Atlas›Domain I · Psychodynamic & depth psychology›Guide 072
Guide I-072

Dynamic interpersonal therapy

Alessandra Lemma, Mary Target, Peter Fonagy2009UK
A 30 · L 56 · M 1422 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Lemma, Target & Fonagy (2011), Brief Dynamic Interpersonal Therapy: A Clinician's Guide (OUP), the standard 16-session, three-phase model for depression, as operationalised in the competence framework of Lemma, Roth & Pilling and in the NHS (HEE) DIT curriculum, which states that it is built on the 2011 book (itself a revision of the 2009 UCL manual). Variants not followed here: a 2017 manual (2nd edn, cited in trial papers but unpublished), the 2024 OUP 2nd edition, the 12-session version (only for therapists with one year post-accreditation practice), and DIT for Complex Care (28 sessions). [source: HEE curriculum; Anna Freud FAQs; Fonagy et al. 2020; OUP 2nd edn pages]

Dynamic Interpersonal Therapy (DIT) is a brief, manualised psychodynamic therapy for depression, and secondarily for anxiety. Developed by Alessandra Lemma, Mary Target and Peter Fonagy, it was built from the competences shared by evidence-based brief psychoanalytic and psychodynamic treatments, and it draws on attachment theory, object relations, interpersonal theory and mentalizing. In this model, depressive symptoms are reactions to threats to attachment and to recurring interpersonal difficulties. These difficulties are organised by a largely non-conscious, repetitive pattern of relating: a view of self, a view of others, and the feeling that links them. The pattern is identified jointly with the patient as the Interpersonal-Affective Focus (IPAF). Change is expected to come from two linked processes. The first is linking symptoms to the IPAF as it shows up in current relationships, including the relationship with the therapist. The second is strengthening the patient's capacity to mentalize, meaning to reflect on their own and others' states of mind, especially under emotional pressure. Together these let the patient step outside the pattern and relate differently to key attachment figures. [source: HEE curriculum (theory and aims); Lemma, Target & Fonagy 2013 abstract; BACP 2017 article]

2. Framework

Format. 16 individual sessions, held weekly (the curriculum refers to weekly measure data). One trial delivered them over about 5 months. Session length is not stated in the sources; 50 minutes is the usual psychodynamic hour [uncertain]. PHQ-9 and GAD-7 are completed each session and the scores are discussed with the patient. Supervision is based on recordings. [source: Lemma, Target & Fonagy 2011 pilot abstract; Fonagy et al. 2020 abstract; HEE curriculum]

Phase 1. Initial / engagement and assessment phase (sessions 1–4)

  • Goals:
    • assess depression severity, risk, overall functioning and suitability;
    • engage the patient and introduce the DIT rationale;
    • elicit and elaborate narratives of past and present relationships;
    • identify one dominant recurring pattern linked to the depression (the IPAF);
    • share it with the patient and negotiate it;
    • agree interpersonal goals tied to it.
  • The IPAF is typically shared around session 4. [source: UCL CORE DIT page (session ranges); HEE curriculum (tasks); Welldoing article (IPAF shared in session 4); BACP 2017]
  • Criteria for moving on [synthesis, drawn from the listed tasks]:
    • a working IPAF is articulated in the patient's own words and imagery;
    • the patient recognises it at least partly, in more than one relationship;
    • one or two concrete, realistic interpersonal goals are agreed;
    • risk has been assessed and a management plan agreed.
  • The IPAF stays provisional and is refined in the middle phase. Titrate how much of it you share to what the patient can manage. [source: BACP 2017]

Phase 2. Middle phase (sessions 5–12)

  • Goals:
    • link recent events, including events in the therapy, and current mood to the IPAF;
    • make the costs and benefits of keeping the pattern explicit;
    • work on the defences and conflicts that maintain it, including in the transference;
    • strengthen mentalizing about IPAF-related situations;
    • translate the IPAF into concrete interpersonal change towards the goals.
  • The IPAF is the “spine” of this phase. Of the three phases, it is the closest to ordinary psychodynamic therapy. [source: HEE curriculum; BACP 2017]
  • Preparation for the goodbye letter begins around session 12. [source: BACP 2017]

Phase 3. Ending phase (sessions 13–16)

  • Goals:
    • work with the feelings and fantasies stirred up by ending;
    • recognise the risk of reverting to the IPAF, and the associated relapse risk;
    • review progress, including disappointments;
    • anticipate future challenges;
    • deliver the goodbye letter and revise it together.
  • A draft letter is brought to session 13. [source: HEE curriculum; BACP 2017; UCL CORE page]
  • The ending date is fixed from the start; the session count is not extended [synthesis: implied by the time-limited model]. Ending themes are addressed from the outset, not only in this phase. [source: HEE curriculum]

Patient fit.

  • Positive indicator: the patient links their depression to childhood or family experience and senses that something repeats without their awareness. [source: HEE curriculum]
  • The patient also needs openness and curiosity about their inner life. [source: Welldoing (DIT practitioner)]
  • DIT can be offered first-line, or as a step-up or step-across after CBT or counselling. [source: HEE curriculum]
  • A practitioner source advises against DIT for significant drug or alcohol problems or very complex presentations; the book's suitability chapter is not drawn on [uncertain]. For complex and chronic presentations the 28-session DIT-CC exists. [source: Welldoing; Anna Freud FAQs]

3. Guiding principles

[source for this section: HEE curriculum competence list (based on Lemma, Target & Fonagy 2011), unless tagged otherwise]

  • Stay on the IPAF. Every intervention should connect to the agreed pattern; material that does not connect is noted but not pursued.
  • Mind over behaviour. Ask about the thoughts, feelings and intentions behind an event (the patient's and the other person's), not only what happened.
  • Here-and-now, recent and affective. Prioritise current feelings in the session and recent interactions, including with you, over distant history. The past is built into the IPAF but is not routinely interpreted. [source: HEE; BACP 2017]
  • Involved, empathic stance. Be warm and visibly engaged. The patient should feel that you are actively thinking about their mind.
  • Active and collaborative. Make decisions jointly (focus, goals, the letter) and explain your reasoning openly. You speak more than in open-ended therapy.
  • Curious, non-judgmental, “not-knowing”. Ask rather than tell; treat your hypotheses about minds as provisional, and model that minds are opaque.
  • Mentalizing stance. Keep emotional arousal in a range where reflection is possible. When mentalizing collapses, restore it before you interpret.
  • Direct and transparent. Name the formulation, the process and the questionnaire results openly, invite feedback, and answer requests for clarification without defensiveness.
  • Respect defences. Name defences and the investment in old patterns and explore their costs. Brief work does not aim to dismantle defences. [source: BACP 2017]
  • Use the relationship as data. Treat the patient's reactions to you and your own feelings as evidence about the IPAF. Note them privately first, and raise them when that would help.
  • Own your enactments. When you are pulled into the pattern, acknowledge your part before you interpret the patient's.
  • Time is part of the treatment. Keep the ending visible from session 1, and treat reactions to time limits as IPAF material.
  • Measure and use the measures. Score session measures every week, link changes in scores to interpersonal events, and adjust the work if the patient deteriorates.
  • Realistic scope. Set goals the patient can reach in 16 sessions, and say clearly what the therapy will not address.
  • Directive work in service of the focus. Structuring and directive moves are for gathering IPAF material and supporting change. They do not instruct the patient in how to change.

4. Intervention inventory

The framework names its competences, but the sources give no scripted procedure for them. The steps below set out each named competence in workable form. Steps marked [synthesis] are my operational detail. Example language is illustrative throughout and is never founders' wording. Main source: the HEE DIT curriculum competence list (based on Lemma, Target & Fonagy 2011). The book's chapters on Techniques, Working in the transference and When things go wrong are not drawn on, so the finer technical detail in them is not reflected here [uncertain].

A. Initial phase (sessions 1–4)

4.1 Assessment of severity, risk and functioning

  • Purpose / when: Session 1, then reviewed weekly. Establishes whether DIT is appropriate and safe, and gives a baseline. [source: HEE II.2]
  • Steps:
    1. Take the patient's account of the current depressive episode: onset, triggers, somatic signs, hopelessness and self-image. [source: HEE I.1]
    2. Score PHQ-9 and GAD-7, plus any service measures.
    3. Complete a standard suicide and self-harm risk assessment following your service protocol.
    4. Note any co-occurring anxiety, trauma, personality difficulties or substance misuse, and explain to the patient that the work will focus on the depression. [source: HEE I.1]
    5. Agree a risk plan with the patient, and involve the GP or wider team where indicated. [source: HEE II.2]
    6. Assess threats to collaboration, such as ambivalence about attending or a history of dropping out. [source: HEE II.2]
  • Example language (illustrative): “Before we look at relationships, I need a clear picture of how low things have got, including whether you've had thoughts of ending your life.”
  • Watch for: Risk that needs a higher level of care. A presentation dominated by substance misuse or crisis. Using the assessment to avoid relational material. Working when the patient can describe their current state and has a shared safety plan.

4.2 Introducing DIT using live material

  • Purpose / when: Sessions 1–2. Helps the patient understand the rationale and engage with it. [source: HEE II.4]
  • Steps:
    1. Explain the frame: 16 sessions in three phases, weekly measures, a shared focus, and a letter at the end. [source: HEE; BACP 2017]
    2. Pick an interpersonal moment the patient has just described and show how it connects to mood. This illustrates the model better than an abstract explanation. [source: HEE II.4]
    3. Invite questions, and respond without defensiveness, including to questions about the questionnaires. [source: HEE II.4]
  • Example language (illustrative): “You said your mood dropped on Sunday after your sister didn't call back. That's the kind of link we'll look at: how what happens between you and the people who matter affects how you feel.”
  • Watch for: The patient agreeing politely without real interest; sounding like a lecture. It is working when the patient starts bringing in their own relationship-mood links.

4.3 Eliciting and elaborating interpersonal narratives

  • Purpose / when: Sessions 1–4. Gathers the raw material for the IPAF. [source: HEE II.3]
  • Steps:
    1. Map the patient's major current relationships (partner, family, work, friends) and key past ones, especially early attachment figures. [source: HEE]
    2. For each, ask for a specific recent episode rather than a generalisation. [synthesis]
    3. Clarify and restate: who did what, what each person felt and wanted, and how it ended. [source: HEE II.3]
    4. Point out repetitions across relationships as you notice them. [source: HEE II.3]
    5. Bring the patient back gently to relationships if the narrative drifts. [source: HEE]
    6. With withdrawn or less psychologically minded patients, start with neutral topics and build up. [source: HEE II.4]
  • Example language (illustrative): “Can you take me through that evening with your partner, moment by moment? What did you notice yourself feeling when he went quiet?”
  • Watch for: Global summaries such as “people always let me down” with no episodes behind them; only the past being discussed; vivid images and phrases worth reusing in the IPAF. [source: BACP 2017 (idiosyncratic language)]

4.4 Attachment assessment

  • Purpose / when: Initial phase. Gives a picture of the patient's attachment style, which informs the IPAF and how separation sensitive the ending may be. [source: BACP 2017]
  • Steps:
    1. Ask about early caregivers, losses and separations. [source: HEE I.2]
    2. A practitioner source describes using the Bartholomew & Horowitz Relationship Questionnaire. Whether the 2011 manual requires it is unconfirmed [uncertain].
    3. Note likely style (autonomous, dismissing, preoccupied or unresolved) as a hypothesis, not a label. [source: HEE theory section]
    4. Note early how the patient handles separations, including breaks between sessions. [source: HEE II.12]
  • Example language (illustrative): “When you were small and upset, who did you go to, and what usually happened?”
  • Watch for: Dismissing patients who play down how much relationships matter; preoccupied patients flooded by attachment material.

4.5 Using the relationship and countertransference as formulation data

  • Purpose / when: From session 1. The pattern often shows up with the therapist before the patient can describe it. [source: HEE II.3]
  • Steps:
    1. Note how the patient relates to you: deferential, testing, dismissive, needy.
    2. Note your own pulls, such as feeling inadequate, bored, protective or controlling, as possible signs of the IPAF or of a barrier to progress. [source: HEE]
    3. Record these privately. Do not interpret them in the initial phase unless they are blocking the work. [source: HEE II.3 (noted without immediately discussing)]
    4. Feed them into the self, other and affect hypotheses for the IPAF.
  • Example language: none in session at this stage. Internal note (illustrative): “I keep feeling I'm failing her, as her mother did.”
  • Watch for: Acting on the pull, for example by rescuing or withdrawing, before you've thought about it.

4.6 Formulating the IPAF

  • Purpose / when: Built across sessions 1–4. The single focus that organises the treatment. [source: HEE; BACP 2017]
  • Components:
    • a representation of self;
    • a representation of the other;
    • the affect that links them;
    • the defensive function of the pattern, meaning the conflict it manages and its costs and gains. [source: HEE I.3 and theory section; BACP 2017] The 2011 book lists “defensive function” as a distinct fourth component; this is [uncertain].
  • Steps:
    1. Out of the episodes you have gathered, pick the one dominant, recurring pattern that is most closely linked to the depression. [source: HEE II.3]
    2. Phrase the self, the other and the affect in the patient's own words and imagery; vivid language makes the focus more usable. [source: BACP 2017]
    3. Check that it generalises: it should be rooted in early relationships and visible across several current relationships, potentially including the one with you. [source: BACP 2017; HEE]
    4. Identify what the pattern protects against (its defensive function) and what it costs. Example: a victim role brings sympathy but keeps the distress going. [source: HEE I.3]
    5. Optionally, place it on the 2023 typology (hostile or friendly, combined with dominant or submissive). This is a research aid, not part of the 2011 version. [source: McFarquhar, Luyten & Fonagy 2023 abstract]
  • Example IPAF (illustrative): “I'm the afterthought nobody notices / others are wrapped up in their own needs / I feel hurt and resentful, but I keep quiet and do more, which protects me from the risk of asking and being refused, and leaves me feeling invisible.”
  • Watch for:
    • several competing patterns (choose one);
    • a list of traits with no relationship in it;
    • a pattern so general it fits everyone;
    • a pattern the patient cannot recognise anywhere in their life.

4.7 Sharing, titrating and negotiating the IPAF

  • Purpose / when: Around session 4. Turns the formulation into a shared focus. [source: Welldoing; HEE II.3]
  • Steps:
    1. Offer the pattern tentatively, using one or two recent episodes as evidence.
    2. Ask for the patient's view, invite corrections, and revise the wording together. [source: HEE II.3; BACP 2017]
    3. Adjust how much you share, especially of the defensive function, to what the patient can bear. [source: BACP 2017]
    4. Agree that the pattern is the working focus and will be refined as you go. [source: BACP 2017]
    5. Writing it down is optional [uncertain: not specified in the sources].
  • Example language (illustrative): “Here's a picture I've been forming, and I want you to tell me what fits and what doesn't. Again and again you seem to end up feeling like an afterthought. Others seem caught up in their own lives, and you feel hurt but say nothing. Does that ring true?”
  • Watch for: Compliant agreement versus genuine recognition. Recognition looks like the patient adding examples of their own. Feeling criticised, which calls for titrating further.

4.8 Agreeing interpersonal goals

  • Purpose / when: Session 4, revisited during the middle phase. Ties the focus to change the patient wants. [source: HEE II.5]
  • Steps:
    1. Agree the highest-priority interpersonal problems linked to the depression.
    2. Frame the IPAF as an obstacle to something the patient values.
    3. Name the conflicts and defences that will make change difficult.
    4. Set one to three goals that are concrete, realistic and achievable in 12 more sessions. [source: HEE II.5]
    5. Say what the therapy will not tackle, and acknowledge other pressing concerns. [source: HEE II.5]
  • Example language (illustrative): “If this pattern loosened a little, what would be different with your brothers by the end of our sessions?”
  • Watch for: Goals about other people changing; goals about symptoms only; goals far too large.

4.9 Routine outcome monitoring as a clinical intervention

  • Purpose / when: Every session. Tracks progress, connects mood to events and gives a window onto the relationship. [source: HEE II.11; pilot study]
  • Steps:
    1. Have the patient complete PHQ-9 and GAD-7 at the start of each session; score and interpret them.
    2. Share the results, and link changes to interpersonal events, therapy events and the IPAF.
    3. If scores deteriorate, review risk and negotiate changes to the work.
    4. Explore what the way they fill in the forms says about the relationship, for example minimising, or scoring high so as to be noticed. [source: HEE II.11]
  • Example language (illustrative): “Your score went up this week, the same week your manager overlooked you. Does that connect?”
  • Watch for: Treating the measures as admin. Within the IPAF, the measures themselves carry meaning.

B. Middle phase (sessions 5–12)

4.10 Tracking the IPAF and linking events and mood to it

  • Purpose / when: Every middle-phase session. This is the core move of the phase. [source: HEE II.6]
  • Steps:
    1. Open with the measures and with what has happened since the last session. [synthesis, from HEE II.11]
    2. Listen for the IPAF in each narrative, whether the patient tells it as self, as other, or with the roles reversed. [source: HEE II.6; BACP 2017 (role reversal in case example)]
    3. Pick one episode in which the pattern is clearly active.
    4. Name the link in the patient's own IPAF words, then ask whether it fits.
    5. Connect the episode to any change in mood or scores that week.
  • Example language (illustrative): “That sounds like the afterthought feeling again: the meeting went ahead without you, and you went home and said nothing. Is that what happened inside?”
  • Watch for:
    • Linking so mechanically that it sounds like a slogan.
    • Missing role reversals, where the patient treats someone else as an afterthought.
    • When it is working, the patient begins to spot the pattern themselves, at first afterwards and later as it happens.

4.11 Clarification and elaboration of mental states in specific interactions

  • Purpose / when: Whenever a narrative is vague or focused on behaviour. Fills in the minds behind events. [source: HEE II.6, II.7, II.9]
  • Steps:
    1. Slow the story down to a single moment.
    2. Ask what the patient felt and thought at that point, and what they assumed the other person felt and wanted.
    3. Draw out the non-conscious assumptions behind those reactions. [source: HEE II.6]
    4. Ask what alternative motives the other person might have had, and what else the patient might have done. [source: HEE II.9]
  • Example language (illustrative): “When she looked at her phone, what did you make of it? … What else might have been going on for her?”
  • Watch for:
    • Answers that are all behaviour (“then I left”).
    • Certainty about what the other person meant.
    • When it is working, the patient begins to talk in mental-state words of their own accord.

4.12 Making costs and benefits of the pattern explicit; working with defences

  • Purpose / when: Once the patient recognises the IPAF. Brings into view why the pattern persists and what holds the patient in it. [source: HEE II.6, I.3; BACP 2017]
  • Steps:
    1. Ask what the pattern protects the patient from, for example the risk of rejection.
    2. Ask what it gains them, for example moral high ground, safety or sympathy.
    3. Ask what it costs them, for example isolation, resentment and low mood.
    4. Name the conflict, such as wanting to be seen against fearing a refusal.
    5. Treat the defence with respect. The aim is awareness and choice, not dismantling it. [source: BACP 2017]
  • Example language (illustrative): “Staying quiet means nobody can turn you down, and that makes sense. The price seems to be that nobody knows what you need. What's that like to look at?”
  • Watch for:
    • Shame, or hearing the intervention as blame. Validate the feeling first.
    • Intellectual agreement with no felt shift.

4.13 The balanced mentalizing sequence

  • Purpose / when: In emotionally charged IPAF moments, both outside the session and in the room. [source: HEE II.9, which gives a prescribed sequence]
  • Steps:
    1. Recognise and validate the patient's current emotional state.
    2. Build curiosity about motives, both the patient's and other people's, and about other ways the patient could have reacted.
    3. Clarify and elaborate the feelings in one specific IPAF scenario. Stay close to the pattern even when the patient is highly aroused.
    4. Connect actions to the mental states and emotions that produced them.
    5. Offer your own perspective as an alternative account of the same event.
    6. If the conversation, including with you, has become non-mentalizing, steer back to current thoughts and feelings and restore a reflective exchange.
  • Example language (illustrative): “You're furious, and it makes sense that you would be. … Let's go back to the moment he cancelled. What did it mean to you? … I wonder whether he was anxious too. That's my guess and you know him better, but how does it land?”
  • Watch for:
    • Offering your perspective before you have validated the patient's state.
    • Arousal so high that curiosity is out of reach. Go back to validation.

4.14 Recognising and responding to non-mentalizing discourse

  • Purpose / when: Whenever reflection collapses, which is common in depression and under emotional arousal. [source: HEE I.3, theory section]
  • Steps:
    1. Look for these markers:
      • concrete, bodily accounts of distress, where psychological pain is experienced as physical;
      • certainty about what is in other people's minds;
      • all-or-nothing statements with no room for ambivalence;
      • fluent but empty pseudomentalizing or hypermentalizing. [source: HEE]
    2. Do not interpret into the collapse. Lower arousal, slow the pace, and ask simple, specific questions about mental states. [synthesis, consistent with HEE II.9]
    3. Challenge pseudomentalizing by asking for a concrete example and the feeling that went with it. [synthesis]
    4. Once reflection is back, link the collapse to the IPAF trigger.
  • Example language (illustrative): “You sound very sure what she thinks of you. Let's slow down. What exactly did she say?”
  • Watch for: Long, polished explanations with no feeling in them, which is pseudomentalizing. When it is working, the patient can hold more than one possible view and shows some doubt.

4.15 Working in the transference

  • Purpose / when: When the IPAF shows up in the relationship with you, and the timing allows it to be explored. [source: HEE II.8; BACP 2017; Tavistock record of book ch. 8]
  • Steps:
    1. Notice IPAF-like moments with you: lateness, “yes, but” responses, compliance, feeling overlooked when you check the time.
    2. Explore with clarification and elaboration before you interpret. Ask what the patient experienced in that moment with you. [source: HEE II.8]
    3. Link the moment to the IPAF, staying in the here-and-now.
    4. Offer a transference interpretation tentatively. Keep it tied to the focus rather than to wider unconscious themes. [source: BACP 2017; HEE]
    5. Invite the patient's response, and ask how the same thing plays out with others.
    6. Use the IPAF to make sense of misunderstandings between you. [source: HEE II.8]
  • Example language (illustrative): “When I suggested you might speak to your brother, you said ‘yes, but’ and went quiet. I wonder if it felt as though I too was putting my agenda ahead of yours, as if you were an afterthought here as well.”
  • Watch for:
    • Interpreting while the patient is too aroused to reflect.
    • Using the transference to avoid outside relationships.
    • When it is working, the patient recognises the pattern “live” and can stay with it.

4.16 Managing enactments and ruptures

  • Purpose / when: When you have been drawn into the IPAF, or when the alliance strains: you forget something, act impatiently, or the patient withdraws or attacks. [source: HEE II.8]
  • Steps:
    1. Recognise your own enactment, for example overlooking something the patient raised.
    2. Acknowledge it openly and without defensiveness, and model reflecting on your own mind.
    3. Ask how it affected the patient, and engage with their response.
    4. Only then consider a transference interpretation that links the episode to the IPAF. [source: HEE II.8]
  • Example language (illustrative): “I think I moved past what you said about your father too quickly last week. I'm sorry about that. I wonder how that felt, given how often you feel unheard.”
  • Watch for: Interpreting before you've acknowledged your part, which can feel blaming. Apologising so much that the patient ends up looking after you. When it is working, the patient can voice negative feelings directly to you, which is itself a change in the pattern.

4.17 Supportive, expressive and directive techniques

  • Purpose / when: DIT combines all three classes of technique and selects among them according to the patient's state and capacity. [source: HEE I.4; Tavistock record of book ch. 7]
  • Supportive [examples are synthesis; not itemised in the sources]:
    • empathic validation;
    • acknowledging strengths;
    • encouragement and realistic hope;
    • structuring. Use when the patient is fragile, ashamed or highly aroused.
  • Expressive:
    • clarification;
    • elaboration;
    • challenge of contradictions;
    • interpretation of conflict and defence linked to the IPAF;
    • transference work (4.15). [source: HEE II.6, II.8; the challenge item is synthesis] Use when the patient can reflect.
  • Directive:
    • keeping sessions on the focus;
    • asking for specific episodes;
    • setting the agenda for review. In DIT, directive moves serve to gather IPAF material, not to tell the patient how to change. [source: HEE I.4]
  • Steps [synthesis]:
    1. Gauge arousal and capacity to reflect.
    2. If arousal is high, use supportive moves first. If the patient is reflective, move to expressive work.
    3. Use directive moves to bring drifting material back to the focus.
  • Example language (illustrative), directive: “Let's hold that thought about work. Can you give me one moment this week when the afterthought feeling was strongest?”
  • Watch for:
    • Drifting into advice-giving or coaching.
    • Becoming so supportive that the pattern never gets examined.

4.18 Encouraging interpersonal change

  • Purpose / when: From the middle of this phase onward, once the pattern is recognised. Turns insight into new behaviour with key attachment figures. [source: HEE II.10]
  • Steps:
    1. Revisit the agreed IPAF goals.
    2. Explore how the patient might relate differently to one key attachment figure in a specific upcoming situation.
    3. Plan it before the next session. This is a jointly planned step that the patient owns, not a prescribed homework assignment. [source: HEE II.10; sources do not describe formal homework]
    4. Next session, review what happened and what each person felt, and link it to the IPAF.
    5. Watch for, and explore, the patient's reactions to your more active stance, such as passivity, withdrawal or compliance. [source: HEE II.10]
  • Example language (illustrative): “You said Sunday lunch is when you usually feel invisible. Is there one small thing you might try differently this time, and what are you afraid would happen if you did?”
  • Watch for:
    • The patient doing it to please you, which repeats the IPAF in the transference.
    • Avoidance.
    • When it is working, the patient reports small new behaviours and others respond differently.

C. Ending phase (sessions 13–16), with ending work starting at session 1

4.19 Working with the ending from the outset

  • Purpose / when: From the assessment onward, then intensively in sessions 13–16. Endings are attachment events that are likely to activate the IPAF. [source: HEE II.12; BACP 2017]
  • Steps:
    1. Assess the patient's sensitivity to separation early, through attachment history and reactions to breaks. [source: HEE II.12]
    2. Name the remaining number of sessions at regular points. [synthesis]
    3. Explore feelings, fantasies and anxieties about ending systematically. Typical ones are being dropped, being an afterthought, relief, and anger. [source: HEE II.12; BACP 2017]
    4. Link these reactions to the IPAF.
  • Example language (illustrative): “We have four sessions left. I wonder if part of you is already expecting to be forgotten once we stop, the way it's happened before.”
  • Watch for: Missed sessions and early “I'm fine now” endings, which can be the pattern being enacted. When the work is going well, the patient can talk directly about what the ending means to them.

4.20 Recognising and linking end-phase deterioration

  • Purpose / when: In sessions 12–16, if scores or symptoms rise. A rise in symptoms around the ending was observed in the pilot study. [source: Lemma, Target & Fonagy 2011 pilot abstract; HEE II.12]
  • Steps:
    1. Review the scores alongside the patient.
    2. Reassess risk.
    3. Explore whether the rise is linked to the ending and to the IPAF, and say so if it is. [source: HEE]
    4. Distinguish a reaction to the ending from a real relapse that needs further care. [synthesis]
  • Example language (illustrative): “Your scores have gone up as we approach the end. I don't think it means the work has been undone. It may be the old feeling of being let go of. What do you make of it?”
  • Watch for: You rushing to offer more sessions, which may enact a rescue; dismissing a real relapse.

4.21 Reviewing the therapy, including disappointment

  • Purpose / when: Sessions 13–16. Consolidates gains and lets the patient voice what was not achieved. [source: HEE II.12]
  • Steps:
    1. Go back over the IPAF and the goals: what has shifted and what has not.
    2. Invite disappointment and criticism directly, and respond without defensiveness. [source: HEE II.12]
    3. Anticipate future triggers and how the IPAF is likely to resurface. Agree early warning signs and what the patient will do when they appear. [source: HEE (anticipate future challenges); details are synthesis]
  • Example language (illustrative): “What hasn't changed that you hoped would? It matters that you can tell me that.”
  • Watch for: An idealised review with no disappointment voiced, especially in compliant IPAFs.

4.22 The goodbye letter

  • Purpose / when: Drafted by the therapist for session 13, with preparation from around session 12, then revised with the patient. It records the work and serves as a transitional object for consolidation and relapse prevention. A practitioner source notes that the letter is borrowed from cognitive analytic therapy. [source: BACP 2017; HEE II.12; Welldoing]
  • Steps:
    1. Write a draft, addressed to the patient in plain language, covering:
      • why they came and the relevant background;
      • the IPAF and the coping strategies they used;
      • the changes achieved;
      • the unfinished work and likely future pressures. [source: BACP 2017]
    2. Include something about the therapeutic relationship and how the IPAF appeared in it. [source: Welldoing]
    3. Present the letter as a draft in session 13, either reading it together or giving it to the patient to take away. Which of these the manual specifies is not confirmed [uncertain].
    4. Invite the patient's corrections and additions, including their own perspective, and revise until you reach an agreed understanding. [source: HEE II.12; BACP 2017]
    5. Give the patient the final version before the last session. [synthesis]
  • Example language (illustrative), letter opening: “Dear Peter, when we first met you described feeling like an afterthought in your family…”
  • Watch for:
    • Jargon.
    • A letter that tells only a success story.
    • The patient's reaction to being written about, such as feeling seen or feeling exposed, which is itself material.
    • When it is working, the patient can recognise themselves in the letter, and add to it.

5. Handling problems

The 2011 book has a chapter on difficulties (“When Things Go Wrong”), but its content is [uncertain]. Guidance tagged [source] comes from the HEE competence list or the BACP article. Everything tagged [synthesis] is my own, written to fit DIT principles.

  • Stuck: no IPAF emerges by session 4.
    • Ask for more specific recent episodes rather than summaries. [source: HEE II.3]
    • Use the pattern you see with the patient in the room. [source: HEE II.3]
    • Offer a provisional, narrower IPAF and agree to refine it. [source: BACP 2017 (IPAF as starting point)]
    • Do not extend the initial phase past session 4 or 5. [synthesis]
  • The patient rejects or cannot recognise the IPAF.
    • Ask what doesn't fit, and rebuild it in their words. [source: HEE II.3]
    • Share less of it, especially the defensive part. [source: BACP 2017]
    • Treat the rejection itself as data. Does disagreeing with you repeat the pattern? [synthesis]
  • Stuck in the middle phase: the IPAF is recognised but nothing changes.
    • Return to the costs and benefits and the hidden gains of staying the same. [source: HEE II.6; BACP 2017 (investment in old patterns)]
    • Check whether the goals are realistic and owned by the patient. [source: HEE II.5]
    • Plan one small, specific interpersonal step. [source: HEE II.10]
    • Use the weekly scores to review the work with the patient. [source: HEE II.11]
  • Resistance: “yes, but”, compliance, intellectualising.
    • Explore the response through clarification and elaboration before interpreting. [source: HEE II.8]
    • Name the defence respectfully, and ask what it protects. [source: BACP 2017]
    • For fluent but affectless talk, ask for one concrete moment and the feeling that went with it. [synthesis]
  • Overwhelm or affect flooding.
    • Recognise that mentalizing drops as arousal rises. [source: HEE]
    • Validate first. Slow the pace, narrow to a single moment, and use supportive moves. [source: HEE II.9; supportive detail is synthesis]
    • Do not use transference interpretations while the patient is in this state. [synthesis]
    • If flooding keeps recurring, review fit; DIT-CC may suit better. [synthesis; DIT-CC per Anna Freud FAQs]
  • Ruptures and enactments.
    • Acknowledge your part openly and without defensiveness, and model reflection on your own mind.
    • Engage with the patient's response before linking the rupture to the IPAF. [source: HEE II.8]
  • The patient reacts badly to the therapist being active, for example by becoming passive, withdrawn or compliant. Monitor this and explore it as IPAF material. [source: HEE II.10]
  • Non-adherence to planned interpersonal steps.
    • Do not push. Explore what made the step hard, and what the patient expected would happen if they took it. [synthesis]
    • Ask whether agreeing to it was itself compliance. [synthesis]
  • Missed sessions or lateness.
    • Not covered in the sources [uncertain].
    • Hold the 16-session frame, and treat missed sessions as communications linked to the IPAF. [synthesis]
    • After a missed session, contact the patient and check for risk. [synthesis]
    • Raise the miss in the next session, gently and with curiosity. [synthesis]
  • Deterioration or rising risk.
    • Review the scores and risk weekly, and negotiate changes to the work. [source: HEE II.11, II.2]
    • If there is acute suicide risk, follow standard risk assessment and service protocol. Involve the GP or crisis team, and step up care if needed; the focus can be paused. [source: HEE II.2 (involve networks); specifics are synthesis]
  • End-phase relapse or requests to continue.
    • Link the relapse to the ending. [source: HEE II.12; pilot abstract]
    • Keep the ending date. Discuss the request openly as IPAF material, and arrange onward referral or follow-up only on clinical grounds. [synthesis]
  • Co-morbidity pulls the focus away (for example trauma, personality difficulties, or substance misuse).
    • Acknowledge it and say clearly that this therapy focuses on the depression. [source: HEE I.1, II.5]
    • Refer on for the other problem where needed. [synthesis]
  • The patient wants advice or CBT-style tools.
    • Explain that DIT's directive moves serve the focus. [source: HEE I.4]
    • Explore what the wish for instructions means in IPAF terms. [synthesis]
    • If the patient's preference stays firm, consider a step-across referral. [source: HEE (step-across); application is synthesis]
  • Therapist difficulties. These include:
    • being too passive for a brief model;
    • drifting off the focus;
    • being pulled into rescuing. Use recorded supervision, roughly one hour per 12 clinical hours after accreditation. [source: Anna Freud FAQs; HEE] Use your countertransference as data. [source: HEE]

Sources

Sources

Books and papers cited (not drawn on in full)

  • Lemma, A., Target, M., & Fonagy, P. (2011). Brief Dynamic Interpersonal Therapy: A Clinician's Guide. Oxford University Press. This is the version followed.
  • Lemma, A., Target, M., & Fonagy, P. (2010). The development of a brief psychodynamic protocol for depression: Dynamic Interpersonal Therapy (DIT). Psychoanalytic Psychotherapy, 24, 329–346.
  • Lemma, A., Target, M., & Fonagy, P. (2011). The development of a brief psychodynamic intervention (DIT) and its application to depression: a pilot study. Psychiatry, 74(1), 41–48.
  • Lemma, A., Target, M., & Fonagy, P. (2013). DIT: Developing a new psychodynamic intervention for the treatment of depression. Psychoanalytic Inquiry, 33(6), 552–566.
  • Lemma, A., Roth, A. D., & Pilling, S. (2008/2009). The competences required to deliver effective psychoanalytic/psychodynamic therapy. UCL CORE.
  • Fonagy, P., et al. (2020). DIT for moderate to severe depression: a pilot RCT. Psychological Medicine, 50(6), 1010–1019.
  • McFarquhar, T., Luyten, P., & Fonagy, P. (2023). A typology for the IPAF in DIT. Psychotherapy, 60(2), 171–181.

Gaps [uncertain]:

  • The book chapters on Techniques, Working in the transference and When Things Go Wrong are not drawn on here.
  • The UCL competence PDFs are not drawn on here.
  • Session length, the exact procedure for presenting the goodbye letter, and the IPAF “defensive function” as a formal fourth component are unconfirmed in the sources.
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