Patricia Coughlin
“Facilitating the Development of the Unconscious Therapeutic Alliance to Overcome Resistance”
The Woman who is heading for a heart attack
I will be presenting the case of a 65 year old woman who has been in therapy nearly all her life, but still suffers from anxiety, depression, a host of physical illnesses (many requiring medication), and a lack of closeness in all relationships, including those with her husband and daughter.
What does ISTDP offer that all the other methods of therapy she has tried did not? Research reveals that only 20% of the patients who consult an outpatient psychotherapist are able to make significant use of interpretation, the primary tool employed by psychodynamic therapists. For the other 80% of patients, a high level of anxiety and heavy reliance on defenses against feelings and close contact with the therapist interfers with accepting help.
Davanloo has developed a systematic series of interventions used in the pre-interpretaitve phase of treatment, in order break down defenses and liberate previously buried feelings and impulses, facilitating the healing process. As he became more and more successful with this group of resistant patients, he discovered a common dynamic operating in nearly every case. He found that these patients were being dominated by guilt and driven by an unconscious need to punish themselves for their rage toward attachment figures who had neglected and mistreated them. If the patient’s need to suffer and be punished is not made conscious, it can overwhelm the therapists efforts and lead to repeated failure.
In this presentation, I will focus on the opening sessions of therapy - illustrating how these powerful techniques for identifying and challenging defense and resistance mobilizes the healthy part of the patient, still hoping against hope for a healing experience. By blocking defense and resistance, we activate complex transference feelings, and facilitate the development of what Davanloo refers to as the Unconscious Therapeutic Alliance.
It is not enough to remove defenses, but to activate and strengthen the patient’s innate desire to attach and to become who they really are. By providing the patient with the opportunity to face complex transference feelings directly, the alliance is strengthened and will become the real engine to healing, operating as a kind of guiding light, leading therapist and patient to the early traumas and core conflicts responsible for the patient’s problems. This is often referred to as the “Breakthrough”, in which patient and therapist discover the unconscious forces responsible for the patient’s suffering. This kind of deep understanding of self is the most lasting result of all effective therapies. However, as Pennebaker has verified in his research, only those who become emotionally involved in the process of therapy achieve this end.
Dr. Patricia Coughlin (Della Selva), Ph.D. is a licensed Clinical Psychologist with over 25 years of clinical experience. In addition to seeing patients in her private practice in Philadelphia, PA, Dr. Coughlin conducts training and supervision groups for mental health professionals around the world. She has held faculty positions at Northwestern University Medical School and Albany Medical College. Currently she is on the faculty at Thomas Jefferson Medical School. Over the past 15 years she has written professionally, given presentations at professional conferences and conducted workshops for mental health professionals around the world. Currently, she is conducting supervision groups and training workshops in California, Washington, DC, Aarhus and Copenhagen, Denmark.
Her first book, Intensive Short Term Dynamic Psychotherapy: Theory and Technique, is considered a classic in the field. Dr. Coughlin’s newest book, Lives Transformed was written in collaboration with Dr. David Malan, and published in 2006 by Karnac Books.