Why Do Clients Resist Change? Defenses and Anxiety in ISTDP

The fundamentals of ISTDP remain the same, but many seem to have been forgotten over the years. In their quest to achieve emotional breakthroughs, many forgo the essential early steps in the process which make a breakthrough into the unconscious both likely and safe.  Conducting a specific, phenomenological inquiry into the nature, history and severity of the presenting complaints is required to form a hypothesis about the unconscious conflicts responsible for the patient’s suffering.  Too often, therapists assume they know what the underlying problem is rather than conducting a thorough assessment.   In addition, the all important defense work can also be given short shrift. Davanloo emphasized the importance of having the patient turn on their defenses in favor of facing and experiencing their true feelings.  If that has not taken place and the therapist is pressing the resistant patient to experience feelings, a misalliance can occur. 

All that said, the real impetus for writing the second edition was to include the accumulating data on clinical and cost effectiveness. In addition, long term follow up (up to 30 years) on the patients featured in the original volume were included.  Thus far, ISTDP is the only treatment that can demonstrate lasting change. In fact, those who respond to ISTDP get better and better over time, with no additional treatment.

There are all kinds of reasons that patients want relief from suffering while resisting the process of change.  Change is hard, and facing what has been long avoided evokes a great deal of anxiety.  No one likes to be anxious, so the temptation to retreat in the face of discomfort remains an obstacle in therapy.  ISTDP actually targets this conflict (and expects it to show up!). Rather than avoiding or trying to minimize the conflict, Davanloo worked to intensify the conflict until the patient experienced the negative consequences of the defenses being used to avoid their anxiety-provoking and guilt laden feelings.

It is particularly impactful for the patient to realize that their avoidant strategies actually create and perpetuate their suffering.  For example, patients who repress their anger and turn it back on themselves comes to realize that this mechanism causes their depression and low self esteem. Since they want to be freed of depression, they come to see that facing their anger toward others honestly is the only way to heal.  If this link between defenses and symptoms is not made clear, the patient will continue to avoid their anxiety provoking feelings.  Of course, there is also the fact that, as Goethe said, “suffering is the hardest addiction to break.” There can be massive secondary gain to being sick and incapable. This must also be called out, and the cost of such a strategy elucidated.

One of Davanloo’s most important contributions was the discovery of what he called “tactical defenses”, designed to create and maintain interpersonal distance.  The “formal defenses”, outlined by Anna Freud, are intrapsychic strategies used to keep the patient from experiencing their own forbidden feelings and impulses.  Tactical defenses are used interpersonally to avoid emotional closeness and vulnerability. These can be both verbal and non-verbal.  Verbal tactical defenses include vagueness and contradictory speech. In other words, you can’t pin the patient down – “Well, it could be, I suppose, but now that I think about it, maybe not. “, is an example. 

Tactical defenses are often non-verbal in nature and include eye gaze avoidance, crossed arms and legs, or laughing and smiling when talking about difficult feelings.  As long as the patient is hiding from the therapist and covering up their true feelings, the therapist and their interventions will be rendered useless. This barrier to engagement, or “wall”, as Davanloo called it, must be addressed before anything therapeutic can transpire.  Pointing out specific defenses against specific feelings, when the patient is neither present nor engaged, will have no impact. These defenses against emotional closeness, when present, must always be the first focus of intervention.  Only once the patient decides to open up and engage will work with specific defenses against specific feelings be effective.

The assessment and regulation of anxiety is of central importance in ensuring that the therapy will be safe and effective. Davanloo discovered three channels of anxiety that all have clinical and diagnostic significance. There is a great deal of confusion about anxiety, with many clinicians confusing defenses (such as rumination and catastrophizing) with the anxiety that drives them. Anxiety is a bio-physiological response to emotional threat.  When channeled into the striated or voluntary muscles (tension in muscles and sighing respiration), it is in the tolerable or optimal zone. 

Patients are typically aware that they are anxious and tense and have a good idea what that is about, such as opening up or facing what they’ve been avoiding. This indicates a high level of ego adaptive capacity and suggests that the patient is capable of facing their unconscious conflicts without any adverse effects.  We expect patients to be anxious when they first come to therapy, so if we don’t observe tension, we inquire about how the anxiety is being experienced. If anxiety is being channeled into smooth muscles (involuntary) with migraine headaches or IBS, for example, we must work to both lower anxiety and to increase the patient’s tolerance for conscious anxiety, before moving on to the experience of the feelings that generate this anxiety. 

Finally, anxiety can interfere with cognitive and perceptual functioning.  These are patients who lose track of their thoughts, blank out, become frankly paranoid or confused, dissociate, and experience alterations in vision (tunnel vision or blurry vision) and hearing (ringing in the ears or being unable to hear what the therapist is saying) when anxious.  When anxiety is that high, it must be downregulated as quickly as possible, as you don’t have a patient in the room with you.  Such patients tend to be quite fragile and need help to build capacity.  Developing effective interventions to both increase anxiety that is too low, when patients are detached and uninvolved, and decrease it rapidly and effectively when it is too high is an essential skill for the ISTDP therapist to master.

The research is clear that emotional engagement in the therapeutic process is required for change.  Empirical data suggest that only 20% of the patients seen in outpatient settings experience emotions as the result of intellectual insight, with such insight leading to change.  Intellectual insight alone has no impact on functioning in most cases, as these patients are employing intellectual defenses such as minimization or emotional detachment. As long as that is the case, no therapeutic change will be achieved. 

As far back as 1946, with the publication of Alexander and French’s research on short and long term dynamic psychotherapy, it was discovered that the “secret of every penetrating result” is the corrective emotional experience. Until and unless the patient viscerally experiences the feelings they have been avoiding, they will not have this corrective experience, in which they feel enlivened by the experience and safe in expressing it to another.

Yes, indeed, why would positive feelings like pride, love, joy, and sexual attraction/arousal be laced with anxiety? Well, think about it – any feeling can be associated with anxiety, depending on one’s experience with that feeling.  If the patient has grown up in a home that favors emotional restraint and punishes any outward sign of strong feeling, including joy and pride, those feelings will become associated with anxiety and avoided.  Imagine a child coming home, brimming with pride about winning a contest at school and getting a response such as “Don’t brag. You think you’re such a hotshot, what about….”.  Some families seem to prefer curt and even angry interactions over loving and tender expressions of care.  I had a male patient who had been continually harassed for his sensitive and caring nature, while being urged to be a tough guy and not “a pansy.” His father repeatedly dunked him in the swimming pool to toughen him up.  Needless to say, his positive, loving feelings were highly anxiety provoking.  One must not assume that only angry feelings have been prohibited, but to explore, assess, and examine each patient’s emotional life.

Conducting follow-up sessions is essential in determining your own effectiveness as a therapist.  Do these changes last? Do other problems crop up over time? Relapse rates are all too high for psychotherapy in general, so the fact that such rates are very low in ISTDP and, in fact, patients continue to improve over time suggests that we are doing something fundamentally different than “therapy as usual”.  It is my guess that the work we do to dismantle defenses is key in the personality transformation experienced by so many patients. When character defenses remain in place while only symptoms are targeted for therapeutic intervention, relapse is likely, as the patient’s characteristic mode of functioning, whether passive, narcissistic, etc renders them vulnerable to future difficulties. 

Even after 45 years of practice, I never cease to be amazed by the resilience of the human spirit and how, once healed, patients go on to become a healing presence in their families and communities. All the energy that was bound up in conflict is freed for creativity and patients create amazing art, businesses and volunteer organizations.  Seeing the lasting impact of the hard work done together is both gratifying and energizing, motivating the therapist to continue in this difficult but rewarding work.  Of course, follow-up also allows the therapist and patient to examine areas of functioning that are suboptimal and to do another round of work, if necessary.