This new study supports what I and other clinicians practicing ISTDP have long observed in our practices, and may signal hope for the 20%-50% of people with depression who do not derive satisfactory benefits from treatment (e.g., Lambert, 2013). In this article, I will contextualize these results by discussing the psychological factors that can make a depression “treatment resistant” and highlight the features of ISTDP that may make it uniquely effective in addressing these factors. I will also reflect upon and review in detail the results of the study.
To understand what makes ISTDP useful for treatment-resistant depression, it is important to understand factors that can make a depression treatment resistant (Abbass, 2015). Here are a few:
Relationship Difficulties with the Therapist
Even if your therapist uses a structured or systematized approach to therapy for depression, the therapy is always more than just a technique—it is a relationship. Many of us have difficulties in approaching relationships of all kinds, and the therapeutic relationship is rarely an exception. Some of us withdraw and detach from the opportunity for closeness. Some of us become fearful and hide or attack. Some of us take a passive role, a controlling role, a codependent role, etc., and we often have a variety of roles we switch between at different times.
These roles or interpersonal stances are often learned in our developmental history. They usually occur automatically and habitually, and they can have real advantages in certain situations—it’s not always smart to be honest and close with everybody in our lives. However, when we take on certain automatic interpersonal roles with our therapist, these can become barriers to engagement in therapy and can render the treatment less helpful.
For instance, if I am passive with my therapist, I may shirk the aspects of therapy only I can do for myself. If I am scared of my therapist, I may spend sessions shaking or attacking rather than feeling safe to communicate my needs. If I withdraw and detach from my therapist, I won’t be able to form the secure attachment that can help me explore my inner world and learn from my experiences. Needless to say, when we take on roles in therapy that form barriers to optimal engagement with our therapist, treatment efforts can fail and our depression may be labeled “treatment resistant.”
Self-Worth Difficulties
People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?
Absolutely. Many kinds of self-hatred arise in and can be addressed in therapy. A sense of worthlessness or unworthiness, hopelessness, self-doubt, withholding from oneself, wanting to hurt oneself—all of us are capable of feeling this way, and usually these feelings and attitudes contribute significantly to depression. These ways of relating to ourselves can come up in therapy, and if they are not addressed adequately they can interfere with the progress of therapy, rendering depression “treatment resistant.”
People tend not to do nice things for people they don’t like. But what if the person you don’t like is you? If therapy, or recovery from depression in general, involves acts of kindness toward oneself, can difficulties with self-worth make depression resistant to treatment?
Repression
Repression is an unconscious (read: automatic, unintentional) psychological mechanism that can contribute to worsening depression. In repression—used differently here than in Freudian psychoanalysis—when anger is stirred up toward people we love, the anger unconsciously reflects back against ourselves. This symbolically “protects” the loved person from our anger. Because of our guilt about our anger, it is channeled into punishing us. In an unconscious effort to protect our beloved from our anger, our unconscious mind can shut down our body to prevent the anger from being felt or thought about. This can be an emotional root of the “vegetative” symptoms of depression, such as feeling heavy, weak, and tired, and can contribute to the physical pain that can come with depression—in repression, the body can become the target of our angry feelings.
Many therapy models attempt to address unconscious repression processes with conscious techniques, such as behavioral activation, education, or medications, which can all help. However, behavioral changes, education, and medications alone cannot help people overcome the unconscious repression process. When repression is contributing to the depression and not being addressed adequately, behavioral activation techniques or medications may fail and the depression may be deemed “treatment resistant.”
Intensive short-term dynamic psychotherapy (ISTDP) has distinctive features that target specific factors that can make a depression harder to overcome in therapy:
Addressing the Therapeutic Alliance
As described above, interpersonal barriers, such as passivity, dependency, opposition, or detachment, can hamper the therapeutic alliance, limiting the effectiveness of any therapist and any therapy approach. For that reason, ISTDP therapists are trained in specific techniques for assessing the intensity of people’s interpersonal barriers and then helping people with them. A good ISTDP therapist will notice and then help you see the ways you wall off from interpersonal contact, and can help you see the damage this is doing in your therapy, your relationships, and your depression. With this new information, you may become more motivated to overcome the barriers you put up, and a good ISTDP therapist will have a variety of ways to support you in that process. Once these interpersonal barriers begin to come down, which can only occur when you are ready to bring them down, it can become possible to get to the root of your depression and resolve it together.
Addressing Self-Defeating Tendencies
In the same way certain interpersonal tendencies can become a barrier between you and the therapist, your tendencies toward self-defeat, self-neglect, and self-attack become a barrier between you and self-compassion. This can severely hinder your ability to let yourself engage in and benefit from therapy. A good ISTDP therapist will make efforts to help you see the ways you treat yourself, notice how they impact your ability to use the therapy, and see how entrenched these patterns have become. Sometimes this process can reignite the self-compassion that is necessary to get a good therapy result. Once you can begin to see yourself with more positive regard, the therapist can support you in getting to the roots of why you had to turn against yourself and become depressed in the first place.
Overcoming Repression
An unconscious and thus out-of-awareness emotional process like repression cannot be overcome unless your therapist can help you see it, which will make it conscious and help you gain some control over it. In ISTDP training, we learn about the verbal and nonverbal cues that let us know repression is occurring, and we learn skills for helping people begin to become consciously aware of their unconscious emotional processes so that they can begin to think about how they feel rather than automatically and unconsciously have those emotions convert into physical symptoms and depression. When people can consciously recognize, reflect upon, and feel the feelings that get buried by repression, this is the antidote to the unconscious repression process, which can help relieve a major contributor to treatment resistance in depression (Abbass, 2015).
One final dimension of ISTDP that may make it uniquely effective for treatment-resistant depression is the therapist’s ability to optimize the intensity of the work by paying careful attention to the level of anxiety you are experiencing, and tailoring the therapy to your unique anxiety tolerance. ISTDP therapists are trained to observe bodily patterns of anxiety. Some bodily anxiety signals (such as muscle tension) tell us, “We are on the right track, and this is a level of anxiety I can cope with,” while other signals, like stomachaches or dizziness, say, “We are over my threshold of anxiety tolerance. Time to slow down, regulate anxiety, and understand what’s happening.”
This ability to carefully track and work with anxiety signals from the body can help therapists optimize your therapy experience, and can help prevent a situation in which either too-low anxiety (such as boredom) or too-high anxiety (flooding, dissociation) becomes a barrier to treatment. This systematic attention to bodily anxiety signaling does not exist in any other therapy model, and can help ISTDP therapists to optimize your therapy in a unique way, reducing the likelihood your depression will not respond to treatment (Abbass, 2015).
The study lasted six months and included 60 participants who were randomly assigned to two groups: ISTDP and “treatment-as-usual,” which included counseling, CBT, CBT group therapy, and increased medication. Self-report measures and observer ratings were used to assess outcomes, and were taken at baseline, three months, and six months from the start of therapy. Here are some of the results found at the six-month mark:
The study is limited by its duration, sample size, and the fact it took place in a clinic that has highly focused ISTDP training for its clinicians. Further studies are needed before we can assess the strength and duration of outcomes and the applicability of these findings to people in other settings.
However, the study provides evidence of large, significant effects—including full remission in some cases—of a brief trial of ISTDP for treatment-resistant depression. It also shows ISTDP had a significant advantage over the counseling, CBT, CBT group therapy, and increased medication approaches that were included in the “treatment-as-usual” group. This may be useful information for those experiencing treatment-resistant depression and finding unsatisfying results with treatment-as-usual, secondary care approaches.
While there is much research to be done to learn more about therapies for treatment-resistant depression, the Town, et al. (2017) study is a promising contribution that may pique the interest of clinicians, researchers, and people in therapy interested in a cutting-edge, efficacious approach for treatment-resistant depression.
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The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org.