“The Controversial Therapy That Deliberately Enrages Patients”

A sharp-eyed friend (with the help of google) alerted me to a piece about ISTDP on a site I had not previously known, vice.com, with the above title.  You can read it here.

I made a few attempts to post a comment, but they didn’t stick, maybe because I included my website URL (www.natkuhn.com).  Maury Yoszef did manage to get an intelligent comment up there, thanks Maury!

In any case, I thought I would post my comments here:

As an ISTDP practitioner, I’d like to comment on some aspects of this article that can be misleading.

As Dr. Said notes, ISTDP is based above all on a therapeutic alliance between the patient and therapist.  ISTDP therapists encourage patients to face painful, locked-away feelings, but for this to be effective it must happen in the context of a relationship where patients understand clearly that the therapist is acting in their best interests  People who try to imitate a naive idea of ISTDP as “antagonistic” or “badgering” rapidly find out that it is not effective and if anything makes patients worse.  Maintaining the appropriate level of intensity requires a great deal of skill and training.

 There is never a time in ISTDP when a patient “literally wants to kill the therapist,” and if a patient of mine ever did, I might well “seek help from law enforcement”–but I’ve never had to, and I don’t know an ISTDP therapist who has.  ISTDP is about helping patients to experience and observe feelings, understanding that feelings and impulses are very different from actions.  In the process of ISTDP therapy, therapists can be relentless in pointing out patients’ self-defeating behaviors; this brings up a mix of positive and negative feelings toward the therapist, which can connect up to unconscious feelings of rage from early life.  When this happens, the patient may experience feelings of murderous rage directed toward the therapist, but patients are able to understand that these are feelings and impulses, not actions they actually want to carry out–in other words, the patient does not, in fact, “fly into a murderous rage.”  Experiencing these feelings (among others) is often an essential element of ISTDP treatment, allowing access to additional material from early life.

While Dr. Said’s own description of ISTDP seems generally accurate, there are a few points (on which he may have been inaccurately quoted) that I would take exception to.  First, there HAS been quite a bit of research on ISTDP, showing that it is effective, though more is definitely needed.  Some of the research can be found on the web site (www.istdp.ca) of one of—if not the—foremost ISTDP researcher, Dr. Allan Abbass at Dalhousie University in Halifax, Nova Scotia.

Second, as many commenters have noted, it is absurd to say ISTDP “always works.”  I have devoted a lot of time and energy to learning ISTDP because it treats a broader variety of patients in a more effective way than any other therapy I know.  But, for example, I would not treat a patient with schizophrenia, or a patient who is actively manic, with ISTDP.  And there are patients who, despite my best efforts, I have not been able to help.

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