Monthly Archives: August 2014

10 Most Common pitfalls in ISTDP

What are the most common mistakes in ISTDP? Thanks to Jeremy for this question.

1. Failure to get the patient to declare an internal emotional problem to work on.

Th: What is the patient you would like me to help you with?

Pt: My wife thinks I have problems with intimacy.

Th: That may be what your wife thinks is your problem, but my question is what problem you would like me to help you with.

Pt: I’m not sure I have a problem.

Th: And yet you are here.

Pt: Uh. Yeah. Well, the doctor thought I should come.

Th: But you came instead of him. What is the problem you would like me to help you with.

Persistently block defenses and return to the focus on the problem. We do not attempt therapy until the patient has declared an internal emotional problem.

 

2. Failure to establish that it is the patient’s will to do therapy.

Th: And this problem of intimacy with your wife, is it your will to look at this?

Pt: I guess so.

Th: I notice you didn’t say yes. If this is not something you want to explore, I have no right to do so. That’s why I have to ask if it is your will to look at this problem of intimacy.

Pt: The doctor thought it would be a good idea.

Th: But he’s not in therapy. The question is whether it’s your will to look at this problem.

 

Persistently block defenses and return to the focus on his will. We do not go further unless it is his will to look at his problem

 

3. Failure to get a specific example where feeling arises so you can explore it.

 

Th: Could we look at a specific example where you have a problem of intimacy with your wife?

Pt: She’s always complaining about things.

Th: But a specific example?

Pt: It’s more of an in general kind of thing.

Th: If we remain general, we can’t get a clear view of your problem. So could we look at a specific example where your problem comes up.

 

Persistently block defenses and return to the focus on a specific example. We cannot explore feelings unless we have a specific example where feelings come up. Very often therapists try to explore feelings without a specific example. As a result, they get nowhere.

 

4. Working when anxiety is too high.

 

Th: What is the feeling toward him for sexually abusing you?

Pt: I feel dizzy.

Th: That’s a sign of anxiety. Notice how these feelings trigger anxiety, and then you get this symptom of anxiety?

 

As soon as anxiety goes into cognitive/perceptual disruption or the smooth muscles, regulate anxiety. If you keep exploring feelings when anxiety is too high, the patient’s anxiety will worsen and she will regress as a result of your treatment, suffering increasing depression and somatic problems.

 

5. Working when anxiety is too low due to failure to ask about feelings and address defenses.

 

Th: What is the feeling toward him for firing you?

Pt: No big deal. I’m glad to be out of the job. I feel relieved. [said with a detached voice]

Th: [Here the therapist might keep asking about feelings rather than address the patient’s defense against contact with the therapist. As a result, anxiety would remain low (because the therapist is not addressing the patient’s distancing which keeps him artificially calm) and the defense would not be addressed.] You don’t sound relieved and you don’t look relieved. You sound and look detached. Do you notice how you detach here with me? What feelings are coming up here toward me that make you detach?

 

When patients use lots of defenses against contact (transference resistance), they will not look anxious. Why? Their defenses are working just fine. If you don’t address their defenses against emotional closeness, no feelings or anxiety will rise.

 

6. Failure to maintain a specific focus. That is, if the patient uses a defense, address the defense and return to your focus on feeling….every time….again and again and again.

Th: What is the feeling toward your girlfriend for betraying you?

Pt: Disappointed.

Th: She disappointed you. What is the feeling toward her?

Pt: I think the reason she did that was because he seduced her.

Th: That’s your thought about him, but the feeling toward her?

 

Persistently address EACH defense and then return to the focus on feeling. Therapists new to ISTDP persist for maybe five times and then they give up, assuming they aren’t doing this right. Patients who have used these defenses for anywhere from twenty to seventy years will not stop using them after only five interventions. Maintain your focus as long as the patient needs. Maybe it will be only fifteen minutes, maybe an hour and a half. The longer your focus, the higher the rise of feelings in the patient, and the deeper the breakthrough you will experience with the patient.

 

7. Failure to see when the patient shifts from resisting feelings to resisting emotional closeness with the therapist.

Th: What is the feeling toward your girlfriend?

Pt: I feel hurt.

Th: She hurt you. What is the feeling toward her?

Pt: [pause] Um. Er. It’s hard to say.

Th: Notice how you slow down now? Notice how you go inside your head and withdraw from me? Notice how there is a wall coming up between us?

8. Failure to address the resistance and then ask for feelings toward the therapist…every time…again and again and again.

9. Failure to differentiate feelings from the defense of discharge

10. Failure to shift into the transference when the patient engages in self-attack.

 

Love Addiction or Addiction to Denial?

I have a patient who wants me to help him move on and put the object of his addiction (his ex-girlfriend) on the shelf. When he holds on to her, I ask about the consequences. He says they are negative. I point out that he puts his life on hold waiting for her, letting his life depend on her while blaming himself for his past mistakes. He says he does not want this, but he cannot help it. He does not want to say goodbye to the tiny chance that she still wants him. He says he is willing to pay the price, if it preserves his hope in her. It looks like addictions to alcohol and drugs. He says he is willing to pay the price, if it preserves his hope in her. Sometimes he says, “Now I see what I’ve been doing. I can see how much it upsets me and my life. I’ll stop it.” But he doesn’t. He also reproaches and tortures himself by thinking of good memories in the past. I think I need to I ask about the problem and the will to work with it.” Thanks to Ebbe for this important question!

 

He is not addicted to his girlfriend. He is addicted to denial in fantasy. He could relate to reality: she left him. Instead, he relates to his fantasy: she’ll come back. Triangle of conflict: mixed feelings of rage, guilt, and grief toward her; anxiety; and the defense of denial through fantasy.

 

Let’s analyze what he says, so we can see his defense and how to address it.

 

“I have a patient who wants me to help him to move on and put the object of his addiction (his ex-girlfriend) on the shelf.”

 

His ex-girlfriend is not the object of his addiction. His FANTASY is the object of his addiction. The real girlfriend left him. His FANTASY girlfriend wants to come back and live happily ever after. The object of his addiction is not a person; it’s a fantasy about that person.

 

Intervention: But this is such a beautiful fantasy: a rejecting girlfriend turns into a loving girlfriend. Why put it on the shelf? [Since his denial is syntonic, mirror it. Then he experience conflict between himself and his defense.]

 

“When he does not let her go, I ask about the consequences. He says they are negative.”

 

The good news: he does not have to let his girlfriend go. She already left. The question is whether he will let his fantasy go: the fantasy of a girlfriend who wants to come back.

 

Intervention: But this is such a beautiful fantasy: a rejecting girlfriend turns into a loving girlfriend. What could be negative about that? [By mirroring his defense, you help the patient experience the irrationality and the price of his defense.]

 

“I point out that he puts his life on hold waiting for her, letting his life depend on her while blaming himself for the mistakes he has done. He says he does not want this, but he cannot help it.”

 

Intervention: You can’t help it that you want the loving girlfriend in your mind rather than the rejecting girlfriend in reality. I can understand that. [Point out his defense and empathize with the underlying feelings it wards off.]

 

“He does not want to say goodbye to the tiny chance that she still wants him. He says he is willing to pay the price, if it preserves his hope in her.”

 

Intervention: It’s important to love her while she rejects you. Can we accept that? [Point out his defense and deactivate projection of will onto you.]

 

“He does not want to say goodbye to the tiny chance that she still wants him.”

 

Intervention: Why say goodbye to your fantasy when it might turn into reality? [Mirror his denial, so he can experience its irrationality and price.]

 

“He says he is willing to pay the price, if it preserves his hope in her.”

 

Intervention: You would rather suffer waiting for your fantasy to turn into reality. Can we accept that? [Point out his defense.]

 

“Now I see what I’ve been doing. I can see how much it upsets me and my life. I’ll stop it.”

 

Intervention: Why stop now? What if your fantasy turns into reality next week? [Mirror his defense. When he promises to stop his defense, he makes a promise to you, not to himself. His intrapsychic conflict becomes interpersonal. The conflict is between you (spokesperson for reality) and the patient (spokesperson for fantasy). I suggest the therapist mirror the fantasy, so the patient experiences the conflict within himself between his wish for the truth and his lie.]

 

“He also reproaches and tortures himself by thinking of good memories in the past.”

 

Intervention: Do the memories hurt? Or does her rejection hurt? [His pleasant memories don’t cause his pain. They numb it by avoiding the memory of her unpleasant rejection.]

 

The issue of declaring a problem and will is interesting. He believes his problem is that she rejected him: how can I get her back? For us, the problem is how he avoids his feelings over her rejection. By denying reality, he fails to deal with it.

 

Will? His will is not to face reality but to deny it by relating to his fantasy instead. And who can blame him? He has very painful feelings over this loss. And, given the strength of his denial, he probably has many other buried feelings over previous rejections as well.

 

Take home point: there is no such thing as a love addiction, just addiction to denial. He is not addicted to a rejecting girlfriend. He is addicted to a fantasy girlfriend who will unring the bell, make time rewind, and resume a life of loving bliss. Denial through fantasy is his drug of choice. And wow!! Is it ever addictive!