What It’s Actually Like to Stand Between Two Ways of Working
There is a period in a therapist’s development where the model that once organised everything begins to feel insufficient.
I originally trained in a psychodynamic framework with a strong top-down emphasis. The work centred on co-regulated meaning making, integration, symbolism, sub-personalities, and the gradual movement toward coherence. It assumed a reflective capacity, and that insight could reorganise experience.
That assumption often holds.
Alongside that training, I had long been interested in Intensive Short-Term Dynamic Psychotherapy. Over time, further training in that approach sharpened my attention to anxiety regulation, defence processes, and moment-to-moment shifts in emotional activation.
The shift in my own practice began to happen through clinical necessity.
Two bodies of water meet at a shifting boundary, reflecting different levels of organisation within the same system.
When reflection is not enough
With some clients, particularly those with deeply entrenched defensive structures, repetition compulsions, persistent over the threshold anxiety and emotional fragility, reflective work did not create structural change.
Sessions could sound thoughtful. Insight was semi-present. Narrative was somewhat coherent.
Yet under pressure, the same patterns re-emerged.
Clients could describe their history fluently while remaining emotionally insulated from it. They could understand their behaviour without their nervous system responding differently in real time.
It became clear that interpretation alone was not addressing the mechanism maintaining the difficulty.
Something more foundational had to be worked with first.
Top-down and bottom-up
Psychosynthesis, at its best, works top-down. It helps organise experience through meaning and integration. It assumes a system capable of reflection.
ISTDP works bottom-up. It begins with anxiety thresholds, defence identification, and the regulation of affect as it emerges in real-time, in session. It focuses less on what is understood and more on what the system does when feeling becomes imminent.
Over time, I stopped seeing these approaches as competing theories because they operate at different levels of the same system.
Some clients can use top-down integration early in therapy. Others cannot. If anxiety overwhelms the system or defences activate automatically, reflective work is absorbed without altering the underlying process.
In those cases, capacity must be built before integration becomes usable.
When meaning becomes a defence
One of the most important shifts in my own development was recognising how easily insight can regulate and temporarily soothe anxiety. Both your anxiety and the clients’ anxiety!
Narrative can distance feeling and explanation can substitute for contact.
Once you begin tracking anxiety and defensive operations closely, reflective language sometimes appears precisely when affect is approaching.
At that point, interpretation may soothe rather than transform.
The task becomes helping the person stay present with what is happening internally, without retreating into coherence too quickly.
Where integration belongs
Integration remains important in my work.
It simply belongs later in the sequence.
When a client can:
Tolerate rising affect without disorganisation
Stay present without immediate defensive withdrawal
Observe internal processes in real time
Differentiate from a critical or punitive voice
Then reflective and integrative work becomes structurally meaningful.
Meaning is no longer a substitute for contact because it becomes a consolidation of lived experience.
In that position, earlier training re-enters the work in a different role. Not as the driver of therapy, but as an organiser of what has already been processed.
Standing between approaches
The period of standing between models can feel destabilising. Almost like a total 180
Language that once felt sufficient begins to feel thin
Technique that once felt compelling may feel premature
Thinking becomes structural
There can be uncertainty about when to regulate and when to press, when to interpret and when to stay with mechanism.
However, this uncertainty feels developmental.
The organising principle gradually shifts from theoretical loyalty to capacity and structural assessment.
How much anxiety can this person (and me) tolerate?
How is the defensive system organised?
What intervention alters structure rather than relieves tension?
What level of confrontation can the alliance hold
Over time, sequencing becomes clearer.
Regulation when anxiety exceeds threshold.
Observation when reflection is possible.
Integration when the system can hold complexity.
The sense of being between approaches softens as stance replaces method.
A different understanding of depth
Working more explicitly with bottom-up process has changed how I understand depth.
Depth is not how much history can be explained. Depth has become about how much feeling can be tolerated without shutdown.
Meaning, purpose, and coherence still matter. They simply require stable ground.
Increasingly, that is where my work begins.
If this reflection resonated, you might explore:
Explore more in reflections
Frequently Asked Questions About Clinical Development and Modality, Structural Change in Therapy
-
Moving between modalities usually reflects a developmental shift. Early in training, a therapist may work primarily within one model. Over time, clinical experience exposes the limits of any single framework. The therapist begins integrating approaches based on patient capacity, anxiety tolerance, and defensive structure instead of theoretical loyalty.
-
A model provides structure and confidence. When its limitations become visible, the therapist may temporarily lose that sense of certainty. Competing interventions can both seem valid in the same moment. This can feel disorienting, but often signals increasing clinical discrimination.
-
Top-down approaches emphasise reflection, meaning, and integration. They assume the client can use insight to reorganise experience.
Bottom-up approaches focus on anxiety regulation, defensive processes, and moment-to-moment emotional activation. They work directly with how the nervous system responds under pressure.
Both operate at different levels of the same system.
-
Yes. Insight can reduce anxiety without altering underlying emotional processes. A client may understand their patterns while remaining emotionally insulated from them. When this happens, interpretation can stabilise rather than transform. Structural change usually requires working with anxiety thresholds and defensive mechanisms in real time.
-
The decision is typically based on capacity. If anxiety exceeds tolerance, regulation is necessary. If the client can remain present and reflective, defensive processes can be examined directly.
-
Structural change refers to shifts in how anxiety is regulated, how defences are deployed, and how affect is tolerated. It goes beyond intellectual understanding. When structure changes, the person responds differently under pressure.
Written by Rick Cox, MBACP (Accred)
Psychodynamic Psychotherapist, UK & Online
