On Paolo Migone’s “What Does ‘Brief’ Mean?”

We are writing regarding Paolo Migone’s “What Does ‘Brief’ Mean?” (JAPA 62/4), in which he discusses various issues related to brief therapy from the perspective of psychoanalysis. We found the paper interesting and concur with many of his views. Our own clinical and research focus is in the area of Habib Davanloo’s model, intensive short-term dynamic psychotherapy (ISTDP). From this perspective and with an up-to-date understanding of ISTDP, we are writing to clarify certain aspects of the model.

Our understanding is that Migone’s observations are based on his viewing a tape of a certain type of patient and process Davanloo presented many years ago, likely before developing and clarifying his current method and elaborating on details of technique. Regarding Migone’s statement that ISTDP appeared formulaic and that each session appeared the same, the current reality is that there are several patient categories and presentations, with different treatment pathways, using the ISTDP framework. Two spectra of patients, those with psychoneurotic disorders and those with fragile character structure, themselves contain subgroups of patients, each with different tendencies to present in treatment sessions (Abbass, Town, and Driessen 2013; Davanloo 2005). Each of these presentations must be met and matched with specific interventions, including focus on avoided complex emotions, focus on barriers to engage in therapy, focus on building anxiety tolerance, and focus on bringing psychic integration in very fragmented patients. The process Migone refers to sounds like the standard or typical process that occurs with a highly defended patient who presents avoiding emotions and avoiding being open with the therapist, but this is only one type of presentation among many (Davanloo 2005).

The second issue we wish to address is the common misconception that ISTDP is about “digging out anger,” or that anger is even prioritized in the treatment. The reality is that the process is focused on all the very complex feelings activated in the transference relationship due to the therapist’s efforts to bond with the patient; this process helps the patient mobilize and experience all the complex feelings and impulses related to broken attachments. The key here is that complex transference feelings, rather than just positive feelings or rage alone, are mobilized to access the unconscious, guilt-laden attachment feelings; to do otherwise would create a split, resulting in either misalliance or idealization and treatment stagnation. The central role of the experience of the complex transference feelings as a gateway to the “corrective emotional experience” Migone refers to has been explored in several process and outcome studies (Abbass, Town, and Driessen 2012, 2013; Johansson, Town, and Abbass 2014; Town, Abbass, and Bernier 2013).

Our third issue relates to ISTDP technical interventions. Pressure, the mainstay intervention in ISTDP, includes all efforts to encourage the patient to be emotionally present, be open, work against his defenses, identify underlying feelings, and collaborate. This is arguably a key common factor in all structured psychotherapies. Pressure in this format is the direct factor that mobilizes or “evokes” these complex transference feelings, which include both deep appreciation and irritation toward the therapist. “Provocation” on the other hand can only mobilize anger and misalliance and would actually shut down access to the unconscious. All efforts must mobilize continuous positive feelings toward the therapist, since his efforts reach through to the attachment center in the patient; this process activates his loving attachment, pain, rage, and guilt about rage and, secondarily, anxiety and defenses against these feelings/impulses. Through this mobilization process, these emotions and defenses can then be collaboratively worked on.

Another misconception relates to the notion of emotional expression versus experiencing. In contrast to what Migone writes, the effectiveness of ISTDP is not simply due to an exercise in being angry and being accepted with this anger; it is due rather to the actual visceral experience of the feelings and impulses that break through the unconscious anxiety and defenses. Such a neurobiological process rebalances the conscious and unconscious forces of inhibition/self-destruction/repression versus the forces of emotion, memory, and health. This effect can directly weaken forces of the punitive superego and liberate the developing healthy self.

Migone refers to the likelihood that newer formats of ISTDP likely exist that he is not familiar with. New ISTDP methods have been developed for patients with major depression, somatization, dissociation, and borderline disorder (Davanloo 2005). Patients in all these categories require systematic work to develop psychic capacities before the unconscious can be safely mobilized (Abbass and Bechard 2007). This is largely a form of supportive dynamic therapy, devoid of the challenges and other heavy interventions that highly resistant patients benefit from. Further, these therapies are not all “brief,” as they average from twenty to eighty sessions depending on how much structural change is required. In a 2002 study, one of us (Abbass) estimated that all the referred patients could be treated in an average of forty sessions, but that means many of the treatments were over forty sessions long and so by definition not short-term. ISTDP is not time-limited and can in some cases be medium-term or even long-term in duration. In published studies the treatment averages fifteen to thirty sessions (Abbass, Town, and Driessen 2012). ISTDP also has a five-session method for symptom reduction and a format called block therapy delivered in three-day blocks a few months apart (Davanloo 2005).

A further question raised is the sustainability of effects. Several recent meta-analyses of ISTDP—and, more broadly, short-term psychodynamic models—point to large to robust effects that persist or even increase in long-term follow-up (Abbass, Town, and Driessen 2012; Abbass et al. 2014; Lilliengren et al. 2014; Town et al. 2012). These findings are a testament to the lasting effects of psychodynamic therapy. Thus, the literature on these shorter psychodynamic models contributes to growing evidence for the power, scope of application, and cost-effectiveness of psychodynamic treatment.