Экспериментальная публикация, от начала до конца на английском полностью с нуля (заняла 3,5 часа, если тоже интересно). У кого есть диплом преподавателя языка - можете судить строго, остальных с недалёкими и непрошеными правками забаню в задницу. Приятного чтения :)
As I'm remembering at the moment, my first encounter with ISTDP was through Jon Frederickson. My current aim then was rather trivial, to get some more in-depth knowledge about working with resistance; as my memory suggests, I've just finished the Ellis' book on the subject.
Well, so relying on my imperfect recollection, I can discern that it was some post on Frederickson's blog, where he mentions Davanloo also. I was quite intrigued from the start, and soon after bought Jon's book "Co-Creating Change", and found several Davanloo's articles on the technique.
Reading through, I just couldn't help to notice that while to some degree this techinque was full of things that I was doing already (as you know, REBT is quite active and directive therapy, and also there's a strong emphasis on persistent challenge), it was actually something more, something beyond my current repertoire and perspective at the time.
I mean, kind of sheer force, raw concentrated power in the way Davanloo did his "disputing" with patients during head-on collisions, first of all. Most of all I was struck by the ground-breaking assumption that we should welcome the resistance in therapy, the more the better. Later, when I read one interview with recent practicioner, he put it in the straightforward principle - "Davanloo's is the path of most resistance, not least".
I'm still deeply resonating with this precept. Despite sounding at first like something cumbersome and awkward, it's pretty elegant in a real practical way, in fact - and as you may well know, Albert Ellis was rather obsessed with elegant solutions in therapy.
Due to my REBT background, which I'm not neglecting and forgetting at all, such kind of therapeutic method and style was much more native to me that it is for member of other "sects", who profess way more passive and less challenging sort of interaction with patients and their resistance. To them, as you still can hear from time to time, it's something "too harsh", "confrontational", even "rude" and "unethical".
But usually these people invoke some sound arguments - first of all, that the therapist's activity could potentialy suppress the activity of a patient, and this isn't very helpful in the long run, since the patient could just end up symbiotically dependent on the therapist. This is an issue which is comprehensively covered in ISTDP, along with other types of character resitance: defiance (when you supposedly just "can't" be directive at all!), compliance, indiffrence etc.
Another vital point was primacy of pressure - the problem that we routinely encounter in REBT and often don't find the right words to adequately address. As I understood later, it became a bit of trouble for later followers of Davanloo as well.
I mean, if we read what Davanloo did and said to his patients carefully, we'll find that he relatively rarely uses challenge per se, in his own definition. Calculating this, I discover that challenge interventions (out of HOC) never were more than 10-15% of his transcribed lines.
But whenever he comes to head-on collision - you immediately understand what he meant all along. I mean, that the most essential ingredient of the technique - is the tangible flavour of disrespect and intolerance for noxious ways of resistance.
And immediately to my mind comes Al Ellis. You know, if we just watch what these two master therapists were actually doing - the inevitable observation would be that they're pretty much the same breed! Of course, Ellis never spoke or wrote anything close to Davanloo's metapsychological formulations about his own interventions - despite it's the fact that he knew about Davanloo successes in ISTDP (however, it's unknown how much).
As I'm aware, Patricia Coughlin is the only person ever who drew some obvious parallels between Ellis and Davanloo, particularly their style in therapy. Both were highly, for some even "extremely" active, assertive, used strong language (Ellis is better known for obscenity, though) and of course directiveness.
Recently, while reading several novel books, interviews and papers, I'm catching again this irrational idea in some ISTDP practitioners that it's some kind of shame, sin or plainly "bad" to be directive, and in ISTDP therapist only "appears" to be like that.
Well, I just moved again to original Davanloo writings, and besides some evident indications of directiveness in the transcripts, you can note that he unequivocally lists some very directive interventions as forms of pressure, challenge or head-on collision. Mainly he talks about directing patient's attention to some difficult areas or nonverbal signs or necessity to think and choose, but it's out of the question that you can read the implied directivity in many other types of his interventions.
One of the most concerning issues for both approaches is a kind of "watering down" by recent students and practitioners. Ellis was explicitly against it, and while Davanloo to my mind didn't ever address it directly on public (I mean, with specific names), I'm pretty assured that he would agree.
David Malan wrote awhile ago that the technique and overall style of Davanloo isn't just alien to many - it's fairly uncomfortable and disconcerting. So a lot of later authors tried to "tame" it a bit, to make it more comfortable, less edgy and hardcore. Obviously, it concerns their own peace and convenience above all, and only then the improvement of patients, which is the common rationalization.
The problem is rather evident. For most trained psychologists, it goes straight against everything they were taught and learned during life and training; instead of soothing, "empathizing" and "supporting" patient, we pressurize him to face what he's avoiding at any cost. Isn't that sadism, really?
Most people in ISTDP training already "have to put up" with the central task of experiencing the chain of painful feelings. Any other traces of aggression are shunned to the highest degree - and we hear "Oh, you know, we can do therapy without challenge at all! I have a research, it shows that we don't have to confont our patients!" and so on.
Of course, we don't have to confront every, or even any, patient. And Davanloo was pretty clear on this issue - but, surely, in a matter-of-fact clinical way: for some patients premature confrontation would be detrimental, so we have to hold it for a while. But this fact shouldn't make us blind to the reality - yes, ISTDP is very demanding to the therapist's capacity for tolerating aggression, both in himself and in the patient.
This could be an appropriate allusion to the life work of Otto Kernberg, by the way - with his elaborated writings on inseparable nature of love and aggression. Unfortunately, most therapists, now and previously, prefer to split the aggression from this formula - after all, "psychoanalysis is a cure through love", right?
If we want to capture the essense of Davanloo's unique approach to ISTDP, it would be an oxymoron: sensitive aggression. Elaborating further, key features could be summarized thus (Catherine Hickey actually wrote a book about it):
- Prime focus on the highest rise of TCR - transference component of resistance. Again, the more - the better; the foremost aim of pressure is the mobilization of all crucial unconscious factors, but the TCR is vital:
- Clearly adversarial, "intolerant" and irreverent attitude toward defenses, resistance and "Perpetrator of unconscious" (Pathological Super-Ego) - all the while maintaining the unconditional respect and sympathy to the patient as a person who suffers as a result of his resistance;
- And, last but not least, emphasis on consistent and systematic MUSC - that is, multidimensional unconscious structural changes, or just "restructuring the unconscious" for simplicity. This should be underlined, that Davanloo gives this process and/or phase the priority.
As a bottom line - thinking of most current therapists, dynamic or not, is very regressive and simple: Davanloo, or Ellis in this regard, is "impudently" aggressive - and thou shall not be aggressive at all! It is bad, you're a scum if you even think that this could be helpful!
However, just as Joan Whittemore brilliantly pointed out in her article - taking away our aggressive means (i.e., pressure and challenge) is akin to removing the scalpel from the hand of a surgeon. Also she mentions a significant difference between restoration and reorganization of defensive system; which would be another good point to look in the light of REBT and ISTDP similarities.
It should be noted that Ellis expressed some clear objections to Davanloo's modus operandi once, albeit indirectly. He was discussing the issue that a lot of patients seem to require pretty acute internal crisis to get to a change at all. Regarding the question - then, should we try to arrange such crises for them with some technical interventions - Albert was transparent: no, hardly this is the appropriate way.
However, as Ms. Coughlin noted, we better watch what our leaders do, not what they say about what they're doing. In many other passages and vignettes from his sessions, Albert Ellis was doing exactly what goes in opposite direction of his opinion above. That is, he did head-on collisions: placing his patients face to face with inescapable consequences of their continued resistance and adherence to irrational beliefs, and this often lead to intrapsychic crisis and mobilization, and sometimes even to the "unlocking" of sorts.
Nevertheless, aside from striking and sometimes predictable similarities, there are differences.
The most significant one is, of course, the major charge from psychoanalytic community to CBT going from most ancient times: that we don't "go deep", we just solve present problems, curtail symptoms and help our patients to manage themselves and feel better, without really getting to the core of original personal issues and verily curative character change.
Well, this accusation has some genuine valid points. Principally, looking from psychodynamic perspective, what we mainly do in REBT as well - we're working in rather supportive, although sometimes rough on the facade fashion, helping a patient to surrender his maladaptive defenses (beliefs, mostly chronic denial, morbid identification, punitive introjects, regressive helplessness and splitting/devaluation, but that's just a major row) and change them to more adaptive ("rational") defenses, like the classic "mature" list below:
- Suppression (conscious escape from irrelevant at the moment thoughts and feelings)
- Intellectualization, rationalisation and isolation of affect (instead of, say, repression and denial)
- Modeling - identification with therapist's "Ego"
- Generalization (rarely)
- Sublimation and displacement
- Philanthropy and socialization
- Humor
- Anticipation and reasonable avoidance.
Strictly speaking, the last one, anticipation is not a defense, as Freud initially formulated, but rather an "autonomous ego function" in modern dynamic theory. But anyway, we're working likewise on liberating and improving the often inhibited by defenses "ego functions" of patients, such as:
- Reality testing, naturally
- Judgement - assessing potential risks and benefits, rational decision making. Quite often the judgement is barred by "Pathological Super-Ego", that is, irrational rules and demands, particularly toward "You must not criticise people!". And it could be immensely therapeutic just to bring these musturbatory taboos down.
- Secondary process (logical rational thinking)
- Self-observation and reflection, which is of utmost importance in any kind of psychotherapy
- Social competence and "ego interests" (vitally absorbing creative activities)
- Abstraction and integration - from structural point of view, if these two are genuinely damaged or dysfunctional, we're unable to do "exploratory-analytic" therapy of any sort, including classic REBT. But if they're just overinhibited, we can help a patient to lose this damping, caused by defensive irrational beliefs.
And so on. Nevertheless, there are still defenses in operation - mature and higher, for sure, and while their consequences are much more eligible, we didn't get to the core unconsious conflict yet, it remains intact. Of course, it's not always possible or even necessary to do so, to get that far, but we better keep this in mind.
On the other hand, Ellis and later others - Harper, Dryden, DiGiuseppe, Walen, Knaus, Grieger and so on - kept reiterating the point that we ideally shouldn't just help patients feel better, the real task is to help them get better and, of course, stay better.
REBT proposition about how to do it best - lies in philosophical realm, that is, in fairly radical change of patient's basic attitudes, cognitive style and belief system. Notwithstanding, it is assumed that this preferrable outcome is rare and generally is beyond therapy reach; that is, it depends largely on "patient factors", most of which are out of any meaningful influence by ordinary therapist.
And, as psychodynamic theorists eagerly will point out, it's still an "essentially intellectualized affair". Hard to miss an opportunity to throw a stone back in the garden - just as much of psychonalysis was before Davanloo, and a serious portion of it is sadly of the same nature up to now. Add lack of activity and evidence base.
Even so, the disputing mode and targeting of REBT is quite profound and dynamic in itself, and sometimes we achieve a lot more than "mere" restructuring of defensive beliefs and behaviors. On top of that, REBT is closely concerned with modification of emotional awareness, experience and expression.
While some may regard the binary theory of emotion as something artificial and again "rationalistic" (indeed, when in ISTDP a patient tries to call a feeling "unhealthy" or "irrational", we're blocking it), it touches several very substantial matters.
After all, this is the same gist that psychoanalytic model conveys in such concepts as defensive emotion or regressive affect. Both REBT and ISTDP practitioners would challenge or at least "deactivate" regressive "sadness" (helpless weeping) in a patient, depending on circumstances; because both fully realize that this affect-laden experience, while being real and "valid", is not a true feeling which should be encouraged and expressed - but precisely the thing that prevents true emotion and by the way consistently defeats the patient.
Furthemore, REBT "philosophical solutions" could possibly enhance ISTDP post-unlocking stages, when we're working on dynamic exploration and analysis of previously unconscious content - it is the best place for a sound interpretation, based on unconditional acceptance and antiawfulizing.
As a passing remark, it also worthy of note that Davanloo himself was pretty versed in rational disputing as a matter of fact. To make sure of that it's paramount to read his earlier works - particularly the paper about clinical manifestations of super-ego pathology.
There you can see without any doubt that he was (and still is) an exceptionally strong disputer in the most profound sense: he's carefully building arguments from the corpus of evidence, he's parsing the concepts and statements with his signature precision of a surgeon, and his overall manner of making the case is something that could provoke some intense envy even in seasoned lawyers!
Points of convergence - REBT vs ISTDP:
- Cognate therapeutic style - active, directive, assertive, transparent (though REBTherapists are more didactic as well for sure);
- Preference for both dynamic flexibility (instead of rote and ritualistic structure) and maximum efficiency of therapetic process, which is supported on both theoretical and technical levels;
- Discouraging the needless gradualism - sometimes we have to thread slightly more slowly and carefully (working with fragile character), but not more than necessary. In other cases, when no structural pathology stops us and we have a patient's will to go - we can move right off to the bottom of the "unconsious truth"
Points of divergence:
- Unequal level of presumable depth - whereas REBT is generally oriented to meticulous work with defensive structure and usually stops there, ISTDP usually goes further to avoided complex feelings in rapid manner, while sometimes bypassing solid reorganization of defences (it's a "sin" of later versions and followers of Davanloo)
- Diverse views on the issue of transference - while it's indispensable and focal for ISTDP, in REBT it's an elective, but surely available option
- ISTDP puts heavy emphasis on visceral experience of physiological aspect of emotions, while in REBT, in contrast, behavioral and mental/cognitive sides are prominent and elaborated, and the somatic features are almost completely absent from view.
As a recap, what I believe could be fruitfully incorporated in REBT from ISTDP:
- Conception of pressure as the leading intervention. In effect, disputing of irrational beliefs is not a series of purely challenging remarks - it's a pressure to reason first and foremost.
- Elaborated assessment of anxiety pathways as a way to monitor patient's feedback
- Even more focused and forceful approach to resistance in therapeutic relationships
- Valuable inclusion of emotive transference interventions, leading to breakthrough and actual corporal experience of avoided feelings in the session
- More sophisticated understanding of the interplay between therapist and patient interpersonal positions
And, vice versa, some take-aways to ISTDP from REBT:
- Concepts of elegant philosophic solution and unconditional acceptance as potential enhancements to head-on collision (pre-unlocking) and systematic interpretation (post-unlocking)
- Binary model of emotions as a way to improve not just experience, but also healthy expression of feelings
- Refined suggestions on defense restructuring, which could be helpful in the context broader than of fragile patients' immature defenses; for example, separative work with syntonic defenses in rigid characters.
- More explicit psychoeducational stance - for that ISTDP practitioners already implement various micro-didactic elements in their work, but somewhat "diffident" about it
- Expanding the role and place of conscious working alliance with improved understanding of it due to internalized in REBT Bordin's theory (again, this is what Davanloo himself never lost, but later trainees tend to miss a bit)
Certainly, the perfect outcome would be a consummate union of two modalities in one metatheoretical integrated approach with larger assimilative potential. But I'm afraid that at this point of history it is fairly unlikely to materialize soon. So in any case, psychotherapeutic evolution never stops, and I believe that it's valuable to learn from each other not just with random offers, but with such thorough analyses as well.