Intensive Short-Term Dynamic Psychotherapy (ISTDP): A Guide for Mental Health Professionals

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What is ISTDP?

Intensive Short-Term Dynamic Psychotherapy (ISTDP) is an evidence-based approach that helps patients experience and process core emotions that have been avoided. It works systematically with anxiety and defenses that block emotional experiences, using the therapeutic relationship as a key vehicle for change.

 

The Evidence Base for ISTDP

ISTDP has a robust and growing evidence base spanning over 40 years. Key findings include:

 

Treatment Effectiveness:

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• Over 40 published outcome studies

• At least 20 randomized controlled trials (RCTs) 

• Independent replications for:

  • Treatment-resistant depression

  • Personality disorders

  • Chronic pain

  • Social anxiety disorder

 

Cost-Effectiveness:

 

• Significant reductions in healthcare costs

• Decreased medication use

• Reduced hospital admissions

• Lower disability rates

• Fewer emergency department visits

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Specific Conditions with Strong Evidence:

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Somatic Symptom Disorders

• Multiple RCTs showing effectiveness for medically unexplained symptoms

• Significant reductions in healthcare utilization

• Particularly strong evidence for chronic pain and functional neurological symptoms

 

Treatment-Resistant Conditions

• ​Effective for patients who haven't responded to other treatments

• Particularly strong evidence for treatment-resistant depression

• Good outcomes with personality disorders

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​Anxiety Disorders

• ​Multiple controlled trials showing effectiveness

• Particularly strong evidence for social anxiety and panic disorder

 

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How ISTDP Compares to Other Approaches

 

ISTDP vs. CBT

While CBT focuses on modifying thoughts and behaviors, ISTDP focuses on helping patients experience and process core emotions that have been avoided. Rather than using cognitive restructuring or behavioral experiments, ISTDP helps patients overcome anxiety and defenses that block emotional experiences. Both approaches are structured and active, but ISTDP works more explicitly with the therapeutic relationship as a vehicle for change.

 

ISTDP vs. EMDR
While both approaches aim to process difficult experiences, EMDR uses bilateral stimulation to help process traumatic memories, whereas ISTDP helps patients experience and process emotions in the here-and-now of the therapeutic relationship. ISTDP has a systematic way of working with anxiety and defenses that block emotional processing, rather than focusing primarily on the trauma memory itself.

 

ISTDP vs. IFS
Unlike IFS which works with different parts of the self, ISTDP focuses on helping patients directly experience core emotions that have been avoided through anxiety and defenses. While IFS aims to create harmony between parts, ISTDP aims to help patients fully experience and integrate previously warded off feelings. Both approaches value the wisdom of the body but work with it differently.

 

ISTDP vs. ERP
Both approaches involve systematic exposure, but to different elements. ERP deliberately triggers anxiety and prevents avoidance/ritual behaviors to achieve habituation. ISTDP also works systematically with exposure, but through the "triangle of conflict" (feelings, anxiety, defenses) and "triangle of person" (current, past, and therapy relationships). In ISTDP, we help patients gradually expose themselves to previously avoided emotions and relationship patterns, while actively working with the anxiety and defenses that arise.

 

ISTDP vs. ACT
Both ISTDP and ACT view avoidance of internal experiences as problematic and emphasize the importance of experiencing rather than avoiding difficult feelings. Both help patients move toward what matters despite discomfort. However, ISTDP has a systematic way of restructuring anxiety and defenses to enable deeper emotional experiencing.

 

ISTDP vs. Schema Therapy
Both work with early attachment/developmental experiences and understand how early relationships create enduring patterns. Both actively work in the therapeutic relationship to create change. The difference is ISTDP focuses more on in-the-moment emotional experiencing versus identifying and modifying schemas.

 

ISTDP vs. DBT
Both pay careful attention to arousal/anxiety regulation and emphasize the importance of the therapeutic relationship in helping patients tolerate intense affects. The key difference is ISTDP aims to help patients fully experience previously warded off feelings versus primarily building skills for emotion regulation.

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ISTDP vs. Traditional Psychodynamic Therapy
While both work with unconscious material, defenses, and use the therapeutic relationship as a vehicle for change, ISTDP takes a more active, systematic approach with specific focus on anxiety and defense restructuring. ISTDP also tends to work more quickly and intensively than traditional psychodynamic approaches.

 

Why Isn't ISTDP More Widely Practiced?

Several factors contribute to ISTDP's relatively limited availability.

 

Training Requirements: ISTDP requires intensive specialized training that typically involves

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• Multiple years of supervision

• Video recording of sessions for supervision 

• Close attention to moment-to-moment process 

• Mastery of specific technical interventions 

 

This level of training investment isn't feasible for many clinicians.

 

​Historical Context: While ISTDP has been developing since the 1960s under Habib Davanloo, MD, it was initially taught to small groups through videotape training. The model has only more recently become more widely accessible through books, training programs, and research publications.

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Common Misconceptions: Some clinicians mistakenly believe ISTDP is too confrontational or only suitable for very high-functioning patients. However, research shows it can be effectively modified for a range of patients and presentations.

 

Training Availability: While growing, there are still relatively few ISTDP training programs and supervisors compared to other modalities. This makes it harder for interested clinicians to access training.

 

Institutional Factors: Many training programs and clinical settings emphasize shorter-term, protocol-driven treatments that can be more easily standardized and researched. ISTDP's focus on individualized intervention and emotional processing can make it a harder fit in some settings.

 

Who Might Benefit from ISTDP?

ISTDP can be particularly effective for:

 

• Treatment-resistant conditions that haven't responded well to other approaches

• Patients with medically unexplained symptoms/somatic complaints

• Patients with characterological issues who have good psychological mindedness

• Anxiety disorders, particularly when emotion avoidance is a key maintaining factor

 

Contraindications for ISTDP

ISTDP is not recommended for patients with:

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• Active psychosis

• Severe substance abuse

• Acute suicidality

• Severe cognitive impairment