Category Archives: General

Healing

Heinrich Racker wrote, “Psychoanalytic cure consists in establishing a unity within the psychic structure of the patient.” What does that mean? What I will say now may come as a surprise to many of you, because, strangely, the implications of our work are often not spelled out in ways that reveal the radical practice that psychotherapy really is. So here goes.
Every image we have of another person outside us is a projection of what is inside us. To be cured, we must re-establish the equation: not-me = me. What I see in you is in me. The disavowed humanity I judge in you is my exiled humanity, which I judge and send off to you for safekeeping. In contrast, when I identify with you, I overcome an imaginary division between us, and finally recognize the ever-present, pre-existent identity that we are. That is why when I truly know you, your humanity, as me, that knowledge is love, for, as Racker tells us, “To understand, to unite with another, and, hence, also to love, prove to be basically one and the same.”
As the ancient Roman playwright Terentius said, “Nothing human is alien to me.” Thus, that which we comment upon, judge, reject, mock, or dismiss in others is ourselves re-located in them (at least in our imagination). To be healed, we, as therapists, must own our projections, judgments, letting our disavowed soul-birds migrate home. And to heal, we must help patients re-marry those aspects of their humanity, which they have tried to divorce.

Am I doing ISTDP?


Often, therapists begin their supervision hour by saying, “Is this ISTDP?”
“I know this isn’t ISTDP?” or, at worst, “I can’t do ISTDP!” Or sometimes colleagues commit secret assassinations, and whisper to others, “He doesn’t do ISTDP!” Why do we kill ourselves off this way? Why do colleagues engage in character assassination? And what is ISTDP anyway?
When learning any complex activity like therapy, chess, or music, we take a long journey, a lengthy learning curve, involving multiple theories, tons of techniques, and the science of psychodiagnosis. We do not learn complex skills from reading but by doing, trial and error, in this case, with real patients with real problems who suffer from our mistakes. To achieve mastery takes years of practice, bearing the guilt that our mistakes make others suffer, and bearing the frustration that real mastery takes longer than the fantasy of immediate accomplishment.
To avoid the pain, guilt, and frustration that comes with mastery, we may idealize any form of therapy, be it ISTDP, psychoanalysis, or CBT, and then measure ourselves by that ideal. Of course, measuring ourselves by any ideal allows us only two solutions: grandiosity (I incarnate the ideal ritual) or depression (I am not the ideal and think, mistakenly, there is something wrong with me.) So we can kill ourselves off (“I can’t do the ritual”) or kill others (“He doesn’t do the ritual.”). Or we can take a look at ritualism and the ways it cripples critical thought.
In case you thought this problem was unique to ISTDP, you can let go of that fantasy too. In psychoanalysis, great analysts from Reich to Kohut have been excoriated for not doing “analysis”. In fact, Robert Langs wrote a book in which he claimed that anything except transference analysis was lie therapy, not psychoanalysis.
So this problem is larger than psychoanalysis or ISTDP or CBT. Trashing others for not doing psychoanalysis or CBT or ISTDP is just political assassination under another name, a power ploy, politics under the disguise of “scientific discussion.” Killing off others with the hope that’s one’s version of reality is the sole survivor after all the others have been annihilated.
So what is ISTDP anyway? In one sense, it is a method for assessing patient responses to determine what the next intervention should be. Techniques from any approach can be used if they increase the patient’s capacity to observe and bear his complex mixed emotions. In this sense, ISTDP is not a technique, per se, but a principle of assessment, which guides the application of techniques. There are two levels: principles and application of principles.
In another sense, the term “ISTDP”, becomes distorted into a symbol, an ideal, a ritual to be enacted mechanistically, with no room for individual variation. Living knowing becomes frozen knowledge, as if the complete “technique” has been discovered, once and for all, needing no development or change because the one, perfect model for therapy has been discovered. Since it is supposedly perfect and all-encompassing, it now steps outside the realm of science since no further research, development, or thinking is necessary.
Of course, this second sense of ISTDP is not ISTDP at all, but the degraded, ritualized fossil of a living body of knowledge that is ever growing, always changing, and forever deepening. We may choose to idealize, ritualize, and fossilize a living body of knowledge to make it easier to learn, to avoid the painful inner growth as a therapist, or to belong to an ideal club of the cognoscenti which condemns the “fallen” from an imaginary tower of “superiority.”
I have heard CBT people devalue dynamic therapies, psychoanalysts devalue short- term therapies, AEDP people devalue ISTDP, and ISTDP people devalue each other for not doing ISTDP. In this risky form of Russian roulette, everyone gets shot, everyone gets hurt, and everyone gets killed off, at least in the imagination of the shooter. But, in the end, did we really prove anything except our capacity to murder those from whom we might have learned?
Perhaps this is our original sin as therapists: to idealize our club and devalue the others. Longing for certainty, wanting to belong to the winning theory, rooting to be right, we are doomed. We are like the theoreticians arguing for Ptolemy’s theory of the universe centuries before Galileo’s illusion shaking findings.
Meanwhile, on the other side of this killing field there is the evidence. 50% of patients get better in therapy on average. 10-15% get worse. 90% of therapists think they are in the top 25%. No single approach has been proven to be markedly more effective across the board.
What is ISTDP? a method for assessing patient responses to intervention, so we can intervene flexibly to meet the patient’s need in the moment. What can we make it into? a highly concretized symbol, a frozen piece of knowledge, an ideal, a fossil—in short, a coffin. So when people ask me if I do ISTDP, I would have to say, “It depends.”