Tuesday, July 12, 2016

A (long) Comment on Scott Alexander's Review of "Unlearn Your Pain"

My son Ben texted me the other day that his favorite blogger, Scott Alexander, had published a post reviewing Howard Shubiner's book Unlearn Your Pain.  Despite being a psychiatry resident, Scott manages to be a prolific writer in areas of interest which appear to be TNTC.  Ben knows him through Effective Altruism, and sent me the review because it mentions ISTDP (Intensive Short-Term Dynamic Psychotherapy), the kind of therapy that I do. I had read some of Scott's other posts with interest, always wishing I had more time to keep up.

I enjoyed the review, and sat down to email a response to Scott, since my thoughts seemed a little long to post as a comment. Scott asked me to post them as a comment anyway, at which point I discovered that his blogging platform agreed with my initial gut feeling.  So I am posting them here, and will post a link to this post in the comment section of his review.

So here is a somewhat edited version of the email that I sent him.

Hi Scott,

My son Ben Kuhn texted me the other day about this post. At his urging I’d read some of your previous posts; I’ve enjoyed and wish I had time to read more. For this one, as a psychiatrist who practices and teaches Davanloo’s Intensive Short-Term Dynamic Psychotherapy (ISTDP), I rushed-right over when he texted me!

Howard Schubiner is an exemplary human being; he has referred a number of patients to me and he has spent a great deal of time corresponding or speaking with almost all of them. Multiply this by a nation of 320 million and I find the implications quite stunning.

Unfortunately, he may have set up a straw man in terms of theory of psychosomatic pain. Having worked for a while after residency as a CL psychiatrist, my overall impression is that psychosomatic ailments are a vast swamp, and it is very easy to get sucked down into the mire, especially if you are theorizing about their cause. And, in general, early medical theories are fairly laughable in retrospect, if not at the time. As an example, the entire premise of the DSM is fairly laughable, it’s just that it is (in some ways) better than what we had before.

So here is your summary of Howard’s theory:
He thinks there may have been some original minor injury, of the sort that most people would get over in a couple of weeks. This causes the nerves to “sensitize” – ie the brain is primed to think about and remember this form of pain.
Here is your alternative:
But I’m not convinced by its more sweeping claims that physical injuries play little-to-no role in chronic pain. Along with Schubiner’s talk of nerve sensitization, one can imagine a scenario in which alternatively apparently-healed physical injuries may leave very small irritations on local nerves, and that the degree of irritation a nerve is able to bear without giving you chronic pain is related to your general neural-non-messed-upness and stress level. In such a scenario psychological factors might play a role in gating the pain, or in tensing or releasing muscles around the pain, but would not entirely explain it.
In his version, the locus of the problem is a “sensitized” nerve connected to a healed injury. In your version, it is a nerve hooked to an injury that is healed enough that people with a non-messed-up nervous system would not perceive it as noxious. At our level of ability to understand, observe, and intervene in these phenomena, I’m not able to detect any practical difference between these two points of view, and so discussions of this kind often turn out to be a waste of breath. A nicer way to say that is that (a) at our current level of measurement, these are not empirically verifiable or falsifiable claims, and (b) even if you could answer this question one way or the other (and perhaps both are true in different cases), it is not clear whether that would have any bearing at all on the question of whether any given treatment is effective or not. For me, and I suspect for you as well, the bottom line is (a) does a particular treatment relieve human suffering, and if so (b) is the time, money, sweat and ancillary suffering need to do the treatment worth it for the benefit it has? I don’t think that we’re at a point where theories of this kind can illuminate these questions, beyond the first step of making it plausible that a psychological treatment could help a “physical” problem like pain (though why we are comfortable with the conclusion that pain is a physical problem when there is no physically observable injury is an interesting question). Your hypothesis and Howard’s both fit the bill for that first step.

Oops, I honestly don’t mean to be getting into bashing you here, so I am going to put my discussion of placebo toward the end.

Second: As much as I like and admire Howard, I would not describe what he does as ISTDP; it is ISTDP-friendly, but all of the “silly-sounding” things you describe in your review are things that I’ve never seen an ISTDP therapist do (and since we videotape our therapy and every presentation involves showing video, this statement actually means something). They sound kind of silly to me, too, though I’ve seen sillier-sounding things, such as EMDR, really help people so I do admire your restraint and I think it is a wise approach. I don't think that much of what I do looks silly, but some of it may look kind of crazy... but it keeps helping people, so I keep doing it.

I think it is more accurate to say that Howard is in the John Sarno tradition than to say he is doing ISTDP. Sarno also had close links with ISTDP; in fact I’ve been told that a psychologist he worked with trained with Davanloo, so that it is possible that much of his thinking originated with Davanloo, but there is a lot of thinking that originated with Davanloo that then diffused out, but is not ISTDP. For example, I am told that Jeffrey Young, the originator of CBT’s “schema” therapy, attended Davanloo workshops.

One of my main discomforts with Sarno is that he tells people “you have to believe that your pain is caused by TMS” (his name for what we’re talking about, Tension Myositis Syndrome). This is not a tenet of ISTDP; in fact, I welcome patients’ skepticism and encourage them to take an empirical, observational, experimental stance toward their interior life. All that is necessary is a willingness to try it out and see whether it’s helpful.

Next: “childhood trauma.” ISTDP says that “neurotic" psychopathology is based on “attachment trauma,” i.e., some kind of trauma to early attachment bonds. So if you find Howard’s claims uncomfortably broad, this is probably even more uncomfortably broad. So that we don’t get caught up in hair-splitting let’s replace “is based on” to “has a very significant component based on.” Attachment trauma includes everything that comes to mind when you say “childhood trauma”: physical abuse, sexual abuse, early parental loss. It also includes covert forms of abuse or neglect. It is possible that it is so broad as to be universal. It is undoubtedly true that there are events which are traumatic to one child but not to another, based on factors that we do not necessarily understand but which may well include a temperamental/genetic component. It is conceivable that a prospective study based on observable putatively pathogenic events would show only a fairly weak correlation with subsequent psychopathology. The point of this theory is not really to predict who will become ill; it is to indicate the kind of therapeutic work that helps people get better. This also does not mean that “therapy that focuses on childhood trauma will help people get better,” or even that “therapy that focuses on attachment trauma will help people get better.” ISTDP has a very specific way of focusing attachment trauma. In addition, it is easy to do ISTDP poorly, and not so easy to do it really well. This means that, while the claim that “Well-conducted ISTDP helps people get better” is potentially verifiable, it is not easy to verify. So I am aware that there is a lot of potential refuge for scoundrels here. However, in terms of your post here, the relevant point is that studies showing a weak link between “childhood trauma” and psychosomatic complaints aren’t necessarily convincing evidence against the ISTDP point of view.

Listen, I could go on and on, and there is some danger that I would (actually, reading this over, I see that I have). But the point is, chronic back pain is an enormous problem from a public health perspective. How much of it is amenable to psychological treatment that would have a strong result (i.e. “it solved my problem [completely or almost completely],” rather than “yeah, I think it probably helped some”). 20%? 90%? 99%? 50%? 10%? I don’t think we have much idea. Even if it’s 10%, that would be very significant from a public health perspective. Chronic back pain is one piece of chronic pain, albeit a large one. Chronic pain is one piece of medically unexplained symptoms. Medically unexplained symptoms comprise a stunningly large percentage of human suffering, doctor visits, and chew up an enormous chunk of our vast medical budget. If you add to that the fact that our treatments for issues that ARE regarded as psychological leave a lot to be desired, we are talking about potentially addressing an enormous amount of human suffering and healthcare expenditure.

One of my main authorities on ISTDP is Allan Abbass, a psychiatrist at Dalhousie University in Halifax, Nova Scotia (www.istdp.ca). After his initial training in family and emergency medicine, he trained extensively with Davanloo. He’s gone on to do quite a lot of research on ISTDP and has surveyed the rest of the research for Cochrane reviews among others. If at some point you want to take a deep dive into the research base you might wait a bit because they have an RCT of ISTDP for treatment-resistant depression that hasn’t yet been published but is on the way. Here is a link to an article describing ISTDP and presenting some of the research. I do hasten to add that ISTDP theory is not particularly attractive, as theory goes. As a former mathematician, I am a big fan of elegance. Sadly for elegance, the more closely I follow the theory, the better my patients get.

Some of Allan's results are quite stunning, e.g. an ED-based intervention for Medically Unexplained symptoms with an average of 3.8 sessions showing something a > 50% reduction in ER utilization in the year after intervention compared to the year before, much greater than matched controls. Symptom relief in ISTDP can be very rapid, though for various reasons musculoskeletal pain can be less rapid than other somatic symptom disorders like migraines, IBS, nonepileptic seizures, etc. The article can be found here.

In terms of my own history, I was positively disposed toward dynamic psychotherapy when I started training, and I trained in a dynamically-oriented program (Mass. Mental Health Center, which then became part of the Harvard Longwood residency program). Over the course of my training I became gradually disillusioned (I won’t say disenchanted because I wasn’t really enchanted to start with) because it seemed to be a welter of competing speculation with no way of discerning the validity of any of it. My experience with ISTDP has been different from that, because you see so much unfolding in front of you in a very explicit, experiential way. It is fair to say I am enchanted with ISTDP, with most all of the positive and negative implications of that word.

For various complicated reasons, the ISTDP world is more fragmented than it needs to be and there has been quite a bit of terminological confusion. I wrote a book called “Intensive Short-Term Dynamic Psychotherapy: A Reference” which is something like a cross between a glossary and a series of blog entries. It is not designed to be read cover-to-cover, though some people have and said that they enjoyed the experience. But if you want to learn more about ISTDP from a book, I would say that the place to start is Allan’s book, “Reaching through Resistance.” Both are available on Amazon, but I also need to say: ISTDP can’t be learned from a book, you definitely need to see video of the therapy, and you definitely need supervision. Allan also offers a 3-day "immersion" in ISTDP every fall.

Here’s one thing I enjoy about ISTDP. You undoubtedly remember from med school hearing about “symptoms and signs” of disease, and learning the distinction very early on. You are obviously also aware that in psychiatry we say a lot about symptoms and zero about signs. (For your non-medical readers: symptoms are things that patients complain about, signs are things that physicians may observe but that patients do not complain about.) Well, ISTDP has honest-to-God signs, in terms of what Davanloo calls the “discharge pathways of unconscious anxiety,” and this is one of the main guides to the therapist in doing the therapy.

Oops, I see that I said I’d say something about placebo. You clearly know the placebo literature much better than I do, though that isn't hard. But is seems to me that when we talk about placebo, we are talking about the mind’s ability to heal the mind and body. What could be better than that? Yet we talk about it as though it is noise, rather than perhaps the most valuable of signals. So I agree that we should be doing everything we can to develop and augment the “placebo” effect. If putting on robes and chanting makes it work better, let’s put on robes and chant. If I ever do learn the placebo literature better, the title of the article I want to write is, “Is it Ethical to Withhold Placebo Treatment?” The point I want to make here, though, is that while it is (mostly) possible to make a viable distinction between medical interventions and placebo, I’m not at all sure that you can make a viable distinction between psychotherapeutic interventions and placebo. Oops, we are at the point of more than “more than enough” so I’ll stop… I did have a question about your remarks on behavioral genetics but I’ll have to save that for another day...

Sunday, December 8, 2013

"The Controversial Therapy That Deliberately Enrages Patients"

A sharp-eyed friend (with the help of google) alerted me to a piece about ISTDP on a site I had not previously known, vice.com, with the above title.  You can read it here.

I made a few attempts to post a comment, but they didn't stick, maybe because I included my website URL (www.natkuhn.com).  Maury Yoszef did manage to get an intelligent comment up there, thanks Maury!

In any case, I thought I would post my comments here:
As an ISTDP practitioner, I'd like to comment on some aspects of this article that can be misleading.
As Dr. Said notes, ISTDP is based above all on a therapeutic alliance between the patient and therapist.  ISTDP therapists encourage patients to face painful, locked-away feelings, but for this to be effective it must happen in the context of a relationship where patients understand clearly that the therapist is acting in their best interests  People who try to imitate a naive idea of ISTDP as "antagonistic" or "badgering" rapidly find out that it is not effective and if anything makes patients worse.  Maintaining the appropriate level of intensity requires a great deal of skill and training.
 There is never a time in ISTDP when a patient "literally wants to kill the therapist," and if a patient of mine ever did, I might well "seek help from law enforcement"--but I've never had to, and I don't know an ISTDP therapist who has.  ISTDP is about helping patients to experience and observe feelings, understanding that feelings and impulses are very different from actions.  In the process of ISTDP therapy, therapists can be relentless in pointing out patients' self-defeating behaviors; this brings up a mix of positive and negative feelings toward the therapist, which can connect up to unconscious feelings of rage from early life.  When this happens, the patient may experience feelings of murderous rage directed toward the therapist, but patients are able to understand that these are feelings and impulses, not actions they actually want to carry out--in other words, the patient does not, in fact, "fly into a murderous rage."  Experiencing these feelings (among others) is often an essential element of ISTDP treatment, allowing access to additional material from early life.
While Dr. Said's own description of ISTDP seems generally accurate, there are a few points (on which he may have been inaccurately quoted) that I would take exception to.  First, there HAS been quite a bit of research on ISTDP, showing that it is effective, though more is definitely needed.  Some of the research can be found on the web site (www.istdp.ca) of one of—if not the—foremost ISTDP researcher, Dr. Allan Abbass at Dalhousie University in Halifax, Nova Scotia.
Second, as many commenters have noted, it is absurd to say ISTDP "always works."  I have devoted a lot of time and energy to learning ISTDP because it treats a broader variety of patients in a more effective way than any other therapy I know.  But, for example, I would not treat a patient with schizophrenia, or a patient who is actively manic, with ISTDP.  And there are patients who, despite my best efforts, I have not been able to help.

Wednesday, January 9, 2013

DEA number renewal needs (non-existant) MCSR expiration date SOLUTION

OK, so I went to renew my DEA number... maybe I let it go a little longer than I should have.  (Are a lot of these posts starting with "OK"?  A little anxiety there, maybe?)

In addition to wanting to know your state controlled substance number (in Massachusetts, the MCSR), they (now) need to know the expiration date of your state certificate.

The only problem: there is no expiration date printed on the MCSR certificate.  The other only problem: when you search the web and get to the Mass DPH "FAQ" page, you are told that the certificates do not actually expire, they are "recalled" every few years at the pleasure of the Mass DPH.

Of course, that doesn't work on line at the DEA renewal site, so I printed the renewal form, filled in "N/A" under expiration date.  No dice; no renewal.  I called the DEA.  They said to call the DPH.  They (the DEA) seemed singularly uninterested in following up on this as a systemic issue.

I called the DPH.  Your certificate does in fact live forever until it dies.  The date on which it does not expire is three years from the issue date.  They also seemed singularly uninterested in following up on this as a systemic issue, though I suggested that if they post this information on their FAQs they might get fewer calls from people like me.

The DEA web site accepted this date and renewed my certificate pretty much on the spot.

Bottom line: use three years from the MCSR's date of issue for its expiration date on the DEA registration site, and it should work.

Monday, January 7, 2013

Evaluation & Management (E/M) "encounter form"

OK, we're all freaking out about the new psychiatry billing codes and the documentation requirements that go along with them, right?  Especially the E/M codes that replace the 90862 medication follow-up.

Over the weekend I made up a form that may help.  (You can skip to the end for the links to download it if you want to cut to the chase.)

The form can be printed out and filled in, either during a session, or afterwards; alternatively, it can be used for reference, to learn the coding system.  It captures—I think—all of the bits of documentation mentioned in the E/M documentation standards for psychiatry.  I tried to make it so that the various pieces are grouped together logically, with reasonably good design. It contains the standards and criteria for all the psychiatry E/M codes that I'm aware of: inpatient, outpatient, initial, subsequent, and all the levels.  (The reference sheet that I did that is available here only does levels 2-4, and only the outpatient follow-up codes; but it does include the psychotherapy codes and add-ons, and the simpler non-E/M evaluation codes, which this one doesn't.)

The form is not
  • something that contains all the elements of a complete medical record note; like the E/M documentation standards, it omits a number of very basic things like, uh, a medication list, a plan, etc.  I may do a second page at some point.
  • a guide to how you should conduct an interview
  • something that can be filled out on line, though it would be possible to turn it into an electronic form, and I may do that at some point
  • any kind of endorsement by me of this whole scheme of coding, billing, and documentation, although—even though I am someone who does not take care of the most complex medication patients—I am sympathetic with the idea that people who do should get paid more
I haven't used it yet, or piloted it in any significant way.  I sent it to a few people and the feedback was positive, so I think it's worth a try.  One of the complaints about the new system is that people worry that they will spend more time thinking about the documentation than about the patient.  It's true that people who are very anxious about the change may do that.  As I mentioned in the other post, I think that the vast majority of outpatient med visits will be 99213s, and these are not so hard to document.  So I believe it's possible to get familiar with the system while we're doing pretty much what we've been doing, and we'll need to learn to adequately document what we've been doing to meet the standards. I think that for outpatient psychiatrists, if you start by using the non-E/M code for initial visits, and you try to understand the difference between 99212 and 99213, all of which is outlined on the other sheet, you will be off to a good start and in fact you may have done everything you need to do.  Others will want to use 99214, and the E/M codes for initial visits.  More power to them.

Some ways you might use it:
  • I originally thought of printing this form two-sided.  It should work well for that, but when I realized that the note will need more than is on the form, I thought I might print it on two pages and use the back for additional notes.  It should work fine for this as well because the name is repeated at the top of the second page.
  • Rather than using it in the session, you could sit down after a session and see where all the data you gathered fits on it, and then use it to see where you are in terms of coding.
  • It can be used as a way to understand the coding system.
As with the reference sheet, I am providing this in the spirit of "open source." There is a link to the pdf below, but you can also download the Word .doc file and change it.  You can redistribute it freely as is.  If you change it, you should just include attribution.  Easy.  Free.  (As mentioned on the other page: donations welcome, via the "Support" button on the right.)

Also as mentioned on the other page: this is a good faith reflction of my understanding as of the moment of the writing.  I am making no representation that it is entirely correct or problem-free, and the responsibility for your coding or documentation rests, as it always has, with you.  But I hope this helps.

So here are the links:
At the moment, the "current" version and the "original" versions are exactly the same, but if I change the form, as I expect I will from time to time, I'll try to keep the "current" links up to date so you don't have to chase around to find the current version; on the other hand, if you don't like the changes you can stick with the original.  Each intermediate version should have a blog entry so that it can be found as well.

Good luck!  Feedback welcome, as long as you're not blaming me for this whole imbroglio.

License info:

Creative Commons License
Psychiatry E/M Encounter Form by Nat Kuhn, MD is licensed under a Creative Commons Attribution 3.0 Unported License.

Sunday, January 6, 2013

Update to 2013 CPT Codes for Psychiatry

I tweaked the ROS section of history to have a complete list of systems, and better prompts.

I also modified the file names so that they have the date on them.  I will leave old versions up, to reduce possible confusion.  I'll try to remember to update the original post (at tiny.cc/cpt2013) so that it links to the blog entry for the latest update.

I'm making progress on the form for sessions/encounters and I hope to post it soon.

2013 CPT Codes for Psychiatry pdf version
2013 CPT Codes for Psychiatry .doc version for revision/remixing; more info with original post at tiny.cc/cpt2013

Friday, January 4, 2013

New Psychiatry CPT Codes: Don't Panic

If you're a psychiatrist (or psychiatric RNCS) in the US reading this, you are almost certainly aware that all of our billing codes changed on Jan 1, 2013.  If you are like most of the psychiatrists I know—at least in private practice—you are at least somewhat freaked out by this.  If so, keep reading.  If not—for example, if you're not a psychiatrist in the US—stop reading this immediately and go do something more interesting, like... well, like just about anything other than memorizing a phone book.  (There used to be things called phone books...  never mind.)

I made up a one-sheet reference, which I think can help with the codes.  There are links to it at the bottom.

Here are some links that I've used for reference, trying to understand this.  The "little" APA has a helpful page with many links, most of which are pdfs available to both members and non-members, at http://www.psychiatry.org/cptcodingchanges.  The "Overview of the 2013 Changes " will get you started; the last two pages, which are also included separately as "E/M Summary Guide: Coding by Key Components," were the single most helpful reference for the complexity-based E/M codes, which you will quickly realize are the only really challenging issue here.  I also found the "Patient Examples Outpatient E/M Visits" helpful.  And finally, the comprehensive reference seems to be "Evaluation and Management Services Guide from CMS ." (Note that while the APA site says that it "does not replace content found in the 1997 Documentation Guidelines for Evaluation and Management Services, abridged version for psychiatrists [listed above]," it seems to contain the full 1997 guidelines as an appendix, so I'm not exactly certain what they mean...)

My advice, at least at the beginning, is to avoid the E/M codes for initial visits, and use the generic initial evaluation code, which replaces 90801.  Some of the E/M codes for initial visits will probably end up reimbursing better than the generic code.  Again, my advice: save that for later.

Unfortunately you need to use the complexity-based E/M codes if you are doing psychotherapy and medications together (e.g., the old 90807), which you now need to code with a complexity-based E/M code and a psychotherapy "add-on."  I suspect I will mostly end up using 99212 and 99213, but some colleagues have pointed out that 99214 is workable, especially for those doing geriatric psychiatry.

So, with the exception of the initial-visit E/M codes, I boiled it down into a one-page reference, which anyone is free to redistribute as far and wide as they link.  Links are at the bottom of this page. When you click on that link, if the file opens in a browser window rather than downloading, you should just be able to go to "Save" in your browser's File menu to save the pdf or .doc file on your hard drive.  I am not charging for it (though in the spirit of "shareware" I'm happy to accept donations from anyone who feels so moved, see the "Support" button to the right).  I'm making it available as "open source" material under a Creative Commons license (more info at the bottom), which means that you could change it and redistribute it as long as you do so in compliance with the license (meaning that if you change it and distribute it to others you attribute the original). The license actually does not rule out commercial use.

Feedback and comments are welcome!  (I am aware, by the way, that I made one simplification: it is possible to hit the criteria on medical decision-making based on problem and data points alone, but I can't really ever see that happening without also hitting the risk criteria).

And of course, the obligatory disclaimer.  I am not an expert in this stuff, this is simply my best understanding of it.  It is quite possible that there are errors in the reference, and if you find any, please tell me.  But you are, as always, responsible for your own coding and documentation and I can't assume any responsibility for any problems that come up for anyone but me.

I've also made a form for taking notes in session (or for learning the system between sessions) which should make documentation and coding easier. More information at tiny.cc/emform.

So here are the links:
I'll try to keep the "current" links up to date so you don't have to chase around to find the current version; on the other hand, if you don't like the changes you can stick with the original.  Each intermediate version should have a blog entry so that it can be found as well.

The licensing information:

Creative Commons License

2013 CPT Codes for Psychiatry by Nat Kuhn, MD is licensed under a Creative Commons Attribution 3.0 Unported License.

Thursday, August 2, 2012

Affect Defenses and Relationship Defenses: a Unifying Approach to ISTDP

I just got home from the UK where I attended the three-day IEDTA meeting and a three-day ISTDP immersion course taught by Jon Frederickson and Rob Neborsky.  Both were excellent.

Over the past several years, I have been watching a spectrum of ISTDP practice and trying to understand their common elements and differences are.  Other than at conferences, most of the work I've been exposed to so far has been from Allan Abbass and Jon Frederickson.  The immersion was the first chance I had to see Rob Neborsky's work in the style that he and Josette ten Have-de Labije have developed.

Trying to fit their work together with what I already understood led me to a new way of thinking about it, which I found helpful, and which I'll describe here.  There are no new concepts here, but I think it's simple, direct terminology that can help us understand what people are doing from a unified standpoint.

Executive summary:
(1) There are two kinds of defenses: affect defenses and relationship defenses.  Affect defenses are used to avoid particular feelings.  Relationship defenses are used to avoid or sabotage an open, caring, constructive relationship either by avoiding relationship altogether or by promoting a dysfunctional relationship.
(2) There are relationship defenses toward others and relationship defenses toward the self.
At more length:

(1) I'm sorry to say that I haven't yet absorbed Rob and Josette's book so I can't comment in detail about the relationship between what I'm saying and their work, but the distinction between affect defenses and relationship defenses is similar if not identical to what they call "cellar-door" defenses and "front-door" defenses.  (They also use the more formal terms "defense at the level of stimulus" and "defense at the level of response," which I must admit I find both very unclear and very cumbersome).

Most of the emphasis in psychodynamic theory has been on affect defenses, but relationship defenses are extremely important and have been comparatively neglected.  When Davanloo divides defenses into "major defenses" and "tactical defenses," he is, roughly speaking, talking about a division between affect defenses and relationship defenses (with the therapist, in the case of tactical defenses).  He is very explicit that it is hard to draw a bright line between them, that tactical defenses often occur in the service of a major defense, and that it is often unclear at the beginning to what extent something is a relationship vs affect defense (e.g. when a patient says that they can't remember something this could be lying [relationship defense] or repressing [affect defense]—and a whole continuum in between).  In ISTDP theory, "resistance against experiencing feeling," refers to affect defenses; "resistance against emotional closeness" and transference resistance refer to relationship defenses.

(2) ISTDP has been explicit in addressing relationship defenses with others (particularly the therapist), but relationship defenses with the self have been addressed more implicitly.  Of course, when Davanloo says "I have to ask myself, 'Why would a person do that to themselves,'" he is addressing a certain sort of relationship that the patient has established with him/herself.  Self-criticism, self-neglect, self-sabotage, indifference to the self etc. can all be seen as enacting a certain relationship with the self.  I have heard Jon talking about how patients avoid intimacy with themselves.

What Josette has shown us is that these relationship defenses with the self can be addressed first, for example by pointing out the patient's self-neglect in terms of awareness of anxiety.  The point behind this particular language is that wherever you start: pressure to feeling, observing anxiety, etc. you are doing the same thing: immediately addressing the destructive defenses that come up, which leads to a rise in complex transference feelings, etc.  Of course that's not say that all approaches are equally good in all situations, just that we can understand all the different options under the ISTDP umbrella.