Intensive short-term dynamic psychotherapy

1. Introduction

Version followed: Abbass's operationalisation (Reaching Through Resistance, 2015) used day to day, organised around Davanloo's central dynamic sequence (CDS) and metapsychology (1990, 2000). Where Davanloo's later Montreal work ("total removal of resistance", multiple major unlockings) differs, this guide says so.

Intensive short-term dynamic psychotherapy (ISTDP) is an emotion-focused psychodynamic therapy developed by Habib Davanloo at McGill. He built it from video recordings of his own sessions. The model holds that interrupted attachments leave complex mixed feelings (love, rage, guilt about the rage, grief). When those feelings come close, they trigger unconscious anxiety, which the patient handles with defenses. Symptoms and character problems are the cost of those defenses. Change happens when the therapist and the patient's healthy will (the conscious and unconscious therapeutic alliance) turn against the defenses. Then the patient can experience the warded-off feelings in the body, in the room, at a level of anxiety they can tolerate. The therapist links those feelings to past and present relationships and to the symptoms. Each such breakthrough is called "unlocking the unconscious". [source: Abbass 2021 Psykologtidsskriftet; Hickey 2015; Hickey 2020 ch.; Abbass 2015]

The method is manualised in books and training rather than as a single session-by-session protocol. Davanloo's original technique is taught today through Abbass, Frederickson, ten Have-de Labije & Neborsky, Della Selva and others. They differ mainly in pace, in how hard they confront, and in how they work with fragile patients. [source: Abbass modules; Kieding/Skorman] [uncertain: exact wording and chapter structure of the 1990/2000/2015 books are not drawn on; the content here comes from published summaries, papers and training outlines]

2. Framework

Two maps used in every session [source: Hickey 2015; Malan 1979; Abbass 2015]

• Triangle of conflict (Ezriel/Malan): Feeling or impulse → Anxiety → Defense. Each intervention targets one corner.
• Triangle of person (Menninger/Malan): Current relationships, Transference (the therapist), and Past figures. Links run C–T–P.

Unconscious anxiety: discharge pathways and thresholds [source: Abbass et al. JFP somatization paper; Abbass 2021]

• Striated (voluntary) muscle: hand clenching, sighing breaths, neck and shoulder tension, and later whole-body tension. This is the pathway you want: the patient can think and feel in it.
• Smooth muscle: gut cramps, urge to urinate, migraine, a spike in blood pressure, wheeze, while the striated muscles look relaxed.
• Cognitive-perceptual disruption (CPD): blurred or tunnel vision, ringing ears, losing the thread, drifting, dissociation, and in extreme cases hallucination.
• Motor conversion: sudden weakness, things dropped from the hand, loss of voice.
• A threshold is the level of feeling at which anxiety switches out of the striated pathway. Smooth muscle, CPD or conversion then signal anxiety above tolerance. The aim is to move anxiety back into striated muscle and widen the threshold step by step.

Patient spectrum (decides the format) [source: Abbass modules; Hickey 2015; PeerJ 2014; Abbass 2021]

• Psychoneurotic spectrum: low, moderate and high resistance, plus high resistance with repression. Anxiety stays striated as the transference feelings rise, and the main defenses are isolation of affect and tactical or character defenses. These patients get the standard CDS with pressure and challenge.
• Fragile character structure: mild, moderate or severe. These patients have CPD or smooth-muscle anxiety at a low rise of feeling, plus regressive or primitive defenses: projection, splitting, projective identification, acting out, dissociation. They get the graded format, which means capacity building before any challenge.
• Psychotic or very low capacity: a supportive format with no challenge to defenses. [source: PeerJ 2014]
• Davanloo grades the rise of transference feelings as low, mid and high. Abbass uses these as diagnostic test points: at each rise, see which anxiety pathway and which defenses appear. [source: Abbass modules]

Phases

Davanloo's seven CDS phases [source: Hickey 2015; Hickey 2020 ch.; Davanloo 2000 papers]

1. Inquiry: the patient's difficulties, and the first test of how they respond.
2. Pressure: toward specific examples and toward feelings, including feelings toward the therapist.
3. Challenge: to the defenses as they show up in the room. This includes the head-on collision with the resistance.
4. Transference resistance: the resistance takes shape inside the relationship with the therapist and rises toward a peak.
5. Direct access to the unconscious: the breakthrough or unlocking.
6. Systematic analysis of the transference: the patient reviews and links what just happened.
7. Dynamic exploration into the unconscious: memories and links to the past, and consolidation.

Session counts [source: PeerJ 2014 citing Davanloo; Abbass 2021; theraplatform (secondary)]

• Low-resistance psychoneurotic patients: 1 to about 15 sessions.
• High-resistance psychoneurotic patients: about 20–40 sessions.
• Fragile patients: about 40–80+ sessions. Abbass puts it at about 20 sessions to 2+ years, depending on severity.
• In one naturalistic service the median was 5 sessions (mean about 10).
• [uncertain: the low-resistance range is a common training figure]

3. Guiding principles

[source: Abbass 2021; Kieding/Skorman; Hickey 2015; Abbass 2015; Davanloo 1990/2000. Where a principle is my own condensation, it is tagged]

• Assess while you treat. Each intervention tests something: watch the response, not the words. In practice, after every intervention, look at the anxiety pathway, the defense, and any signal from the unconscious alliance.
• Anxiety is the gauge of the dose. Striated anxiety means go on. Smooth muscle, CPD or conversion means stop mobilizing feelings and regulate. In practice, look at the hands, breathing, gaze and gut before you speak.
• Defenses, not people, are the problem. You side with the patient against what hurts them. In practice, every challenge names the defense and its cost, never the patient's character. [source: Abbass 2021; Kieding/Skorman]
• Conscious alliance first: an internal problem, the patient's will, an agreed task. In practice, don't add pressure until the patient has said what they want to change and that they want to face their feelings to do it. [source: Kieding/Skorman]
• Voluntariness. In practice, compliance counts as a defense, and the patient may always choose to keep a defense. [source: Abbass 2021: passive compliance is treatment-defeating]
• Clarify before you challenge. In practice, a defense must be identified, seen by the patient and agreed to be costly before you challenge it. Challenging too early feels like an attack. [source: Abbass 2021]
• Timing is the technique. In practice, pressure, then challenge, then head-on collision, in that order. Use the head-on collision only once the resistance has formed inside the transference. [source: Hickey 2015]
• Work in the here and now and stay specific. In practice, take one specific recent example, one feeling, and how it feels in the body right now.
• The transference is the main arena. In practice, the feelings that come up toward the therapist are where the past is relived, and where you can watch it and work with it. [source: Davanloo via Hickey 2015]
• Ally with the unconscious therapeutic alliance (UTA). In practice, treat sudden memories, images, links and dreams that arise as the UTA speaking, and follow them. [source: Hickey 2015/2020]
• Grade intensity to capacity (graded format). In practice, fragile patients get cycles of mobilization and recap, not continuous pressure. [source: Abbass modules; Kieding/Skorman]
• Neutral, warm, persistent stance. In practice, keep a calm, matter-of-fact tone, positive regard, and no retaliation when provoked. [source: istdp.no 2023 course outline]
• The therapist's own feelings carry information. In practice, notice your own urge to rescue, push or withdraw, and treat it as data about the system in the room. [source: istdp.no 2023]
• Don't over-function. In practice, let silence and the cost of the defense register, and don't do the patient's work for them. [source: Kieding/Skorman]
• Interpret after experience, not instead of it. In practice, keep cognitive linking for after a breakthrough or for anxiety regulation. [source: theraplatform (secondary); Hickey 2015]
• Videotape and review. In practice, record sessions with consent, and review micro-responses and your own timing. [source: Davanloo method; Hickey 2015]
• Safety outranks depth. In practice, any sign of unmanageable regression, dangerous self-attack or a medical flare overrides the goal of unlocking. [source: Abbass 2021 contraindications] [synthesis for the hierarchy]

4. Intervention inventory

The interventions are grouped as A: assessment, B: anxiety and capacity, C: the central dynamic sequence (mobilisation), and D: breakthrough and consolidation. All example language is illustrative unless it is quoted and cited. [source for section: Davanloo 1990/2000 via Hickey 2015/2020; Abbass 2015; Abbass 2021; Abbass et al. JFP; Kieding/Skorman; Frederickson 2013. Each item adds its own tags]

A1. Psychodiagnostic evaluation (trial therapy)

• Purpose / when: The first meeting with every patient. It diagnoses the resistance level or fragility and the anxiety threshold. It is also therapy: it tries for a first breakthrough and shows the patient how the method works. Abbass calls the response to a trial of therapy the single best indicator for treatment. [source: Abbass 2021; PeerJ 2014]
• Steps:
  1. Book about 2–3 hours. Get informed consent to an emotion-focused method, and to video recording if you use it.
  2. Screen for exclusions before mobilizing feelings: active intoxication, psychosis or mania, active inflammatory bowel disease or an unstable autoimmune or cardiac condition, and acute suicide risk. If any is present, run a standard risk or medical assessment and use a supportive format only. [source: Abbass 2021 contraindications; risk step = synthesis]
  3. Inquiry (A2). Get one specific recent example of the problem.
  4. Raise the feeling a little (C2). Watch which anxiety pathway appears (A3) and which defenses come in (A4).
  5. Psychoneurotic picture (striated anxiety, isolation of affect): go on into the CDS. Fragile picture (CPD or smooth muscle at a low rise, projection or splitting): switch to the graded format (B3).
  6. End with a recap of what was seen (B2), the formulation, an agreed plan, and the format and session expectations.
• Example language (illustrative): "Today is partly a test drive. We'll look at a real example of the problem. We'll notice what happens in your body when feelings come up. Then we'll decide together whether this approach fits you."
• Watch for: A patient who becomes vague or compliant and "agrees" without will. Treat that as a defense, not consent. It's working when the patient makes links on their own and anxiety stays striated as feelings rise.

A2. Inquiry and establishing the internal problem, will and task (conscious alliance)

• Purpose / when: At the start of therapy and of every session. Without an internal problem the patient wants to change, pressure has nothing to act on. [source: Kieding/Skorman; Hickey 2015]
• Steps:
  1. Ask what they want help with.
  2. Turn external complaints ("my boss") into internal ones ("what I do with my anger at my boss").
  3. Ask whether it is their own wish to work on it.
  4. Ask for a specific recent example: who, when, what was said.
  5. Summarise the problem and check the patient agrees before going deeper.
• Example language (illustrative): "What is the problem you want my help with?" / "Is that something you want to change for yourself, or something others want you to change?" / "Can we look at one specific time this happened?"
• Watch for: No stated problem, a problem that belongs to someone else, or "I don't know." These are the first defenses, so clarify them (A4) rather than push past them. [source: Frederickson seminar outline, "no declared problem, no will"]

A3. Reading and tracking unconscious anxiety

• Purpose / when: Continuously, after every intervention. Anxiety decides whether you push, hold or regulate. [source: Abbass et al. JFP; Abbass 2021]
• Steps:
  1. Scan the hands (clenching), the breath (sighs), and the neck and shoulders. This is striated anxiety.
  2. Ask about the gut, bladder and headache, and look for limp relaxation. This is smooth muscle anxiety.
  3. Ask about vision, hearing, thinking and memory. If the patient goes blank or "far away", that is CPD.
  4. Watch for sudden weakness. That is conversion.
  5. Note the level of feeling at which the pathway changes. That is the threshold.
  6. Name the pathway with the patient, so that noticing anxiety becomes their skill too.
• Example language (illustrative): "When you talk about him, I notice you sigh and your hands tighten. Do you notice that?" / "Are you having any trouble thinking clearly right now? How is your vision?"
• Watch for: A patient who looks "calm" but has a cramping stomach or is drifting. Abbass et al. warn this apparent calm ("belle indifference") is common. [source: Abbass et al. JFP] It's working when the patient starts to report the pathway themselves and, with practice, anxiety returns to striated muscle more quickly.

A4. Identifying and clarifying defenses

• Purpose / when: As soon as a defense blocks the feeling. Clarification makes a defense visible and makes it feel foreign to the patient (dystonic) before any challenge. [source: Abbass 2021: challenge without clarification feels like attack]
• Defense classes to recognise [source: Davanloo 2000 tactical defenses papers (TOC); Abbass 2021; Abbass et al. JFP]:
  • Tactical: cover words, vagueness, generalising, hypothetical speech, diversification, rumination, argumentativeness. Non-verbal: smiling, looking away, nodding.
  • Isolation of affect: intellectualising, rationalising, minimising. The patient feels the emotion in the head, not the body.
  • Repression: weepiness, self-attack, depression, somatisation. The feeling turns inward.
  • Character: compliance, defiance, detachment, passivity.
  • Regressive or primitive: projection, splitting, projective identification, acting out, discharge, dissociation.
• Steps:
  1. Name the behaviour.
  2. Ask whether the patient notices it.
  3. Explore its function: what does it help them avoid?
  4. Explore its cost: what has it done to their life and to this session?
  5. Ask whether they want to go on with it or let it go.
• Example language (illustrative): "You say you were 'a bit annoyed'. Is that a way of making the feeling smaller?" / "Notice that when we come close to the anger, you start explaining. Shall we look at what that explaining does?"
• Watch for: The patient complying with your words while the defense goes on. It's working when the patient catches the defense in themselves and turns against it.

A5. Showing the costs: making defenses dystonic

• Purpose / when: After clarification, when a defense is still felt as "just who I am" (syntonic). [source: Abbass modules, "detecting syntonic resistances"; Hickey 2015]
• Steps:
  1. Draw the triangle of conflict with the patient's own material.
  2. Link the defense to the presenting symptoms and to their losses: relationships, health, mood.
  3. Ask whether that is what they want for themselves.
• Example language (illustrative): "So when you feel angry, you get anxious, and then you go quiet and blame yourself. And that's the depression you came in with. Does that fit?"
• Watch for: Intellectual agreement with no change in the body. It's working when the patient becomes concerned about, or even angry at, the defense itself.

B1. Anxiety regulation (intellectualising about anxiety)

• Purpose / when: At once, whenever anxiety moves into smooth muscle, CPD or conversion, or the patient becomes overwhelmed. It brings cognition back and drops anxiety into striated muscle. [source: Abbass et al. JFP; Abbass 2015]
• Steps:
  1. Stop mobilizing feelings.
  2. Ask the patient to describe the anxiety in detail: where it is, what it feels like, what changed.
  3. Get them to think about it: "what just happened?"
  4. Link it: feeling → anxiety → defense.
  5. Check for signs of recovery: clear vision, sighing returns, gut settles.
  6. Only then bring the feeling up a little again.
• Example language (illustrative): "Let's pause. Tell me exactly what you're noticing in your body right now." / "Your vision blurred when we came close to that anger. That's anxiety. Let's look at it together."
• Watch for: Pushing on through CPD. That risks dissociation, panic or a medical flare and teaches nothing. It's working when the patient's thinking clears and the hands or breathing show striated anxiety again.

B2. Recapitulation (cognitive recap)

• Purpose / when: After a rise of feeling and anxiety, after a breakthrough, and at the end of every session. Recapping builds the patient's own ability to reflect, bringing the observing ego into the room. [source: Abbass 2021: recapitulation listed among core interventions; istdp.no 2023: "recapping"]
• Steps:
  1. Ask the patient to say what just happened, in sequence.
  2. Add any missing corner of the triangle.
  3. Link it to symptoms and to the triangle of person.
  4. Check their understanding ("does that fit?").
• Example language (illustrative): "Let's go back over what just happened. What did you notice first?" / "So the feeling came up toward me, the anxiety went into your stomach, and then you started to drift. Is that how you saw it too?"
• Watch for: You recapping for the patient. Have them do it. It's working when recaps come faster, more accurately, and without being asked.

B3. Graded format (cycles of mobilisation and recap)

• Purpose / when: For fragile character structure, and for patients whose anxiety goes to smooth muscle or CPD at a low rise, including many with somatic symptoms or severe depression. The goal is to raise the threshold until standard CDS work is safe. [source: Abbass modules; PeerJ 2014; Abbass 2021; Kieding/Skorman]
• Steps:
  1. Raise the feeling gently with a specific example and a question about the body.
  2. Go just to the threshold, at the first sign of smooth muscle or CPD.
  3. Stop and regulate (B1).
  4. Recap (B2) the link between feeling, anxiety and defense.
  5. Repeat the cycle. Over sessions, raise the feeling a little higher each time.
  6. Use no head-on collision and no unremitting pressure. Clarify defenses without systematic challenge.
  7. Restructure the main defense (B4–B6).
  8. Move to more standard work once anxiety stays striated at a mid rise.
• Example language (illustrative): "Let's go a little bit into the feeling and then stop and look at what happens. We're building your capacity, not rushing."
• Watch for: Long periods of only regulating, with the feeling never raised; that is collusion. Watch too for pressure creeping in. It's working when the threshold rises across sessions and the patient begins to notice CPD and stop it themselves. [uncertain: Whittemore's 1996 graded-format paper is not drawn on; the steps follow Abbass training outlines and secondary sources]

B4. Restructuring repression (building isolation of affect)

• Purpose / when: For depressed, weepy, self-attacking or somatising patients whose feelings go inward, into the body or into self-attack, instead of being felt. Build the capacity to think about feelings first, then to feel them. [source: Abbass modules: "structural change" in depression with repression; Abbass et al. JFP]
• Steps:
  1. Pick a specific situation with someone else.
  2. Ask what feeling they had toward the other person, keeping it separate from feeling toward themselves.
  3. As the feeling rises, look for weepiness, self-blame or physical symptoms.
  4. Name the moment it turned inward.
  5. Ask them to think about it: whom was the feeling toward?
  6. Repeat until they can name and reflect on the feeling without symptoms.
  7. Then move toward experiencing it in the body.
• Example language (illustrative): "You started to cry just as you were about to say you were angry at him. Did you notice? It's as if the anger turned into tears and blame toward yourself."
• Watch for: Self-attack getting more intense. Assess suicide risk in depressed patients using standard risk assessment. It's working when the patient can say "I was angry at him" with striated tension and no symptoms.

B5. Restructuring projection (deactivating projections)

• Purpose / when: When the patient sees their own feeling, will or judgement in the therapist ("you're pushing me", "you think I'm stupid"). Until the projection is undone, no alliance is possible. [source: Frederickson seminar outlines; istdp.no 2023; Kieding/Skorman]
• Steps:
  1. Stop all pressure.
  2. Ask what they perceive in you. Explore it sincerely, since it may be partly accurate.
  3. Separate what you actually said or did from what is being imagined.
  4. Return the will to them: the choice of whether to look at feelings is theirs.
  5. Ask what they feel toward the person they see in you.
  6. Over time, link it to past figures.
• Example language (illustrative): "You feel I'm pushing you. Let's check that. I'm not going to make you do anything, and you decide what we look at. If no one's pushing, is there something you want to look at?"
• Watch for: Behaving like the projection expects (insisting, defending yourself). Don't do it. It's working when the patient takes the wish or the judgement back as their own.

B6. Blocking regressive and discharge defenses (splitting, acting out, weepy regression)

• Purpose / when: When feelings are discharged rather than felt: shouting, storming out, sudden helpless tears, all-good or all-bad views of people. [source: Frederickson seminar outline: "identifying and blocking regression"; istdp.no 2023: splitting] [uncertain: the detailed steps are drawn from Frederickson 2013 and training outlines]
• Steps:
  1. Notice the discharge.
  2. Calmly separate feeling from action.
  3. Ask them to put the feeling into words and notice it in the body instead.
  4. For splitting, bring both sides into view together ("you love her and you're furious with her").
  5. Regulate the anxiety.
• Example language (illustrative): "Let's slow down. Rather than shouting, can you tell me what the feeling is and where you feel it?" / "There's love for your mother and rage toward her. Both are here."
• Watch for: Mistaking discharge for a breakthrough. It's working when the feeling can be held in the body with striated anxiety while the patient stays in contact with you.

B7. Bracing, quick links and pressing (Abbass graded-format micro-skills)

• Purpose / when: Named in Abbass's fragile-patient teaching as tools for timing and capacity building, alongside recapping and anxiety regulation. [source: istdp.no 2023 course outline]
• What is documented: A quick link is a short, rapid connection between a feeling just felt and an anxiety, defense or symptom. Bracing and pressing are listed but not defined in the sources used. [uncertain]
• Steps (synthesis, tentative):
  1. Quick link: right after a small rise, say the link in one sentence and get the patient's agreement.
  2. Bracing: before raising the feeling, prepare the patient by agreeing what to watch for and how you'll pause together.
• Example language (illustrative): "Just now, the irritation came and your stomach cramped. Notice that link."
• Watch for: Don't present these as Abbass's exact definitions. Check them against Reaching Through Resistance or his training before you rely on them.

C1. Pressure toward specificity

• Purpose / when: In the inquiry, whenever the patient is vague or general. Feelings only come up around specific events. This is the first form of pressure in the CDS. [source: Hickey 2015: pressure for specificity; Davanloo 2000 "Phase of pressure" (TOC)]
• Steps:
  1. Ask for one specific instance.
  2. Ask for a concrete detail: when, where, what was said.
  3. Each time they generalise, gently bring them back to the specific example.
• Example language (illustrative): "Can we take one specific time? When was the last time it happened?" / "What exactly did she say?"
• Watch for: Pressure that sounds like interrogation. Keep it collaborative. It's working when the scene becomes vivid and feeling (striated tension) starts to rise.

C2. Pressure toward feeling (experiencing in the body)

• Purpose / when: Once you have a specific example and an alliance, and anxiety is striated. It mobilizes the feeling and, with it, the anxiety and defenses, so the triangle of conflict becomes visible. [source: Hickey 2015; Abbass et al. JFP: ask how the feeling feels physically]
• Steps:
  1. Ask what they felt toward the person in that moment.
  2. Tell feeling apart from thought ("I felt that he...") and from anxiety ("nervous").
  3. Ask how the feeling shows in the body, for example the heat or energy of anger, as distinct from tension.
  4. Check the anxiety pathway at every step.
• Example language (illustrative): "What's the feeling toward him?" / "'That he was unfair' is a thought. What's the feeling?" / "How do you experience that anger physically?"
• Watch for: A shift into CPD or smooth muscle; regulate at once (B1). It's working when the anxiety lessens as the feeling is felt and you can see the energy of the feeling rising. [source: Abbass et al. JFP: experienced feelings "push out the anxiety"]

C3. Pressure toward feelings in the transference

• Purpose / when: Once the resistance shows up in the relationship with you: detachment, distance, keeping you out. Davanloo puts the transference at the centre of the operation, and raising the transference component of the resistance (TCR) is the aim. [source: Hickey 2015; archivespp 2011 abstract]
• Steps:
  1. Point out the patient's detachment, distance or guardedness toward you.
  2. Ask what they feel toward you right now.
  3. Ask for the bodily experience of that feeling.
  4. Keep the focus here and now.
• Example language (illustrative): "Notice you're keeping a distance with me. What's the feeling toward me right now?"
• Watch for: In fragile patients this is the trigger most likely to push anxiety into CPD; use it only within capacity. It's working when the feeling toward you becomes intense and alive and the defenses against closeness start to crystallise.

C4. Mobilising the will to the task

• Purpose / when: When the patient is passive, compliant or uncommitted, or waiting for the therapist to do the work. [source: Frederickson seminar outline "mobilizing the will to the task"; Kieding/Skorman]
• Steps:
  1. Point out the passivity.
  2. Ask whether they want to do this work.
  3. Respect a "no".
  4. If they say "yes", agree the next step together.
• Example language (illustrative): "It seems like you're waiting for me to do this. Is it your wish to look at this feeling, or not?"
• Watch for: A "yes" that is only compliance. It's working when the patient starts initiating and steering toward the feeling themselves.

C5. Challenge to tactical and character defenses

• Purpose / when: Only after a defense has been clarified and the patient sees it as costly, and only in psychoneurotic patients or in a fragile patient who now has adequate capacity. The challenge asks the patient to drop the defense and face the feeling underneath. [source: Hickey 2015; Davanloo 2000 "Phase of challenge" (TOC); Abbass 2021; PeerJ 2014]
• Steps:
  1. Name the defense.
  2. Point to the patient's will and capacity to let it go.
  3. Direct them toward the feeling.
  4. As the transference resistance rises, the challenges become more direct. Their target is still the defense, not the person.
• Example language (illustrative): "Can you look at me rather than away?" / "You can keep explaining, or you can let yourself feel it. What do you want to do?"
• Watch for: Challenge given too early, which creates a misalliance and makes the patient feel attacked. It's working when the defenses break down and the feeling rises with striated anxiety.

C6. Head-on collision with the resistance

• Purpose / when: The most powerful intervention against resistance in the CDS, usually aimed at the transference resistance. Use it only with psychoneurotic, highly resistant patients, after the resistance has crystallised in the transference and after earlier pressure and challenge. Never use it with fragile patients. [source: Hickey 2015; Davanloo 2000 "Head-on collision with resistance" (TOC); Kieding/Skorman; Abbass modules: timing of head-on collision]
• Steps [uncertain: the components summarise secondary descriptions, not Davanloo's text]:
  1. Calmly summarise the resistance in the room and how it is defeating the patient's own goals.
  2. Name its cost to their life.
  3. Acknowledge that you can't do it for them, and that the work is a partnership.
  4. Put the choice to their will: keep the defenses or face the feelings.
  5. Accept whatever they choose.
  • Skorman, as reported by Kieding, gives an early, conversational version and then repeats shortened versions as needed.
• Example language: "Which side are you on?" (Skorman, quoted in Kieding). Illustrative: "We have a problem here. Whenever we get close to the feeling, a wall goes up between us. If we let that wall stay, I can't help you, and you'll leave the way you came. What do you want to do?"
• Watch for: Hostile delivery, an argument, or a patient who submits rather than chooses. It's working when the UTA comes up: memories, images, or a surge of feeling toward you.

C7. Addressing self-sabotage and the punitive superego

• Purpose / when: In highly resistant patients whose defenses protect them from guilt and who sabotage the therapy or their lives. Davanloo frames removing guilt and the TCR as central. [source: archivespp 2011 abstract; Kieding/Skorman: speak directly to the superego rather than bargain with it; pacja review: separating ego from "punitive superego"]
• Steps:
  1. Point out the self-defeating pattern in the room.
  2. Frame it as a force against the patient's own wishes.
  3. Side with the patient's will against it.
  4. Don't negotiate with self-punishment.
• Example language (illustrative): "There's something in you that seems determined to fail here, even though you came for help. Do you want to let that win?"
• Watch for: Rising self-attack or suicidal thoughts in depressed patients. Assess the risk and slow down. It's working when guilt comes up as a feeling, not as self-attack.

C8. Psychoeducation about the method (orienting)

• Purpose / when: Early in therapy, and whenever the patient is confused about why you focus on feelings and the body. [source: Abbass et al. JFP: explain the need to approach feelings, likened to relaxing the guarding of an abdomen during an exam; Abbass 2015]
• Steps:
  1. Give a brief explanation of feelings, anxiety and defenses, using the patient's own example.
  2. Explain why you'll watch their body.
  3. Check they agree.
• Example language (illustrative): "When feelings come up, the body gets anxious and something shuts them down. That shutting down is linked to your symptoms. So I'll keep an eye on both with you."
• Watch for: Lecturing instead of experiencing. Keep it brief. It's working when the patient agrees and begins to observe these things in themselves.

D1. Facilitating the somatic experience of rage and its portrayal

• Purpose / when: At a breakthrough of anger or rage in a patient with enough capacity: anxiety striated, defenses down. It helps the patient experience the rage fully and get to what is underneath it. Davanloo's model has rage felt somatically and then portrayed as an impulse in imagery, which then gives way to guilt and grief. [source: Abbass 2021: guilt-laden buried rage; Hickey 2015/2020; Davanloo 1990] [uncertain: the exact protocol for portraying the impulse is not drawn from a primary text]
• Steps:
  1. Help the patient feel the physical energy of the anger: heat, a surge upward, the wish to grip or lash out.
  2. Ask, in imagination only, what that rage would want to do if it came out toward the person.
  3. Follow the patient's own imagery at their pace.
  4. Watch for the moment it turns to guilt or grief, and move with it (D2, D3).
  5. Afterwards, recap fully (B2) and keep a clear line between imagining and doing.
• Example language (illustrative): "How do you feel that anger in your body?" / "If that energy went out toward him, just in your mind, what would it want to do?"
• Watch for: This is not for fragile patients outside a late, high-capacity phase, nor for patients with a history of violence that hasn't been assessed. Stop if anxiety goes to CPD. Check that the patient feels clearly in control of action. [synthesis for screening] It's working when the rage passes through and leaves calm, then a strong wave of guilt or grief, and the unconscious alliance brings up memories.

D2. Passage of guilt

• Purpose / when: Right after rage is experienced, or when guilt comes up about harm (real or imagined) to a loved one. Davanloo's work makes guilt about rage the central unconscious emotion. Abbass treats guilt as central to building capacity in fragile patients ("immersive technique"). [source: archivespp 2011 abstract; istdp.no 2023; Abbass 2021]
• Steps:
  1. Notice guilt: pain in the chest, tears with eye contact, sorrow at the harm.
  2. Don't regulate it away.
  3. Let the wave pass, staying close.
  4. Then link it to the past figure and to self-punishment patterns.
• Example language (illustrative): "There's a lot of pain there. Just let it come." Verbatim example from a reviewed ISTDP text: "Just cry, just cry. Don't Suppress." [source: pacja review of ten Have-de Labije & Neborsky 2012]
• Watch for: Guilt turning into self-attack (repression), which needs B4. It's working when you see deep sobbing with eye contact and relief, followed by spontaneous memories and links.

D3. Grief and love (passage of complex feelings)

• Purpose / when: As guilt resolves, or directly in patients whose main buried feeling is unresolved grief. The complex mix of love, rage, guilt and grief toward the same attachment figure is the core of the work. [source: Abbass 2021; pacja review]
• Steps:
  1. Help the patient stay with the loss, the longing and the love.
  2. Name the mix of feelings toward the same person.
  3. Keep contact (eye contact, presence).
  4. Let the patient bring up memories.
• Example language (illustrative): "You loved him and you were furious with him. Both are true."
• Watch for: Grief used as a defensive weepiness against anger, which is a regressive defense. It's working when the grief is deep and connected and is followed by calm and a softer view of self and other.

D4. Linking (triangle of person; C–T–P)

• Purpose / when: After feelings have been experienced, or in quick, small links during the graded format. Linking connects the pattern in the room with present relationships and the past. [source: PeerJ 2014; Hickey 2015; Malan 1979]
• Steps:
  1. Ask whom else this feeling and this pattern come up with.
  2. Ask where the patient first learned it.
  3. Connect the transference (T), current figures (C) and past figures (P), and link the pattern to the symptoms.
  4. Let the patient make the links whenever they can.
• Example language (illustrative): "The way you just went quiet with me, does that happen with your partner too? And when you were small?"
• Watch for: Linking used as intellectualising before any feeling has been felt. It's working when links come spontaneously and with feeling.

D5. Systematic analysis of the transference (consolidation after unlocking)

• Purpose / when: CDS phase 6, right after an unlocking. This is where the experience is integrated cognitively and the multidimensional unconscious structural change (MUSC) consolidates. [source: Hickey 2015]
• Steps:
  1. Ask the patient to review what happened between you: their feelings toward you, the defenses, the breakthrough.
  2. Examine how the resistance worked against closeness with you.
  3. Link it to the past and to the presenting symptoms.
• Example language (illustrative): "Let's look back at what happened between us today, step by step."
• Watch for: The defenses coming back during the review; just point them out. It's working when the patient grasps the pattern and how it worked in a way that is new to them.

D6. Dynamic exploration into the unconscious

• Purpose / when: CDS phase 7, when the unconscious alliance brings up memories, images and dreams after an unlocking. [source: Hickey 2015/2020]
• Steps:
  1. Follow what the patient brings up.
  2. Explore the memories in specific detail.
  3. Notice new feelings and work with them through the triangle of conflict.
  4. Keep track of the core formulation.
• Example language (illustrative): "That memory came up just now. Tell me more about it."
• Watch for: You leading the material. It's working when memories come with feeling and fill out the formulation.

D7. Repeated unlockings and working through

• Purpose / when: Across the middle phase, until every major front of resistance and every feeling (rage, guilt, grief, love) toward the key figures has been experienced. Davanloo grades unlocking as partial, major, extended major, or multiple major. [source: Hickey 2015; Abbass modules: "repeated unlockings"]
• Steps:
  1. Start each session by reviewing what changed and what remains.
  2. Go for the next front: a new figure, a new feeling, or another layer.
  3. Run the CDS at whatever level of capacity the patient now has.
• Example language (illustrative): "What have you noticed since last time? Where is the problem still showing up?"
• Watch for: Smaller unlockings that repeat themselves without progress; look for a defense you haven't spotted. It's working when symptoms and character patterns change outside the sessions.

D8. Termination

• Purpose / when: When the goals are met and both agree. ISTDP has no fixed number of sessions. [source: PeerJ 2014] [synthesis for steps]
• Steps:
  1. Set an end date together.
  2. Explore the feelings about ending, including grief and anger toward the therapist.
  3. Recap what changed.
  4. Arrange follow-up if indicated.
• Example language (illustrative): "We're nearing the end. What feelings come up about saying goodbye to me?"
• Watch for: Old defenses coming back around the ending.

D9. Videotape review (therapist practice)

• Purpose / when: Throughout. Davanloo built the method from video, and training relies on reviewing sessions moment by moment. [source: Hickey 2015; Frederickson seminar outline; theraplatform (secondary)]
• Steps:
  1. Get written consent to record.
  2. Review the anxiety pathways, the timing of interventions, and your own countertransference.
  3. Bring sessions to supervision with someone trained in ISTDP.
• Watch for: Practising the head-on collision or intensive work with fragile patients without supervision. Formal ISTDP training is usually done in core programmes run over several years. [source: theraplatform; istdpsweden pages]

5. Handling problems

Safety limits for fragile and low-capacity patients [source: Abbass 2021; PeerJ 2014; Abbass modules; Kieding/Skorman] [synthesis where tagged]

• Assessing anxiety tolerance: At each low, mid and high rise of feeling, record the anxiety pathway and the defense. Do this in the trial session and again whenever there's a new front.
  • CPD or smooth muscle at a low rise means the patient is fragile: use the graded format.
  • Anxiety that stays striated through a high rise means the standard CDS is suitable.
  • Re-assess at every session. [source: Abbass modules; Hickey 2015: severity of fragility judged by cognitive-perceptual disruption]
• Hard limits:
  • With fragile patients: no head-on collision, no unremitting pressure, and no systematic challenge.
  • Stop mobilizing at the first sign of CPD, smooth-muscle flare or conversion.
  • Don't end a session with the patient dissociated: recap until cognition is back. [last point: synthesis]
• Medical caution: In active inflammatory bowel disease, some autoimmune conditions, active psychosis or mania, and intoxication, use a supportive format, stabilise first, or don't use ISTDP. In smooth-muscle patients (IBS, migraine, asthma-like symptoms, hypertension), expect a flare if you over-mobilize. [source: Abbass 2021; Abbass et al. JFP]
• Risk: In depression with repression, self-attack can rise during the work. Use a standard suicide risk assessment and safety planning, and slow to capacity building. [synthesis]

Ethical note [synthesis]: Pressure and challenge always serve the patient's stated will, and are aimed at defenses, never at the person. The patient may decline or stop at any point. Written informed consent covers the intensive, emotion-focused nature of the work and any recording.

Sources

Sources:

• Abbass, A. (2021). ISTDP: Methods, Evidence, Indications and Limitations (Psykologtidsskriftet)
• Abbass et al. Somatization: diagnosing it sooner through emotion-focused interviewing (J Fam Pract)
• Hickey, C. (2015). The Major Mobilization of the Unconscious and the Total Removal of Resistance in Davanloo's IS-TDP, Part I (Am J Psychotherapy)
• Hickey, C. A review of Davanloo's metapsychology of the unconscious (chapter abstract, Understanding Davanloo's ISTDP)
• Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers (Wiley contents page)
• Davanloo's IS-TDP: Application and understanding (Archives of Psychiatry and Psychotherapy, 2011, abstract)
• Abbass A. ISTDP training modules 2016–2018 (ISTDP Sweden)
• Abbass immersion: Bringing Structural Changes in the Fragile Patient (Norsk Institutt for ISTDP, 2023)
• ISTDP in a tertiary psychotherapy service (PeerJ, 2014, article 548)
• Kieding, J. Key take-aways from over a decade of training in ISTDP with Marvin Skorman (ISTDP Sweden)
• Review of ten Have-de Labije & Neborsky, Mastering ISTDP (PACJA)
• Abbass, Town & Driessen (2013). ISTDP: A Treatment Overview and Empirical Basis (DOAJ abstract)
• Frederickson seminar outline, DPSP Aarhus 2016
• Frederickson seminar outline, ISTDP Sweden 2020
• Reaching Through Resistance: media and events
• Theraplatform: Intensive short-term dynamic psychotherapy (secondary)

Books cited (not drawn on):

• Davanloo, H. (1980). Short-Term Dynamic Psychotherapy. Jason Aronson.
• Davanloo, H. (1990). Unlocking the Unconscious: Selected Papers of Habib Davanloo. Wiley.
• Davanloo, H. (2000). Intensive Short-Term Dynamic Psychotherapy: Selected Papers of Habib Davanloo. Wiley.
• Abbass, A. (2015). Reaching Through Resistance: Advanced Psychotherapy Techniques. Seven Leaves Press.
• Frederickson, J. (2013). Co-Creating Change: Effective Dynamic Therapy Techniques. Seven Leaves Press.
• ten Have-de Labije, J., & Neborsky, R. J. (2012). Mastering Intensive Short-Term Dynamic Psychotherapy: A Roadmap to the Unconscious. Karnac.
• Hickey, C. (2020). Understanding Davanloo's Intensive Short-Term Dynamic Psychotherapy. Routledge.
• Malan, D. H. (1979). Individual Psychotherapy and the Science of Psychodynamics. Butterworths.
• Della Selva, P. C. (1996). Intensive Short-Term Dynamic Psychotherapy: Theory and Technique. Wiley.
• Whittemore, J. W. (1996). Paving the royal road: the graded format of Davanloo's ISTDP. Int J Short-Term Psychotherapy. [uncertain: citation details not verified]