Psychoanalysis · 2010
Dynamic Interpersonal Therapy (DIT)
Change occurs by making visible and mentalisable an unconscious interpersonal-affective pattern that links attachment threats to present symptoms.
Dynamic Interpersonal Therapy (DIT) is a brief, manualised psychodynamic protocol, originally developed for depression and organised in sixteen weekly sessions, which concentrates treatment on a recurrent and predominantly non-conscious interpersonal-affective pattern — the interpersonal-affective focus, or IPAF — linked to the onset or maintenance of the symptoms. The model integrates attachment theory, object relations, interpersonal psychoanalysis and mentalising in order to understand how internalised representations of oneself in relation to others, along with affects and defences, are reactivated in current relationships and in the therapeutic relationship. The therapist helps to connect symptoms, attachment threats and relational difficulties, formulates a circumscribed focus collaboratively, tracks its activation through interpersonal narratives and transference, encourages the identification of one's own and others' mental states, points out defences and repetitive patterns, and supports alternative ways of understanding and responding within relationships. The temporal structure is an active part of the work: sessions 1–4 are devoted to assessment and formulation, 5–12 to work on the IPAF, and 13–16 to separation, taking stock of the process and preparing for future vulnerabilities.
Theory of change
The person changes when they recognise the IPAF that organises their relationships, can mentalise the states of their own and others' minds that activate it, and try out less repetitive relational responses.
Core ideas
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Symptoms are understood in relation to interpersonal and attachment threats
DIT formulates depression and anxiety as responses that may emerge when current relational problems are experienced as threats of loss, separation, rejection or unavailability and therefore as threats to the self. This formulation shifts attention from the isolated symptom towards the interpersonal configuration that activates and maintains it, without reducing the aetiology of depression to a single psychological cause. (Lemma, Target & Fonagy, 2010, Psychoanalytic Psychotherapy; Fonagy et al., 2019, Psychological Medicine).
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The IPAF turns a broad dynamic psychotherapy into a focal treatment
DIT's technical identity depends on selecting a dominant, repetitive interpersonal-affective pattern connected with the symptoms and making it the shared focus of the treatment. The IPAF integrates representation of the self, representation of the other, affects and defences, and allows a sixteen-session treatment to maintain clinical continuity without attempting to encompass the whole personality or the whole biography of the patient. (Lemma, Target & Fonagy, 2010, Psychoanalytic Psychotherapy; Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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Self–other representations organise interpersonal repetition
DIT takes from object relations the idea that the person brings to current relationships internalised configurations of themselves in relation to others that steer expectations, affects and responses. When a configuration is activated rigidly, the patient may select, interpret or respond to situations in ways that recreate precisely the relationship they fear, reinforcing the distress and the apparent certainty of their interpersonal model. (Lemma, Target & Fonagy, 2010, Psychoanalytic Psychotherapy; Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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Affect is part of the pattern's structure, not an accompaniment to the account
The IPAF is interpersonal and affective because representations of self and other acquire clinical force by activating concrete feelings and defences intended to manage those feelings. DIT follows affect in the here and now, helps to recognise unverbalised emotions and links what is felt with what is thought and done, so that the pattern can be lived and understood rather than reduced to an intellectual explanation. (Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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Mentalising widens the capacity to respond to interpersonal conflicts
DIT assumes that intense activation of attachment and affect can impair the capacity to think flexibly about one's own mind and the other's. The treatment promotes curiosity, the differentiation of facts from inferences and the consideration of alternative perspectives, allowing the patient to understand better what happens when the IPAF is activated and to have more options before reacting automatically. (Lemma, Target & Fonagy, 2010, Psychoanalytic Psychotherapy; Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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The present takes priority over an exhaustive reconstruction of the past
Early experiences matter because they contextualise the relational representations operating in adult life, but DIT devotes its limited time to how those configurations appear in current relationships and in the session. The past is used to give historical coherence to the focus, while most of the work is directed at present interpersonal functioning and at current opportunities for change. (Lemma, Target & Fonagy, 2010, Psychoanalytic Psychotherapy; Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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Transference offers a live sample of the IPAF and a bridge towards external change
DIT uses the therapeutic relationship to observe how the patient recreates expectations, self–other positions, affects and defences that also appear outside the consulting room. Transference interpretation is used selectively and then connected with current relationships, so that the knowledge generated in session can become greater freedom to respond differently in everyday interpersonal life. (Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy; UCL CORE, Specific analytic and dynamic techniques).
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Interpretation is a collaborative and revisable process
Interpretations are built gradually through clarification, confrontation, observation of the transference and attention to non-conscious communications; they are offered as hypotheses, how they were arrived at is explained, and the patient's response is assessed. The possibility that an interpretation is inaccurate or badly timed is part of the method, so receptiveness to criticism and repair of the alliance are technical competences, not concessions external to dynamic work. (UCL CORE, Specific analytic and dynamic techniques; Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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Brevity demands greater focus and therapist activity
DIT was designed so that psychodynamic therapists could work coherently within a limit of sixteen sessions. Brevity translates into early focal formulation, frequent reference to the IPAF, flexible use of expressive and supportive techniques, a greater readiness to ask questions and redirect, and explicit support for relational change, while at the same time maintaining attention to the unconscious meaning the therapist's activity may acquire. (Lemma, Target & Fonagy, 2010, Psychoanalytic Psychotherapy; Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy).
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The end of treatment is an active phase of elaboration
The time limit means that separation and loss form part of the clinical material from the outset and become an explicit focus during the final four sessions. Reactions to the ending may reactivate the IPAF and show defences or attachment expectations with particular clarity; working with them makes it possible to review change, recognise vulnerabilities and consolidate an understanding the patient can keep after finishing. (Lemma, Target & Fonagy, 2011, Brief Dynamic Interpersonal Therapy; UCL CORE, Specific analytic and dynamic techniques).
Influences
- Attachment theory
- Object relations theory
- Harry Stack Sullivan's interpersonal psychoanalysis
- Mentalising theory
- Transference-Focused Psychotherapy (TFP)
- Supportive-Expressive Therapy
- The Psychodynamic Competences Framework
Key references
- Lemma, A., Target, M., & Fonagy, P. (2010). The development of a brief psychodynamic protocol for depression: Dynamic Interpersonal Therapy (DIT). Psychoanalytic Psychotherapy, 24(4), 329–346. https://doi.org/10.1080/02668734.2010.513547
- Lemma, A., Target, M., & Fonagy, P. (2011). Brief Dynamic Interpersonal Therapy: A Clinician’s Guide. Oxford University Press. ISBN 978-0-19-960245-2.
- Lemma, A., Target, M., & Fonagy, P. (2011). The development of a brief psychodynamic intervention (Dynamic Interpersonal Therapy) and its application to depression: A pilot study. Psychiatry, 74(1), 41–48.
- Fonagy, P., Lemma, A., Target, M., O’Keeffe, S., Constantinou, M. P., Ventura Wurman, T., Luyten, P., Allison, E., Roth, A., Cape, J., & Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine. https://doi.org/10.1017/S0033291719000928
- Lemma, A., Roth, A. D., & Pilling, S. (2008). The competences required to deliver effective Psychoanalytic/Psychodynamic Therapy. University College London, Centre for Outcomes, Research and Effectiveness.
- UCL CORE. Specific analytic and dynamic techniques. Competence framework for psychoanalytic/psychodynamic therapy.
- Lemma, A. Dynamic Interpersonal Therapy (DIT) for Depression: What skills can service users expect their therapists to have? Tavistock & Portman NHS Foundation Trust.