"Am I Doing ISTDP?" When the Therapist Tries to Make Therapy Work for Two People

David M Rudesill, LCSW

The clinical illustrations in this article are composites drawn from supervision. Identifying details have been changed or omitted to protect confidentiality.

“Am I doing ISTDP?”

It is a question therapists often ask when treatment feels stalled. The patient continues to describe the same problems and situations over and over again. Attempts to focus on feelings go nowhere. Defenses appear faster than the therapist can identify them. The clinician begins to wonder whether they are being too passive, insufficiently precise, or not applying the model correctly.

In a recent supervision, a therapist described working with a patient who arrived each week with urgent, emotionally charged stories about other people. The patient was highly articulate and could speak at length about what her family members, spouse, or friends were doing. Yet whenever the therapist tried to explore what was happening inside the patient, the focus quickly returned to someone else.

The therapist felt intimidated. They hesitated to point out defenses. When they did ask about the patient’s feelings or behavior, the patient often dismissed the inquiry and resumed her story.

“I don’t really attempt ISTDP with her,” the therapist said. “The defenses seem so strong.”

I found myself asking a different question:

“Put aside ISTDP as if it’s some authority we must submit to. Are you being real with the patient about what she’s setting up relationally?”

That question changed the direction of the supervision. The problem was no longer simply whether the therapist was "doing ISTDP" correctly. The more basic question was whether a collaborative psychotherapy had been allowed to form at all.

When Therapy Becomes a One-Person System

By a “one-person system,” I mean a relational arrangement in which only one person’s mind is permitted to organize the encounter.

The patient may welcome the therapist’s attention, warmth, validation, and availability. The patient may attend consistently, speak openly, and even report that therapy is helpful. Yet the therapist is not fully permitted to exist as a separate person with an independent clinical perspective.

The therapist may be allowed to listen, mirror, reassure, or confirm. But when the therapist notices something the patient has not noticed, asks a question the patient did not choose, or invites attention toward an internal conflict, the therapist’s contribution is experienced as intrusive, irrelevant, or unwanted.

In the supervision, the patient seemed to prefer a tightly controlled relationship. She could speak about other people while remaining protected from deeper contact with herself. The therapist could be present as an audience but not fully as another mind, as a helper.

The patient’s control offered short-term benefits. She could discharge stress. She could feel heard. She could leave the session somewhat relieved.

But short-term release is not necessarily the same as psychological change. The therapist and patient may silently hold very different ideas about what therapy is for. One may be seeking a place to speak without interruption; the other may be trying to help the patient understand and alter the patterns that perpetuate suffering.

Neither aim is inherently illegitimate. Supportive listening can be valuable. The problem arises when the mismatch remains unspoken and both people continue to call the arrangement collaborative psychotherapy.

A person can attend therapy every week without permitting psychotherapy to develop.

The Therapist’s Two Temptations

When a patient keeps the treatment in a one-person system, the therapist commonly moves toward one of two positions.

The first may be passive withdrawal:

The therapist stops offering observations and allows the patient to ruminate until the session ends. This may look respectful and nonintrusive. Sometimes it is. But it may also represent the therapist’s adaptation to the patient’s resistance: I have learned that my mind is not welcome here, so I will quietly remove it.

The second temptation is the opposite: the therapist begins working harder.

The patient brings an external problem, and the therapist tries to make it internal:

“That must have been hurtful for you?”

“You seem angry.”

“Perhaps you are turning the anger against yourself?”

“What do you feel toward her?”

These interventions may be empathic and clinically plausible. Yet if the patient has not identified an internal problem or expressed a wish to understand it, the therapist may begin supplying what the patient has not supplied: the feelings, the formulation, the psychological task, and the motivation to change (the unconscious therapeutic alliance).

During supervision, the therapist saw this clearly:

“I’m trying to provide insight into her internal problem, her internal suffering.”

A moment later, when asked who was supplying the desire for internal focus and healing, they answered:

“Me. I’m the one that wants to try to get on the inside.”

The therapist was repeatedly offering emotional and psychological “life preservers,” while the patient continued to bat them away.

The Substitute UTA

In ISTDP, the unconscious therapeutic alliance, or UTA, refers to the patient’s healthy wish to understand the problem, overcome the resistance that drives their suffering, and move toward greater vitality.

The UTA is not simply the therapist’s hope that the patient will improve. It cannot be manufactured by the therapist’s enthusiasm, insight, or technical effort alone.

When the patient’s desire to heal is obscured by resistance, the therapist may become tempted to omnipotently provide what could be called a substitute UTA. The therapist supplies the focus, momentum, curiosity, hope, and desire for change that the patient is not yet using.

This often occurs for understandable reasons.

The patient appears distressed. The therapist cares. The therapist does not want to become passive or neglectful. The clinician may also feel ashamed that the therapy is not progressing and conclude that greater activity will solve the problem.

But the result can be paradoxical. The more psychological work the therapist performs, the less the patient has to do.

The patient remains focused outside herself while the therapist tries to create an internal focus for her. The patient continues telling stories while the therapist finds their emotional meaning. The patient dismisses the therapist’s interventions while the therapist works increasingly hard to make them useful.

The therapist’s effort to rescue the psychotherapy unwittingly preserves the patient’s resistance in psychotherapy.

In the supervision, this was formulated as an attempt to overcome externalization by “omnipotently providing the UTA” and supplying the energy that the patient was not bringing to the internal task.

Enthusiastic Externalization

One reason therapists become confused is that a patient may appear emotional or speak in an energetic manner about an external situation. The session may contain considerable energy. The therapist understandably thinks, "There is finally a therapeutic focus here. Now we can work."

But verbal animation about an external problem is not necessarily internal psychological mobilization.

A patient may speak passionately about an intrusive relative, an unreasonable partner, an unfair employer, or a disappointing friend while remaining disconnected from her own bodily feelings, anxiety, conflict, defenses, wishes, and choices.

The external problem may also be real. The other person may indeed be difficult, intrusive, or hurtful. Clarifying externalization does not require invalidating reality.

The question is whether the patient has identified how the external situation becomes an internal psychological problem that she wants help addressing.

In the supervision, the therapist initially became encouraged because the patient was animated and clearly upset. Yet the identified “problem” remained almost entirely outside the patient: another person was interfering, another person was behaving badly, and another person needed to change.

The therapist could not treat that other person.

Without a clearly established internal problem, it was difficult to know what task therapist and patient had agreed to undertake together.

The existence of distress does not automatically establish the existence of a shared psychotherapeutic task.

Before applying pressure toward feeling, the therapist may need to ask:

What is the problem you want help with inside yourself?

What would you like to understand or change within yourself?

How is this affecting your emotional life, your choices, or your relationships?

Do you want my help examining that?

Without some shared answer, the therapist may begin treating a psychological problem that only the therapist has identified.

Name What Blocks an Internal Focus

The alternative to supplying the patient’s internal experience is not passivity.

The therapist can actively clarify how the patient’s defenses prevent an internal focus from developing.

For example:

“I’ve noticed a pattern in our session today. Several times you’ve brought in situations involving other people. When I ask about what is happening for you, our attention quickly returns to another person or another story.”

The therapist might then clarify the consequence:

“As long as our attention remains focused on them, I can learn a great deal about your account of other people. But neither of us gets to know what is happening inside you or what you would like help changing.”

And then return agency:

“Is understanding your own experience something you want my help with?”

This is different from inserting feelings into the patient. It helps the patient observe the mechanism that prevents self-understanding and collaboration.

A particularly useful intervention developed in the supervision was:

“I get to know your stories about other people, but we don’t get to know what we can do for you personally.”

The therapist can also ask:

“What kind of relationship would we maintain here if our attention remained almost entirely on other people?”

The answer may reveal the broader relational cost: distance, nonreciprocity, pseudo-connection, and a therapy in which the patient is known primarily through stories rather than through direct emotional contact.

The Patient May Not Want the Therapy the Therapist Wants

This possibility can be difficult for therapists to tolerate.

We may assume that because a patient attends therapy, the patient wants to be collaborative, challenged, emotionally known, and helped to change.

The patient may instead want "support," witnessing, stress relief, advice, validation, or a reliable person who will listen without introducing an independent perspective from a separate mind.

Again, those wishes are not inherently wrong. But they may not match the treatment the therapist believes they are offering.

There is nothing inherently resistant about the wish to be supported. Being listened to carefully and generously is essential to psychotherapy. A collaborative therapy may involve long periods in which the therapist says very little and the patient has substantial room to think, feel, and speak.

The important question is not whether the patient wants to be heard. It is:

What must happen to the other person for the patient to feel heard?

Can the therapist listen while remaining psychologically present as a separate person—someone who may ask a question, notice a pattern, misunderstand, be corrected, or offer an observation the patient did not already hold?

Or does “being heard” require the therapist to receive and reflect the patient’s existing account without introducing another mind into the room?

In the first arrangement, listening supports a two-person process. The patient has space, but the therapist also exists. Both minds can contribute to understanding the patient’s suffering.

In the second arrangement, listening becomes the mechanism through which a one-person system is maintained. The patient speaks; the therapist witnesses. The patient’s account organizes the entire encounter; the therapist’s observations are dismissed, redirected, or experienced as interference. The patient may feel temporarily relieved, but neither person is permitted to examine how the patient’s defenses shape the experience being described—or the relational dynamics being created in the consulting room.

The unspoken request becomes:

“Please hear my mind, but do not bring your own mind close enough to affect me.”

A therapist caught in this enactment may comply by becoming increasingly quiet. Alternatively, the therapist may work harder—supplying feelings, insight, an internal problem, or a motivation to change. In either case, the patient’s one-person system remains intact. The therapist either disappears or attempts to conduct the psychological work for both people.

Differentiated Therapeutic Authority

The therapist does not need to choose between submission and coercion.

A differentiated therapeutic position sounds like this:

I will not force you to examine feelings you do not want to examine.

I will not pretend that we are collaboratively examining them when we are not.

I will not disappear from the relationship merely because my observations make you uncomfortable.

I will describe what I see, clarify its consequences, and allow you to decide what you want to do.

This is therapeutic authority without omnipotence.

The therapist does not become responsible for making the patient see reality. The therapist becomes responsible for honestly offering a clinical perspective on the reality occurring between them.

In the supervision, the therapist recognized that she had a choice: she could bring the relational reality into view or continue concealing it. The patient would then have her own choice about whether to use what was offered.

The therapist’s role is not to create the patient’s UTA. It is to ally with the UTA when it appears and clarify what prevents it from becoming active.

Questions to Ask When Therapy Feels Stalled

When clinicians find themselves asking, “Am I doing ISTDP?” it may help to pause before searching for a more technically impressive intervention.

Ask:

• Has the patient identified an internal psychological problem?

• What does the patient actually want help changing?

• Is there a shared therapeutic task?

• What happens when I offer an observation the patient did not generate?

• Am I more invested in internal exploration than the patient is?

• Am I supplying feelings, insight, motivation, or hope in order to keep the therapy moving?

• Am I filling the relational space created by resistance instead of describing that space?

• Are we practicing collaboration—or repeating the patient’s one-person relational system?

These questions apply beyond ISTDP. No model of therapy can be meaningfully carried out by one person on behalf of two.

CBT requires a shared problem and active experimentation. Psychodynamic therapy requires curiosity about internal life and relationship. Experiential therapies require willingness to approach experience. ISTDP requires an alliance with the patient’s healthy wish to face what causes suffering.

Technique cannot substitute for participation.

So, Am I Doing ISTDP?

The deeper question is:

“Are we doing therapy together—or am I trying to do it for both of us?”