1. Intensive Short-Term Dynamic Psychotherapy for Treatment-Resistant Depression Allan Abbass MD, FRCPC

2. Plan ISTDP evidence Patient categories
Key processes with video examples
Some slides courtesy Dr Joel Town

3. Short-term Psychodynamic Therapies
About 200 RCTs
Meta-analyses show moderate large effects that tend to increase in follow-up for Depression, PD, Somatic Symptoms
Outperforms controls
As effective as Bona Fide models

4. ISTDP Developed by Davanloo with videotape large case series research
Broad application: developed since the 1970s for treatment resistant populations
Emphasis on the direct experience and working through of feelings related to attachment trauma:
Access by “unlocking the unconscious”: Unconscious Therapeutic Alliance
Capacity building as needed
Over 40 randomized controlled trials
11 studies of complex or refractory populations: Effect Size (N=10) d=1.59 (Very large)
Meta-analysis 2016: outperforms bona fide controls in follow-up

5. ISTDP Case Reports Case Series RCT Meta analysis Anxiety Disorders x
Depression
Personality Disorder
Somatoform Disorders
Dissociative Disorders
Psychotic Disorders
Bipolar Disorder
Eating Disorders
Substance Use Disorders
Dementia X

6. Halifax Treatment Resistant Depression Trial
Design
Parallel group RCT
Treatment
20 weekly sessions of intensive short-term dynamic psychotherapy
Control
Secondary care community mental health team treatment as usual
Therapists
Trained Psychologists and Psychiatrists from the Centre for Emotions & Health. VIDEO.
Sample 60
Follow-up
18 months
Arguably important part of study design is generalizability to our local services.
Comparing routine care in MDT mental health team vs. ISTDP provided at tertiary clinic
PTs were recruited as new referrals to CMHT; either allocated to tertiary service or CMHT
60 patients recruited and f/u 18 month post randomization
Town et al, 2017

7. 90% had Personality disorders 91% had comorbid chronic illnesses
Clinical characteristics of sample illustrate comorbidity, disability
(CLICK) Inclusion only required 1 failed ADM for current ED, however, multiple failed tx efforts
(CLICK) For many, they were experiencing a chronic course of depression
But had a lifetime history of multiple depressive episodes
(CLICK) The vast majority (80%) had acute symptom distress in the severe range
80% of participants’ depression symptoms
severe/very severe

8. 6 month Outcomes Town et al, 2017 HAM-D
At the end of 6 month assessment: we looked at change in depression scales over time
the decrease in symptoms was SIG for both grps but ISTDP decrease was twice as steep
The difference between group levels of depression at 6 month can be described as mod-large to large

9. 1 yr Follow-up: Treatment Received 7 – 18 months
ISTDP group less ongoing treatment
STDP group less likely to have medications added/changed
ISTDP on significantly less medications
ISTDP group more likely to be on zero psychiatric medications
6 month data was clear around benefits of ISTDP:
Bearing in mind many did not reach full remission- roughly 96% in TAU and 64% in ISTDP
(CLICK) In f/u we found…
(CLICK) Participants in the TAU condition more likely to receive ongoing tx and the dose of tx received was significantly higher
60% at CMHT; 24% tertiary services; 21% private services
Unpublished 1 f/u data : 6mth istdp with 1/3 receiving some f/u vs. 18 mth S-TAU

10. Distribution of Depression Severity at 18 months 40% fully remitted in ISTDP Group
80% at baseline had severe depression
Only 5% of ISTDP group had severe depression at 18 months
Looking more closely at the distribution of depression severity at 18 mths reveals a story
CLICK- bearing in mind that 80% were in the severe or very severe range
CLICK- at 18 months, compare dichotomous outcomes, while approx half of ISTDP grp
Are recovered or only mild symptoms,
-the notable difference is how few in the ISTDP group have severe symptoms

11. Impact of Major Unlocking during Treatment N=500.
Johansson, et al 2014

12. Impact of Major Unlocking on Healthcare Costs**
Town et al, 2013

13. BOND
With
Parents
BOND
With
Others

14. BOND Trauma With Parents PAIN FEAR Rage, Guilt about the Rage
Intergenerational
Transmission of Trauma
Depression
Character Disorder
Other Symptoms

15. Transference
(Therapist)
Current
person
New 1.2
Past
person

16. Unconscious Defense Unconscious Anxiety Unconscious
2.1
Unconscious
Impulses & Feelings

17. 2. Monitor Anxiety & Defense responses 1. Pressure on Feelings
Unconscious
Defense
Unconscious
Anxiety
1. Pressure on
Feelings
or Defenses
NEW 6.1
Unconscious
Impulses & Feelings

18. 4 main patterns
Muscle tension (Hands clench and Sigh) and Isolation of Affect (Intellectual defenses, Isolation of Affect)
Smooth muscle anxiety and Repression of Affect
Conversion: Muscle weakness and Repression of Affect
Cognitive perceptual disruption and projection/primitive defense
All relate to intensity of underlying rage and guilt

19. Spectrum of Psychoneurotic Disorders
Spectrum of Patients with Fragile Character Structure
Highly Resistant
Low Resistant
Moderate Resistant
Severe/ Borderline
Mild
Moderate
Striated Muscle + Isolation of affect
3.1
Smooth Muscle/Conversion + Repression
Cognitive-Perceptual Disruption + Primitive Defenses

20. Spectrum of Psychoneurotic Disorders
Spectrum of Patients with Fragile Character Structure
Low Resistant
Moderate Resistant
Highly Resistant
Severe/ Borderline
Mild
Moderate
Violent Rage
3.2
Murderous Rage
Primitive Murderous Rage
Primitive Torturous Rage

21. Complex Transference Feelings (CTF)
Complex feelings mobilized in therapy linked to the past bond, trauma, pain, rage and guilt about rage.
Includes appreciation and irritation toward the therapist (T) because of the challenge to resistance

22. Unconscious Therapeutic Alliance (UTA)
This is the unconscious healing force in the patient
UTA is mobilized in proportion to the degree of mobilization of the complex transference feelings
Elevates mood over minutes
Brings mental images and clear linkages to trauma

24. Transference
(Therapist)
Current
person
New 1.2
Past
person

25. Unconscious Defense Unconscious Anxiety Unconscious
2.1
Unconscious
Impulses & Feelings

26. 2. Monitor Anxiety & Defense responses 1. Pressure on Feelings
Unconscious
Defense
Unconscious
Anxiety
1. Pressure on
Feelings
or Defenses
NEW 6.1
Unconscious
Impulses & Feelings

27. Initiating ISTDP: Steps
1. Handle barriers to engagement
2. Find the Front of the System
3. Psychodiagnosis
4. Monitor and work with anxiety/defense/dynamic parameters
These will determine next interventions, pace and expected processes

28. STEP 1: Barriers to engagement
Barriers to collaborative engagement must be undone to see anxiety and defense manifestations
Conscious resistances must be addressed by a conversation and conscious decision making by the patient

29. STEP 2: Find the Front of the System
1. Activated and avoided complex feelings: focus on the cognitive and somatic experiences of the underlying complex feelings. 2. Active defenses at the front: turn him against the defences in the room and focus on underlying feelings.

30. 4 Fronts
3. Active Unconscious Anxiety: focus on the underlying feelings. If anxiety is too high, reduce it by recapping or reviewing bodily symptoms. 4. Flat with no activation: Take history. Explore problem areas searching for signs of anxiety and resistance.

31. STEP 3: Psychodiagnosis: 6 responses
Feel Feelings with inquiry: Low Resistant
Feel feelings after pressure: Moderate R
Defend: High Resistance
Go Flat: Repression: High r with repression
Go Flat: Projection or CPD: Fragile
No Response: Search for the anxiety and resistance

32. Striated muscle anxiety plus feel complex transference Feelings
Complete
treatment
in 1 or 2 sessions
Breakthrough
of grief about loss
Low
Resistance
Inquiry
Resistance Rises
Striated muscle anxiety
plus feel complex
transference Feelings
Moderate
Resistance
Pressure
Repeated unlocking,
working through,
termination
Resistance crystallizes
in the transference
Striated muscle anxiety
plus feel complex transference feelings
Clarify,
Challenge,
Head on Collision
High
Resistance
6.2
Depression, smooth
muscle anxiety or motor conversion
High Resistance
with Repression
Capacity
Building
Formats
GO FLAT: No striated muscle anxiety
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure

33. N=0 Complete treatment in 1 or 2 sessions Inquiry Breakthrough
of grief about loss
Low
Resistance
N=0
Resistance rises
Striated muscle anxiety
plus feel complex
transference Feelings
Moderate
Resistance
Pressure
Repeated unlocking,
working through,
termination
Resistance crystallizes
in the transference
Striated muscle anxiety
plus feel complex transference feelings
Clarify,
Challenge,
Head on Collision
High
Resistance
6.2
Depression, smooth
muscle anxiety or motor conversion
High Resistance
with Repression
Capacity
Building
Formats
Go flat: No striated muscle anxiety
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure
Reaching through Resistance, Allan Abbass MD

34. N=1 Inquiry Resistance rises Striated muscle anxiety plus feel complex
transference Feelings
Moderate
Resistance
Pressure
Repeated unlocking,
working through,
termination
Resistance crystallizes
in the transference
Striated muscle anxiety
plus feel complex transference feelings
Clarify,
Challenge,
Head on Collision
High
Resistance
6.2
Depression, smooth
muscle anxiety or motor conversion
High Resistance
with Repression
Capacity
Building
Formats
Go flat: No striated muscle anxiety
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure
Reaching through Resistance, Allan Abbass MD

35. Moderate resistant patients
Tend to respond to most treatments
Have some buried rage and guilt and grief
Anxiety is all striated
Main defense is isolation of affect
Focus on feelings mobilizes the unconscious therapeutic alliance

36. Unlocking of the Unconscious Moderate Resistance
Pressure: Complex Transference Feelings are experienced: anxiety and defence are removed or reduced
Unconscious Therapeutic Alliance becomes higher than resistance
Images of the unconscious emerge: UTA
Exploration with experience of feelings
Recap and treatment planning
Short course up to 10 meetings

40. N=3 Inquiry Resistance rises Pressure Repeated unlocking,
working through,
termination
Resistance crystallizes
in the transference
N=3
Striated muscle anxiety
plus feel complex transference feelings
Clarify,
Challenge,
Head on Collision
High
Resistance
6.2
Depression, smooth
muscle anxiety or motor conversion
High Resistance
with Repression
Capacity
Building
Formats
Go flat: No striated muscle anxiety
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure
Reaching through Resistance, Allan Abbass MD

41. Search for Resistance
If there are no signals of unconscious anxiety and defence, then we must search for the resistance and press in that direction to mobilize the unconscious

42. Why no signals? Blockers of Primary Engagement in the Process
Anxiety goes other places
Hiding the anxiety
Character defenses
Organic factors
Psychotic/Projective processes
Repression
Suicidal or homicidal intention
Absence of unconscious Problem
Technical Problems

47. N=10 Inquiry Resistance rises Pressure Repeated unlocking,
working through,
termination
N=10
6.2
Depression, smooth
muscle anxiety or motor conversion
High Resistance
with Repression
Capacity
Building
Formats
Go flat: No striated muscle anxiety
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure
Reaching through Resistance, Allan Abbass MD

49. Threshold to Repression
Conscious
Feelings
Threshold to experiencing impulse/feelings
Threshold to Repression
Striated Muscle Anxiety
Isolation of Affect
15.1
Unconscious
Anxiety
Severe
Repression
Moderate
Repression
Mild
Repression

50. Threshold to Repression
Conscious
Feelings
Threshold to Repression 3 2 1 3
Striated Muscle Anxiety
Isolation of Affect 2
Unconscious
Anxiety 1
15.2
1. Pressure to feelings or to defenses
2. Rise in complex transference feelings and anxiety
3. Intellectual recap to bring isolation of affect

51. Conscious
Feelings 3 1
Threshold
Unconscious
Anxiety 2
15.3

52. Reflection: Recap Pressure BRACING Use when below thresholds
Evoke feelings
Activate somatic
pathway of rage
Develop images
Fire limbic areas including amygdala
Use to optimize rise without being over threshold
Combine both self-reflection and pressure
Train brain to fire both functional regions together
Use when above thresholds
Self-reflect
Link phenomena
Observe the body
Observe thoughts
Fire brain self- reflective centers
15.4

53. Reaching through Resistance, Allan Abbass MD
Inquiry
Resistance rises
Pressure
Repeated unlocking,
working through,
termination
6.2
N=13
Capacity
Building
Formats
Go flat: No striated muscle anxiety
Cognitive-perceptual
disruption or
primitive defenses
Fragile Character
Structure
Reaching through Resistance, Allan Abbass MD

54. Fragile Character Structure Patients
Dissociate, lose vision, lose hearing, hallucinate
Projection, splitting projective identification
Need capacity building then look neurotic
Pre and post: structural changes Striated muscle tension and isolation of affect
The regular breakthrough of underlying feelings, working through and termination

55. Self-destruct Symptoms WEAK Trauma BOND PAIN Rage, Guilt
about the Rage
Self-destruct
Symptoms

57. Projective Identification
Projection
Cognitive Perceptual
Disruption
Repression
Smooth Muscle
Isolation of affect
Striated Muscle
16.1
Severe Fragile
Borderline
Moderate Fragile
Mild Fragile

58. Rapidly Rotating Fronts
Cognitive Perceptual Disruption
Self attack or seek
punishment
Projection: Afraid
Repression: Flat, weak, depressed

59. Self Escalation
Guilt about rage
is repressed
Rage
about
the attack or
punishment
Projection
of rage or
punishment
Fear attack or
punishment

61. Threshold to CPD or primitive defenses
Conscious
feelings
Pressure
Rise in CTF
Recap
Threshold to CPD or primitive defenses 3 3 2 1 2
Unconscious
anxiety and
defense 1
Isolation of affect
Striated muscle
Therapeutic window
FIGURE16.3
Severe fragile,
borderline
Moderate
fragile
Mild
fragile

62. Projective Identification
Cognitive Perceptual
Disruption
Projective Identification
Projection
Repression
Smooth Muscle
Isolation of affect
Striated Muscle
16.2
Severe Fragile
Borderline
Moderate Fragile
Mild Fragile

63. Threshold to CPD or primitive defenses
Conscious
Feelings
Threshold to CPD or primitive defenses 3 2 1 3 2
Striated Muscle Anxiety
Isolation of Affect
Unconscious
Anxiety 1
15.2
1. Pressure to feelings or to defenses
2. Rise in complex transference feelings and anxiety
3. Intellectual recap to bring isolation of affect

64. Threshold to CPD or primitive defenses
Conscious
Feelings
Threshold to CPD or primitive defenses
Therapeutic window 3 2 1 3 2
Striated Muscle Anxiety
Isolation of Affect
Unconscious
Anxiety 1
15.2
1. Pressure to feelings or to defenses
2. Rise in complex transference feelings and anxiety
3. Intellectual recap to bring isolation of affect

65. Course of Time Limited ISTDP
Capacity
Building
Partial
Unlocking
Termination
Start
20 sessions
End

66. Course of Intensive “Long-term” DP
Capacity
Building
Repeated
Unlocking
Working
Through
Termination
Start
End

67. Who can Benefit? Case 56 yr old man on social assistance
Stroke affecting motor cortex 2 years prior
Low education, Learning Disorders
Sleep Apnea
History alcoholism 25 years: sober 10 yrs
Avoidant and dependent features
Passive, disconnected from people
Biparental detachment: father WW2 POW
Chronic conflict with siblings

68. Limits of 20 session Time-limited ISTDP
Biological and Medical factors
Socio familial factors
Environmental factors
Stressful life factors
Complex Personality Structures: need more time
Fragility: need more time
Severe Repression: need more time

69. More Information Reaching through Resistance: Amazon
ISTDP TRD manual based on Reaching through Resistance:
16th Halifax Immersion September 30-October 2: All on the Unconscious Therapeutic Alliance
More info, papers, events:
Allan Abbass MD

70. Barriers to Engagement
Reaching through Resistance
CHAPTER 6 No
Yes
Resolve by conversation
Initiate Process
Assess Front of System
No Signals
Defense
Active
Feelings
Anxiety
Take History
Striated
CPD or
Smooth
Signals
No Signals
Press on and
Clarify Defense
Press on
Feelings
Reduce Anxiety
Search for Cause
of no signals
CHAPTER 7
Monitor Parameters: Degree of Rise, Discharge pathways, defense patterns, syntonic vs dystonic, height of thresholds
Psychodiagnostic
Assessment
Feel Feelings
Go Flat: thresholds to CPD, Primitive defense, Repression
Defend
High
Resistance
Low
Resistance
Moderate
Resistance
High Resistance
with Repression
Mild to Moderate
Fragility
Severe Fragility
Clarify challenge Defense
Head on Collision
Syntonic dystonic
Small then bigger
breakthroughs of CTF
Strengthen and Follow UTA
Handle Tactical
Defense
Focus on Grief
Clarify challenge
defense
Press to feelings.
Follow UTA
Psychic Integration: overcome splits,
Projection to make integrated
but anxious person
CHAPTERS 8-16
Graded Format:
Cycles of Pressure or Bracing
And Recapitulation
Monitor thresholds
Focus on Guilt about rage
to build capacity
ISTDP
Treatment
1-5 Sessions
Process grief
Repeated unlocking
Working through to
termination in
5-20 Sessions
Repeated unlocking
Working through to
Phase of termination in
20-40 Sessions
Repeated partial then major unlocking
Working through to Phase of termination in
Sessions
A Abbass 2018

71. Barriers to Engagement
Yes No
Resolve by conversation
Initiate Process
Assess Front of System
No Signals
Active
Feelings
Anxiety
Take History
Defense
CPD or
Smooth
Signals
No Signals
Striated
Search for Cause
of no signals
A Abbass 2018

72. A Abbass 2018 Psychodiagnostic Assessment Press on and Clarify Defense
Feelings
Reduce Anxiety
Monitor Parameters: Degree of Rise, Discharge pathways, defense patterns, syntonic vs dystonic, height of thresholds
Psychodiagnostic
Assessment
Feel Feelings
Go Flat: thresholds to CPD, Primitive defense, Repression
Defend
Moderate
Resistance
High
Resistance
High Resistance
with Repression
Mild to Moderate
Fragility
Severe Fragility
Low
Resistance
A Abbass 2018

73. A Abbass 2018 ISTDP Treatment Low Resistance Moderate Resistance High
High Resistance
with Repression
Mild to Moderate
Fragility
Severe Fragility
Handle Tactical
Defense
Focus on Grief
Clarify challenge
defense
Press to feelings.
Follow UTA
Clarify challenge Defense
Head on Collision
Syntonic dystonic
Small then bigger
breakthroughs of CTF
Strengthen and Follow UTA
Psychic Integration: overcome splits,
Projection to make integrated
but anxious person
Graded Format:
Cycles of Pressure or Bracing
And Recapitulation
Monitor thresholds
Focus on Guilt about rage
to build capacity
1-5 Sessions
Process grief
Repeated unlocking
Working through to
termination in
5-20 Sessions
Repeated unlocking
Working through to
Phase of termination in
20-40 Sessions
ISTDP
Treatment
Repeated partial then major unlocking
Working through to Phase of termination in
Sessions
A Abbass 2018