CBT and ISTDP: how are they related?

“I want to thank you for making ISTDP available to the general public and clinicians across the globe. I wanted to ask how you understand the relationship between ISTDP and CBT. On the surface, CBT is quite compatible with ego psychology, particularly around adaptive functioning. As I understand it, ISTDP considers maladaptive cognitions as defenses. That seems fine to me. However, cognitive theory, a la Beck is all about schemas, implicit cognitions, core beliefs that are triggered via environmental stimuli, which then present as intermediate assumptions, attitudes and automatic thoughts.

So my question is: how are core or implicit core beliefs about self, the world, others or the future, defenses? Which comes first: schemas then affect, or the other way round? Clearly, working with beliefs, or meaning-making, is relevant to our attempts to have meaningful lives. What place do beliefs have in ISTDP?” Thanks to one of our Aussies for sharing this question.

Although CBT and ISTDP differ in terms of their understanding of what causes psychopathology, they share much in common in terms of technique. Allan Kalpin wrote a great article on the ways we can incorporate cognitive therapy techniques into ISTDP.

Causality: in ISTDP we understand that forming a relationship triggers unconscious feelings which evoke anxiety based on past relationships. To ward off those feelings and anxiety, the patient uses defenses which were effective in past relationships. These defenses are understood, according to ego psychology, as healthy forms of adaptation to the environment. The tragedy is that what saved the patient’s life in the past often ruins his life today. Some patients’ defenses come together to form a pathological relationship known as the transference resistance (or schema in CBT). Here, the patient has feelings with you that trigger anxiety. Then the patient forms the kind of relationship he had to live with as a child. It is his unconscious form of relational adaptation to his early environment. Within this early form of relationship, he has many thoughts and perceptions that are congruent with that relationship. We deal with his thoughts, feelings, and relational behaviors as a whole, as transference, and help him face the feelings which this entire complex wards off.

In CBT anxiety is believed to be triggered by conscious or implicit cognitions which are triggered by the environment. Thus, earlier forms of CBT help patients see those thoughts and their irrationality. Later forms of CBT address the transference, the patient’s unconscious mode of relating to you. In CBT, transference is called a schema. Jeffrey Young and others help patients recognize unconscious patterns of relatedness and the related thought patterns. As in transference analysis, they help patients reflect upon patterns of relating that cause problems in their lives. They have great techniques for helping patients see the schema (transference) and the cost/benefits of the schema which are very useful in ISTDP as well. ISTDP differs in that we view the transference (schema) as a defense against unconscious feelings toward the therapist. So in ISTDP, after the schema work, we go one more step and help the patient face and experience the feelings which the schema (transference) wards off.

ISTDP causality: relationships trigger unconscious feelings and anxiety and defenses.

CBT causality: the environment triggers implicit cognitions, beliefs, and schemas which trigger feelings and anxiety.

Neuroscience has buttressed the idea of causality that is proposed by psychoanalysis and ISTDP: non-conscious perception of threat (Damasio, Panksepp) triggers emotions (Damasio) which evokes anxiety (LeDoux) and defenses (Freud). This is why Barlow said that CBT therapists would need to shift their idea of causality to incorporate the findings of neuroscience. And it is why third wave CBT is incorporating emotion, implicit cognition, and schemas much more into their model. It’s important for non-CBT people to realize that CBT is a very different model now from its first iteration.

Even though the theories of causality appear to be different, there is a very interesting overlap. Helping patients see how maladaptive thoughts can trigger anxiety can be an effective intervention. Why?

We have seen that unconscious feelings trigger unconscious anxiety and unconscious defenses which cause the presenting problems and symptoms. However, some defenses, such as projection and maladaptive cognitions, can perpetuate anxiety! A patient is sad over the death of her uncle. The sadness makes her anxious. She tries to distract herself from her sadness by rumination. But the rumination triggers more anxiety. The cognitive therapist would correctly address the rumination, which will bring the patient’s anxiety down. The ISTDP therapist would do that as well. Then the ISTDP therapist would focus on the underlying grief, knowing that if the patient can face her grief, her anxiety will drop further, and her defense will no longer be necessary.

From this point of view, ISTDP sees that the patient feels a feeling, becomes anxious about sharing it, and uses a defense such as maladaptive cognitions. CBT sees that the environment triggers the maladaptive cognitions.

ISTDP: feelings trigger anxiety which evokes defenses which can perpetuate anxiety.

CBT: maladaptive cognitions (defenses) perpetuate anxiety.

So from my point of view, cognitive therapy causality is absolutely correct, at the tail end of the chain of causality. CBT work on maladaptive cognitions (defenses) is an essential step. ISTDP adds one more: facing the underlying feeling that the defenses warded off.

Let’s look at some other similarities between ISTDP and CBT. In ISTDP we use cognitive techniques for defense identification and clarification, and for restructuring projection and other regressive defenses. We promote cognizing with fragile patients who do not have sufficient access to isolation of affect.

We not only share certain techniques in common, but certain intervention strategies.

Let’s translate ISTDP into CBT terms:

ISTDP: exposure therapy with response prevention (exploring feelings while blocking defenses)

Defenses: implicit memory processes, maladaptive behaviors and cognitions

Projection: assumptions or automatic dysfunctional beliefs

Transference resistance: schema

Pressure to feeling: exploring dysfunctional beliefs, schema, and behaviors, exposure to feeling

Clarification of the price of the defense: exploring the relationship between cognitions and behaviors, the cost/benefit analysis

Challenge of defenses: asking the patient to shift thoughts or behaviors, response prevention

Recapitulating links between past and present and the triangle of conflict and the triangle of conflict: behavior analysis

Graded format: graded exposure

As you can see, the two models show much in common. CBT techniques can be very helpful and it’s useful for everyone to know them. At the same time, ISTDP can add to CBT the emphasis on unconscious feelings, new ways of handling resistance, new ways of assessing and working with anxiety, new ways of listening for unconscious material, and new ways of working with the unconscious. Now for your next question!

How could core beliefs be defenses? Let’s suppose a woman is angry with her abusive husband. In therapy she mentions her anger, becomes anxious, and then says, “I’m just worthless. I deserved that slap.” Here her thought/belief has a defensive function. She turns the anger toward her husband back upon herself. It is not just a belief. This thought has a function: to turn anger upon the self. Where cognitive therapy looks at the content of thoughts (their irrationality), ISTDP looks at their function (to ward off feeling). Function: does this thought amplify her ability to face and feel her anger, or does this thought inhibit her ability to do so?

Obviously, beliefs do not always serve defensive functions. Suppose the patient is angry with her husband and then says her religion condemns anger. Now she enlists a thought about religion to inhibit the experience of her anger. Another person might speak about her religion as it relates to the ontology of personhood. This could be a healthy intellectual discussion about the very meaning of what it is to be human. The issue is not whether a belief, per se, is a defense. It is whether a belief is misused in the service of defense. And any thought or belief can be misused for defensive purposes as we read in the papers every dayJ

Until we succeed with 100% of our patients 100% of the time, we have more to learn. What is the relationship between ISTDP and CBT or ISTDP and anything else? Hopefully the relationship of openness and learning from one another. All of us work with the same patients and issues. In spite of grandiose claims, no treatment model has yet been conclusively shown to be markedly more effective than other treatment models across the spectrum of patients. So we’re in no position to idealize our pet theory or devalue others. Those are the games of children, not the scientific work of adults. So let’s keep learning from others. Let’s keep looking at the evidence in our videotapes. Let’s keep relating to other theories and thinkers.







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