Though working in IAPT, a CBT-dominant mental health service, if you have read any of my posts before you’ll know that my temperament aligns far more naturally with the dynamic, interpersonal and exploratory therapeutic modalities. This means I often find myself in unpleasant moral dilemmas where I worry that I am short-changing my clients by sticking faithfully to the ‘Behavioural Activation Protocol’, but have zero other training that could better guide me with my clients.
So, I’ve started to read the textbooks of other psychotherapies, for some pointers of what kind of approach I have a better fit with, and to inspire ideas as to where my career path goes next…
The first book I’ve finished is Alessandra Lemma, Mary Target & Peter Fonagy’s Brief Dynamic Interpersonal Therapy: A Clinician’s Guide (2011), and it felt like balm to my CBT-crushed soul. The book is a treatment manual for practicing clinicians to deliver short-term, focussed, psychodynamic therapy for complex cases of depression and anxiety. (And they define short-term as 16 sessions! What would they call my 6 thirty-minute IAPT sessions I wonder?).
This is an interesting concept, because psychodynamic clinicians are usually allergic to manuals and time-constraints, seeing the complexity and variety of human nature as bound to doom any standardised approach to failure.
There are three key points about this kind of therapy that make it far more appealing to me than CBT.
Firstly, the importance given to interpersonal processes, both past and present. DIT structures itself around an Interpersonal-Affective Focus (IPAF), which it does by identifying one dominant and recurring unconscious interpersonal pattern. For example, an individual might find that, for whatever reason, they tend to see themselves as ‘a flawed woman’ and significant others as ‘critical and superior’, which, played out enough times in various relationships, would quite naturally lead to depressive symptoms. The logic behind this is the idea that because we are social animals that depend so strongly on others, most forms of psychological distress will likely be caused by, and then maintained, in some disrupted interpersonal functioning. Maybe we experience some form of interpersonal trauma, which then makes us fearful of getting emotionally close to someone, so we withdraw, but then feel lonely and depressed. From my limited clinical experience thus far, it does seem like the vast majority of psychological distress is usually due to, or resulting in, problems in relationships. Because of this focus, a key DIT technique involves working within the transference relationship, as this is a ‘live’ relationship in which those patterns are likely to surface, and hence can be a useful place to begin exploring those patterns in a safe and non-judgemental space.
Second, the attention to affect. To most fruitfully use the transference and countertransference processes that occur within the therapeutic relationship, DIT takes a far more detailed and exploratory approach to the individual’s affect on a moment-by-moment basis during the sessions, as these affects are likely to give important clues about their interpersonal patterns. The thought here is that the better able we are at identifying our affects, the more control we will have over them in future, as we might be able to shift the perspective and not get so wrapped up in the more automatic/unconscious affective patterns that might otherwise control us.
And third, the move away from symptoms and towards a more holistic view of what makes a life worth living. (The absence of symptoms does not a meaningful life make!) DIT understands symptoms as existing further along the line from where the problem started. Symptoms, such as anxiety or panic, might be manifestations of faulty interpersonal/affective patterns as they are enacted in situations that are not well suited to them, so are more like the tip of the iceberg. CBT approaches tend to treat panic symptoms as if that were the only thing going on in that person’s internal world (they might well be), whereas psychodynamic approaches are more interested in why and how that symptom started. They attend more to an individual’s underlying personality structure, which typically might not even bring a person into therapy in the first place (most of us take our personality as a given). The idea here is that by working at the deeper levels of human psychology, the therapeutic benefits will hopefully be more long-lasting, as the anxiety or panic won’t just pop up later on in another form. I think this narrow attention of CBT on presenting symptoms only, especially the low-intensity CBT in IAPT, might explain the 50% relapse rates (within a year) of the clients who ‘recover’. And we must not forget that those clients who ‘recover’ are only ~50% of those ‘completing’ treatment.
I’ll finish this post with a quote from the book summarising the main aims of DIT, being to:
- ‘Identify what he/she feels, encouraging the patient to stay with a current feeling as it emerges in the session.
- Communicate what he/she feels more effectively.
- Build greater facility in connecting his/her feelings, thoughts, and actions, and how these relate to others’ internal states and behaviour.
The therapist thus strives to help the patient to identify the way in which his/her feelings are guided by the particular self and other representation that is activated in a given relationship. The patient’s conscious affect, though important given that this is what the patient feel’s troubled by … may yet conceal latent affect that may be even more disturbing to the patient.’ (pg. 158).