Patricia Coughlin and Habib Davanloo’s ISTDP: Why understanding your trauma isn’t enough

You can understand exactly why you are miserable and still remain miserable.

A person can spend years in therapy discussing childhood trauma, understanding why they fear intimacy, recognizing their destructive patterns and identifying the origins of their suffering.

And then go home and repeat the same patterns.

American clinical psychologist Patricia Coughlin became frustrated with precisely this problem. She had been trained in psychoanalytic psychotherapy. Her patients sometimes developed considerable insight into their difficulties, but understanding did not reliably translate into change.

Then, in 1988, she encountered the work of psychiatrist Habib Davanloo.

What Habib Davanloo discovered

Davanloo had developed Intensive Short-Term Dynamic Psychotherapy (ISTDP), a method designed to help patients confront previously unconscious emotional conflicts more directly than conventional interpretive psychoanalysis.

Instead of spending years interpreting what patients said, Davanloo examined what happened when they approached feelings they desperately wanted to avoid.

A patient might describe being humiliated by his father while smiling politely.

Another might talk endlessly about a painful relationship without ever allowing herself to feel the anger, grief or longing beneath her words.

Davanloo paid attention to those defenses. He helped patients recognize the ways they were avoiding feelings, confront the costs of that avoidance, and decide whether they wanted to experience what they had been hiding from.

He also studied how unconscious anxiety appeared in the body, watching for signs that the emotional work was exceeding a patient’s capacity to tolerate it. The therapist could then adjust the pace and intensity.

As defenses weakened, feelings that had been buried could emerge: rage, guilt, grief, love, tenderness and desperate longing for closeness.

Davanloo called this process unlocking the unconscious. His work challenged the assumption that reaching deeply rooted psychological conflicts necessarily required years of analysis.

Coughlin trained directly with Davanloo in Montreal for three years, often as the only woman in her training group.

Patricia Coughlin’s next question: What happens after the breakthrough?

Breaking through someone’s defenses is not the same as changing their life.

An emotional breakthrough can expose the origins of a person’s suffering. But what happens afterward?

How does someone who has spent thirty years hiding from conflict learn to stand up for themselves?

How does a person who repeatedly sabotages relationships learn to experience intimacy without destroying it?

How do we replace old defensive habits with genuinely healthier ways of living?

These questions became central to Coughlin’s work.

She placed greater emphasis on what therapists call working through: revisiting conflicts, understanding their different causes, recognizing the compulsion to repeat old patterns, repairing ruptures in relationships and translating emotional discoveries into sustained changes in behavior.

In a 2020 interview with the Swedish association for ISTDP, she argued that the middle phase of therapy had been neglected within the field. Unlocking the unconscious opens a door; it is not the whole treatment.

Sexuality, jealousy, rivalry and autonomy matter too

Coughlin also challenged what she regarded as an excessively narrow focus on attachment trauma and guilt over anger toward loved ones.

Human suffering does not revolve exclusively around one kind of unconscious conflict. Sexuality, jealousy, rivalry, competition, shame, independence, pride and the need for autonomy can be central to a person’s difficulties.

Someone who repeatedly sabotages their own success might not simply be afraid of closeness. They might also be struggling with rivalry, winning, independence or guilt about surpassing other people.

Coughlin insists that therapists must discover the particular conflicts at work in the person sitting across from them, rather than force every patient into one theory.

And she stresses something else: a healthy person needs both connection and autonomy. Becoming psychologically healthier means more than establishing secure relationships. It can mean developing the ability to stand on your own feet, regulate your emotions and make decisions without constantly seeking approval.

Why the therapist’s personality matters

Coughlin argues that therapists must develop themselves as human beings, not merely master a set of techniques.

A therapist who cannot tolerate uncertainty, emotional intimacy or difficult feelings in themselves may struggle to help patients face theirs.

She has criticized training that teaches interventions without teaching the underlying theory, and training that overlooks the clinician’s personal development. In her own teaching, she emphasizes case formulation, therapist growth and an ability to respond flexibly to the patient.

Complex psychotherapy, explained in accessible books

Coughlin has also done something valuable for a field known for its dense terminology: she has made a demanding form of psychotherapy considerably easier to understand.

Her books explain complex psychological processes through clear arguments and detailed transcripts of real therapy sessions, showing what therapists do, why they do it and how patients respond.

• Intensive Short-Term Dynamic Psychotherapy: Theory and Technique — a systematic introduction to Davanloo’s method, with a revised second edition in 2026.
• Maximizing Effectiveness in Dynamic Psychotherapy — an examination of effective therapy and the skills and personal qualities therapists need.
• Facilitating the Process of Working Through in Psychotherapy: Mastering the Middle Game — why a breakthrough is not enough, and how patients and therapists pursue more lasting change.
• Lives Transformed, written with David Malan — a close examination of therapy sessions and outcomes.

These are primarily books for clinicians, not simplistic self-help manuals. Their accessibility lies in how well they explain the reasoning behind a difficult clinical method.

There is no promise that every problem can be resolved in a handful of sessions. No magic technique that works on everyone.

There is, however, a demanding proposition at the heart of her work:

Understanding why you suffer is only the beginning. The real task is to stop living as though the circumstances that created your suffering still control your life.

Featured portrait: Patricia Coughlin, reproduced as an editorial identification photograph from ISTDP Sweden. Cropped to fit the website. The original source does not identify the photographer or reuse license.

Sources and further reading

• Thomas Hesslow, interview with Patricia Coughlin, ISTDP Sweden (12 May 2020) — Coughlin discusses her training with Davanloo, sexual and rivalry conflicts, autonomy, therapist development and working through.
• Routledge, Facilitating the Process of Working Through in Psychotherapy — description and chapters covering repeated conflicts, ruptures, autonomy and emotional corrective experiences.
• Routledge, Maximizing Effectiveness in Dynamic Psychotherapy — clinical approach and therapist effectiveness.
• Psychwire, Patricia Coughlin: clinical psychologist and ISTDP author — biography and publication history.

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