Specificity of technical interventions in Davanloo's intensive short-term dynamic psychotherapy: part I

CCC 1096±7028/98/040231±21$17.50# 1998 John Wiley & Sons, Ltd.

International Journal of Intensive Short-Term Dynamic PsychotherapyInt. J. Intens. Short-Term Dynam. Psychother. 12, 231±251 (1998)

Specificity of TechnicalInterventions in Davanloo'sIntensive Short-TermDynamic Psychotherapy:Part I

THERESE AUGSBURGER*Stadelhoferstr. 28, CH-8001 Zurich, Switzerland

This is the first of a three-part article focusing on the specificity of technical inter-ventions in Davanloo's IS-TDP. Here the author will briefly summarize some of theimportant aspects of Davanloo's technique and his scientific method of the exploration ofthe unconscious. The first thirty minutes of a trial therapy interview conducted in a live,closed-circuit supervisory program will be analysed in depth to highlight the importanttechnical and metapsychological issues necessary for properly conducting the first part ofthe trial therapy. # 1998 John Wiley & Sons, Ltd.

Introduction

As a result of over thirty years of systematic research, Davanloo has made anumber of scientific discoveries which have led to the development of a specificand highly powerful technique of Intensive Short-Term Dynamic Psychotherapy,as well as a Short-Term Psychoanalytic system. (Davanloo, 1991, 1992a,b, 1994a±c). He has clearly shown his metapsychology of the unconscious and has clearlydemonstrated the structure and function of the unconscious. His work has beenpresented in a large number of national and international audiovisual symposiaand courses and has been partly published (Davanloo, 1975, 1976a,b, 1977, 1978,1980, 1984, 1990a). For years he has been presenting in depth audiovisualexploration of the unconscious (Davanloo, 1977, 1990b, 1991, 1993a, 1995a,e,1997). The technique demonstrates how rapidly a therapist could make access tothe pathogenic zone of the unconscious in patients who are highly resistant withmost complex psychopathology. Nevertheless, criticism has been expressed thatthe impressive results seen in long-term follow-up of patients are due to anextraordinary personal gift, the charisma of his character rather than to thesystematic application of a therapeutic technique. Linked with this criticism is the

*Correspondence to: Dr. med. Therese Augsburger, Stadelhoferstrasse 28, CH-8001 Zurich,Switzerland.

statement that Davanloo's Intensive Short-Term Dynamic Psychotherapy and hispsychoanalytic technique cannot be learned and therefore their therapeuticeffectiveness cannot be reproduced.

Fortunately a large body of evidence falsifies the claim that his techniquecannot be reproduced. There are many therapists, trained by Davanloo, who havepublished their own cases and they are successfully applying Davanloo'stechnique in their practice as well as teaching his technique in various institutesand teaching medical centres, both in North America as well as in Europe.

This article, the first in a series focusing on the scientific validity ofDavanloo's technique and his metapsychology of the unconscious, highlights thehigh specificity of the therapeutic interventions in the exploration of themetapsychology of the unconscious, as outlined by him. Videotechnology hasalways played a key role in the systematic research and training of this technique.A comprehensive training program briefly consists of in-depth audiovisualexploration into the unconscious as well as in-depth analysis of technical andmetapsychological roots of the technique. Closed-circuit live supervisory settingplays an important, key position in a training program (Davanloo, 1996±1997). Itprovides on-going identification of technical and metapsychological problemsof the trainee. The closed-circuit supervisory process closely monitors theunconscious of the patient in the process, as well as the unconscious ofthe therapist. Obviously, there is a third unconscious: namely the unconscious ofthe supervisor. If the process is facing a technical difficulty, during the break thiscan be easily identified and corrected. The therapist stops the interview eitherafter a given time period or whenever the need for reevaluation arises. Thisprovides a unique opportunity in a supervisory training program to discuss in-depth metapsychological or technical problems of the therapist. Briefly,videotechnology, which Davanloo introduced in the early 1960s, is consideredthe most powerful tool for training, teaching and ongoing systematic research(Davanloo, 1975, 1976a, 1977).

In this three-part article, the author primarily focuses on the specificity of thetechnical interventions in Davanloo's technique. First, I will briefly summarizeimportant aspects of his technique.

Overview

Rapid Direct Access to the Unconscious;Unlocking of the Unconscious

`Direct access to the unconscious' (Davanloo, 1990b, 1992b, 1995c) can takeone of the following forms:

(a) First breakthrough into the unconscious(b) Partial breakthrough(c) Major unlocking of the unconscious(d) Extensive and extended mobilization and exploration of the unconscious.

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# 1998 John Wiley & Sons, Ltd. Int. J. Intens. Short-Term Dynam. Psychother. 12, 231±251 (1998)

`Central Dynamic Sequence and the Process of Unlocking of theUnconscious' (Davanloo, 1988b±e, 1995c)

Briefly this consists of a number of phases:

(a) Phase of Inquiry; exploration into the patient's difficulties, which rapidlymoves to the phase of dynamic inquiry

(b) `Phase of Pressure' (Davanloo, 1986a,b, 1988d, 1995c); which is considered animportant phase, both in the trial therapy as well as throughout the processof treatment. The task of the therapist is very specific. He must rapidlyidentify the patient's character defenses; the `major resistance and its tacticalorganization' (Davanloo, 1996a,b). Some of the specific functions of the phaseof pressure can be summarized as follows:. Mobilization of the transference feelings. Mobilization of unconscious anxiety. `Tilting' of the patient's character defenses in the direction of the trans-

ference (Davanloo, 1986a, 1992a,b). Crystallization and intensification of the resistance. Psychodiagnostic function.

(c) `Phase of Challenge' (Davanloo, 1986a,b, 1988d, 1995c); challenge andpressure, and their proper application, are highly specific to Davanloo'stechnique;. The transition from the phase of pressure to challenge might have

passing moments of challenge, but systematic challenge should only startwhen the patient's character defenses are well tilted in the direction of thetransference (Davanloo, 1995c)

. Further mobilization of the transference feelings

. Further rise in unconscious anxiety

. Crystallization of the patient's character resistance in the transference

. Mobilization of the ùnconscious therapeutic alliance' (Davanloo, 1997,1987a).

. The therapist systematically conveys a lack of respect for the patient'sresistance, which has paralysed his function; and turning the patient againstthe forces of the resistance.

(d) Phase of Transference Resistance; the specificity of the intervention might bebriefly summarized as follows:. Challenge to the transference resistance. High mobilization of the transference feelings, intensification of the

patient's resistance in the transference. Application of a specific form of head-on collision with the transference

resistance, bringing the patient face to face with the destructive organiz-ation of his resistance

. The above specific intervention aims at a mobilization and a `loosening' ofthe patient's psychic system which aims at the direct access to theunconscious (Davanloo, 1994a±c).

(e) Phase of Intrapsychic Crisis and the direct access to the unconscious; Davanloohas clearly outlined that before the final access to the pathogenic zone of theunconscious there is a state of high tension between the forces of the resistanceand the dynamic force of the unconscious therapeutic alliance. This tensionbetween the two forces, he refers to as ìntrapsychic crisis' (Davanloo, 1986a,1988d, 1995c). The therapist's specific interventions consist of:. To intensify the inner tension between the resistance and the unconscious

therapeutic alliance. Further mobilization of the unconscious therapeutic alliance against the

forces of the resistance. Direct experience of the transference feelings and the direct access to the

unconscious, which can be partial or major.

Specificity of Technical Interventions I 233


As this paper focuses on the specificity of the interventions, all the elementsof the central dynamic sequence are obviously important for the direct and rapidaccess to the unconscious. But most important is the transference, which isconsidered Davanloo's first discovery and which subsequently led to otherdiscoveries and development of a comprehensive new metapsychology of theunconscious, the technique of Intensive Short-Term Dynamic Psychotherapy aswell as his psychoanalytic technique (Davanloo, 1995c, 1996c). here I will quoteone of his earliest slides: `the degree of unlocking of the unconscious is exactly inproportion to the degree that the patient has experienced the complex transferencefeeling' (Davanloo, 1988d, page 4).

For the brevity of this presentation, I will focus on the specificity of theintervention of the format of direct and major access to the unconscious. Thehighlights of the interventions are as follows:

. To mount a direct and systematic pressure and challenge to all the forcesmaintaining the resistance

. Intensification of the transference feelings

. Application of ìnterlocking chain of head-on collision' (Davanloo, 1986a,1995c)

. Extensive mobilization of unconscious therapeutic alliance

. Direct experience of the transference feelings, passage of the murderousrage in the transference

. The murdered body of the therapist is transferred to a figure or figures ofthe past, which is the function of the unconscious therapeutic alliance

. Passage of intense guilt-laden unconscious feeling which then follows bythe passage of grief-laden unconscious feeling

( f) Phase of Consolidation and Analysis of the Transference.

Unconscious Therapeutic Alliance (Davanloo, 1987a)

Courses on Ìn-depth audiovisual exploration of the unconscious', which havebeen presented by Davanloo, clearly show the operation of the unconscioustherapeutic alliance both in trial therapy as well as in treatment (Davanloo, 1992a,1993b, 1997).

This can be summarized as follows:

(a) `First breakthrough', the first dominance of the resistance by the unconscioustherapeutic alliance (Davanloo, 1992a,b)

(b) Partial mobilization of the unconscious therapeutic alliance against the forcesof the resistance; this speeds up the therapeutic process; Davanloo's researchclearly demonstrates in major mobilization of unconscious therapeuticalliance there is no latent content of the dream (Davanloo, 1992a,b)

(c) Optimum mobilization of the unconscious therapeutic alliance, which is acharacteristic of his psychoanalytic technique, there is no latent or manifestcontent. The unconscious position is such that Davanloo calls it `Dreamingwhile awake' (Davanloo, 1992a,b, 1995e, 1996c).

The Guidelines to the Unconscious

As long as no direct access to the dynamic unconscious of a patient has beenestablished, the therapist relies on a number of parameters that serve as indicatorsfor the position of the unconscious and guide the specific therapeutic intervention.

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One of these indicators, a signalling system, is unconscious anxiety. Especiallyduring the first part of the initial contact, when the therapist makes hispsychodiagnostic evaluation, the observation of unconscious anxiety, its pathwayand its dynamic reaction to interventions are a crucial source of information. Asthe central dynamic sequence progresses towards unlocking of the unconscious,the mobilization of the tactical defenses, the mobilization of the major resistance,eventually the mobilization of complex transference feeling and the directexperience of these transference feelings provide further indicators of thegradually changing position of the unconscious (Davanloo, 1986a,b, 1995b±e,1996a±c).

`The Somatic Pathway of the Primitive Murderous Rage'(Davanloo, 1990b, 1992b, 1995d,e)

Davanloo's systematic research shows that the unconscious of all resistantpatients, suffering from character neurosis, contains murderous or primitivemurderous rage and intense guilt as a result of overt or covert traumatic lifeexperiences (Davanloo 1995b). Most traumatic to child development are all sortsof impairments and ruptures within the human attachments, usually within therelationships to the nuclear family. The intensity and the extent of the murderousrage within the unconscious corresponds with a number of factors. Among themare, on the one hand, the onset of the trauma, the pain of the trauma and, on theother, the chronicity and how overt or covert the traumatic experiences are. As themurderous rage is directed towards the significant figures of the early lifeconfiguration to whom a bond exists, intense guilt-laden unconscious feelings arealways present (Davanloo, 1990b, 1994a±c, 1995d,e).

Davanloo's research, based on a large series of patients, shows that thepassage of the unconscious murderous rage follows a somatic pathway corres-ponding with structures of the nervous system, starting from the solar plexusmoving upwards to the thorax and heavy branches of the nerves that are at theshoulders moving towards the arms, forearms and the hands. Patients describe asensation in their lower abdomen often like heat or a balloon, or a feeling ofvolcano or fireball, that gradually intensifies and rises upwards towards the chestand finally culminates in a sensation `like exploding into the head', but then flowsin the form of strength into the arms and the phenomena of grabbing with thehands (Davanloo, 1990b, 1995d). For the therapist, this system is the most reliableguideline regarding the activation, the mobilization and the passage of theunconscious murderous rage (Davanloo, 1992b, 1996c, 1996±1997). Also it isimportant to note that with the passage of the primitive murderous rage we see aninstant total drop in unconscious anxiety.

`Psychic Integration'

In Davanloo's system of IS-TDP `psychic integration' plays a central role.(Davanloo, 1993b, 1996c). One aspect of this multidimensional system is to makethe patient familiar, during the trial therapy, with the somatic pathway of themurderous rage buried in his unconscious. Thereafter, any confusion between



defensively acting out; explosive discharge of affect, and the inner experience ofunconscious murderous feelings can be easily clarified and prevented.

Another task of psychic integration is to increase the patient's capacity toexperience and tolerate anxiety, to be fully in touch with the experience of theunconscious murderous rage and guilt. This anxiety has numerous sources,among them the unconscious perception of the patient that feeling that murderousimpulse leads to actually doing it. Another source of anxiety is the patient'sperception that, under the projective mechanism, the therapist will retaliate andmurder the patient (Davanloo 1992a,b).

The patient's first experience of the somatic pathway of unconsciousmurderous rage and clearly being able to distinguish this experience fromthe familiar experience of anxiety is one of many milestones of psychic integra-tion. Another is the ability to overcome anxiety and to be together with thetherapist in touch with powerful feelings and memories from the past. Repeatedanalysis of the patient's experiences on structural terms provides the patient fromthe very first session with a deepening knowledge about his own psychicfunctions and prepares for further working through in the therapeutic processahead.

This is the first part of a three-part article illustrating the specificity oftherapeutic interventions with Davanloo's system of IS-TDP. The first vignette,which comes from a live interview in a closed-circuit supervisory setting, demon-strates the first thirty minutes of a trial therapy with a patient. The transcripts areprinted in their original version. This will be followed by the supervisor'sconceptualization of this first part of the trial therapy, which will be discussed indetail, as well as the conclusions drawn and the corrections suggested by thesupervisor.

In the second article, there will be presentation of further clinical material todiscuss to what extent the therapist manages to build the technical steps discussedinto the further process and with what result. In part three, another segment of theinterview will be presented, which was conducted after supervision, to discuss theimpact of adding further, previously missed interventions on the therapeuticprocess.

The Case of the Grabbing and Ripping Woman

At the time of the initial interview the patient was in her mid-thirties, marriedwith no children and working full-time as an administrator in a company. Shesuffered from diffuse symptom and character disturbances as well as fromobsessive±compulsive symptomatology, episodes of depression and major prob-lems in interpersonal relationships. Her character disturbances included the needto maintain a facade, to keep people emotionally at a distance, conflict overintimacy and closeness, a need to cover up her insecurity with an air of intellectualsuperiority, difficulties to assert herself with either complying or withdrawing,and an inability to live up to her potential with a self-defeating and self-sabotaging pattern. She had previously undergone psychoanalytic treatment for180 hours without significant changes.

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Initial Contact

The patient is visibly anxious and the therapist opens the interview byfocusing on her anxiety and then rapidly shifts to the phase of pressure to herunderlying feelings in the transference.

Anxiety in the Transference

TH: How do you feel right now?PT: Anxious bu ah only a little bit, not the same as last time.TH: Hm hmm so you're anxious, right now.PT: And ah.TH: Since when are you anxious?PT: It began in the train.TH: So anxiety started on your way here.PT: Yeah.TH: What do you account for being anxious right now in seeing me?PT: Ah to come here. To to see you and and to work.TH: So you're anxious in seeing me and to work here with me.PT: Yeah.

Phase of Pressure toward the Transference Feelings

TH: So can we look? You must have certain feelings about working and seeingme.

PT: Hm Hmm, there was another feeling I have, it's not uhmm, was not uhmhappy to come here, I was not content.

TH: You were not happy to come here.PT: Hm hmm.

Further Pressure

TH: Now that's a sentence and can we see how you feel about it. You sayyou're not happy, and how do you feel about seeing me?

PT: I didn't like to expose myself to . . .TH: Hm Hmm but my question is how do you feel about not liking to expose

yourself here with me?PT: Anxious and I'm confused.TH: Now you move to confused. That does not tell usÐand we know you're

anxiousÐthat does not tell us how how you feel about exposing yourselfhere to me. Besides anxiety.(Pause)

The patient had been briefly seen for a preliminary intake evaluation and hadentered that first interview highly anxious. Anxiety then had started a week priorwith nausea, diarrhea and weakness in her legs. In this session, anxiety clearlyshows itself in the form of tension in the striated muscle system, indicating thatthe striated discharge pattern of the anxiety is heavily in operation. Thereforeother psychological and somatic concomitants are not further explored. The



therapist establishes that the patient's anxiety is linked with the present interviewand therefore contains transference implications. The process rapidly enters to thephase of pressure, which here is pressure to her feelings in the transference.

Some explanation here is necessary: anxiety in such an initial contact can havea variety of sources. Pictured on a continuum, on the one side lies the anxiety of apatient who is generally an anxious person on the other end lies the anxiety of thepatient who has `ready made transference feelings' and whose anxiety therefore istriggered directly by feelings for the therapist (Davanloo, 1988b,c; Bleuler, 1996;Gaillard, 1989; Worchel, 1986). In most patients, initial anxiety stems from amixture of sources. Putting pressure to the feelings underlying anxiety focusesexclusively to that segment of anxiety originating from the unconscious andlinked to the feelings buried deeply within the neurotic core (Davanloo, 1992a,b,1996±1997).

The aim of the application of the phase of pressure at this early phase consistsof: rapid further mobilization of the patient's transference feelings, signalled bythe increase in the level of anxiety; crystallization and mobilization of the tacticalorganization of the major resistance. A few tactical defenses so far mobilized, suchas Ì was not happy' or Ì am confused' all avoid the patient's feelings and thetherapist simply exerted pressure by pointing out that it is a sentence (Davanloo,1996a,b). Now we return to the interview.

Anger in the Transference

PT: I felt angry about ah exposing me to you and then to so many other people.I ask myself why I . . .

TH: So you felt angry . . .PT: Yeah.TH: . . . about exposing yourself. Do you say anger has been and has gone or

has been and is it still?PT: It's still . . . it's still here.TH: So you still are angry.PT: I still uh, I still am asking myself why, why I should expose myself the way

you like me to.TH: But that's . . . now what do you account . . . that's why you're angry but

can we focus a moment on your anger, that you have anger, that you feelangry.

PT: It's a thought, it's not . . . I can't feel it.TH: You tell me that's a thought, But can we look, you must have a feeling that

you call anger. Can we look how you experience your anger.(Long pause)

Under the continuing pressure to her underlying feelings, the patient furtherintroduces a set of tactical defenses, an important one being the statement ofanger. In fact she very nicely declares herself that anger is only a thought, andused as a defense against the actual experience of inner feelings like rage ormurderous rage. Nevertheless the therapist shifts her pressure towards how thepatient actually, physically experiences this anger. This is technically not the

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optimal decision to take. As pressure in this early phase is aimed at mobilizing theunconscious and simultaneously at mobilizing the defense in the transferencesituation in a systematic way, using the most effective system of pressure results inthe most productive process. Pressure to the underlying feelings is far morepowerful in mobilizing the unconscious than pressure to experience anger. Thisholds true up to the point in the interview when the first signs of a reactivation ofthe somatic pathway of unconscious rage or murderous rage are visible, forinstance when the patient becomes heated or starts to bounce back in the trans-ference with emotional concomitant. Then the shift to pressure towards the actualexperience of rage is indicated.

The course of the interview clearly demonstrates what happens: The processbecomes somewhat protracted and circulatory. The patient again and again statesthat she is not in touch with her anger. The therapist starts to add pressure to thewill of the patient to do something for herself, and makes a short head-on collisiondirected at mobilizing the patient's will. In highly complex and highly resistantpatients, who belong to the extreme right of Davanloo's spectrum of psycho-neurotic disturbances (Davanloo, 1995b), this technical error in the application ofthe phase of pressure would lead the interview into difficulties and protraction.Whereas with this patient, that diagnostically belongs to the group of high but nothighest resistant patients, the applied non-optimal pressure still arrives atproducing a further mobilization of the patient's unconscious feelings and furthercrystallization of her character defenses. Now we return to the interview.

TH: You become silent.PT: I feel, I feel my body much more than in other situations. I feel my

stomach.TH: What does that tell us how you experience your anger that you feel your

stomach? That is your anxiety.PT: It's what I can say, I feel much more of my uhmm body, I feel . . .

Further Pressure for the Actual Experience of Anger in theTransference

TH: But my question is how do you feel of your anger right now here with me?There must be something that you give the name I feel angry.

PT: I don't know, was the thought.TH: Now you move to Ì don't know' but that does not answer my question

how do you experience the anger you feel right now? . . . And right nowyou're hands are like this and your legs are like that.

PT: I don't know what to say.TH: But do you want to look at these feelings here with me?PT: Yes I came to do.TH: So moving to Ì do not know' does not help us. Still we don't know how

you experience that you call anger here with me.(Pause)

The therapist continues exerting pressure toward the avoided feelings; as theprocess is in the transference, there are passing moments of challenge and bringsinto the focus the patient's tactical defense of becoming silent. At the same time



we see `deactivation of the transference' (Davanloo, 1992a,b, 1995c), addressingthe patient's will, asking the patient if she wants to examine, focusing on thedefense of avoidance and then making reference to the `resistance against theemotional closeness in the transference' (Davanloo, 1988d, 1992a,b, 1996±1997).

TH: And again you become silent now.(Another pause)

PT: (Clears throat) (Pause)I realize I'm trying to avoid but I don't know.

TH: So now you're avoiding.PT: Yes.TH: And do you want to do something about that here with me? And now you

avoid and you're avoiding your own feelings. And do you want to dosomething about that? That you avoid and in a certain sense that you putup a wall like that between you and me. (Pause) Because as long as youavoid, as long as I ask how you feel and as long as you avoid then we havea wall between you and me. And the end of this session this morning willbe useless to you and do you want that?

PT: No I, I don't want to have that at the end.

The therapist gently addresses the will and barrier in the transference,emphasizes the destructive aspect of this resistance, points out the consequenceswhich is the failure, again puts the will into the hands of the patient, deactivatesthe transference and the patient responds that she does not want to opt for failure(Davanloo, 1987b, 1988a). The therapist returns to the phase of pressure. Now wereturn to the interview.

Pressure and Some Degree of Challenge

TH: So still . . . So we can see how you feel your anger if you do not wantto avoid.(Pause)

PT: It's like I don't trust the whole thing.TH Now you move you do not trust . . . Which still does not tell us how you

feel this anger that you have here with me.PT: I don't feel anger except in uhmm tension, a feeling in my stomach, a a

tension.TH: Now you move to you don't feel anger but then why . . . some minutes ago

you said Ì feel angry, I felt and I still feel anger.' (Pause)TH: So moving to Ì don't' still does not tell us how you feel this anger here

with me.PT: I feel a, a tension. A tension in in my arms and I feel my stomach.TH: Hm hmm but still this is tension, which is a form of anxiety, does not tell

us how you feel your anger here with me.PT: Then I don't feel anger.

In the above passage, the patient uses the tactical defense Ì don't trust'. This isa common tactical defense against emotional closeness (Davanloo, 1996b) and thetherapist challenges this defense and continues exerting pressure toward the

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actual experience of anger in the transference. It is important to note that thetherapist avoids getting entangled with the resistance against emotional closeness,which at this point of the process would be considered as diversification. What thepatient is actually experiencing is anxiety and she finally moves to the positionwhere she does not feel angry (Davanloo, 1988d, 1992a,b).

From a technical point of view, the pressure applied so far has crystallized thepatient's defenses in the transference situation. It is important to see the specificityof the unconscious reaction of the patient according to the interventions of thetherapist: after putting pressure on the will of the patient to do something abouther problems, which at the same time contains deactivation of the transference,the therapist introduces one round of pressure on other feelings she has besidesanxiety. Immediately, the patient's unconscious anxiety is further mobilized andshe gives a sigh.

It is important to note that all patients suffering from character neurosis areunable to differentiate between anxiety and anger. This inability to differentiate isin the service of the resistance, which brings up another aspect of the specificity:when the pathogenic organization of the unconscious contains murderous orprimitive murderous rage then the anger is a tactical defense against the rage,violent rage, and the rage by itself is a tactical defense against murderous orprimitive murderous rage. It is on that basis that when the therapist exertspressure toward the feelings, or pressure for the actual experience of anger,unconscious response is mobilization of anxiety and mobilization of the tacticalorganization of the major resistance against the primitive murderous rage andintense guilt (Davanloo, 1990b; Bleuler, 1996; Lachenmeier, 1993; Schubmehl,1996).

Another important dimension of Davanloo's technique needs to be con-sidered: putting pressure on the patient to experience her feelings in the transfer-ence is never separated from working on the resistance in the transference. Thetherapist should make this as explicit as possible in her communications to thepatient: `What you describe is anxiety, anxiety is a way you deal with anger, but isimportant to see how you internally, physically experience this anger towardsme.' `You give a deep sigh, this is a way you deal with anger, but still you areterrified to experience this anger towards me. So let's see how you physically,internally experience this anger or rage towards me!' Not optimally working onboth stations together further contributes to a protraction of the rise intransference feelings.

Now we return to the interview.

Phase of Pressure and Challenge

TH: But there is something that you called it that makes you say you're angryand you tell me you're not in touch and my question is do we want to dosomething against it? There you are in a certain way crippled, but youhave to decide that, to be in touch with your own feeling.

PT: Yes, yes, I want to do something against it.TH: So then let's see what you feel besides the anxiety. So far what you describe

is anxiety which still does not tell us how you feel your anger, here to me.And now your hands . . . Are here.



PT: (Sighs)TH: And you give another sigh.

From here on, the therapist keeps putting pressure on the experience of angerin the transference and concomitantly challenges the defenses of the patient asthey arise, one after the other. This constant work, even though not optimallytargeted, finally starts to show results: the patient makes a first communicationindicating that she is beginning to experience a sensation in her abdomen relatedto the activation of the somatic pathway of the murderous rage from the uncon-scious. Unconscious anxiety is higher now and manifests itself in repeated sighingrespiration, build-up of tension in the intercostal and subdiaphragmatic muscles.Now we return to the interview.

Further Pressure and Challenge

(Pause) (Patient sighs)TH: And still we don't know how you experience your inner anger here with

me.(Pause)

PT: It's like to have more energy inside of me.TH: But that's a sentence to have more energy. Does not tell us how you

experience your anger. (Pause)TH: Now you're nearly bent. Do you notice that?PT: Yes, I realize.TH: Which is another crippled position but that's on you to decide, that you go

bent with your inner feelings. And now your eyes move to the floor.(Pause)

PT: (Sighs)TH: And you give another sigh. (Pause)PT: (Sighs) It's not, it's nearly not possible.TH: Still you are paralyzed.PT: (Sighing)

The degree of mobilization of the `visceral pathway of murderous rage' is themost reliable criterion regarding the position of the unconscious (Davanloo,1992a,b, 1994a,b, 1996±1997), namely to what extent the patient experiences at thismoment the transference feelings that are related to feelings previously lockedwithin the unconscious. In the above vignette, the patient declares a sensation ofmore energy inside her that clearly contrasts with her previous statements ofhaving thoughts about anger but feeling only anxiety. The therapist brushes thisaside as the nonverbal defenses of the patient are strongly in operation: she issitting in an immobile and bent position. Unconscious anxiety is high, expressingitself in repetitive sighing respiration.

At this point, the therapist should have clarified the task for the patientthrough a brief exploration of how she physically experiences this ènergy'. Mostlikely the patient would have localized the sensation in her lower abdomen.Establishing this serves like a point of reference: `First you felt only anxiety in theform of weakness in your abdomen and anxiety is a way how you deal withanger. Now you feel energy in your lower abdomen, that you connect with anger

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or rage, and in your chest is still a sense of emptiness. So you are partly in touchwith your inner feeling of rage, that starts in the abdomen, but in your chest is stillanxiety as a way of defending against the full experience of inner anger or ragedirected at me. But it is important to see how you experience the full inner force ofthis rage towards me!' In this way it is clear to the patient what the therapist islooking for, and she can immediately apply pressure for further increasedexperience of the somatic pathway of the murderous rage.

The great importance of mobilizing the somatic pathway to a high degree,that will eventually lead to the direct experience of transference feelings, lies in thedynamic shift of intrapsychic forces that underlie the experience of transferencefeelings and enable access to the unconscious: namely for a first time unconscioustherapeutic alliance has been mobilized to the point of domination over the forcesof resistance (Davanloo, 1987a, 1992a,b, 1994a±c, 1996±1997).

The therapist misses the opportunity to clarify the task and instead keepschallenging the patient's defenses and putting pressure to experience her innerrage. The interview is taken up where it was left.

Resistance Against Emotional Closeness; Head-on Collision

The patient, again, uses the tactical defense `trust'. So far, our indicator fromthe unconscious clearly demonstrates that there is mobilization of the unconsciousanxiety, which is exclusively in the form of tension in the striated muscles, such asfrequent sighs and becoming immobile; there has been mobilization of thetransference feelings as well as mobilization of the unconscious. Now the therapistmoves to head-on collision with the resistance against emotional closeness withthe aim of: further mobilization of the transference feelings; deactivation of thetransference; once more bringing into focus the destructive component of theresistance; undoing the omnipotence; and pressure on the unconscious therapeuticalliance (Davanloo, 1990b, 1992a,b, 1995c,d; Gaillard, 1989; Said, 1996).

PT: I realize what I'm doing but I don't trust.TH: And now you move you do not trust. (Pause)

Which immediately shows us something else. That as long as I want toshare your feelings and understand you and your inner thoughts, yourinner feelings, your inner self, then you move to this wall, that you call Ìdo not trust.' Look at it, examine it. Something in you does not want me toget close to you, does not want me to understand what your inner feelings,your inner thoughts your intimate life. And as long as I want to under-stand you move to Ì do not trust' and that's the maximum wall here.(Pause) Now if you want to solve the problems you have then this wall thatyou build between you and me is an obstacle. And it makes me useless toyou. And the result will be that you carry your problems unresolved to theend of your life. And why should you do that? (Pause)But if you want to do that and if you want to keep the wall, and if youdon't want me to understand your inner feelings there's nothing anybodycan do about it.But do you want to do something about this wall? Which is another wayof keeping a cut-off life. Do you want to do something about it?



(Pause)Because as long as it is here with me, you and me, we will fail and you willkeep the problems you have and your cut-off way of living.(Pause)

PT: I'm afraid.TH: That is another part of the obstacle, that you are afraid. You are terrified to

let me into your inner feelings isn't it. You're terrified to let me into yourinner life and what are we going to do about that? That you're terrifiedand still the point is to share your anger with me. (Pause) And what arewe going to do about that?

PT: (Signs)(Pause)I have to put away this wall.

TH: Is that what you want?PT: (Sighing)

Return to Pressure and Challenge for the Actual Experience ofAnger in the Transference

TH: So let's see how you feel this inner anger to me. And still you have a sigh.PT: I have a picture to make a fist and to slap.TH: But that's a picture. How do you feel . . .PT: (Deep sighing)TH: That's a picture of how you put it out hmm?PT: Hm Hmm.TH: That still does not tell us how you feel the inner rage towards me in terms

of inner feelings. To punch and to slap you need feelings inside.PT: It's an ener . . . And energy that comes up in me.TH: Yeah but energy . . . You're talking about anger and slapping and . . .

That's rage! And my question is what do you experience of this? That'srage is you want to hit and slap and attack. What do you feel of this innerrage? And still you're hands are holding your legsÐyou notice? Andyour face is . . . very tense, you notice that too?

PT: I feel tenseTH: And you're talking about inner rage, about feelings and you are without

. . . You're very tense and without expression which is the anxiety partof it.

To further recapitulate, the therapist is heavily working on the patient'sdefenses and focuses on the resistance against emotional closeness in thetransference. The main emphasis of the interactions lies in challenging theresistances. Pressure is only briefly applied, namely, on the one hand, to give upthe wall and, on the other, to the physical experience of inner rage. The questionarises as to why this heavy activity on the therapist's side is not paralleled with acorresponding increase in the direct experience of transference feelings.

Davanloo repeatedly emphasizes the great importance of the properapplication of the phase of pressure. With this patient, in the initial phase,pressure is mainly directed to the underlying feelings in order to mobilize the

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unconscious, to mobilize the transference feelings and to intensify the resistance.In subsequent phases, challenge and pressure to the defenses are added in anincreasingly powerful manner, but pressure is never given up. In the abovevignette, the patient is struggling with contradictory inner forces: a firstmobilization of the visceral pathway of the murderous rage and some mobil-ization of the unconscious therapeutic alliance, on the one hand, and a highdegree of unconscious anxiety and the unconscious defensive structure activatedin the transference, on the other. The therapist's activities should address alldimensions of the inner forces in operation:

(1) Challenge to the resistance should be systematic. Here the therapistchallenges the tactical organization of the major resistance in a fragmentedway: one after the other. Systematic and persistent challenge and pressureon the whole system of resistance is what the therapist wants to do(Davanloo, 1986a, 1992a,b, 1996±1997)

(2) Pressure should continue at a high level, with the aim to mobilize andexperience the transference feelings at the maximum level and giving up theresistance directed in the transference

(3) Deactivation of the transference: the patient's unconscious perception of thetherapist might easily become coloured by the patient's unconscious feelingstoward the figures in her past, such as father, mother or others, which mightmobilize some malignant character defenses such as stubbornness, defianceor regressive defenses. On that basis, deactivation of the transference is ofcrucial importance in the process: `Your life is yours, misery is yours andhappiness is yours, and you are here on your own will to do somethingabout those forces that have paralyzed your life.' `We are here together toput our joint forces, based on your own will' (Davanloo, 1992a,b, 1995c).Now we return to the interview.

Return to the Phase of Pressure and Challenge

TH: That obviously you still are terrified to feel your inner rage and you getanxious and what we see then is the anxiety here. But what do you feel ofthe inner rage is the question that we have.(Pause)And again you're postponing.(Pause)Now your hand is holding the chair. You still are terrified to meet yourinner rage and do you want to do something against that? And when I sayterrified right away your eyes get wet. You still are terrified to meet yourinner rage that has to do with attacking.(Pause)

PT: It's it's ah feelings I like to, to come out to . . .TH: But that's a sentence and if you want to come out then the problem is that

you still are terrified hmm. And when you say come out you have tears,you have a sigh and you hold your legs. That's the crippling factor, thatyou are terrified to meet your inner feelings and it's rage right now. Andas long as it is, it's a crippling factor and you go crippled to your grave.And you want to do something about this? So let's see what you are goingto do that you still are terrified to meet your inner feelings and terrified toshare them with me. That you are terrified that here is catastrophe if you're



not an anxious crippled woman hmm. And what are we going to do aboutthat?

PT: I'm not, I'm not only crippled. I can feel like it would be, I can feel it tocome out to . . .

TH: But still with tears? That's the crippled way and do you want to come outin a crippled way? Or do you want to meet your inner attack with all yourcourage.

PT: (Sighing) (Pause)

The process now clearly shows evidence of stagnation. The therapist keeps herstrategy of challenging the defenses in a fragmented way and directs her pressuremainly towards the will of the patient to do something for herself. Theseinterventions are not powerful enough to help the patient overcome her high inneranxiety about experiencing her inner murderous rage, that is at present partlymobilized.

As I have already indicated, this interview was conducted in a live, closed-circuit supervisory setting. After this thirty-minute interview, the therapist brieflysums up the process of the interview to the patient and suggests taking a shortbreak.

Assessment of the Process So Far; Actual Position of thePatient's Unconscious

(a) The patient shows clear evidence of a rise in transference feelings, but not toa high degree

(b) High mobilization of the unconscious anxiety, repetitive sighing respiration.(c) Resistance is crystallized in the transference(d) We have evidence that the somatic pathway of the unconscious murderous

rage is mobilized(e) High degree of unconscious anxiety indicates that the somatic pathway of the

passage of the murderous rage is not close to the threshold needed for thepassage.

Main Technical and Metapsychological Problems of the Therapist

(1) The therapist is not using systematically the guidelines for working with theunconscious according to their reliability, based on Davanloo's techniqueand research

(2) Rapid and immediate identification of the patient's character defenses:major resistance and its tactical organization

(3) Maintaining a persistent tuning with the signalling system of theunconscious

(4) As the therapist applies a specific intervention, she must rapidly search forthe corresponding response from the unconscious

(5) Systematic application of the phase of pressure is extremely important forrapid mobilization of the transference feelings. While it is true that the phaseof pressure has passing moments of challenge, the therapist should notintroduce systematic challenge until the patient's character defenses are wellcrystallized in the transference: the process of piecemeal challenge andpiecemeal pressure is not conducive to the systematic and persistentmobilization of the transference feelings and mobilization of the uncon-scious therapeutic alliance

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(6) In the phase of pressure, it is highly advantageous to maintain pressure onthe patient's transference feelings; `You feel anxious about seeing me. Let'sto see how you feel about seeing me?' The focus on the transference feelingswould immediately mobilize anxiety and results in the further mobilizationin the transference feelings and, in turn, there will be intensification of theresistance in the form of a series of new defenses. When the patient declaresanger, as this woman did, the therapist should not have shifted from thepressure toward the transference feelings to pressure for the actualexperience of the anger. The therapist should have maintained the positionof pressure to the transference feelings: Ànger is a word, doesn't sayhow you feel towards me.' Technically, the shift from pressure toward theexperience of the transference feelings to pressure for the actual experienceof the anger should have taken place when the unconscious clearly signalsthat some degree of activation of the somatic pathway of the murderousrage has taken place in the solar plexus

(7) From the early part of the interview, the therapist must vigilantly monitorall the parameters, such as: mobilization of the anxiety; mobilization of thetransference feelings; mobilization of the tactical organization of the majorresistance; and nonverbal defenses, as the therapist starts to exert the phaseof pressure. We have anxiety and the degree of mobilization of unconsciousanxiety and its somatic pathway. Another parameter is the rise in trans-ference feelings and another, which is concomitantly mobilized, is the majorresistance and its tactical organization as well as nonverbal defenses andthen, concomitantly, we have activation of the somatic pathway of themurderous rage. As the process moves forward, we are going to see themobilization of the unconscious therapeutic alliance and the therapist's taskis to apply the technique in an integrated, persistent way

(8) Therefore the most reliable criterion regarding the position of the uncon-scious, the degree of mobilization of the visceral pathway of the murderousrage, has not been ascertained. Instead, the therapist takes anxiety and,respectively, the absence of anxiety as the most reliable criterion. Corres-ponding with this lack of technical clarity, a set of technical problems arises.The therapist does not make it clear to the patient what they are looking fortogether: namely the experience of the somatic pathway of the murderousrage in the transference situation. Also, the transference is not made explicit:`How do you feel this rage internally, physically, that is directed at me?'`You are terrified to unleash it on me.' Such interventions serve to reducethe patient's anxiety, as the clearly spelled out transference provides a senseof security

(9) Another important point has to do with the `multidimensional unconsciousstructural change' which is central to Davanloo's technique in either form:namely Intensive Short-Term Dynamic Psychotherapy or his PsychoanalyticTechnique (Davanloo, 1992a,b, 1993b, 1996±1997). While it is true thatapplication of the technique of intrapsychic integration must be verysystematic and extensive in patients with fragility in their character structure,or those with psychosomatic disorders, the same system, to a greater orlesser extent, applies when working with character neurotic patients, suchas the one being presented. With character neurotic patients, with diffusepsychopathology, the therapist must rely heavily on technical interventionswhich aim at intrapsychic integration as a counterpart to the isolatory effectof the defensive system. Basically, Davanloo's entire dynamic system is anintegratory process in many dimensions with its mobilization of the patient'sunconscious feelings in the transference, with the crystallization of thedefenses in the transference and, finally, with the domination of unconscioustherapeutic alliance over the forces of the resistance and the unlocking of theunconscious as its result. The therapist's interventions obviously need toproceed in a manner tuned to this integratory task. In this first half-hour



interview which was discussed, the therapist misses many chances in thisrespect. The most important ones can be summarized as follows:(a) Interlinking pressure towards the underlying feelings with challenge

and pressure towards the resistance. Working on these two systems inan integrated way in itself gives clarity to the patient what the therapistis aiming at and intensifies the build-up of feelings. Isolated pressureeventually grows repetitive and ineffective as well, and isolatedchallenge will confuse the patient

(b) Linking the tactical organization and the experience of anger for thepatient: `You use avoiding, withdrawing, erecting a wall between youand me as ways to deal with your anger towards me. Still you areterrified to experience your anger here with me!'

(c) Working with the tactical organization in an integrated instead offragmented way. The integratory effect for the patient lies in helping thepatient see the entire dimension of the destructive forces of the resist-ance directed towards the transference and turning the patient againsthis own defenses. In the above vignettes, we see a wide range of thedefenses such as silence, immobility, withdrawal, avoidance, resistanceagainst emotional closeness, etc., which the therapist periodically canrecapitulate on them all together, and on their destructive effect in thetransference. This can be done with a short range format of head-oncollision immediately followed by further pressure on the resistance andon the experience of the patient's transference feelings: `Look, you haveall sorts of difficulties in your life, professionally and personally, butyou are the one to decide on that. You have a higher potential, butsomehow you have a need to sabotage and defeat your goals and whyshould you do that, go crippled to your grave in a defeated way? Nowyou have come here to change the course of your life, to say goodbye toyour crippled life. So we have a task together you and me. Now, if youlook how you relate here with me: you are withdrawn from me, you aresilent with me, you go to a retarded position with me, you even godead with me and in all these ways you erect a barrier between you andme, and as long as we have this wall between you and me, this processis a dead, useless process, defeated to begin with, and why should youdo that? Crippled life outside and crippled process here. So let's seewhat you do against the wall here with me and let's see how youexperience this inner rage here towards me!'

Recommendations and Corrective Steps for the Second Partof the Interview

To help the patient see the therapeutic task clearly and to create the climate ofa joint venture, a short recapitulation is recommended: `We have focused on youranger towards me and we have seen that you have a difficulty to actually andphysically experience this anger. You have problems with other feelings as well,which have paralyzed your life. You have your potentiality as well as thedestructive forces that have affected your life, but that is up to you to decide! Ifyou want to get rid of your paralyzed life, we are here to get to the engine of theseproblems. You have some thoughts, but that is not the issue here. You are anxiousand you had indicated that you have anger towards me. You are intelligent torealize that such a force does not die, so let's see how you actually experience thisanger towards me' (Davanloo, 1996±1997).

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After recapitulation, the therapist should again stay with pressure on theexperience of anger in the transference, working concomitantly on the defenses inthe interrelated way spelled out above. A short-range format of head-on collision,with the aim to apply further pressure and to mobilize transference feelings, atthis point has a specific indication. The major task of the therapist is not theunlocking of the unconscious. Her task is systematic and integrated application ofthe technique, with the many dimensions discussed above. In doing so, it willeventually lead to the unlocking of the unconscious with this patient.

Summary and Conclusions

This is the first part of a three-part article. A patient in her mid-thirties wasinterviewed by the therapist prior to the live closed-circuit supervisory program,and the case was presented to the supervisor, who provides the therapist with in-depth discussion about the technical and metapsychological issues necessary fordirect access to this patient's unconscious. Then the therapist interviews thepatient. The first thirty minutes of the interview in a supervisory setting have beenpresented. The process has been analyzed stepwise in regard to the position of theunconscious of the patient and also in regard to the technical interventions of thetherapist. Technical shortcomings have been identified. A comprehensive evalua-tion of the final position of the patient's unconscious after dynamic interventionshas been presented. The metapsychological implications of technical problemshave been discussed and a set of corrective interventions have been formulated.The second part of this article will present the interview after the break and willanalyze and discuss the impact of altered technical proceedings to what extent thetherapist has been able to apply the new insights and what are the correspondingresults.

Acknowledgements

In this article, the author has used a set of concepts and technical inter-ventions, such as ùnlocking the unconscious', intrapsychic integration', `centraldynamic sequence', `tactical defense center', `visceral pathway of unconsciousmurderous rage', unconscious therapeutic alliance', `resistance against emotionalcloseness', `head-on collision with the resistance', `complex transference feeling'and other technical interventions. All these concepts and interventions come fromDr Davanloo's published or unpublished work. Additionally the author has madereferences to metapsychological conceptualizations of an ongoing therapeuticprocess, that all are gained from Dr Davanloo's teachings.

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Specificity of technical interventions in Davanloo's intensive short-term dynamic psychotherapy: part I