An Interview with Jon Frederickson, MSW, on Experiential Psychodynamic Psychotherapy
David Van Nuys, Ph.D.
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Jon Frederickson, MSW on Experiential Dynamic Psychotherapy. Frederickson talks about Experiential Psychodyanmic Psychotherapy, which is based on Freud's original conceptions of repression and transference, but presented in a shortened, and far more active and experiential format than has been characteristic of traditional Psychoanalysis. An experiential dynamic therapist may work with a client for 40 to 50 sessions total (more or less) and actively push the client to experience avoided and unconscious emotions in the therapy session, whereas in contrast a traditional analyst (those few who are left) might work with a client for hundreds of sessions multiple times a week and take a more passive, intellectual approach to the work. Frederickson is quite comfortable describing what experiential therapists do using cogntive and neuroscientific concepts. His major criticism of cognitive therapy is that it is too superficial with regard to describing what is actually happening during effective therapy; dealing as it does with the cognitions (defenses) that drive avoidance and dysfunctional emotion, but not the underlying and primary emotional states that are avoided in the first place, which need to be felt in order to be unlearned. It's the difference between the map and the actual territory; analysts and cognitive therapists work with the map; whereas experiential therapists try to work with the map and the actual territory. Though working directly with avoided emotions can cause fragile clients to decompensate, the underlying psychodynamic theory, updated with neuroscience insights, helps therapists know when to push and when to back off (which was not the case with earlier experiential forms of therapy such as Gestalt therapy and Lowen's Bioenergetics). The experiential dynamic therapist seeks to understand the client's responses as falling into three categories: a feeling (avoided or not), anxiety in response to a feeling, and defensive behaviors undertaken to escape from the anxiety, and further seeks to help the client become more aware of how their particular version of this chain of emotion and avoidance functions.
David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show we'll be talking with Jon Frederickson, MSW, about his work with an approach known as Experiential Dynamic Psychotherapy. Jon Frederickson, MSW, is co-chair of the Intensive Short-Term Dynamic Psychotherapy Training Program at the Washington School of Psychiatry, and treasurer of the International Experiential Dynamic Therapy Association. Jon is also co-chair of the ISTDP Training Program hosted by the United Kingdom ISTDP Society, London, England, and chair of the ISTDP Training Program hosted by the Norwegian Society. Jon also provides training in Denmark, Poland, Italy, and the US. He's the author of over 20 published papers and a book titled Psychodynamic Psychotherapy: Learning to Listen from Multiple Perspectives.
Now, here's the interview.
Jon Frederickson, welcome to Wise Counsel.
Jon Frederickson: Well, thank you.
David: One of my listeners wrote to suggest an interview on experiential dynamic psychotherapy and cited you as one of its primary practitioners here in the United States, so I'm happy to have this chance to speak with you.
Jon Frederickson: Well, I'm glad to have a chance to talk about experiential dynamic therapy.
David: Okay. Well, maybe the best place for us to start is to have you tell us just what experiential dynamic psychotherapy is.
Jon Frederickson: Sure. It's really an umbrella term for a group of experiential short-term therapies that are based upon psychodynamic theory. So, in essence, we have a model of therapy that's designed to be a comprehensive system of therapy, which involves a much briefer treatment than traditional psychodynamic or psychoanalytic therapy. It's considered one of the short-term dynamic psychotherapies, and it's experiential in the sense that it's based on the actual experiencing and expression of feelings that patients usually avoid. And it's psychodynamic in that it's based on Freud's concepts of the unconscious, conflict, transference, defense, and resistance. So it's a psychodynamic therapy but it's experiential in focus and much faster in its approach than traditional psychoanalytic therapy.
David: Now, when you say traditional psychoanalytic therapy, are you thinking of, I guess, three to five times a week for maybe five years? Is that sort of the…
Jon Frederickson: Exactly. Yeah, so that this is a kind of a short-term treatment that tries to achieve significant character change within a very brief amount of time. So if you have a fairly low resistant patient, you should be able to do some significant change in 10 sessions; if it's a high resistant patient, maybe 40 sessions; and if it's someone who's fragile, then maybe 50 to 150 sessions. Because it's an approach that applies to a wide range patients, but it's designed to achieve character change but in a much more rapid pace than, say, psychoanalytic treatment of four times a week for five years.
David: Okay, 40 or 50 sessions might not sound short-term to some people; however, when you contrast it with three to five times a week for, perhaps, as long as five years, I guess it is short-term in relation to that yardstick.
Jon Frederickson: And when we look at the kind of conditions that we're treating, because we've done research where we've worked with patients who, for instance, were personality disordered or patients who have significant somatic disorders or patients where they have recurrent problems - the classic kind of somatic disorders where they have stomach difficulties, IBS - or patients who suffer, say, from severe depression. And so for many of these patients, where we're able to get within 40 sessions significant character change and we're able to see good long-term follow up, then it's a substantial result for a short-term therapy.
David: Yeah, I was on the association website, the International Experiential Dynamic Psychotherapy Association website, and I was surprised to read that many of Freud's early treatments were quite brief.
Jon Frederickson: That's right.
David: And that would probably surprise most of our listeners as well. What can you tell us about that?
Jon Frederickson: Oh, it's a great story. You know, Freud's early analyses didn't last much longer than six months. He treated people who came in from out of town, and in fact, there are very famous short-term therapies he did. For instance, the composer Gustav Mahler sought him out for treatment, and they went for a walk for about three hours in the afternoon, during which Mahler's difficulties were resolved during the course of a three-hour session on a walk out in the park. And the conductor Bruno Walter also came to Freud, also for a short-term treatment that I think lasted just one or two sessions.
David: Oh, that's fascinating. I wasn't aware of those cases. So how did it evolve to the situation that we later came to know, where it became such a long-term process?
Jon Frederickson: Well, it's a very interesting story. Freud, in his early work, thought that you needed to be very, very active with the defenses, and that you need to be very engaged with the patient. And in fact Freud himself was a very active therapist who was very engaged and talked a lot with the patient. And what happened is he became - I think, in a way, partly because of the theory, partly because of his character, partly because of difficulties in his life - he became demoralized in his work and came, by the end of his work - remember his paper "Analysis: Terminable and Interminable" - he came to really have doubts about psychoanalysis as a treatment modality at all. And what happened is he became, and advocated, a much more passive stance for the therapist over time, although what happened is that therapist, analyst, became far more passive than Freud ever was. There was a funny paper written in the Journal of the American Psychoanalytic Association some years ago, how Freud would never be allowed to graduate from an institute today because he was so active.
David: That's fascinating.
Jon Frederickson: And that he talked so much. You know, one of his cases was a famous case of the Wolf Man, and the notes for the case were, for a particular date: "He was hungry, he was fed." Okay? Because the Rat Man was in poverty at that time. So what we see is that psychoanalysis moved away from a very experiential focus and very active working on the defenses to a much more passive, inactive, approach.
And it's interesting: some of Freud's followers, for instance, Ferenczi and Rank developed a form of short-term therapy that was based on psychoanalysis in the 1920s. And one of Ferenczi's students, Michael Bálint, also developed a short-term therapy based on psychoanalysis in the '40s and '50s in England. And his student, David Malan was a major researcher in short-term therapy in London at the Tavistock Center, a real center of psychoanalysis.
And Malan, of course, growing up in an area of psychoanalysis, the analysts were all saying, well, short-term therapy is a superficial model, right? And so he did some follow-up research comparing patients who had gone through analysis and patients who had gone through his model of short-term therapy. And what they found is that the results from short-term therapy were just as good and in some cases better than those who went through psychoanalysis.
David: Well, that's really fascinating. Now, we live in a time when cognitive behavioral therapy has become kind of the dominant modality, and part of the reason for that, I suppose, is they would argue that it's short-term in nature. Clearly, you're in another camp and the psychodynamic approach, broadly speaking, has declined even though there are many practitioners. What's your take on CBT, if I may put you on the spot?
Jon Frederickson: Not at all. In fact, I think it's important to think of experiential dynamic therapy as based on psychodynamic theory, but that it will use techniques from any of a number of approaches. And so, for instance, I think what I would like to do is approach your question really from the idea of causality. For instance, how do a patient's difficulties get caused? And in psychodynamic theory, we rest on this kind of causality: that there's an event that happens in a relationship and it triggers some feelings in the patient. The patient becomes anxious as a result of those feelings and then uses defenses to deal with the anxiety and feelings. Those defenses create the patient's presenting problems and symptoms.
So let's take, for example, a woman comes into your office. She is a bit depressed. She describes a problem situation where a boyfriend had slapped her. Now we know that, obviously, the adaptive response would be to be angry at someone who's slapped her. And what we learn is that she's angry and it makes her anxious. But then when we ask about her anger, she ruminates a great deal, I suppose. She says, "Well, I must have done something wrong. It must be my fault. I'm not sure quite why he did that." So we'd see turning of rage against the self; we'd see rumination; we'd see intellectualization. And those defenses together would make her depressed, and they would keep her stuck in a bad relationship.
Now, cognitive therapy says, quite correctly, that when she ruminates and that when she intellectualizes and has these faulty cognitions, they'll make her depressed. And that is absolutely true. Where we would disagree with cognitive therapy is we'd say it's an insufficient model causality. Because we could help her with the cognitions - which in our language would be defenses - but we also have to help with the anxiety that her anger triggers, and we have to help her experience her anger as deeply as possible so that it no longer triggers anxiety, so it no longer triggers defenses, and so that she can learn to bear and tolerate her anger and channel it in healthy, adaptive self-assertion rather than use maladaptive defenses. So, for us, we would agree very much with cognitive therapy because it catches the tail end of causality, but we would disagree in terms of it encompassing all of causality.
The other thing is that cognitive therapy we think puts the tail on the wrong end of the horse, because in cognitive therapy the belief is that the cognitions cause anxiety. In our approach, we understand that feelings trigger anxiety, and then to deal with the feelings of anxiety the patient will use the faulty cognitions as a kind of defense to deal with her anger and anxiety. So for us, we understand that it's the unconscious feelings or barely conscious feelings or sometimes even conscious feelings, say, of anger or sadness that trigger anxiety and then lead to defense.
David: That's interesting. I think this touches a long-standing debate between psychodynamic and cognitive approaches, because if I understand the cognitive camp correctly, they would say once you eliminate the rumination, the thoughts and mistaken assumptions and beliefs, that you would also be eliminating the anxiety; that those thoughts, in fact, are what are creating the anxiety.
Jon Frederickson: Right, but we know… You see again, though, Dave… and you know Barlow, who's a very important cognitive therapist, has actually abandoned that idea of causality. And the reason he abandoned it, and correctly so, was that he said we have to pay attention to what neuroscience is showing us. Because neuroscience is really showing us - for instance the work of Joe LeDoux - it's showing us that it's unconscious detection of threat triggers anxiety in the amygdala, and then it's only after the amygdala has gotten activated, only then does the slow road go to the cortex where these thoughts can get generated. So, in fact, unconscious activation occurs first; only later does the cortex get activated, at which point conscious thoughts can happen and they can then inhibit. And why is it that emotions cause unconscious detection of threat? Well, because we are, of course, animals, and animals - to survive in the wild - have to have a system of unconscious threat detection for survival, and they have to react immediately in order to run away from a predator, right?
Jon Frederickson: Any of our ancestors that sat around, said, "Hmm, free quadruped. Hmm, nice claws. Hmm, big growl. Running towards me." Crunch. Any ancestors like that just became lunch. They have no gene pool that's left. So there has to be an automatic system that leads to survival. And, of course, we're seeing that in neuroscience, and Joe LeDoux's work has been a great explication of that. And why is it then in humans, why is it that emotions activate that threat is a key, because for us, our anxiety system doesn't get triggered by lions, tigers, and bears because they're just not part of our life. But for humans to survive as infants, we actually have to have caretakers for at least 10 years in order to survive on our own.
David: Yes, at least.
Jon Frederickson: And so the infant and child needs to have its caretakers, and so any emotion the child has that makes parents anxious is potentially a threat to the child's safety because it threatens the safety of the bond. And so then through this kind of what you can call, like in behavior therapy, a conditioned response, that when the child realizes that it has certain feelings and parents respond badly, or when it has certain feelings and a parent responds with anxiety, you get a conditioned response of feeling anxiety. And then the child ideally can turn to its parents to help her with those feelings, and then the child learns to regulate its feelings, and those feelings come along in a relationship.
With the patients who come to our office, usually what happens the parents don't respond so well - that perhaps there's punishment, maybe there's judgment, maybe the parents look scared. What happens is the child then learns to depend on its defenses for affective dissociation rather than depend on parents for affect regulation. And so where we would agree with the behaviorists is that anxiety gets linked to these affects through conditioning, and that we actually have to break that conditioned bond. And whereas the behaviorists might try to expose someone to a particular stimulus, such as crossing a bridge or an airplane if someone has a fear of crossing a bridge or getting on an airplane, here we have to expose the patient, really, to the stimulus, which is a particular emotion which triggers anxiety and then these automatic defenses which were a form of survival for the child early on, but then become really the creator of the presenting problems in adult life.
David: That's a great response, both for you and for our listeners. You mentioned David Barlow, and I interviewed him in this series, actually.
Jon Frederickson: Oh, fabulous.
David: Yeah, about a year ago. And I just attended a continuing education workshop where they covered the work of Joe LeDoux a bit and talked about the amygdala and that sort of bypassing of the forebrain and going immediately to the fight-or-flight response that the amygdala so quickly mediates. So it's really great to hear those ideas echoed here. Now, the approach - it's quite a mouthful: experiential dynamic psychotherapy - had been called short-term dynamic psychotherapy. What motivated the name change?
Jon Frederickson: We wanted to emphasize that it's an experiential approach, that what we share in common is a belief that it's a psychodynamic therapy, but that the emphasis is on the experience of the patient's emotions in the session. And that is also on the experience of the patient's emotional closeness and attachment in the session.
David: Okay, now probably other people, other, say, more traditional psychoanalysts, might claim, "Well, what we do is experiential. Defenses come up and we analyze the resistance and the defenses, and people have emotions coming up and so it's experiential." So say a bit more about what it is that makes your approach experiential and how it accelerates the therapeutic process.
Jon Frederickson: That's a great question. I think a lot of it is really getting clear what do we mean by feelings. I think what we're extremely clear about - and I think what's getting clear, really, in our field - is that feelings are first and foremost a physiological experience in the body. Feelings aren't just what you think they are; they're a feeling experience in the body. So remember the worry search by Antonio Damasio, where he's pointed out that our ability to feel feelings, and the physical experience of those feelings, provides a basis for a core sense of self. And where he's able to show that patients who had brain damage that impairs their ability to experience their feelings no longer, really, had what we call gut intuition. They make impaired decisions. And we see the worry search by Levinson, that shows that every feeling is associated with its own unique activation of the autonomic nervous system. And then we have the research by Ekman, which shows that every feeling is associated with its own unique facial expressions, and that's world wide. And then we have research by Fosha that shows that every feeling is associated with its own adaptive action tendency.
So we think about feelings differently than an analyst would because, for us, every feeling has three components. There's a cognitive label, for example, anger, okay? And then there's the physical experience in the body. We'll ask, "What are you feeling?" And when a patient says they're angry or sad or whatever, then we ask, "How do you experience that anger physically, emotionally, and in your body?" Oftentimes the patient can't tell you, and that lets you know that there's defenses that are in operation, and so that gives us a sense of where we need to work.
Then the third component is not just the label, not just the physical experience, but what's the impulse that goes with that feeling. So, for instance, someone who's sad, they can say they're sad, but we might not see any physical symptoms of sadness in the body. And so we work with them and, hopefully then, they'll feel the heaviness in the chest, a lump in the throat, tears in the eyes, and then there's the impulse to cry and where the patient actually cries. And as we know, with patients who have to grieve a loss, the grief is not going to be full and helpful unless the patient can actually label the feeling, feel the experience, and then actually cry.
And we also find with patients who have conflicts around anger, they need to not only be able to label their anger - they could label it but still be very detached and intellectualized. They could talk about their feeling, but without actually feeling it, and that's not helpful to a patient. And that's where, I think, whether it's psychoanalysis, other forms of therapy, the big danger is that a patient talks about a feeling but doesn't feel it, in which case, then, their intellectualization is running the show rather than the actual experience of this feeling that they are repressing through intellectualizing and cognizing.
David: Yes. Now, there's a third step, though, right? I think you said there were three. So there's the cognition of recognizing it, the feeling of it, and then is there a third step?
Jon Frederickson: The impulse, how do you experience that impulse, right? And so, for instance, let's go back to our example of the woman whose boyfriend slapped her. We might ask her what's the feeling towards him. And she might say, "Well, I just feel like I really offended him," which would be intellectualization. We say, "Well, that's your thought, but if we don't cover your feeling with a thought, what's the feeling towards him?" And then she might say, "Well, I felt angry." And so we say, "So how do you experience that anger physically towards him?" She might say, "Well, I feel anxious."
Here she doesn't distinguish her anxiety from the feeling that triggers it, the anger. So we say, "Well, that's your anxiety. Yeah, this anger makes you anxious. So if we don't cover the anger with anxiety, let's see if we can have an uncensored look at this anger. How do you experience this anger towards him?" Then perhaps she gets a little teary, and then we might have to notice, "Do you notice how these tears come in to wash away your anger? Do you see that? Do you think that might be getting you depressed?" Because we'd see here a defensive affect comes in to cover the anger.
And so through that kind of defense work we help her get more and more aware of that anger. And then soon she's going to start to feel probably some heat in her belly. She may have looked a little limp and depressed, and then we're going to hear energy in her voice. We're going to see her arms start to move, and we'll say, "What do you notice feeling in those arms?" And maybe we'll see a fist. "What's that impulse there?" "Well, I feel like I want to hit him." "So in your imagination, how do you picture that?" So once she can label her feeling, she can be aware of how she experiences a feeling, and she can feel the impulse, then we might introduce an experiential technique like visualization to help her deepen her awareness of that feeling and get in deeper touch with it.
David: This is bringing to mind Gestalt Therapy, Fritz Perls approach to Gestalt Therapy. He came out of a psychodynamic background; he wanted to make it very experiential and quick; got people in touch with their bodily experience, etc. Would you say that that approach would fall under this same umbrella?
Jon Frederickson: Well, I think Gestalt Therapy is a body of great techniques but without a theory. And we do obviously use Gestalt techniques: obviously, encouraging her to visualize that way would be something straight out of Gestalt. The problem you have with Gestalt, though, is if you don't have a theory that's grounding you, then you don't know quite where to move or why. And let me give you an example.
Let's suppose the patient says - we ask, "And how do you experience that anger?" and she gets really anxious, okay? In Gestalt, you might just go ahead and ask her to visualize, whereas for us, if she's really anxious, we need to differentiate her feeling from anxiety. Because if she can't differentiate the two, as you keep asking about the anger, her anxiety's going to get worse and she's going to get symptoms. So unless you understand the importance of differentiating feeling from anxiety, you're not going to get it.
Likewise, if you ask about her anger and she says, "Well, I just feel I'm a bad person," if you don't have a concept of the triangle of conflict, of feeling anxiety defense, then you wouldn't understand, okay, this patient when I ask about feeling, she presents defense; she can't differentiate the two. We need to help her differentiate feeling from defense, because in Gestalt, if you keep inviting her to visualize, her defensive self-attack will get worse and she'll get more depressed in session and maybe more symptomatic after session.
And another problem is that when you don't have a theory that guides your techniques, then your techniques are kind of random, right? And you might be causing symptoms. A really great example is like in Gestalt Therapy there's no theory about anxiety, and in experiential dynamics therapy, we understand that anxiety is a biophysiological pattern of activation in the body that's mediated by the somatic nervous system and the autonomic nervous system.
Now, that's a big mouthful, right, but basically what it means is that when patients experience anxiety in your office, there's a range of symptoms they have. And that range of symptoms is psychodiagnostic for what their anxiety and affect tolerance is. So if you have a high capacity patient, what happens as you ask about important issues, the patient starts to sigh when you ask about a feeling. She tenses up, so you see muscle tension. And when you see this muscle tension and the patient sighs and you see her hands are clinging to one another, that's strided muscle tension, and that means her somatic nervous system is activated. And that's a patient where you can ask about her feeling; she's got high affect tolerance; her anxiety will not get out of bounds.
In contrast, you take a more fragile patient, you begin to ask about their feelings, and as you're talking to the patient, the patient mentions that she's a little dizzy. At this point, what's happened, the patient's anxiety has gotten so high, that her parasympathetic system has gotten activated. Her blood pressure, pulse, and breathing has slowed down so quickly that her brain is actually not getting enough blood, and it's not working properly, which means that you immediately need to regulate the patient's anxiety, or else we're going to see regressive defenses and we're going to see projection begin to dominate the session within the next minute or two.
So, when you have something like Gestalt and there's no theory of anxiety, then there's now way of knowing, okay, what is the patient's tolerance level at this point? Because if we just explore feeling with everybody, but aren't able to regulate or psychodiagnose their anxiety, then we really run a risk of exceeding the patient's capacities.
David: Okay, well, I'm really impressed by your grasp of the literature and how you're able to cite so many people in the literature. And you mentioned, sort of in passing, the triangle of conflict, and I remember reading about that on the Association website. Say a little bit more. What is the triangle of conflict, and why is that important?
Jon Frederickson: Well, thanks so much for reminding me. That's such a central part of our work. It really goes back to 1923, Freud's paper "The Ego and the Id," because Freud initially had this theory: patients have these unconscious feelings; there's these defenses in the way; we need to knock the defenses out of the way, and then the feelings will rise. And then in 1923 he said, "I had to go back to the drawing board, and I realize there's this conflict." And unfortunately, when his work got translated, there are always Latinate terms that actually don't exist in the original, because the idea of ego, id, super-ego, it's actually nowhere in the German original. So we have these really weird words.
Jon Frederickson: Okay, so what's it mean? It means that unconscious feeling triggers unconscious anxiety, which triggers defenses. So there you are. But when Freud got translated in English, they really wanted to scientize everything so that the American Medical Association wouldn't just run Freud out of the country. Because, actually, the word psychoanalysis also isn't in the original. Freud's original was seele analysis, which is analysis of the soul.
David: Oh, that's fascinating.
Jon Frederickson: Yeah, and so when we talk about the triangle of conflict, it's really talking about Freud's basic idea of conflict, which is that unconscious feelings in the patient trigger unconscious anxiety in the body, which is mediated by the autonomic nervous system. Think about it, you see these nature films, right, and you see a lion running after a zebra, when that zebra is running, its autonomic nervous system is at full tilt. Its sympathetic nervous system is going at full speed. And that is the same system that goes off in a patient when they touch on a feeling in the room.
So the problem is we've got an animal system for fear that's operating the response to emotions in the room. And that's why when patients say, "Gosh, I just feel so afraid," well, they should feel afraid. They've got this animal system going on about a cue that really is not dangerous to anybody. It's just an emotion. But when you have an animal system going off, and the patient's blood pressure has just gone up 30 points, and their heart rate is up to 100, and their hands go cold and the blood is all going to the large muscles, yeah, their body's reacting that way.
So the triangle of conflict is, yeah, we have this unconscious feeling that triggers unconscious anxiety in the body, and then that triggers these defenses that patients use. And the reason that's such a central concept, not only in terms of conflict, it's such a fantastic way of trying to figure out what's going on. Because when we start out with a patient, we can know a patient's depressed, but we don't know why, and we don't know what to treat.
So when we hear the patient, then we know, from our approach, everything the patient says is going to fall into one of three categories: either the patient will be feeling something and describing the feeling; the patient will be describing her anxiety or she will be saying or enacting a defense. And so when we ask about her feeling, we know the next thing she's going to do is either she's going to feel her feeling, she's going to get anxious, or she'll use a defense. And so every time we ask and explore about feeling, we start to learn where her anxiety gets discharged, and we see what are the defenses she uses, and then we learn, oh, these are defenses she uses; this is what's creating her presenting problems; now we get a sense of what we need to treat.
And since we can point it out in the session, moment by moment by moment, we're just showing the patient how she responds, how to understand her response moment by moment by moment, so that collaboratively we can see together, wow, yeah, looks like when you have this anger emotion, it makes you really anxious. Do you notice that? And after about three times of that - gee, when you get angry, you get anxious, and you notice that you start to criticize yourself instead of being angry at this guy who slapped you; yeah, you notice that? - that we can develop a consensual understanding of what's happening in her, which then prepares the way to really setting up the therapeutic task, what we're here to do.
And that's also very different from psychoanalysis, where you're just supposed to sit and say what comes to mind. Because in our approach we feel it's really important to get consensus about what's going on in the patient, and really important to get consensus about what our therapeutic task would be, what we're here to do and why we're here to do that.
David: Okay, now you mentioned early on that research has been done on this approach, and I gather one Habib Davanloo is one of the key movers in this approach, and that he did important research at Harvard using video. Perhaps you could describe some of that research.
Jon Frederickson: Oh, absolutely. A brilliant clinician, a brilliant clinician, and he initially trained at Harvard, but his research actually was up in Montreal. He was at McGill University, and for many years he videotaped sessions and looked at the sessions in detail to try to figure out what is it that really leads to change. Because, although he was psychoanalytically trained, he was actually disappointed with the results of psychoanalysis as a treatment model. And so he developed a psychoanalytically informed treatment which was this intensive short-term dynamic psychotherapy, which is one of the forms of EDT. And, although he did a lot of research, he didn't publish his research. Instead, he published several books which had, really, his theories about technique and listed a lot of transcripts of his cases.
But one of his students, Alan Abbas, has actually published a lot of research on this. And, of course, there is, I think, about 60 controlled trials now of short-term dynamic therapy that have been published. And the trials are all showing that it's more effective than minimal treatment controls and wait lists. In fact, there was an article recently came out by Svartberg in the American Journal of Psychiatry, in which they did this short-term dynamic psychotherapy versus cognitive therapy with personality disordered patients, and they found that short-term dynamic psychotherapy brought significant symptom reduction, but cognitive therapy didn't. And it suggested that short-term dynamic psychotherapy may have added benefits in more resistant and complex symptomatic patients.
And I think that's important because cognitive therapy does something really, really important in the way that it addresses these defenses and how defenses can create presenting problems. But since it addresses that dimension but is not systematic in addressing anxiety and in the feelings that trigger anxiety, then if we don't address enough dimensions, then I think we're going to be at greater risk of relapse.
Jon Frederickson: For instance, I don't know if you ever saw, there was a very interesting article by Drew Westen where he looked at the cognitive therapy results with the NIMH study on depression. And what they found was that they had to pick patients who only suffered from depression and not other diagnoses, and so that ruled out about 50% of patients. Of the 50% that they could work with in cognitive therapy, 50% of the patients had a good outcome. But then in two year follow up, they had a 50% relapse rate, so of the initial group of patients, 50% could be treated, and so of the initial pool, only 12% had a good outcome. Of the group that they treated, only 25% had a good outcome. So I think what we're really interested in is not just the results we have at the time, but what's follow up, what's the follow up.
Jon Frederickson: I think any treatment to have really good follow up is going to have to address more than one dimension, and I think we have to be very respectful for the skills we can learn from cognitive therapy about what it does around the dimension of particular defenses, but that it's really important to address the dimensions of anxiety regulation and help patients with the affect experience in tolerance and so on that will really build capacity and then lead to less defenses in the future.
David: Okay, now I notice that the International Experiential Dynamics Psychotherapy Association is, in fact, an international association. Is this approach, in fact, better known and more widely practiced abroad than in the US?
Jon Frederickson: It is practiced abroad. I wouldn't say that it's any better known anywhere. A lot of the developments we're doing have been really emerging in recent years, but we have a training program at the Washington School of Psychiatry. Alan Abbas has a program up in Dalhousie. There's a program at UCLA and down at San Diego. I'm affiliated with training programs in London and Norway, Denmark, Poland and Italy. So there's a lot of activity in Europe of people getting trained in this.
David: So is it on the rise, would you say? I mean, it's got its roots back in the 1920s.
Jon Frederickson: It has its roots in 1920. I think it's important. What was it that Goethe said? If you want to surpass your fathers, you must master their knowledge. And I think it's important to respect the really good knowledge of the past, but we have to also integrate. We can't just discard what was good from the past, but we have to integrate with the most current knowledge we have today.
What we can see with neuroscience and biophysiological research, Freud's idea that there's unconscious motivation is obviously true, but the way we think about unconscious activation is radically changed now as a result of neuroscience work. And I think that, also, as we integrate with neuroscience and biophysiology, we really are having to look at the integration of mind, as we think about in psychoanalysis or in cognitive therapy, but also the body - how we feel feelings in the body. Anxiety: how is anxiety discharged in the body? That I think we're at a point now in our field where we see in a lot of areas where we're trying to really integrate, in neuroscience, psychoanalysis, the insights of cognitive therapy, behavior therapy. Because we have to integrate affect, cognition, and behavior. If you do only one of those, it's not going to be enough.
David: Yeah, we have another wing of therapy that we haven't discussed, which is sort of the body therapists. I'm thinking of Alexander Lowen and his followers, bioenergetics people, who felt that, hey, all of this is rooted in the body, so they try to go straight through that modality.
Jon Frederickson: Right, and oftentimes they got into trouble because they didn't understand how to assess anxiety. And of course we see - and I see repeatedly in people who've been doing the body work - it's beautiful, their capacity to focus on the body, focus on feelings in the body. But again, where they get into trouble is are they assessing anxiety appropriately. Because sometimes, you know, in body work you'll see patients experiencing their rage, and you see the patient shaking. And then they'll think, oh, this is great; they're releasing some feeling. No, they're shaking because the sympathetic nervous system is so activated that adrenaline is running through the body, and they're actually trembling. And they're at too high a level of anxiety to actually benefit from any integrative experience.
Because anxiety needs to be high enough that learning is going to take place, but when it gets too high, then therapy just becomes another feared experience. And when anxiety's too high, as we know, the hippocampus shuts down, and so you're not going to have integrative, declarative memory, but you may have more primitive forms of memory that take place that won't be that helpful to the patient.
David: Interesting. Now, you've written a book titled Psychodynamic Psychotherapy: Learning to Listen from Multiple Perspectives, and I guess it's addressed to therapists. What are the main points that you were wanting to get across in that book?
Jon Frederickson: What I was wanting to get across is for people who work in a psychoanalytic or psychodynamic point of view, there's oftentimes a misguided notion that when we talk about listening, we're all talking about the same thing. But in fact, no matter what we listen to in this blooming…
David: Buzzing confusion.
Jon Frederickson: Yeah, right, of William James. In all this amazing flood of data that comes flying out of any therapy session, you have to pick and choose. There's just too much. So any time we listen, we are having to make some choice about what we pay attention to and don't pay attention to. And there's nothing wrong with that; it's just inevitable.
But the important thing is for us to be aware of what we are deciding to focus our attention on, and what we're not focusing our attention on. And then that way, then the book showed there were different ways of listening and showing how, for instance, conflict - we're trying to organize everything that we hear in terms of feeling, anxiety, defense. In terms of transference analysis, really what you're listening to is not what the patient says, you're listening to what we call the "latent content." You're trying to translate everything the patient says into terms of how they might be thinking about you in that moment.
And so what I was trying to help them see is see if people could realize that listening is really a tool. There's many different ways of listening, and learning to be able to shift gears, because not one way of listening is ever going to be optimal for every patient. I think in our field, unfortunately - and this is such darned hard work, and it's so incredibly complex. I don't know how far you are in the field, but I'm just amazed. At this point in my field, I thought, oh, surely I'm going to know the answer all the time. You know, it's like famous illusions that bit the dust.
Jon Frederickson: And you realize that the human mind and these conditions are so complex, that we really need to have a lot of different approaches at our fingertips so we can be optimally flexible. It's like my father's a blacksmith, and when I was a kid growing up with him, I really grew up in his shop, because I was supposed to take over his blacksmith shop. And you have many, many different tools; you have many different kinds of hammers and so on.
And I always thought it was funny, because as a blacksmith, you've got to use all kinds of tools, but in psychotherapy oftentimes the idea is that someone finds a tool that worked with one patient, and then they decide, okay, this is the tool I'm going to use. So I'm just going to do cognitive therapy, or I'm just going to do transference analysis, or this or that. And they join the cognitive therapy club, or they join the transference analysis club, and then it becomes like a little cult, where everyone is worshipping a technique. And we don't think about how weird it is, but if we saw carpenters who had a screwdriver convention, and they all worshipped screwdrivers, we'd say, wow, I got to make sure not to hire that guy.
David: Well, I totally agree with you about that, and that's one of the reasons why I like doing this series and interviewing people from so many different perspectives, because it's like the old story about the elephant, right, and the blind men.
Jon Frederickson: Exactly.
David: And, truly, human beings are extremely complex, and there's no one approach that's got a lock on the whole story.
Jon Frederickson: Absolutely.
David: At least that's my impression. Now, if one or more listeners are intrigued by what they've heard here, first of all, for professionals, how would they find training, and if they're not professionals, how would they go about finding a therapist?
Jon Frederickson: Well, two ways: I would encourage them, they can certainly visit out website at the Washington School of Psychiatry. They can email me if they want. They can to the IEDTA.net, which is the website for the International Experiential Dynamic Therapy Association, so it's IEDTA.net. We also have a huge conference - it's going to be next summer in British Columbia, a beautiful place, where a lot of us will be presenting. And for your listeners, you might be interested: in our kind of training, all our training is done with videotapes of our work. When we do a conference, no one can present unless they are showing videotape of their work.
David: That's fascinating.
Jon Frederickson: We have a journal. It's called the Ad Hoc Bulletin of Short-Term Dynamic Therapy. No paper is accepted unless it's a word-by-word transcript of a case with the analysis of what you do.
David: That's fascinating. Now, you said people could email you. Are you comfortable giving out your email address here?
Jon Frederickson: Yeah, that's okay, that's okay. It's not a problem.
David: Yeah, what is it?
Jon Frederickson: It's email@example.com.
David: Okay, great. Well, Jon, we've run out of time here. I really want to thank you for sharing so generously, and for being my guest today on Wise Counsel.
Jon Frederickson: Well, thank you. It's been a real pleasure. This is great fun.
David: I hope you got as much out of this interview with Jon Frederickson as I did. As you heard me remark, I'm extremely impressed with his grasp of the research literature. For someone who I believe is primarily a psychotherapist, I'm struck by how on top of recent developments in our understanding of the brain he is. It's good to see clinical theory and practice integrated with our updated understanding of neuroscience. I think Freud would be delighted to know that some of his fundamental notions are still alive and well, and are being updated with the latest scientific findings. After all, he was trained as a neurologist.
And speaking of Freud, you might be interested in a follow-up email Jon sent me right after our interview. Among other things he wrote: "You seem interested in the issue of Freud's mistranslations. You would enjoy Bruno Bettelheim's book Freud and Man's Soul, where he shows how Freud's ideas were misrepresented in Strachey's translations." I'm thinking some of you listeners might want to check out that Bettelheim book. In the meantime, if you wish to learn more about experiential dynamic psychotherapy, that website again is IEDTA.net, for the International Experiential Dynamic Therapy Association.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.
Jon Frederickson, MSW, is Co-Chair of the Intensive Short Term Dynamic Psychotherapy (ISTDP) Training Program at the Washington School of Psychiatry and treasurer of the International Experiential Dynamic Therapy Association. Jon is also Co-Chair of the ISTDP Training Program hosted by the United Kingdom ISTDP Society, London, England, and Chair of the ISTDP Training Program hosted by the Norwegian ISTDP Society, Drammen, Norway. Jon also provides ISTDP training in Denmark, Poland, Italy, and the U.S. He is the author of over twenty published papers and a book, Dynamic Psychotherapy: Learning to Listen from Multiple Perspectives.
Funding is Provided by Methodist Healthcare Ministries of South Texas, Inc