Illustration by Drue Langlois
When you think of psychotherapy, what likely comes to mind is an image of a cross-legged therapist in a dimly lit office who's passively commenting on his patient's neuroses while writing in a notepad. Maybe he even fixes his glasses and waits for a pause in the patient’s histrionic rant about his mother before saying something like, “And how does that make you feeeeeel?”
Now imagine a different type of therapist, one who purposely tries to upset their patient, pushing relentlessly through their tears and hysteria, escalating the situation until the patient either breaks down or flies into a murderous rage. While that type of antagonistic therapy sounds ridiculous, it's a actually real method currently being taught and administered by Dr. Tewfik Said at McGill University in Montreal. It's known as Intensive Short-Term Dynamic Psychotherapy, or ISTDP for short, and naturally it's pretty controversial.
Here’s how it works: Rather than take the classic route of coddling a patient to make sure they're comfortable at all times, this therapy takes the opposite approach. Based on Freudian therory, it relentlessly confronts what the doctor sees as the patient's childhood trauma, and pushes the patient to feel the most intense mental anguish possible, as quickly as possible. The idea is that this helps unearth the patient’s unaddressed past issues by attacking his or her defenses until the patient can’t handle the pressure and breaks down. The subconscious guilt from things like childhood trauma comes flowing out and, theoretically, the patient no longer has to live with that darkness. Pretty straightforward, right?
The intensity of this breaking point is so shocking that at first glance it appears to be abusive. According to Dr. Said, a feeling of murderous rage is common in this stage. The patient is brought to a point where he literally wants to kill the therapist. One would presume that most trained professionals might press a panic button under their desks or seek help from law enforcement at this point, but Dr. Said and other ISTDP therapists see it as progress. They even go so far as to ask the patients to describe, in detail, how they would carry out the murder.
To the average person this approach probably seems absurd, and it has an undeniable weird edge to it, like a psychological fight club run out of a church basement. It’s because of this, according to an ISTDP trainee who prefers to remain anonymous, that many psychiatrists dismiss ISTDP, adding, "Doctors who hate his therapy think Dr. Said is making his patients cry for no reason."
I was dying to know more, so I sat down with Dr. Said to figure out how it all works. With his weathered smile and soft chuckle, it was hard to imagine him bringing someone to the brink of murder. He seemed more like someone’s favorite uncle than a professional rage artist.
VICE: What is Intensive Short Term Dynamic Psychotherapy?
Dr. Said: ISTDP in a nutshell consists of defeating the patient’s defenses—acquainting them with their resistance and subsequently letting them experience their feelings in order to heal. This is done by directing their resistance into the therapeutic alliance—the bond between patient and therapist—and allowing the therapeutic alliance to dominate their resistance. This is done by skillfully applying pressure to their defenses in a very exact way, with the precision of a neurosurgeon. Nothing on my part is done at random.
In one of the original ISTDP transcripts that I read, the therapist had the patient describe in detail how he would strangle the therapist to death. When do you back off? When is it too much?
As a general rule, pressure is applied and intensified if their anxiety is defensive, because those defenses are what I aim to break through. This anxiety is positive because it helps mobilize the therapeutic alliance. Most of the time murderous rage is considered positive anxiety. If, on the other hand, they become detached or disorganized in their anxiety, this signals to me to back off or change the direction of my pressure because their anxiety is unproductive.
Has this treatment been validated scientifically?
Unfortunately there isn’t sufficient scientific data on its efficacy because randomized control trials haven’t been conducted specifically on ISTDP, although they have been done on other forms of short-term psychotherapy. And despite remarkably high levels of patient satisfaction being reported, these are only considered testimonials and can’t be used as a strong argument for its scientific legitimacy. Every one of my sessions is recorded audio-visually and this has been a strong source of validation for the treatment. There are countless recordings of patients who return for subsequent therapy years later and are visibly doing much better. As a part of the therapy, they are invited to comment on what changes they have seen in themselves. Despite the adversity it has faced, [ISTDP] has still managed to land a measurable impact on psychotherapy, and improved it.
So in your mind, are there major problems with mainstream psychology?
Yes. One of the problems with mainstream psychotherapy is the stigma attached to it. If you take these people and put them on antidepressants or antianxiety meds for life and you don’t know what you’re treating, this perpetuates the stigma. My approach does not involve any prescription of medication but rather focuses on attacking and removing the root problem. If you're able to treat it and get it out and it’s finished, this renders people more apt to come out and get treatment. Another problem is the compartmentalizing of the patient. The danger with using DSM criteria... is we see the patient as different parts, rather than as one entity. I teach all my students to try to see the patient as a whole.
What is it like for you as a therapist during a session?
ISTDP has a tremendous emotional impact on the therapist as well. Watching someone unearth their guilt is a very painful process, especially when you're actively involved. During a session, my own painful feelings become mobilized. In a recent session I had to help someone mourn for a loved one and I was in tears. Knowing how to handle those feelings myself is an essential part of my ongoing training. I had to learn how to become desensitized to seeing people break down in front of me, to be professional so I can help them as best I can. We think because we're psychiatrists that we have an automatic stamp of mental health… no, absolutely not.
Does ISTDP always work?
Yes, it always works.
You obviously believe in it, but ISTDP seems strange and borderline abusive. You must hear that a lot, though.
You know, there’s always one student in my seminars who asks, ‘How often do patients attack you?’ And these things never happen. It is controversial because it goes against the grain of what is usually taught. It’s very confrontational, and it can be aggressive, but I can assure you, it’s the most gentle. I have the utmost respect for my patients, but I have no respect for their resistance. The scientific community has difficulty differentiating between the two and this is where the controversy comes from.
Do you ever get tempted to use the techniques outside of the therapy, say, on your wife?
I’ve had the opportunity to try these techniques on others—it doesn’t work. It can destroy your personal life. It’s not a game and you cannot go and apply it in your everyday life, you will lose relationships. People get irritated with you and you’re not going to break through to them, you just become unlikeable. So it’s for these reasons that I don’t try it anymore with my wife, for example. The specific dynamic of patient and therapist is what makes it possible—friendships are much different.
More on controversial ways to "help" people: