The Basics

ISTDP is a collaborative therapy, one that you and your therapist do together. Rather than merely showing up, bringing up what comes to mind, and getting instruction from the therapist, you actively engage in:

1. defining the particular problem you want me to help you with;
2. observing yourself (thoughts, feelings, and behaviors) closely and accurately;
3. discovering automatic, and often unconscious, habits of thinking and acting that block you from knowing or working toward what you want;
4. deactivating those habits;
5. learning how to identify anxiety that covers up your true desires or that makes it difficult for you to act on them; and
6. developing your capability to regulate and tolerate that anxiety.

This work leads to a truer, more caring, and more positive relationship with yourself based on knowing what you want and being able to identify and overcome internal obstacles hindering you. The work also results in greater capability to choose satisfying relationships and ways of relating.

ISTDP achieves these results through a special kind of listening and intervention in which your therapist pays close attention to what you say and do moment-by-moment in each session and then helps you identify and overcome the automatic, unconscious habits that hold you back. This effort often involves facing feelings that you avoid, a process that may create anxiety and discomfort. But your therapist will be standing with you during that process, helping you to manage anxiety and to proceed at a pace that aims at the fastest possible, secure progress.

 

The Evidence

Evidence for ISTDP as for other therapies exists on a spectrum. At one end are rigorous experimental tests in the form of clinical trials. Some of these tests include features such as random assignment of some people in the pool to treatment and others to no treatment, features that increase the reliability of the results. These tests typically examine whether the therapeutic approach alleviates particular well-defined (Diagnostic and Statistical Manual) symptoms such as depression or panic attacks. Experimental tests, including those with features such as random assignment, provide strong evidence that ISTDP is effective for:

1. a variety of mood disorders including various depressive disorders;
2. a variety of anxiety disorders, including panic disorder;
3. a wide range of somatic symptom disorders in which individuals experience physical problems with no apparent medical cause;
4. dissociative disorders; and
5. personality disorders.

A good summary of the current state of the research can be found on the ISTDP Institute Website, and the same website has a page listing some of the research articles.

At the other end of the spectrum are qualitative clinical reports of improvement across a range of issues. Some of these issues, although extremely important to the individual, are difficult to test experimentally because they cannot be easily defined or measured. Clinical reports on ISTDP note many positive outcomes, including, but not limited to: increased self-esteem; greater self-confidence; the ability to share greater depth of feeling with loved ones; closer and more caring relationships; greater enjoyment of life; more productive and fulfilling work experiences; the ability to identify true desires for work and relationships; overcoming procrastination; greater ability face losses such as death or divorce; and learning to express anger appropriately and use constructive self-assertion.

 

The Process

As noted above (The Basics), at the heart of ISTDP is a special kind of listening and intervention in which the therapist pays close attention to what you say and do moment-by-moment in each session and then helps you identify and overcome the automatic, unconscious habits that block you from knowing and achieving what you want. This approach requires the therapist to be very active with you. If your therapist senses that you are engaged in statements or behaviors that constitute one of these harmful habits, your therapist will interrupt the process, allowing you to observe the habit and creating the opportunity for you to turn against it. Your therapist also will participate with you in monitoring anxiety and your felt experience by asking questions and pointing out external signs that you are exhibiting.

Feelings that you have pushed away usually are underneath the habits and the anxiety that impede you. Uncovering these feelings is critical to your progress, the gateway to knowing your true desires and being able to act on them. In helping you to interrupt, become aware of, and overcome the blocking habits and anxiety, your therapist is not trying to criticize you. Compassion for you requires assisting you in removing these blocks and helping you not only to put symptoms behind you but also to gain new-found freedom and vitality.

To complete the picture it is important to realize that: (i) the blocking habits and anxiety are often unconscious, that is, you are not aware of them; and (ii) they typically are protective reactions that at one time were adaptive but now are hindering you. A classic source of the habits and anxiety is attachment trauma, arising from pushing away feelings during infancy or childhood that endangered your relationship to the caregiver / parent upon whom you were utterly dependent. The unfortunate result of this at-one-time wise adaptation is buried complex and conflicting feelings, still very active in the unconscious, that give rise to suffering in the form of symptoms and harmful behaviors.

Addressing this picture requires you to work together with your therapist to monitor anxiety and identify the blocking habits in order to uncover the underlying, often complex and painful feelings that arise from broken or defective attachments. It is not enough simply to have intellectual understanding of the situation. Central to the effectiveness of ISTDP is the direct experience of the relevant feelings in the therapy session itself. These feelings may be directed toward current figures in your life, past figures, or toward your therapist.

Since therapy encourages closeness, it is natural that you will have feelings toward your therapist. It is typical that the process of observing your blocking habits and anxiety as they occur will trigger mixed emotions such as gratitude and anger toward your therapist. Often your feelings toward your therapist will mirror critically important feelings toward current and past figures. As a result, these feelings provide very valuable information and experiencing them in real time in the therapy room is enormously useful. Not surprisingly, research indicates that working with feelings toward your therapist in the manner prescribed by ISTDP is one of the most effective ways to make progress in therapy. It is important to realize that your therapist is not trying to stir up feelings toward him. The nature of the process and past patterns combine to generate the feelings. We mine them together for their value, which is considerable.

Anxiety and its regulation plays a central role in ISTDP. Too little anxiety indicates that you are not successfully approaching the critical hidden feelings, but too much anxiety short circuits the process. We jointly pay close attention to the level and manifestations of anxiety, and a major gain from ISTDP is an enhanced ability to identify, tolerate, and regulate anxiety.

ISTDP is a true collaboration that requires a full, 100% commitment on your part and on the part of your therapist to be successful. What does a 100% commitment from you look like given that you are facing unconscious habits, powerful and sometimes painful unconscious feelings, and, often, significant anxiety when you challenge these habits and experience the feelings? Three elements characterize such an effort: that you tell your therapist the difficulties you want to work on; that you are willing to observe yourself moment-to-moment as honestly as you can; and that you report your thoughts, feelings, and reactions to your therapist, including your feelings and reactions toward the therapist himself. ISTDP is hard work but offers substantial rewards: not only the relief from disturbing symptoms, but also a transformation that leads to a new life of greater freedom, engagement, and real choice.

 

The Mechanics – Length and Number of Sessions; Videotaping

Two features distinguish ISTDP from most other therapies: the initial session is a lengthy trial therapy typically lasting around three hours, and, with your consent, sessions are videotaped. The trial therapy allows the therapist to gain a deep understanding of your difficulties and capacities, indicating whether and how ISTDP can be helpful for you. In addition, progress during this first session can instill hope and motivation for the full course of ISTDP therapy ahead.

Interactions between you and your therapist are complex. The ability of the therapist to review what takes place on a videotape is invaluable and can make a big difference in your treatment. In addition, there is the possibility of receiving consultation from trained experts on a confidential basis, adding considerable further value. These benefits have led to videotaping being the norm in ISTDP. Videotaping requires your consent, and, if you have concerns about videotaping, you should consult with your therapist or choose a therapist willing to proceed without videotaping.

After the initial trial therapy, the length and number of sessions vary. Session lengths around 90 minutes work well for most individuals, but longer or shorter sessions are sometimes desirable. The number of sessions required to achieve results depends on a number of factors, including the nature of the underlying issues and your degree of commitment. ISTDP is designed to be efficient, offering change in a shorter time, with fewer total sessions and hours of therapy.