sentences. It includes agreement around goals and the therapeutic task, but it goes beyond that. The patient should have the sense that the therapist is in their corner, and a sense that the therapist is concerned with their suffering. When this goes well, the patient does not experience the therapist as laying a trip on them, as pushing an agenda on them, and this sense of collaboration and togetherness continues even during heavy pressure and challenge.
In line with what he learned from Davanloo, Mr. Skorman frequently mentions that not until the process of getting a clear phenomenological, descriptive picture of the presenting problems as well as the patient’s emotions is impeded by resistance does inquiry stop and give rise to focused defense work (prior to this juncture, tactical defenses may be briefly commented on). This can of course happen right out of the gate in the first minute of the first session, or further down the road — depending on rightward or leftward location on the psychoneurotic spectrum. Depending on ego-adaptive capacity, what “focused defense work” looks like varies a great deal.
It is important to underscore that some level of mobilization of the patient’s unconscious affective system is desired even during the phase of inquiry, but we distinguish between organic, lower level mobilization (tier one) and higher level mobilization (tier two) through targeted forms of added pressure on the foundation of a conscious therapeutic alliance. More on what I mean by added pressure in a minute. Not moving to the second level of mobilization until there has been sufficient work done on the conscious therapeutic alliance is a very prominent feature in this approach, and when a graded format is called for, this added pressure is graded indeed (J. Whittemore, 1996).
Another prominent feature of this approach is that even when a patent has the ego-adaptive capacity to face the de-repression of the unconscious, we do not automatically press ahead towards an unlocking. Some patients with higher ego-adaptive capacity want to take the edge off their symptoms and are not interested in reaching “the top of the mountain,” so in this approach we go with what the patient is clear on that they want and thereby avoid a battle of wills scenario or a scenario where the therapist pushes an agenda onto the patient. We may say to a patient, “You have clearly made a lot of progress, but there are also signs you are not out of the woods fully. Is this good enough for you?” The patient may say that it is. If the patient has a track record of selling themselves short and not being honest about what they really want in their heart of hearts, we may press a little, “are you sure? Are you settling in a way that sells you short?” But at the end of the day, if the patient says that where they are is good enough for them, then it is and we accept that.
There may also be sessions dedicated to taking a victory lap, celebrating the progress in the patient’s life, perhaps even ending the session early because the patient is wanting to just enjoy where they currently are, knowing that next week they may again wish to dig deeper. Bottom line: regardless of the patient’s capacity, we do not get ahead of their conscious will and we are open to the possibility that for some patients, unlocking the unconscious is just not where it is at for them, and other, different types of therapeutic work is what is needed. Remaining in touch with not just psychodiagnostic information we get from the patient but also with our felt sense helps us make these determinations of what, when, and with whom.
This approach also stresses the importance of arriving at a dynamic formulation of the psychodynamic conflicts giving rise to the patient’s presenting problems. The triangle of person as well as nuanced, unique themes related to the patient’s intrapsychic conflicts are a major focus. “What is the formulation here?” is a question I have heard Mr. Skorman ask countless times.
In the context of Mr. Skorman seeing scores of trainees with previous exposure to ISTDP and noticing that many of the trainees were out of step with their patients for one reason or another (observations I also make with my students and trainees) — some applying well-rehearsed straight-lines and rote techniques, others so focused on looking for signs of unconscious communication that they aren’t actually hearing what the patients are saying, yet others so focused on dragging patients through the central dynamic sequence — that the foundation gets lost, the actual contact and connection between patient and therapist is often not there, replaced by attempts at applying techniques.
The basics of dynamic inquiry, understanding how the patient sees things, ensuring the therapist has properly understood the meaning of what the patient is trying to convey by summarizing and underscoring key themes with dynamic significance, establishing a conscious alliance, these things have been observed to be missing or in need of more work.
Mr. Skorman and I sometimes compare notes and discuss the prominent trends we see in our trainees. He often observes that he sees his trainees suffering, that there is something about either how the model might be taught (probably going all the way back to Dr. Davanloo), or alternatively, the trainee’s own neurosis hijacking the training process, creating suffering. Mr. Skorman reflects on a culture he noticed around Davanloo where unless the trainee had an unlocking of the unconscious with their patient within the first ten minutes of a therapy session, that the therapist was seen as defective. It is clear that to Mr. Skorman, these unfortunate events and dynamics do not cancel out an iota of his gratitude and admiration for Dr. Davanloo, who he describes as a true genius in the consultation room. “Not a day goes by when I don’t say to myself, “Thank God for Dr. Davanloo,” Mr. Skorman confides in me.
During one of our discussions, Mr. Skorman shared the following with me: “Davanloo used to say, ‘With the help of each other, if we work hard, we can get to the bottom of your problems.’ That was his way of saying it [that the heart of this work is about the emotional connection and collaboration between patient and therapist].” Mr. Skorman continued: “So much of that essence of Davanloo seems to have gotten lost, the admiration and affection part, it somehow got ‘techniqued’ away. The technique was secondary for Davanloo, it came from his intuition, which I think is an invitation to all of us to use our intuition” (personal communication, 2021).
An element of non-gushing warmth and support, but confrontation is far from dead
With the emphasis on emotional closeness and connection with the patient, some may get the impression that the Skorman approach is mainly about being supportive, empathetic, and without discipline around psychodiagnostic precision. This is not my view, though it is true that Mr. Skorman is concerned about an over-emphasis on technique and an excessive attachment to diagnostic categories that get in the way of a human-to-human connection with the patient.
The key criteria always guiding the Skorman approach: at this moment in time, what will further the treatment/what is the main impediment to progress? What will enhance the emotional connection and closeness between therapist and patient? For some patients what will accomplish these things will preclude a certain form of pressure so as to avoid duplicating past trauma (getting out of transferential shoes) and to facilitate a corrective emotional experience, for others, a rapid movement towards an unlocking of the unconscious is critical.
Other stand-out items emphasized in this flavor of ISTDP: where malignant resistances crop up and the ego-adaptive capacity allows for it, we engage in what Dr. Davanloo referred to as, “talking down to the super-ego,” and not “bargaining with the super-ego,” undoing projections by being different from the projection, and not allowing patients to manipulate us out of having an opinion, or getting sucked into colluding with the patient’s maladaptive defenses, i.e., pampering, coddling, or otherwise going along with an insecure attachment with the patient (insecure attachment reference — Jon Frederickson, personal communication, 2020).
The central role of the head-on collision
This approach hones in on different types of head-on collisions based on the patient’s ego-adaptive capacity and the strength of the conscious and unconscious therapeutic alliance. A complete taxonomy of the different types of head-on collisions we use in this approach is outside the scope of this write-up, but in addition to ego-adaptive capacity and the status of the conscious and unconscious alliance, the patient’s unique history, ego-syntonicity vs. ego-dystonicity of defenses, and severity of the need for self-defeat also factor in.
For example, with a patient with signs of fragility and a history fraught with rejection and abandonment, we may leave out the “if you remain distant like this, this process is doomed to fail.” Instead we may just say with a calm, edge-free tone, “So when you are like this, you are out of reach, and we are treading water, aren’t we.” We may add, “and that is of course your right, I am not going anywhere, I am here if you decide you would like to engage.”
A few paragraphs down under the “premature pressure is problematic” subsection, I give another example of a type of head-on collision that conveys both empathy for the patient’s conflict while still pointing out the reality that the therapist cannot be helpful while the patient remains guarded.
A different presentation, say an absence of fragility, ego-dystonic defenses, a highly malignant, destructive form of resistance may call for a head-on collision using a “talking down to tone” that not only underscores that the therapy will fail but also questions the point of even meeting, in line with what Dr. Davanloo referred to as conveying “studied disrespect” towards the defenses (H. Davanloo, Unlocking the Unconscious, 1990, p. 214).
The head on-collision is often critical, not just in order to undo the omnipotent transference resistance, intensify intrapsychic conflict towards the needed crisis-point, but also in order to cement and solidify the conscious therapeutic alliance and help the patient turn against her maladaptive defenses. When we help a patient see that there is a battle inside of them between the side that wants to remain guarded and the side that wants freedom, and ask the patient: “Which side are you on?” We are inviting the conscious will, we are “putting the patient at choice.” When and if the patient convincingly declares that they are on the side that wants to discontinue the avoidance strategies, the patient “turns against” her defenses and the conscious therapeutic alliance is solidified.
This may make it clear that even though this approach stresses the importance of not allowing a technical mindset to get in the way and become a therapist-created barrier against emotional closeness, expertise in moment-to-moment assessment of patient-response to intervention and expertise in how to most skillfully intervene based on response and ego-adaptive capacity is very important. This approach is not anti-technique, it is anti technique (and theory) that gets in the way of being present and emotionally connected to ourselves and our patients. I imagine this sentiment is shared by many if not all, but Mr. Skorman stresses this point more than anyone else I have come across.
On the topic of staying present with the patient and not mechanically plowing ahead in a cook-book fashion (allowing theory and technique to get in the way), I am reminded of Mr. Skorman’s comment: “this is intervention-response, not intervention, intervention, intervention, and ‘I’ll see you next week.’”
Premature pressure is problematic
Another hallmark of the Skorman approach: Not applying any added pressure — added as in additional pressure on top of the inherent pressure contained in inquiry into personal and emotionally charged areas of the patient’s life — into their defenses and into what it is that the patient wants — without the patient having convincingly declared their will to let go of defenses in favor of facing feelings.
This goes back to the two tiers of mobilization. The first tier can be achieved conversationally by simply asking about the patient’s priorities and feelings, making links, and reflecting back to the patient what is observed about their responses. The second tier is when we ratchet up the pressure but at that point we want a conscious alliance as the foundation. Moving ahead to second-tier level pressure without adequate foundational work is what is often problematic.
In other words, in this approach we do not try to get a high rise on complex transference feelings before there is a sturdy conscious therapeutic alliance and the patient has begun to turn against their defenses. Since some variety of the head-on collision is often central to helping the patient turn against her defenses, this intervention (modified to be suited to the patient in front of us) is typically done prior to a high rise of complex transference feelings, and later repeated (typically in abbreviated format so as to not deflate rise in feeling) as needed. An early head-on collision here is not meant to “block” defenses but is done conversationally and matter of factly so as to help the patient make an informed decision around holding onto or letting go of their defenses. As alluded to in the previous paragraph regarding the two tiers of pressure, some level of mobilization is typically desired and needed even prior to using added pressure and the head-on collision. We cannot help a patient meaningfully turn against her defenses outside the context of some level of feelings and defenses being stirred up.
In fact, not until the stage of increasing pressure and challenge where we aim for an unlocking of the unconscious by decisively blocking all defenses (blocking everything that is not the experience of raw feeling and impulse) — aka unremitting pressure and systematic challenge — does the conversational quality of the treatment give way to what is more clearly and overtly an applied technique, though Mr. Skorman stresses that even then, if the pressure and systematic challenge fails to enhance the felt sense of connection with the patient, it may be best to hold off on these more advanced interventions until they can be done without sacrificing the sense of collaboration and closeness with the patient. This portion is not used in the graded format.
In the context of defenses and resistance impeding the progression of therapy, and the patient being reluctant to let go of their defenses, I can’t count the times I have heard Mr. Skorman very calmly say something to this effect: “I understand, allowing people close to you hasn’t been a good experience for you so far. And yet this represents a dilemma in our work, because the one thing I need in order to have a shot at being helpful to you is access to your most intimate thoughts and feelings, and it is also the one thing you say you abhor the most, letting people in, close to you. So here we are.” At these types of junctures, this is a conversation, not an attempt to mobilize complex transference feelings.
The bottom line: without a conscious alliance around facing feelings, we don’t exert heavy pressure toward feelings. Without a conscious alliance around letting go of defenses, we don’t exert heavy pressure to relinquish defenses. Not getting ahead of the patient’s conscious will is a central tenet in this approach. There are no repeated “so what feelings are coming up” or “how do you experience that feeling” questions until the patient is on board with such a focus and has a crystal clear understanding of how those questions (and that task) relate to their concerns and priorities for treatment.
Creativity is highly valued in this approach. I am reminded of hearing about a teaching moment where Mr. Skorman supervised a supervisee, and the supervisee presented a case where his female patient was in a dreadful custody situation with her abusive ex-husband. The patient had a major compliant streak, a need to take care of others and had perfected this with her ex-husband. Mr. Skorman suggested leveraging her skills in taking care of the ex-husband towards looking after the welfare of the children, who could be greatly harmed if their father won custody rights. Prioritizing this focus (time was of the essence) was both in line with the patients concerns and the safety of the children, and addressing the maladaptive component of the patient’s compliance could be dealt with down the road, once the children were out of harm’s way.
Mr. Skorman also developed a format of ISTDP adapted to couples therapy that I have elaborated on. The approach to couples therapy is elegant and often very effective. A YouTube video exists that explains this approach in detail — simply type in the search words: “ISTDP Inspired Couples Therapy” on YouTube to access that video.
Supervision and Teaching
The Skorman approach to teaching and supervision is characterized by using who the trainee is, their life and clinical experience as a starting point, and then integrating ISTDP into that so as to enhance the trainee’s strengths, rather than trying to make the trainee void who they are in order to fit into a mold. This is hopefully how all teachers supervise, but I bring it up because it is stressed so greatly in this approach.
When difficulties arise, the default assumption in this approach is that the training or teaching approach needs to be questioned or adjusted, not that the trainee is defective. Central to this approach is the idea that the therapist in training is wise if they do not try to make themselves into a copy of the supervisor, but instead find their own voice and integrate whatever is learned into their own personality. I have had heated disagreements with Mr. Skorman. Differences are OK, healthy, and welcomed.
If it’s ever a choice between didactics, letting the trainee know what they could have done differently with their patients, or meeting the trainee where they are and modeling how to not get ahead of the patient by not getting ahead of where the trainee is, we opt for the latter, shelving didactics in favor of a conscious alliance with the trainee and modeling how to be with patients.
In the Skorman lineage, the teacher decides on a case-by case basis when a trainee is ready to teach others. For better or worse, transmission, that is recognition of readiness to teach, occurs one-to-one, outside institutionalized trappings.
As I am writing this in 2021, I realize it’s been 14-years of intensive immersion in learning on this path, and that capturing the stand-out items of this learning is a tall order. I imagine I have fallen short in capturing the distinct quality that is the Skorman approach, but I hope a general flavor has come across. Whatever mistakes I have made in characterizing this model rest on my shoulders alone.
As Mr. Skorman heads for the exit, I mourn the loss of this teacher that has been so formative for me. To my mind, our profession is losing a giant who chose to live, practice, and teach in relative obscurity. His wish has been for his students to take what they can from him but then chart their own course, keeping the flame alive but in a way that honors the uniqueness of who we are as individuals.
I raise a metaphorical glass to him, and to Dr. Davanloo, who made all of this possible.
References and acknowledgment:
Elad Jair Chone, Clinical psych. — close student of Mr. Skorman — in an editorial capacity, has graciously assisted in the making of this text.
Marvin Skorman, LMHC, Personal Communications (2007 – 2021).
Davanloo, H. (1990). Unlocking the Unconscious (p. 3). N.p.: John Wiley & Sons.
Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo, MD Chichester, England: John Wiley & Sons.
Whittemore, Joan W. “Paving the Royal Road: An. Overview of Conceptual and Technical Features in the Graded Format of Davanloo’ s Intensive Short-Term Dynamic Psychotherapy.” International Journal of Short-Term Psychotherapy, vol. 11, 1996, pp. 21-39.
Jon Frederickson, MSW, Personal communication, (2020).