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?
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.