Reaching Through Resistance

1. Unconscious Emotions Drive Our Suffering

A child who shuts down his complex feelings can grow into an adolescent who experiences interpersonal avoidance, self-destructiveness, physical illness, depression, anxiety, or anorexia.

Early trauma's impact. Our deepest psychological struggles often stem from early attachment trauma, such as interrupted parental bonds, abuse, or neglect. When a child cannot process the intense pain, rage, and guilt associated with these experiences with a loved one, these complex emotions are buried in the unconscious. This unresolved emotional baggage becomes a central pathogenic force, manifesting in a wide array of psychological and physical symptoms later in life.

Transference reveals hidden pain. In therapy, the therapist's caring presence can inadvertently reactivate these buried emotions, a process known as transference. The patient's past, unresolved feelings toward attachment figures are projected onto the therapist, bringing the core conflict into the present moment. This activation is crucial because it provides a direct pathway to understanding and addressing the root causes of suffering, rather than merely treating surface-level symptoms.

Therapist's reactions as cues. The therapist's own emotional responses, or countertransference, serve as vital diagnostic tools. These reactions can be objective (universal responses), subjective (empathic attunement to the patient's inner world), or neurotic (based on the therapist's own unresolved issues). Recognizing and managing countertransference is essential for the therapist to remain a compassionate and effective guide, preventing personal biases from hindering the healing process.

2. Resistance is a Signal, Not an Obstacle

That is why we say that unconscious anxiety and defenses are signals of unconscious feelings.

Anxiety's diverse manifestations. When unconscious pain, rage, and guilt are stirred, they trigger unconscious anxiety, which manifests in distinct physiological patterns. These patterns are crucial signals, indicating the patient's underlying emotional state and guiding the therapist's interventions. Recognizing these signals helps differentiate between various forms of anxiety:

• Striated (voluntary) muscle anxiety: Visible tension, clenching, sighing, leading to physical pains like headaches or fibromyalgia. Often linked to "isolation of affect."
• Smooth muscle (involuntary) anxiety: Hidden tension in organs, causing symptoms like IBS, asthma, or migraines. Often linked to "repression."
• Cognitive-perceptual disruption: Mental confusion, visual blurring, dissociation, or even hallucinations. Linked to "projection, splitting."
• Motor conversion: Weakness or paralysis in limbs. Linked to "repression."

Defenses protect from pain. Alongside anxiety, patients employ various defenses to avoid experiencing these overwhelming unconscious feelings. These range from "tactical defenses" (e.g., cover words, rumination, intellectualization) that are loosely held, to "major resistances" (e.g., isolation of affect, repression, projection, splitting, and the punitive superego). Major resistances are deeply ingrained and protect against intense, often murderous, rage and guilt.

Guilt's self-sabotaging power. The "resistance of guilt," or punitive superego, is a formidable force, driving patients to unconsciously sabotage their own healing and success. This internal mechanism punishes the patient for their buried rage toward loved ones, leading to self-defeating behaviors, self-hatred, and a pervasive sense of unworthiness. Understanding these signals and defenses is paramount, as they are not obstacles to be overcome, but rather signposts revealing the hidden emotional landscape that needs to be explored and healed.

3. Patients Exist on a Spectrum of Resistance

The earlier the trauma, the more severe the pain, rage, and guilt will be and, thus, the greater the defenses and self-destructiveness.

Resistance levels define patient types. Patients are categorized along two main spectra based on the nature and intensity of their defenses and anxiety, which directly correlates with the age and severity of their attachment trauma. This diagnostic framework guides the therapist in tailoring the treatment approach.

• Psychoneurotic Disorders:
  • Low Resistance: Trauma after age seven, primarily unresolved grief, minor tactical defenses.
  • Moderately Resistant: Trauma between ages four and seven, unprocessed pain, murderous rage, guilt; striated anxiety, isolation of affect.
  • Highly Resistant: Trauma before age four, intense grief, rage, guilt; punitive superego, syntonic defenses, repression, isolation of affect.

Fragility's primitive defenses. The "Fragile Character Structure" spectrum represents patients with even earlier and more severe trauma, leading to a fragmented sense of self and primitive defenses.

• Mild Fragility: Primitive phenomena at high anxiety levels.
• Moderate Fragility: Primitive phenomena at mid-level anxiety.
• Severe Fragility (Borderline Organization): Primitive defenses (projection, splitting, projective identification) and cognitive-perceptual disruption at very low anxiety levels.

Tailoring treatment to capacity. This diagnostic precision allows the therapist to anticipate how a patient will respond to interventions and adjust the pace and intensity of therapy accordingly. For instance, fragile patients require careful capacity-building before directly confronting deep emotions, while low-resistance patients may achieve rapid resolution. Recognizing these distinctions is crucial for safe and effective treatment, preventing exacerbation of symptoms or misalliance.

4. The Unconscious Therapeutic Alliance is the Healing Force

The degree to which a person can experience love, rage, and guilt combined equals the degree to which the unconscious therapeutic alliance can be activated.

Beyond conscious cooperation. While a conscious therapeutic alliance (rapport, shared goals) is important, it is often insufficient to penetrate deep-seated resistance. Davanloo's major discovery is the "unconscious therapeutic alliance" (UTA) – a powerful, non-volitional force within the patient that actively works to bring unconscious feelings and impulses to consciousness for healing. This alliance is mobilized in direct proportion to the patient's capacity to experience "complex transference feelings."

Ambivalence as a catalyst. Complex transference feelings involve simultaneously experiencing warm feelings, appreciation, irritation, anger, and guilt toward the therapist. This capacity to tolerate ambivalence is the central key to activating the UTA. When the patient can hold these mixed emotions without resorting to defenses, the UTA strengthens, overriding resistance and facilitating deeper emotional processing. The therapist's own ability to tolerate this ambivalence is equally crucial.

UTA's subtle manifestations. The UTA communicates its presence through a spectrum of phenomena, from subtle "whispers" (concise insights into inner obstacles) and Freudian "negations" or "slips of the tongue" (revealing unconscious wishes while denying them), to "linkages" (clear connections between past and present feelings), and ultimately, vivid "visual imagery" or "dreaming while awake" (e.g., seeing a deceased parent's image during emotional breakthrough). Recognizing and following these communications allows the therapist to become a "copilot," guiding the patient through their unconscious landscape.

5. Pressure is the Engine of Change

Pressure is all your efforts to help the patient to be emotionally present, identify processes and emotions, and overcome her defenses.

The core intervention. Pressure is the most vital intervention in ISTDP, serving as a constant declaration of the therapist's deep concern and commitment to helping the patient heal. It is the primary means by which the therapist "reaches through resistance" to connect with the person trapped beneath their defenses. This sustained effort mobilizes complex transference feelings and, consequently, the unconscious therapeutic alliance.

Formats of pressure. Pressure takes many forms, all designed to encourage the patient's active engagement and emotional processing. These include:

• To identify, experience, and express feelings: "How do you feel toward her?" "How do you experience this anger physically?"
• To the task: "Could we take a look at this problem?"
• To be specific: "Can you describe a specific time this anxiety happened?"
• To the person's will: "Is it your wish to work on this problem?"
• To positive self-regard: "Let's see what we can do so you will have a good feeling about yourself."
• To active collaboration: "What do you think we should do next?"
• Against specific character defenses: "Are you sure now is the time to solve this problem?"

Sustained effort is key. Unlike challenge, which aims to stop a behavior, pressure encourages a positive action for the patient's well-being. It must be consistently applied whenever resistance is active, acting as a lifeline to the patient's struggling self. Dropping pressure can lead to increased anxiety and defensiveness, as the patient may perceive the therapist as disengaging. Effective pressure is precisely timed and targeted, avoiding misalliance by focusing on the patient's internal processes rather than external blame.

6. Confronting Resistance Requires Precision

Combined, clarification and challenge muster the conscious and unconscious therapeutic alliance to battle the resistance.

Clarification precedes challenge. Before directly challenging a patient's defenses, the therapist must first clarify their nature, function, and damaging effects. This step helps the patient understand what they are doing, why they are doing it, and how it harms their relationships and therapy. Clarification begins to turn the patient against their own defenses, making them "dystonic" (problematic) rather than "syntonic" (acceptable).

Timing is everything. Clarification is introduced at a "mid rise" in complex transference feelings, when resistances begin to crystallize in the therapeutic relationship. Challenge, which actively discourages self-defeating behaviors, is then delivered at "mid to high rise" in these feelings. Premature challenge, before the unconscious therapeutic alliance is sufficiently mobilized, can be perceived as criticism, leading to misalliance and a drop in emotional engagement.

Head-on collision for high resistance. For highly resistant patients, when defenses are heavily "crystallized" in the transference, a more powerful intervention called "head-on collision" is required. This is a direct, honest confrontation of the resistance, emphasizing its destructive nature, the patient's responsibility for change, the limits of the therapist, and the potential of the alliance. It is a realistic examination of the intrapsychic crisis, designed to create a wedge between the patient and their long-held defenses, ultimately leading to a breakthrough of complex feelings and direct access to the unconscious.

7. The Graded Approach Builds Capacity for the Most Fragile

The paralyzed prisoner needs to be educated, see his dungeon and castle, care for himself, and become energized to revolt and break free of this destructive setting.

Addressing severe repression and fragility. For patients with high resistance and repression (the "paralyzed prisoner") or fragile character structure (the "terror in the dungeon"), a standard, unremitting approach can exacerbate symptoms. These patients often lack the capacity to tolerate intense emotions, repressing them into somatic symptoms, depression, or primitive defenses like projection and splitting. The "graded format" of ISTDP is specifically designed to build these crucial capacities.

Cycles of pressure and recapitulation. The graded format involves carefully titrated cycles of pressure, alternating with extensive recapitulation. When anxiety approaches the patient's "threshold" for repression or cognitive-perceptual disruption, the therapist reduces pressure by reviewing the links between emotions, anxiety, and defenses. This intellectual examination helps the patient develop self-reflective capacity and "isolate affect," gradually shifting anxiety from smooth muscle or cognitive disruption to striated muscle, which is more tolerable.

Building internal strength. This multidimensional structural work aims to:

• Increase anxiety tolerance: Desensitize the patient to complex feelings.
• Enhance self-reflection: Replace repression and primitive defenses with conscious awareness.
• Foster positive self-regard: Counter self-punitive tendencies.
• Integrate fractured self-parts: Address splitting and projection.

By working within the patient's "therapeutic window" – near but not above their anxiety tolerance threshold – the therapist systematically strengthens the patient's internal resources, preparing them for deeper emotional processing and eventual "unlocking" of the unconscious.

8. Unlocking the Unconscious Transforms Lives

This "unlocking" event brings lasting change in psychic function, loosening overinhibited brain operations.

The pivotal therapeutic event. "Unlocking the unconscious" is the central dynamic sequence in ISTDP, where the patient directly experiences their repressed complex feelings (love, pain, rage, guilt) in relation to past attachment trauma. This profound emotional breakthrough is facilitated by the therapist's persistent efforts to mobilize the unconscious therapeutic alliance and overcome resistance. It is a moment of intense emotional discharge that fundamentally alters the patient's psychic landscape.

Degrees of emotional release. Unlocking can occur in varying degrees:

• Partial Unlocking: Primarily grief, with some rage and guilt, often bringing clear linkages to past trauma.
• Major Unlocking: Includes the passage of murderous rage in the transference, with a visual transfer of the image to the past attachment figure, followed by intense guilt.
• Extended Unlocking: Prolonged experience of rage and guilt directly with the past figure, signifying complete dominance of the unconscious therapeutic alliance.

Enduring character change. These unlocking events lead to significant and lasting changes. Symptoms often cease, psychiatric medications may be reduced or stopped, and patients return to work or improve their relationships. The experience of guilt, in particular, is a powerful healing force, reducing the need for self-punishment and allowing for genuine self-forgiveness and forgiveness of others. This process frees the patient from the burden of their past, enabling them to live a more integrated, authentic, and fulfilling life.

9. Somatic Experiences are the Language of the Unconscious

Detailed videotaped case studies reveal direct physiologic concomitants of unconscious impulses and feelings.

Emotions manifest physically. The body provides a direct, observable language for unconscious impulses and feelings. Recognizing these specific somatic pathways is crucial for the therapist to accurately track emotional activation and guide the patient toward deeper experience.

• Positive feelings: Experienced as warmth, upward-moving energy, an urge to reach out, and a sensation of calm.
• Rage: Begins in the lower body (feet/abdomen), moves upward as heat or energy, creating an urge to grab or act violently. Its experience displaces unconscious anxiety.
• Guilt: Manifests as upper chest and neck pain, intense sobbing, and profound remorse, often linked to imagery of rage toward loved ones.
• Grief: Characterized by thoughts of loss and a general sense of sadness, without the severe physical pain of guilt.

From cognitive to affective. ISTDP aims to move patients from a purely cognitive awareness of their emotions to a full, somatic, affective experience. This involves activating limbic structures and memory systems in the brain, overriding defensive regions. When patients can viscerally feel their emotions, it leads not just to symptom reduction but to enduring character change.

Guiding the emotional journey. By closely monitoring these physical cues, the therapist can effectively "brace" the patient, helping them tolerate and integrate intense feelings without resorting to defenses. For instance, when rage is activated, the therapist encourages its full somatic experience, knowing that this will eventually lead to the passage of guilt and the release of underlying love. This deep engagement with the body's emotional language is fundamental to unlocking the unconscious and facilitating profound healing.