Abstract
Dr Habib Davanloo is Professor of Psychiatry at McGill University, Montreal. His theory of intensive short-term dynamic psychotherapy has been around for several years but this book brings his theoretical ideas together in a single up-to-date volume. As indicated in the subtitle the chapters consist of a progressive series of papers on his work. Unfortunately almost all the references at the end of each chapter are to his own published or presented work, there being only six to another author (JM Gaillard).
Davanloo introduces his technique by describing two spectrums of patients who can be successfully treated by this method: (a) the spectrum of psychoneurotic disturbances and (b) the spectrum of patients with fragile character structure.
The spectrum of psychoneurotic disorders has at one extreme those highly responsive to psychotherapeutic intervention, with ‘circumscribed problems’, a ‘single psychotherapeutic focus’, a ‘very mild degree of resistance, and absence of unconscious murderous rage’; this end of the spectrum would include mild obsessional or mild phobic disorders. At the other end of the spectrum are patients with the most complex character neuroses who demonstrate ‘extreme resistance, diffuse symptom and character disturbances’ and ‘highly complex core pathology’ with ‘highly primitive unconscious torturous rage and intense guilt and grief, multidimensional in relation to early figure(s)’. The profile of patients at this end of the spectrum, based on research, ‘demonstrates with no exception the presence of trauma, abandonment in the very early phase of life and the presence of a highly painful feeling in relation to the trauma and abandonment’.
The spectrum of patients with fragile character structure may have mild, moderate or severe fragility. ‘Those with severe fragility cannot withstand the impact of their unconscious during the first interview, that is during the trial therapy’.
Davanloo describes the developing therapeutic alliance and using it to help the patient acknowledge his defensive manoeuvres as a result of the therapist challenging these defences by confronting ‘head on’. The technique then proceeds in a spiral – exploration leading to resistance, this resistance is then challenged resulting in a rise in the intensity of the transference and further resistance; interventions by the therapist are then aimed at weakening the transference resistance, a return to exploration and so on. The process of therapy is quantitatively and qualitatively much more difficult for those on the left of the spectrum than for those on the right. He describes ‘unlocking the unconscious’ and ‘the passage of the murderous rage in the transference with the emergence of sadness’ followed by ‘the passage of the guilt-laden unconscious feeling’ leading to a direct view of the ‘psychopathological dynamic forces responsible for the patient's symptom and character disturbances.’
Davanloo emphasises that challenge to the resistance inside and outside the transference by pointing out, questioning, countering or blocking a defence is the key intervention and it can range ‘from relatively mild to extremely powerful culminating in head-on collision’. He also emphasises that the therapist maintains the greatest respect and sympathy for the patient but has neither respect nor sympathy for the patient's resistance and conveys that to the patient.
This book describes Davanloo's method of intensive short-term psychotherapy in the treatment of patients with characterological problems in great detail. The advantage of the book is the case vignettes which make it clear how he works. How he works with the ‘fragile character structure’ is less clear. While his method is holding to the extent of emphasising the establishment of the therapeutic alliance and having respect for the patient, it is very confronting and he does not appear to use empathy as part of his approach. There is no index.