Category Archives: Defenses

Premature Challenge II

“Thanks for your post. I probably should have been more clear about what I meant about this ‘apparent change in ISTDP.’ I was referring to things that I heard from Maury Joseph and Tom Brod. Maury said: “with depressed and fragile patients, we use almost exclusively pressure to lift them up, recaps when they pop a threshold, and challenge only when the rise is high. Challenge triggers anger towards the therapist, and in somebody who’s in repression that will make them more depressed in an instant.” Tom said: “Challenge used to be one of the stages of the Central Dynamic Sequence. Davanloo wants to avoid the word and make it all Pressure, so as not to feed the resistance. He emphasizes the importance of using Head On Collision as the pressure to “unlock the unconscious.” The proper intensity cannot really be defined a priori, and so what is the now-forbidden “challenge” is also not defined.”

So I’m getting the impression that we should hold off on challenge and use it much more sparingly.” Thanks to Jeremy for this request for more on premature challenge!

We use systematic challenge only with highly resistant patients with isolation of affect. Low and moderately resistant patients relinquish their defenses without needing their defenses challenged. Fragile and depressed patients cannot tolerate a high rise of feeling without becoming overwhelmed with anxiety, depression, or somatization. Challenging defenses causes a sharp rise of reactive anger which will overwhelm their capacities. As a result, challenge will make them flatten out, get depressed, or overwhelmed with anxiety and projection. So never use systematic challenge with depressed or fragile patients.

Although ISTDP gained some of its notoriety for the use of challenge, this intervention is used with only about 25% of patients (highly resistant with isolation of affect) and only after the defenses have formed a transference resistance.

When therapists do not realize the importance of helping the patient see the defenses and their price and function (restructuring of defenses), they often use challenge prematurely, resulting in misalliances. Also, if therapists have not been through their own therapy, their affect tolerance may not be high enough to identify and clarify the resistances in the highly resistant patient. As a result, when feelings rise, therapists may use challenge prematurely.

To deal with this problem some trainers avoid talking about challenge, relying only on pressure to feelings instead. Some avoid pressure to feelings, fearing that could be dangerous! Instead, they emphasize exclusively restructuring.

The truth is that in any complex model of therapy, we must see how all the parts fit together. Simplistic solutions will not do.

Challenge is a useful intervention, but at the right time, right place, and with the right person. I would urge you not to challenge defenses at all! If you are challenging a defense against a feeling instead of a resistance to emotional closeness, you are engaging in premature challenge. Wait until the defenses begin to work as a system to form a pathological relationship, the transference resistance.

Once the defenses coalesce into the transference resistance, identify and clarify the resistance. Once the patient can see his transference resistance, its price and function, THEN you can challenge the resistance and you won’t have to worry about a misalliance.

Having asked you not to be simplistic, I’ll be simplistic for a moment.

Fragile patients: invite feeling and regulate anxiety, identify and restructure projection and splitting. No challenge

Moderate resistance: invite feelings, block, identify, and clarify defenses. No challenge.

High resistance with repression: invite feelings, identify and clarify defenses and then ask for feelings toward you. No challenge.

High resistance with isolation of affect: invite feelings and identify and clarify defenses. When defenses coalesce into a transference resistance, identify the resistance and invite feelings toward you. Clarify the resistance and ask for feelings toward you. When the patient sees the resistance and its price, then you can challenge the resistance.

Premature challenge

“I’ve been hearing a lot of talk about “premature challenge” but I’m having a hard time wrapping my head around this apparent change to ISTDP. I think that part of the problem may stem from the fact that “challenge” means different things depending on who is using it. I was wondering if you might want to do a post on the appropriate timing of challenge.” Thanks to Jeremy for asking this important question!

When the patient presents a specific example of a problem, we invite him to share his feelings in that example so we can find out the triangle of conflict: what feelings, anxiety, and defenses create his presenting problems?

When we explore feelings, defenses arise. At first, we block the defenses by asking for feelings again. That is enough to brush aside tactical defenses, which are lightly held by the patient.

If those defenses remain, however, we identify them and then ask for feelings.

Th: That’s your thought, but what’s the feeling underneath that thought?

If the patient sees the defense as a result of your work but still uses it, clarify the defense.

Th: That’s your thought but your thought is not a feeling. That’s how you cover your feeling. (clarifying the function of the defense) If we look under the thought, what is the feeling toward him?

If the patient sees the function of the defense, clarify the price. “If you cover the feeling with thoughts, you’ll stay confused (price). So can we look under the thoughts and see what the feeling is toward him?”

Once the patient sees the defense and price and it continues, this is usually a sign that the resistance has moved from resistance against feeling to resistance to emotional closeness. The patient is not just distancing from his feelings; he is distancing from you!

Now instead of a defense here and there against feelings, his defenses work together to form a pathological relationship with you called the transference resistance.

Once the patient can see his defenses and their price, we can challenge his defenses.

Th: What can we do about this habit of covering your feelings with thoughts?

If you challenge the patient before he sees the defense, he will believe you are attacking him as a person instead of commenting on his defense. This leads to a misalliance. Or the patient may become confused, unsure what you are talking about. If the patient sees the defense but not the price or function, you are asking him to give up something that he believes is good and helpful. Without seeing the price of the defense, why should he give it up?

Once the defenses coalesce into the transference resistance, likewise, we do the same sequence.

  • identify the resistance and ask for feelings.

Th: Notice how you look away and avoid my eyes. That becomes a barrier between us. I wonder what feelings might be coming up here toward me that make you avoid?

  • Clarify the price of the resistance and ask for feelings

Th: If you keep avoiding me, we won’t get to find out who you really are and then you’ll remain a lonely man. I wonder what feelings are coming up here toward me that make you put up this wall?

Once the patient can see his resistant behavior and its price, THEN you can challenge it.

  • Again we see this wall of avoidance coming up here between us. But this will defeat your efforts here. What do you think we can do about this wall you are putting up here between us?

Just to be clear, we NEVER challenge the patient. We challenge the defense’s usefulness today. We challenge the defense’s punitive effects upon the patient. Then we ask the patient to let go of a defense that hurts him.

When the patient can see his resistance and how it hurts him, he can finally let go of it.

If he can’t see the defense or how it hurts him, there is no reason he should he let go of it. Always do your preliminary steps of identifying the defense/resistance, and clarifying its price and function. Once those two steps are accomplished, then challenge the defense.

Jeremy wondered if this is an “apparent change” in ISTDP. The answer is no. Davanloo was always very clear about the dangers of premature challenge and the preliminary steps of restructuring that are necessary. However, because our feelings get aroused when working with patient resistance, we therapists sometimes go to premature challenge to avoid the rising feelings within ourselves. This is where building affect tolerance within therapists is so important.