The Major Mobilization of the Unconscious and the Total Removal of Resistance in Davanloo’s Intensive Short-term Dynamic Psychotherapy

The Early Work of Davanloo

Davanloo’s Intensive short-term dynamic psychotherapy (IS-TDP) has gained increased attention during the last few decades because it can be used to treat a wide variety of patients (Davanloo, 2001a). Through a career spanning more than four decades, Dr. Davanloo videotaped countless hours of psychotherapy sessions, repeatedly watched these videotapes, and critically analysed the components of successful interviews. By doing so he arrived at an understanding of the human unconscious based on empirical and direct evidence rather than theory or intuition (Davanloo, 2001b). His early work showed that his technique was applicable to patients suffering from anxiety, depressive, and functional disorders (Davanloo 1987a; Davanloo 1987b; Davanloo 1989a; Davanloo 1989b). Later, Dr. Davanloo focused on treating patients with psychosomatic conditions and fragile character pathology. He was able to demonstrate that these patients could be treated successfully with some modifications to the technique. While several reviews discussed the efficacy and cost effectiveness of IS-TDP across a wide variety of psychiatric disorders and treatment settings (Abbass, 2008 & 2012), many of the studies under review were heterogeneous in nature and conclusions were difficult to make. Treatment adherence and fidelity varied in each. More rigorous research is needed into the current techniques and methodologies of IS-TDP.

Brief Summary of Basic Concepts in IS-TDP

Included in part one of this series is a more comprehensive explanation of the theoretical underpinnings and major technical principles of IS-TDP, but to briefly summarize: the cornerstones of this technique are the twin factors of transference and resistance (Davanloo, 1980). Early in his career, Davanloo discovered that these factors greatly interacted with one another, and the degree to which they interacted determined the outcome of the interview. He discovered a third important parameter, which he called the unconscious therapeutic alliance or UTA (Davanloo, 1984). This refers to the entity, created by both patient and therapist, which seeks to enable the patient to experience the most painful unconscious emotions. Such an experience will be uniquely liberating for the patient. The above three factors (transference feelings, resistance, and unconscious therapeutic alliance) are constantly in dynamic equilibrium and must be constantly monitored by the therapist throughout the interview (Davanloo, 1988).

More recently, Dr. Davanloo has stressed the importance of a fourth parameter that must be monitored throughout the therapeutic process—the transference component of the resistance ([TCR] Davanloo, 2009, 2010, 2011, 2012, 2013). This refers to that portion of the patient’s resistance that is directly in the transference. The balance of these four parameters determines the series of interventions that the therapist applies. When the TCR is extremely high, a major mobilization of the unconscious occurs and direct access to the patient’s core neurotic structure becomes possible.

In IS-TDP “direct access to the unconscious,” and to all of the pathogenic dynamic forces that contribute to the patient’s symptoms and character disturbances, is possible (Ausburger, 2000).

The first article in this series explored the initial session of a highly resistant therapist being interviewed by Dr. Davanloo as a participant in the closed circuit training program in Montreal, Canada. In this article the focus on this case continues as vignettes from the second interview with Dr. Davanloo and the therapist are analysed. The focus of the review is on the concept of the transference neurosis. This will be done both historically—as a psychoanalytic concept—and as an entity in IS-TDP to be assiduously avoided.

The Transference Neurosis

In the last several years Dr. Davanloo greatly refined his technical mastery in diagnosing and removing the transference neurosis. But before focusing on this, it is important to understand some historical considerations and the role the transference neurosis plays in traditional psychoanalysis.

Freud believed that the transference neurosis was an important manifestation of treatment and required careful analysis, which would result in important insights and therapeutic value (Freud 1940/1959). Unlike Freud, Davanloo rejects the notion of the therapeutic value of the transference neurosis. While Freud argued that the transference neurosis was the “latest creation of the disease,” (Freud, 1905, pp.116-117) emphasizing it as a metamorphosis of the neurosis rather than the psychoanalytic treatment itself (Reed, 1990a), Davanloo, argues that the transference neurosis is a completely morbid force, resulting from an insufficient rise in the transference component of the resistance (TCR) and a poor unconscious therapeutic alliance (UTA) between the patient and therapist.

In this context, there is no tolerance for the development of the transference neurosis in Davanloo’s techniques. Freud argued that the transference neurosis develops “when the treatment has obtained mastery over the patient” (Chessick, 2002). However, in Davanloo’s technique, the transference neurosis develops only if the psychoneurotic illness has obtained mastery over the patient. The transference neurosis is felt to be a highly destructive manifestation of the resistance and is to be avoided at all costs during the course of therapy.

What complicates the matter further is the insidious nature of the transference neurosis and the difficulties in diagnosing and treating it. As Reed suggests (1990b):

It is important to understand the evolution of the transference neurosis in IS-TDP. When the TCR is high, a transference neurosis does not develop. However, learning how to create an extremely high rise in the TCR is not a simple task. Working skilfully with resistance and transference feelings is not taught in most residency training programs and often require decades of training.

Some of the therapists who come for training at Dr. Davanloo’s closed circuit program display a transfer neurosis, which indicates prior unsuccessful IS-TDP treatment.

We shall return to the case to understand these concepts further.

Case Study

Session 2

The patient was interviewed as a participant in the closed circuit training program in Montreal, Canada. This program has been running since 2008 under the supervision of Dr. Habib Davanloo. Generally, 10 to 20 therapists come to the program for three to five blocks of training (each consisting of approximately five days) per year. During this training, participants may interview or be interviewed by their peers or Dr. Davanloo. Each interview is witnessed live by the other therapists and is recorded. The DVDs of the interviews are reviewed repeatedly, with Dr. Davanoo providing live, formative feedback. This results in a highly charged environment where participants are highly mobilized. The objective of the program is to allow participants to learn this technique experientially. Participants are given the opportunity to work through any technical or emotional issues that limit their potential to operate successfully as a therapist.

The patient is a 55-year-old therapist from Europe. She is married and is the mother of four children. She has had lifelong character neurosis and has suffered from rigidity, stubbornness, and resistance against emotional closeness. She has had lifelong migraines and the more recent onset of insomnia. She lies on the mid-right of the spectrum of psychoneurosis.

She had a course of private IS-TDP (outside of the closed circuit training program) in 2004 to 2007, which consisted of 17 blocks of treatment. She, as a therapist, was able to identify that she had a transference neurosis consisting of sexualized feelings and idealization towards this therapist. Most of these blocks focused on her father from whom she grew distant as an adolescent. He was a passive man but was loving and affectionate when the patient was a small child, he just didn’t display as much affection in her adolescence. She also had a loving relationship with her mother and grandmother. In this private therapy, there was little focus on her mother and virtually no focus on her grandmother—the stubborn “Queen Bee” of the family. These two important figures emerge as the true focus of her original neurosis and this will be discussed below.

The patient’s mother (Anne) lost her father to tuberculosis when she was nine years old. Following this, she lived in poverty with her mother and infant brother. When the patient was a child, everyone in the family was submissive to the grandmother who is described as the “Queen Bee” or “the Roman Emperor.” In light of this information, the therapist formulates that the original neurosis may well lie in the rage and guilt the patient feels for her mother and grandmother, both of whom she perceives as driving her away from her father. In addition, there is the element of destructiveness in the grandmother who did not allow Anne to mourn her father. One must question if this destructiveness was passed on in an intergenerational transmission of psychopathology. The private therapy, which lasted from 2004 to 2007, did not touch on any of these issues. Rather, the original neurosis lay buried under the transference neurosis.

The patient terminated the therapy in 2007 when she perceived no further benefit. She entered the closed circuit training program in 2009. What follows is her second interview with Dr. Davanloo in this format.

Vignette I: The Therapeutic Task and the Phase of Dynamic Inquiry

Evaluation of Vignette I

As in the first session with this patient there is a phase of dynamic inquiry. The therapist asks for details surrounding the patient’s understanding of the early life of her grandparents. The patient’s grandmother was in her twenties when she married the patient’s grandfather. When the patient’s mother, Anne, was nine years old, her father died of tuberculosis, after coming home to the family from the sanatorium. Clearly, this tragic and unexpected event had a lifelong impact on the patient’s mother. The grandmother did not allow the patient’s mother to grieve fully the loss of her father. Anne was not allowed to attend the funeral and was discouraged from crying about her father’s death. As a result, the patient’s mother became stuck in a state of pathological mourning.

Vignette II: The Rise in the Transference Component of the Resistance (TCR)

Evaluation of Vignette II

The communications in the above vignette are of supreme importance. The therapist’s goal was to create an extremely high rise in the TCR. This rise was so high that it is referred to as the “vertical position.” The therapist points out obvious truths about the mother and grandmother. The mother was blind, obedient and compliant in relation to the grandmother. Clearly, the grandmother was a Queen Bee figure and compliance obviously resulted in the best reception from her. With this type of grandmother, one had to be obedient. The patient knew this to be true, but she had tremendous, conflicted feelings about it. Not only did this communication address the reality of the mother’s life, which was highly destructive, it also addressed the reality of the patient’s life.

The patient had the desire to protect her mother when the therapist called her catatonic. While the patient had murderous rage towards her mother, she also had loving feelings towards her, and became angry that the mother was labelled. The patient held on to her anger and related to the therapist as though he were the grandmother. In this sense, projection was in operation.

The vignette illustrates important communications from the unconscious. The patient herself was compliant and catatonic in order to compete with her mother for her grandmother’s love and with her grandmother for her mother’s love. The patient, herself, identified with her mother and had character traits of blindness and compliance. In IS-TDP this is referred to as destructive competitiveness. It becomes the hallmark of the patient’s life and the engine of a pernicious guilt in her unconscious. At this point, it is unclear why the grandmother had destructive competitiveness towards her daughter and granddaughter. What is clear was that the phenomenon of intergenerational transmission had occurred and the patient had a need to torture her mother and herself. It resulted in an addiction to suffering and torture of the self.

The trait of destructive competitiveness was evident in the patient’s relationship with the former therapist, and it was crucial in the development of the transference neurosis in that relationship. She took an extremely crippled and paralyzed relationship with her past therapist. The patient became compliant with that therapist. In a sense, she was like the “catatonic puppet” her mother had been to her grandmother and her father had been to her mother. The patient idealized the previous therapist despite knowing that the course of therapy was not helpful. In the setting of a highly malignant transference neurosis, the therapist in her former course of therapy became the “Queen Bee.”

Dr. Davanloo has used the phrase “soar like an eagle” to demonstrate the use of imagery to highlight a patient’s potential in a clinical interview (Davanloo,1990). The patient has tremendous potential in life but she had not yet met it. She had settled for a compliant and catatonic position in various relationships in her life, including in her past private therapy. Highlighting these obvious, yet painful, truths had a dramatic impact on the unconscious of the patient. This created a high rise in unconscious transference feelings and leads to the development of a high rise in the TCR.

Vignette III: Further Rise in the Transference Component of the Resistance (TCR)

Evaluation of Vignette III

In the above vignette, the therapist concentrated on the patient’s father. It is important to understand the role he played in the patient’s core neurotic structure.

He had been the focus of the patient’s previous therapy, which had been characterized by a malignant transference neurosis. What emerged in the closed circuit training program was that the original neurosis was towards the mother and grandmother. The father was compliant to both of these figures in the patient’s early life and was a “catatonic puppet” in this triangular relationship. In this sense, he remained relatively innocent in comparison to the two.

The patient was aware of this on an unconscious level, and her father’s innocence greatly increased the volume of guilt she had in relation to him. It became clear that he had been the incorrect focus in her previous therapy. This had disastrous consequences for the patient, it increased the guilt in relation to the father and resulted in an entirely inadequate experience of guilt in relation to the mother and grandmother.

Indeed, the volume of guilt towards the patient’s mother, unexamined in the previous therapy, became exponentially worse because of the transference neurosis. As a result, the patient’s complex core pathology remained unexamined and she continued with disabling symptom and character disturbances.

Vignette IV: The Major Mobilization of the Unconscious, the Removal of Resistance and the Passage of Guilt

Evaluation of Vignette IV

The patient was able to experience her unconscious murderous impulse towards the therapist without acting on it. Because of the very high dominance of the UTA over the resistance, the visual imagery of the therapist transfers to the visual imagery of the grandmother. As she looks to the eyes of the therapist, she sees the image of the therapist transfer to a rich, visual image of her grandmother, complete with the grandmother’s eye colour.

The passage of the murderous rage towards the therapist is far more primitive compared to what occurred in the first closed circuit session: In this rage, the patient attacked the most sensitive and painful areas—the rectum and eyes. In addition, the volume of rage was higher, and followed by a tremendous passage of guilt. This passage of guilt was intense because the patient knew her grandmother struggled to bring the best to her children and grandchildren. While the grandmother was damaged, the patient had a deep love and appreciation for all that she did for the family. This love resulted in tremendous guilt.

While the murderous rage was more primitive, and reflected a higher volume than previously, there was a delay in the passage. The fundamental question was: why the delay? Most likely, the patient had a high degree of projection towards her grandmother due to an early phase of her life. The patient has held back a massive reservoir of murderous rage towards the grandmother from an early age. But this reservoir was constantly unexperienced by the patient because of the loving behaviour of the grandmother.

Because of this massive reservoir of murderous rage and guilt, the patient developed a specific type of defensive structure throughout her life. On one hand, she identified with the mother, and had the character trait of her mother’s catatonic obedience. On the other hand, she held a tremendous stubbornness. This stubbornness developed in the patient’s early life before her defensive system had fully developed. Its purpose was to serve as a means to deal with guilt.

The patient’s defensive structure will change as the reservoir of guilt drains. By evacuating the guilt in relation to the mother and grandmother, the patient was able to restructure her defences. Stubbornness decreases as the defensive structure changes. In addition, her approach to her own patients should change as that same volume of guilt will not be dragging her down.

Discussion

In the closed circuit training program, there is extensive discussion of the live interviews—sometimes the patient remains in the room and sometimes the patient sits in the waiting room. The most prominent teaching point of the case presented was how to deal with the metapsychological and technical considerations of the transference neurosis.

The transference neurosis greatly increases both the volume of guilt towards the patient’s genetic figures and the degree of damage to the patient’s defensive structure. Throughout the process, the therapist constantly builds the patient’s defensive structure, with the goal of removing the transference neurosis. This is an exercise in increasing the patient’s capacity to face the transference neurosis.

Under the malignant power of the transference neurosis, the patient’s unconscious is said to exist in a state of “avalanche.” The true and original neurosis is obscured and unexamined because of the powerful and destructive impact of the transference neurosis. As a result, a major part of the patient’s potentiality is under the powerful force of the avalanche. In this case, the patient begins to understand how she has abused and damaged her potential in life. This, itself, creates a tremendous feeling of guilt. The patient is torn between the choice of changing her life versus remaining like her mother and grandmother.

Conclusion

This interview had a powerful impact on the unconscious of the patient. We were able to see with great clarity the triangular relationship with the patient, her mother, and her grandmother. We see the destructive competitiveness of the patient with her mother. This destructive competitiveness focused on the need to destroy her mother to gain her grandmother’s love. She simultaneously needed to destroy her grandmother to gain her mother’s love. We were also able to observe with greater clarity the nature of the patient’s transference neurosis from her previous course of therapy, and the destructiveness of that relationship becomes immediately clear.

Dr. Davanloo’s IS-TDP is about human autonomy and the ability of individuals to meet their potential in life. Patients are given the opportunity to make a choice in their lives. Change is available. They can terminate their destructiveness and climb the peak of their potentiality in a proper way. In this case, the patient could have continued to hold on to her eternal love of destruction and lived the crippled life of her mother and grandmother.

It is important to note that the two closed circuit training blocks created the foundation for the treatment of the transference neurosis. These blocks were not the actual treatment of the transference neurosis. The patient needed sufficient structural changes in the unconscious to allow for treatment of the transference neurosis.

The above vignettes illustrate the total removal of resistance in a patient. In them we see a patient experience a primitive passage of rage towards a woman she loved very much. This love, and the destruction of that person she loved, was in the core of her lifelong neurotic structure. The patient had crippling symptom and character disturbances her entire life, but she was fully in touch with these forces and this was very healthy.