[1] The therapy's primary goal is to help the patient overcome internal resistance to experiencing true feelings about the present and past which have been warded off because they are either too frightening or too painful.
The ISTDP model attributes these to the occurrence of distressing situations where painful or forbidden emotions are triggered outside of awareness.
Breuer's breakthrough was the discovery that symptomatic relief could be brought about by encouraging patients to speak freely about emotionally difficult aspects of their lives.
These included Sándor Ferenczi, Franz Alexander, Peter Sifneos, David Malan, and Habib Davanloo.
One of the first discoveries was that the patients who appeared to benefit most from therapy were those who could rapidly engage, could describe a specific therapeutic focus, and could quickly move to experience their previously warded-off feelings.
However, these patients represented only a small minority of those arriving at psychiatric clinics; the vast majority remained unreachable with the newly developing techniques.
[13] The question of how maladaptive patterns of interpersonal behaviour could arise from early childhood experiences in the family of origin was postulated within psychoanalytic theory.
John Bowlby, a British psychiatrist and psychoanalyst, was very interested in the impact on a child of adverse experiences in relation to its primary attachment figures (usually the mother, but often the father and others) in early life.
He also elucidated the nature of attachment, a system of behaviours exhibited by human and other mammalian infants which are innate and have the goal of physical proximity to the mother.
Long term consequences included increased propensity to psychiatric disorders, poor relationship function, and decreased life satisfaction.
Childhood traumatisation to the attachment bond, usually through separation from or loss of the primary mother or mother-substitute, led to adult difficulties.
Since Bowlby, the effects of trauma over development have consistently been shown to have a significant detrimental impact on adult psychological functioning.
Davanloo noted, in concert with Malan's Triangle of Conflict, that patients would unconsciously resist the therapist's efforts to get to the root of their difficulties.
Symptoms and interpersonal difficulties (usually unconscious efforts to ward off intimacy and closeness) are the product of guilt, which turns the rage back on the self.
The goal of the ISTDP therapist is, as rapidly as possible, to help the patient overcome resistance, and then experience all the waves of mixed, genuine feeling, previously unconscious, triggered by the intense therapeutic process.
The first stage is clarification, which is the therapist's effort to confirm that resistance is operating, and also to acquaint the patient with the specific defense being deployed.
Clarification takes the form of a question, meant to clarify the defense to both patient and therapist: "Do you notice that when you speak of being angry with your boss that you smile and giggle?
As with all powerful interventions, if it is misapplied, the consequences can be severe: rapid misalliance with the therapist, worsening of symptoms, and treatment dropout.
However, the proper use of challenge is as an aid or enhancement to the therapeutic alliance by removing an obstacle to the rise in complex feelings with the therapist.
The main purpose of challenge is to remove any obstacles in the way of the mutually agreed upon task of getting to the engine of the patient's present difficulties: warded-off, complex feelings in relation to traumatizing experiences with important attachment figures in the past.
This wall is erected automatically and is an over-learned, habitual response, used to avoid emotional intimacy, both with the therapist and with other important figures in the patient's personal orbit.
This complex intervention is simultaneously aimed at the patient's will, is a reminder of the task, and is a wake-up call to the therapeutic alliance to exert maximal effort against the resistance.
It is also worth stressing that ISTDP, unlike traditional psychodynamic therapies, assiduously avoids interpretation until such time as the unconscious is open.
He maintains a large video library of treated cases which he uses for teaching conferences, though this has not yet been made available for other psychotherapy researchers to independently verify and quantify Davanloo's claims.
There are now over 120 published outcome studies in ISTDP including 50 randomized controlled trials for depression, anxiety, personality, somatic symptom and substance use disorders.
[52] Without distinguishing between different forms of STDP from Davanloo's ISTDP, modest to large short-term gains were reported for a broad range of people experiencing common mental disorders.
[52] Further research is required to determine the effectiveness and long term benefits of psychodynamic psychotherapies for common mental disorders.
[52] Neuroscientist and Nobel Prize winner, Eric Kandel refers to Davanloo's technique and its effectiveness in providing relief from emotional disturbances.
[53] Cognitive therapy (CT), developed by Aaron T. Beck, focuses on illogical thoughts as the main driver of emotional difficulties.
CBT has been shown effective in numerous trials,[54] particularly for depression and anxiety disorders [55] While ISTDP accepts the presence of faulty cognitions, the causality is thought to be reversed.