What Do We Mean by ‘Intensive’ in ISTDP?

Some of the feedback I hear about the word intensive in Intensive Short-Term Dynamic Psychotherapy (ISTDP) is how anxiety-provoking it can sound. It can bring to mind a fairly brutal approach to therapy, where somebody is pushed hard towards difficult emotions.

But for me, intensive means something quite different. We are intensive in our examination of what is happening, so that we can be as specific and helpful as possible in how we respond.

In this sense, the intensiveness is about the level of care we give to understanding the person as fully as possible, and creating the conditions in which they can work as effectively as possible in therapy. This isn't about creating intensity for its own sake, but allowing change to happen at a pace that is meaningful for the individual.

What does intensive look like in practice?

I think one of the best ways to show this is to demonstrate what an intensive approach might look like during a particular part of a therapy session.

Perhaps somebody comes to therapy because they struggle to express themselves in their relationships.

They tell me about a recent argument with their partner:

"My partner criticised me again last night. I was annoyed, but I didn't say anything. I just went upstairs."

There are lots of potentially useful ways we could explore this. We might talk about what happened during the argument, why they think they didn't say anything, whether this is a familiar pattern or how their previous experiences might help us understand their response.

But we can also look more intensively at what is happening as they talk about it.

Client: "I was annoyed with him, but I suppose I can understand why he said it."

Therapist: "You said you were annoyed with him, but I notice that almost immediately you're moving towards understanding his position. Can we stay with your experience for a moment and see what was happening for you?"

(Rather than following the conversation towards the partner's perspective, I'm bringing attention to the shift that has just occurred. I'm also inviting the client to look at this with me, rather than simply deciding for them what it means.)

Client: "Yeah. I suppose I was angry."

The client begins to smile and look away.

Therapist: "As you say you're angry, I notice you begin to smile and look away. That can be a way of moving away from the feelings right now. What do you notice happening for you in this moment?"

(Here I'm bringing attention to what happens as the client approaches the feeling. Rather than allowing the shift to pass unnoticed, we're looking together at whether the smiling and looking away might be moving them away from their emotional experience.)

Client: "My chest feels quite tight."

Therapist: "So as we get closer to the anger, you're noticing some tightness in your chest. What else do you notice as you stay with it?"

(We now have some indication that anxiety is present. I'm interested in how the client experiences that anxiety and whether they remain able to think clearly and stay engaged. That information helps determine whether we continue towards the feeling or need to regulate the anxiety.)

Client: "I can still feel the tightness, but I'm okay."

Therapist: "Okay. So if we stay with the anger towards him, what do you notice?"

Client: "Actually, maybe angry is too strong. He'd had a difficult day. I probably shouldn't have taken it so personally."

Therapist: "So what we notice right now is that as you begin to look at your anger towards him, you start to detach from it and move away from what you're feeling. So right now we have a choice. Do we go with that, or do you want to stay with the feelings and see if we can help you connect with how you genuinely feel, so that you can feel more able to understand your own experience?"

(Here we're bringing together what we've observed across the sequence and making the choice explicit. Rather than the therapist simply pushing past the client's way of moving away from the feeling, the client can see what is happening and decide whether they want to work against that pattern in the service of what they came to therapy for.)

All of this might happen within only a few minutes of a therapy session.

For me, this is where the word intensive becomes much clearer. We're examining the process at a high level of detail, but we're doing that collaboratively. The client's words, feelings, anxiety, physical responses and ways of moving away from their experience are all giving us information.

The intensive part is the attention we're giving to that information, moment by moment, and using it to make increasingly informed decisions about what might be helpful next.

Being specific about what is happening

This matters because two things that look very similar on the surface can require quite different responses.

If somebody moves away from a feeling because their anxiety is becoming too high, helping them regulate that anxiety may be important.

If their anxiety remains manageable but they habitually move away from their feelings, we may instead want to help them notice what they're doing and understand how it gets in the way of what they want from therapy.

If I've misunderstood what's happening altogether, then we need to recognise that too.

The more specifically we can understand what is happening, the more informed we can be about what might be helpful next.

This is why, for me, intensive doesn't simply mean applying more pressure.

Sometimes working intensively might mean encouraging somebody to stay with something for a little longer. At another point, it might mean slowing the work down. We might need to regulate anxiety, clarify something that isn't clear or approach the difficulty from another direction.

The intensity is in continually trying to understand what the person needs from the therapy at that particular moment.

Working with the problem as it happens

This moment-to-moment attention can also give us an opportunity to see the difficulties somebody has come to therapy with happening within the session itself.

In the example above, the person came to therapy because they struggle to express themselves in relationships.

As we explored their interaction with their partner, we began to see how quickly they could move from their own feelings towards anxiety and then away from their own emotional experience.

We are no longer only talking about the pattern. We're able to examine how it happens.

That gives us an opportunity to understand the process more fully and, where possible, begin to help the person respond differently while it is actually occurring.

For me, this is an important part of the intensiveness of ISTDP. We're not trying to make something happen simply because we believe it should. We're paying close attention to what is already happening and using that information to guide the therapy.

Intensive in the most caring way

Ultimately, I think about the word intensive in ISTDP as describing the level of care and attention given to understanding the person in front of us.

Their words matter, but so does what happens as they speak. Their feelings matter. Their anxiety matters. The ways they've learned to manage difficult experiences matter. Their responses to me and to the therapy matter. And whether what we're doing together is actually helping matters too.

Working intensively means trying not to take any of this for granted.

For me, that's what makes an intensive approach a caring one. It means giving somebody's experience the attention it deserves, so that we can understand as fully as possible what is happening and what they need from the therapy.

The aim isn't to make therapy as intense as possible.

It's to work with enough care and specificity that change can happen at a pace that is meaningful for the person. Interested in ISTDP?

If you're interested in exploring whether ISTDP might be helpful for you, or would like to arrange an initial session, you can get in touch using my contact form.

I offer ISTDP therapy both in person and online.