Intensive Short-Term Dynamic Psychotherapy (ISTDP) is a psychotherapeutic model known for its intensity and its claims of deep, rapid emotional change.
This public letter examines how ISTDP’s theoretical assumptions—particularly its treatment of trauma, fear, and dissociation—can place certain patients at risk when the model is treated as complete rather than partial. What follows is the culmination of a three-year effort to raise these concerns within the ISTDP community; you can find the comprehensive background here, and my two prior essays to the community here and here.
To the ISTDP Community,
I am writing this letter as my three-year effort to protect patients with traumatic stress syndromes within ISTDP treatment has reached a final impasse: institutional silence.
In good faith, I’ve raised pointed questions about theoretical gaps that place patients at risk, and in doing so I have encountered ideological rigidity and a refusal to engage the substance of my critique. Although some have acknowledged the validity of these concerns, leadership has refused to recognize these issues as matters of ethical responsibility. Survival terror is still disavowed, and patients with terror-induced suffering (traumatic stress) are at best poorly understood, and at worst retraumatized.
The difficulty in engaging my critique is not its complexity, but its implications: it undermines ISTDP’s claim to offer an exhaustive metapsychological account of the psyche. The logic is straightforward. For example, if collapsed immobility is acknowledged as the final form of survival terror encoded in neurobiology, then severe trauma must be understood as injury caused by overwhelming external threat. If trauma is injury, it cannot be reduced to intrapsychic conflict alone. And if that is true, ISTDP cannot function as a total theory.
If trauma is injury, it cannot be reduced to intrapsychic conflict alone. And if that is true, ISTDP cannot function as a total theory.
While it may seem self-evident that no psychotherapeutic model could function as a total theory of the mind, this community has often treated ISTDP as though it were one—and it is this assumption that brings us back to the impasse. The seeds were planted in July 2024, when I responded to a listserv discussion and noted that ISTDP lacks any robust conceptualization of dissociative disorders. My intention was simply to name a domain that clearly lies outside the model’s theoretical reach—evidence that ISTDP cannot be exhaustive.
Allan Abbass, a preeminent ISTDP researcher and senior teacher, responded with the assertion that the final third of his book, Reaching Through Resistance, is “all about” dissociative disorders. I was stunned. I had read the book and knew unequivocally that it does not in any substantive way address dissociative disorders as they are defined within standard diagnostic and clinical frameworks. At the time, however, I chose not to press the point.
A year later—after presenting my critique with colleagues in San Diego and sharing two detailed letters with this community outlining my concerns—I decided it was time to address Allan’s claim directly. On July 18th, 2025, I wrote:
“Allan, in a previous message to this listserv, you mentioned that the final third of Reaching Through Resistance focuses on treating dissociative disorders. I’ve read your book closely and learned much from it, but I could not find reference to the standard diagnostic criteria or the five core symptoms that define dissociative disorders – derealization, depersonalization, identity confusion, identity alteration, and amnesia. Are you working from a different conceptual framework for what constitutes a dissociative disorder? If so, could you clarify what you mean by ‘dissociative disorder’?”
Despite the obvious relevance of this question to patient care and clinical integrity, no response was offered. Returning to the present, Allan has once again declined to respond—this time regarding the classification of PTSD within ISTDP discourse. I have argued that PTSD should not be classified as an anxiety disorder in his widely shared research summary document, as this categorization was formally revised on the basis of the scientific literature with the publication of the DSM-5.
This is not a minor issue. If PTSD remains framed as an anxiety disorder, ISTDP can remain unchanged; but if PTSD is recognized for what it is—a disorder arising from overwhelming external threat—then ISTDP must change in order to maintain the claim to theoretical completeness.
What elevates Allan’s silence from an individual failure to a systemic one is the unwillingness of other senior leadership to confront it and to address what it represents: the preservation of institutional control at the expense of patient wellbeing. This refusal to engage appears to directly violate the IEDTA’s stated values and the Canadian Medical Association Code of Ethics, which defines ethical medical practice as requiring active inquiry, humility about the limits of one’s knowledge, openness to new evidence, and responsibility to patients. Put plainly, when someone makes strong public claims from a position of authority—claims that therapists and patients will rely on—and then refuses to substantiate them, that conduct is directly and unequivocally unethical.
This failure of leadership is not anomalous. Broad and unfalsifiable claims are intrinsic to ISTDP as it is currently theorized and taught in many institutional contexts. The model’s core ideas are often articulated in such totalizing terms that reality is effectively pre-interpreted before the patient speaks, leaving no room for the full complexity of psychological and neurobiological truth, of human experience. While ISTDP often presents itself as uniquely sophisticated and complete, this very claim to totality results in a profound reductionism. This is clearly illustrated in the program description offered by The New Washington School of Psychiatry. They write:
“All ISTDP therapists understand that a patient’s problems result from defenses that arise in response to the anxiety that is coupled with unconscious feeling. The goal of therapy is to help the patient develop the ability to attend to internal experiences to regulate anxiety and turn against maladaptive defenses.”
Given the centrality of these ideas to ISTDP, it is worth examining this statement closely. The phrase “all ISTDP therapists understand” is itself telling: it enforces unanimity and codes disagreement as misunderstanding—a linguistic hallmark of dogma. By defining all patient ‘problems’ as the product of ‘maladaptive’ defenses and signal anxiety, causality is collapsed into the 'maladaptive' aspects of the psyche. This is not positioned as one dimension of truth, but rather as the truth. In a single rhetorical move, external sources of injury such as traumatic stress, and normal causes of ‘problems’, such as developmental realities—being young, neglected, or structurally disenfranchised—disappear from view. The difficulties of being young—inexperienced, unsure how the world works—are not maladaptive; and the appropriate response is support, not correction. Good gardeners do more than trim plants: they also provide water and sunlight.
Good gardeners do more than trim plants: they also provide water and sunlight.
When ISTDP is treated as a complete explanatory system, it predetermines what can be recognized as clinically real. Within such a framework, both pathology and change are narrowly defined by what the theory already knows how to see. Suffering that arises from injury rather than intrapsychic dysfunction is therefore reinterpreted as pathology within the patient, not as evidence of external harm. Experiences of injury become problems of the self, which foreclose forms of recognition, accompaniment, and care that challenge the models explanations. The consequences of these theoretical errors were not abstract for me; they became immediately and painfully apparent in my own treatment.
I remember the moment with a kind of horror: it was shocking to realize the model disavows fear. I was recounting a terrifying traumatic memory—one that had not yet been reconsolidated—and I described the fear I was experiencing in it. My therapist asked, “What feelings are underneath that anxiety?” I immediately clocked that something was wrong. I wasn’t anxious. I was afraid. This was not signal anxiety; it was fear in the memory itself. The moment called for compassionate accompaniment. Instead, there was a failure of attunement so complete it bordered on the surreal.
I pushed back: I’m not anxious. I feel afraid. This is scary. He looked uncomfortable—slightly irritated—as though I were failing a task rather than describing an experience. I clearly wasn’t “doing it right.”
Later, I turned to the books of his teachers and discovered that this wasn’t only a personal limitation; it was structural. The inability to conceptualize fear was embedded throughout the model. It is bizarre—one of the largest and wildest collective denials I have ever encountered. It would never pass the “person on the street” test. The denial of fear is so obviously removed from reality it cannot withstand ordinary human scrutiny. A theory of mind that denies fear does not merely misunderstand patients; it gaslights them.
A theory of mind that denies fear does not merely misunderstand patients; it gaslights them.
Fear is real. It is primary. Hypervigilance, flashbacks, and trauma triggers are all forms of fear conditioning—survival responses that are normative and hardwired adaptations across species. And because survival is paramount, it is not easy or direct to undo (reconsolidate/extinguish) the fear learnings. Indeed, the extreme difficulty of fully altering fear learning is the reason PTSD continues to generate sustained and intensive research.
An upcoming ISTDP trauma training poses the question, “How do we understand the consequences of trauma from an ISTDP perspective?” This reverses the order of inquiry, from theory to reality, not reality to theory. The issue is not how trauma fits ISTDP theory. The issue is whether ISTDP theory fits trauma. As it stands, ISTDP theory does not fit the realities of trauma.
The phenomenological truth of PTSD is missing from ISTDP theory, and it is replaced with a wildly reductive and inaccurate formulation: PTSD symptoms are a form of self-punishment. Indeed, ISTDP encounters serious problems when its organizing idea—resolving guilt about rage—is applied to suffering caused by overwhelming external threat rather than intrapsychic conflict. Though unlocking unconscious material can facilitate memory reconsolidation and reduce fear learning, its effects are inconsistent and often insufficient for traumatic stress. When unlockings did sometimes reduce PTSD symptoms for me, the mechanism was phenomenologically obvious: traumatic memories reconsolidated, and experiences of helplessness shifted into experiences of agency and power. The difficulty is not that change sometimes occurs, but that ISTDP theory misidentifies why it occurs.
In my public exchanges with senior ISTDP teachers, there has been near-universal allegiance to the claim that PTSD symptom improvement reflects a reduction in self-punishment driven by punitive superego dynamics. This explanation misattributes the source of change, conflating injury with intrapsychic conflict, displacing causality from overwhelming external threat into the ‘maladaptive’ psyche of the person harmed, and enacting victim-blaming at the level of theory.
As one idea among many, the possibility that self-punishment may be involved in some cases of PTSD is not a toxic concept—sometimes it's likely true. But when this idea is elevated to the exclusive explanatory principle, it becomes an extreme moral inversion—one that will predictably create the very dynamic it claims to treat. Because severe fear conditioning is distinct from conflicts involving rage or guilt, a model that frames PTSD as guilt-based self-punishment ensures that when symptoms persist despite deep “unlocking,” failure is attributed not to the limits of the intervention but to the inability (or unwillingness) of the patient to resolve conflicts. Self-blame—a punitive relationship to the self—will often follow.
The patient may also experience a lack of genuine empathy and attunement from the therapist, because full attunement would require the therapist to tolerate their own helplessness and to bear witness to psychological injury that does not conform to expectations of rapid resolution. That emotional capacity is not merely underemphasized, but actively disavowed as therapeutically necessary within ISTDP theories of change. Traumatic affect is instead defensively coded as “regression” or “resistance,” a move that ironically evacuates the very emotional closeness ISTDP otherwise recognizes as central to therapeutic change.
To confuse cause and effect at the level of the impacts of devastating interpersonal violence is not merely conceptually incoherent; it is morally abhorrent.
I will say this clearly and unequivocally: any psychotherapist who finds themselves loyal to the above formulation should question whether they are competent to treat massive psychic trauma. To confuse cause and effect at the level of the impacts of devastating interpersonal violence is not merely conceptually incoherent; it is morally abhorrent.
Within ISTDP training culture and discourse, ethical questions are frequently minimized in favor of the belief that technical fidelity alone guarantees ethical care. This belief is dangerous, as it places the model above good clinical judgement – a superordinate category. Fidelity is often described as the most ethical form of treatment precisely because ISTDP is framed as unusually powerful and deep. This reflects a troubling fixation that obscures harm: if the theory is the most comprehensive and effective, how could a therapist “doing it right” cause harm? Yet it is this very belief that virtually guarantees negative outcomes—and, more troublingly, ensures that therapists struggle to recognize or learn from failure. Across the community, I have seen and heard repeated accounts of senior teachers engaging in plainly unethical behavior, implicitly justified by allegiance to ISTDP’s presumed superiority.
One such breach involves the misuse of the primary teaching tool this community most cherishes: clinical tapes. At a recent conference, a senior teacher presented a recording in which unrelenting pressure, challenge, and head-on collision were applied to a deeply traumatized patient, eventually producing a breakthrough of feeling. During this period of sustained pressurization, the patient repeatedly asked to stop, expressing clear and unmistakable distress. In any ethical psychotherapeutic framework, this should have constituted an immediate stop condition. The teacher did not stop, continuing until a breakthrough occurred. Only later did I learn that this was a failed case: the patient had subsequently dropped out of treatment, a fact known to the presenter but not disclosed to the audience.
This was not an isolated incident: a colleague shared that this same teacher had shown a different case in a core training, again involving unrelenting pressure and challenge, without disclosing that the patient had abruptly terminated treatment. Perhaps unsurprisingly, this was the same teacher who told me, when I asked what they do when anxiety regulation fails, that for them, anxiety regulation ‘never fails.’ There is no therapist who never encounters failure—but there are those who are constitutionally unable to perceive it.
I often think about the patient from the IEDTA conference when I reflect on the harms of ISTDP. What happened to her afterward? Was she able to recover from an experience of being forcefully overridden? She had protested, and yet the interventions continued. Did she find another therapist, or did she fully lose trust in psychotherapy? And, what kind of therapist overrides an obvious ‘no’, and then shows the tape without telling the audience it was a failure?
The patient protested and directly asked the therapist to soften their approach. In response, the therapist laughed. The unrelenting pressure continued.
If this were an isolated incident—one teacher, one lapse—that would be one thing. But it is not. Another colleague described an experience in a core training in which a “master” ISTDP teacher presented a case that began with carefully graded work and then escalated into sustained, unrelenting pressure and challenge. The patient protested and directly asked the therapist to soften their approach. In response, the therapist laughed. The unrelenting pressure continued. To my colleague, it was obvious that an abusive interaction was occurring—one presented to trainees as exemplary work. Other trainees who witnessed it were left unsettled, questioning themselves rather than the authority in the room. Many defaulted to the assumption that the work must be healing because it was being performed by a revered figure, and that their discomfort reflected their own inadequacy. For my colleague, what they had witnessed was unambiguously wrong.
I personally encountered a similarly grave ethical failure. A senior teacher told me about a case in which they were treating a patient with a potentially deadly behavioral addiction. As the patient failed to improve, the stated goal of treatment shifted to helping them accept their impending death. The admission was delivered with such confidence and certainty that I initially struggled to grasp its stunning implications. Eventually it crystallized: by failing to recognize when referral was ethically necessary, the teacher revealed that their attachment to ISTDP’s supremacy outweighed their commitment to protecting life.
This same teacher also told me that patient dropout following a “successful” trial therapy does not prompt any change in their methods, as doing so would “compromise efficiency.” In both instances, fidelity to method superseded responsibility to the patient. In this context, “trial therapy” appears less like a collaborative assessment of suitability than a test of endurance—a hazing mechanism that tests patient buy-in while establishing a deeply asymmetrical power hierarchy.
Beyond the unethical treatment of patients, there are teachers in the community who are (in)famously harsh toward trainees. This, in turn, produces a hazing culture in which it becomes a source of pride to endure abuse and “master” the model. This is dangerous. Cruelty toward trainees is not separate from patient harm. Disrespect of learners will inevitably mirror disrespect of patients. A true healer does not emotionally abuse their trainees. A training culture that normalizes humiliation and contempt is a safety risk for everyone downstream. It is also fair to question how such a personality—someone who is cruel to trainees—would fare with a patient who is their intellectual equal and awake to patterns of domination.
These episodes should be deeply disturbing to anyone concerned with patient safety, as they demonstrate how coercion, concealment of failure, and theoretical certainty can coexist under the banner of “expert” care. When a model is considered total, and someone believes they are doing it ‘right’, negative outcomes or patient non-response is ignored as meaningful data that might require change on the part of the therapist. If the therapist cannot be altered by the patient’s reality—in understanding, in theory, or in self-reflection—then the work is not truly relational. It is authoritarian.
If the therapist cannot be altered by the patient’s reality—in understanding, in theory, or in self-reflection—then the work is not truly relational. It is authoritarian.
The truth is that when a model’s classic interventions are named “pressure,” “challenge,” and “head-on collision,” it has the potential to attract practitioners for whom control and domination distort ethical and compassionate care. While it is neither possible nor appropriate to infer the psychological structures of individual practitioners who refuse to acknowledge failure data, it is necessary to acknowledge that human populations reliably include many individuals with deficits in empathy and unintegrated antisocial drives. When such drives encounter an incisive potentiator—ISTDP theory coupled with ideological totalism—harm will follow.
Though most people, including senior teachers, are interested in real healing, that is not universally true. One of ISTDP’s most important contributions is its recognition that human aggression contains sadistic drives, yet what remains unaccounted for is sadism that is constitutionally syntonic, aggression uncoupled from guilt and unconstrained from within. Though uncomfortable to consider, it is a basic psychological fact that not everyone is organized around care or conscience. It is well known that individuals with narcissistic and antisocial structures do not self-select out of positions of authority (such as being a doctor, psychologist, or psychotherapist), and that such positions reliably include a minority of individuals for whom power and control are intrinsically rewarding.
It follows, then, that some patients may defend because it is wise to do so. While ISTDP discourse often interprets defensive phenomena as evidence of intrapsychic conflict, this can obscure a simpler and equally important truth: patients may defend because they do not like, feel safe with, or fully trust the therapist. Such defenses are not pathological; they may be psychologically healthy responses to real interpersonal threats. Being emotionally open to someone who lacks a reliable capacity for empathy and mutuality is a genuine risk, thus we might call this ‘defending in service of the self’. In this case, protective functioning is usefully oriented towards safety, not avoidance of emotional truth. If this distinction is not clear to a therapist, pressure and challenge become domination and violation.
Similarly, while ISTDP’s genius lies in its capacity to restore human connection and hope through emotional intimacy, a serious risk emerges when this insight is universalized – when it is assumed that all emotional closeness will be healing. Connection alone is insufficient. After all, domination is a form of connection, but it is rarely a reparative one.
Connection alone is insufficient. After all, domination is a form of connection, but it is rarely a reparative one.
Painfully, it is the most vulnerable among us who are most harmed by practitioners organized around unintegrated sadistic drives—and this group of patients includes those living with complex dissociative disorders. This returns us to the present impasse, in which leadership has chosen collusion and silence in the face of unsubstantiated claims that directly affect the treatment of these patients.
Dissociative disorders are not synonymous with fragility, a conflation that has repeatedly obscured clinical reality within ISTDP discourse. Indeed, against the theory, DID patients who have been presented in trainings and shown to me privately have often displayed a high capacity for the full experience of rage and guilt, while also dealing with extreme PTSD symptoms. These cases neither progressed more efficiently than is normal for such pain and complexity, nor fit within ISTDP’s conceptualization of severe fragility.
More fundamentally, because ISTDP is organized around the assumption of a unified ego, and fails to conceptualize injury/traumatic stress, patients with complex dissociative disorders—traumatic stress syndromes—fall outside the model’s theoretical map altogether. The resulting harm is neither abstract nor speculative.
On a public forum, a patient described how her ISTDP therapist refused to acknowledge dissociative parts when they emerged in a shocking manner during an unlocking, a refusal she experienced as profoundly retraumatizing. Although she entered treatment hoping to address severe somatic symptoms, the therapist’s inability to recognize or engage dissociative phenomena ultimately forced her to terminate therapy. When she sought clarification publicly, a senior teacher compounded the harm by reclassifying her experience as cognitive perceptual disruption, and attributing the presence of dissociative states to “signal anxiety”—a claim so fantastically implausible that it will require separate and detailed treatment elsewhere. The harm this patient experienced is not an aberration, but a predictable consequence of privileging dogma over phenomenological reality.
The harm this patient experienced is not an aberration, but a predictable consequence of privileging dogma over phenomenological reality.
I believe senior leadership has betrayed the heart of ISTDP. The soul of the model lives in the power of love and reparative guilt, yet leadership has failed to actualize either in the service of protecting the most vulnerable. Instead, I have witnessed sustained collusion with ongoing harm, expressed through a leadership-wide refusal to acknowledge harm as legitimate—despite its foreseeable emergence within ISTDP’s totalizing discourse and powerful techniques.
It is not enough to say that the model is brilliant, that deep and transformative work is done, or that good people across the field are empowered by ISTDP to change lives. All of that is true. The beauty, power, and undeniable genius of ISTDP is real. My life was transformed by ISTDP, and I love the model deeply. And the harm is still real.
Truly powerful tools require a safety culture—whether fire, knives, heavy machinery, or psychological techniques. The more potent the tool, the greater the restraint and care required to use it responsibly. ISTDP is powerful because it leverages foundational psychological truths with real transformative potential. But when ISTDP is held as complete—when it is presented as uniquely sufficient—the theory itself depends on denial: the denial of fear, trauma, external reality, risk, harm, and failure. Profound power therefore exists alongside profound risk, and when harm occurs, that same power magnifies the devastation.
ISTDP covers one essential aspect of clinical and psychological reality—intrapsychic conflict—but it is only one aspect. Like a primary color, ISTDP captures something foundational and true, yet cannot, on its own, produce the full picture of human suffering. Much of what we encounter in clinical work lies beyond intrapsychic conflict, and all therapists must be prepared to work in those spaces.
If I were to enter therapy to process three years of epistemic and ontological erasure within a group of eminent psychotherapists who consider themselves masters, I would not be processing anxiety, rage, or guilt, because I do not feel any of those things. I would be processing moral injury—the grief and horror that arise when positions of power are held by people unworthy of them. I would need the therapist to accompany me and bear witness as I unspool the meaning of it all, and as I feel into the relief and freedom of my first experience of full allegiance to my mind, to my voice.
I have asked, and the answer is no.
I am no longer hoping for institutional change, nor am I asking permission. Senior leadership has shown itself to be incapable of ethical awareness and ethical action, and there is no evidence of change on a scale that would materially protect patients from those who cause harm while emboldened by a totalizing ideology. Clear discussion of patient harm has failed to move the needle. So, I’ve come to accept that for now, disavowal of reality is a culturally entrenched pillar defense. I have asked, and the answer is no.
This brings me to Ethical ISTDP. This space will take up functions that are unfilled in the broad ISTDP community: protection and safety, and theoretical clarity that seeks to illuminate rather than foreclose on phenomenological reality. It is intended for patients, therapists, and trainees within the sphere of ISTDP. The final form is unknown, as the space will naturally grow. Whatever emerges, it will always be helpful, kind, and clear.
It is a great gift that ISTDP belongs to the commons. The inspired light that moved through Davanloo’s mind will evolve onward.
Mae Ana Sefami, LCSW