1. health and fitness
2. therapy

Brief Dynamic Interpersonal Therapy for
Depression (DIT)
Competency Framework
September 2010
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IAPT Programme - Competency Framework for Interpersonal Psychotherapy
Introduction
This document details the competences that staff delivering
Brief Dynamic Interpersonal Psychotherapy for Depression
(DIT) need to demonstrate to work in IAPT services. The work
to derive these competences was commissioned by the
Improving Access to Psychological Therapies (IAPT)
programme.
The updated NICE Guidelines for Depression (available at
www.nice.org.uk) indicate that these therapies are all effective
treatments for depression. In November 2009, the IAPT
programme embraced this advice and committed to making
these therapies available in IAPT services.
The publication of the competency frameworks, for the
modalities additional to the previously published framework for
Cognitive Behavioural Therapy (CBT), is a key milestone for
the programme.
You can find out more about the Improving Access to
Psychological Therapies Programme and download all the
competency frameworks by visiting www.iapt.nhs.uk
While NICE recommends a range of interventions, based on a
wide-ranging evidence base, for the treatment of depression,
choice of therapy and treatment should be made at a local
level with the full involvement of the patient, supported by
good quality patient information.
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IAPT Programme - Competency Framework for Interpersonal Psychotherapy
Brief Dynamic Interpersonal Therapy for Depression (DIT)
Brief Dynamic Interpersonal Therapy (DIT) is a form of brief
psychodynamic psychotherapy developed for the treatment of
depression. Psychodynamic psychotherapy is a
psychological treatment that can help people with emotional
and relationship problems. It is also referred to as
psychoanalytic psychotherapy’.
thoughts and feelings (conscious and unconscious) as these
manifest in the context of the therapeutic relationship. In
practice active use is made of what happens in the
relationship between therapist and client in order to focus on
the client’s interpersonal difficulties.
DIT has a dual aim:
DIT is a 16 session psychodynamic treatment for depression
(Lemma, Target and Fonagy, in press). It has been explicitly
developed out of the Psychodynamic Competences
Framework (Lemma et al., 2008) (which also provided the
basis for the National Occupational Standards (NOS) for
psychological therapists practicing in the UK). The
Competences
Framework
describes
a
model
of
psychodynamic competences based on empirical evidence of
efficacy. It indicates the various areas of activity that, taken
together, represent good clinical practice.
The aim of DIT has been to identify common denominators of
a brief psychodynamic approach and to help practitioners
structure these around a focal unconscious conflict related to
the onset and/or maintenance of depression. DIT thus aims to
provide psychoanalytically/dynamically trained practitioners
with a structure within which to conduct a time-limited,
manualised psychodynamic therapy with depressed patients.
DIT conceptualises depression in terms of an underlying
temporary disorganization of the attachment system caused
by current relationship problems, which in turn generates a
range of distortions in thinking and feelings typical of the
depressive process. In the therapy a focus is maintained on
this emotional ‘crisis’ through an elaboration of the client’s
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a) to help the client understand the connection
between his presenting depressive symptoms and
what is happening in their relationships through
identifying a core, unconscious, repetitive pattern of
relating that becomes the focus of the therapy;
b) to encourage the client’s capacity to reflect on his
own states of mind and so enhance their ability to
manage interpersonal difficulties.
This
model
consists
of
three
phases:
an
engagement/assessment phase (sessions 1-4), a middle
phase (sessions 5-12) and an ending phase (sessions 13-16),
each one with its own distinctive strategies. Throughout the
therapy the therapist is active and aims to support
interpersonal changes that will resolve or alleviate the
depressive symptoms.
Lemma, A., Target, M., Fonagy, P. Dynamic Interpersonal
Therapy: A Clinician’s Guide (Oxford: OUP, in press)
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Why identify competences?
The IAPT programme involves delivering high quality
treatments, and this requires competent practitioners who are
able to offer effective interventions. Identifying individuals
with the right skills is important, but not straightforward.
Within the NHS, a wide range of professionals deliver
psychological therapies, but there is no single profession of
‘psychological therapist’. Most practitioners have a primary
professional qualification, but the extent of training in
psychological therapy varies between professions, as does
the extent to which individuals have acquired additional postqualification training. This makes it important to take a
different starting point, identifying what competences are
needed to deliver good-quality therapies, rather than simply
relying on job titles to indicate proficiency.
Clinicians need background knowledge relevant to their
practice, but it is the ability to draw on and apply this
knowledge in clinical situations that marks out competence.
Knowledge helps the practitioner understand the rationale for
applying their skills; to think not just about how to implement
their skills, but also why they are implementing them.
Beyond knowledge and skills, the therapist’s attitude and
stance to therapy are also critical – not just their attitude to the
relationship with the client, but also to the organisation in
which therapy is offered, and the many cultural contexts within
which the organisation is located (which includes a
professional and ethical context, as well as a societal one). All
of these need to be held in mind by the therapist, since all
have a bearing on the capacity to deliver a therapy that is
ethical, conforms to professional standards, and which is
appropriately adapted to the client’s needs and cultural
contexts.
The development of the competences needs to be seen in the
context of the development of National Occupational
Standards (NOS), which apply to all staff working in health
and social care. There are a number of NOS that describe
standards relevant to mental health workers, downloadable at
the Skills for Health website (www.skillsforhealth.org.uk).
---------------------------------A competent clinician brings together knowledge, skills and
attitudes. It is this combination that defines competence;
without the ability to integrate these areas, practice is likely to
be poor.
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Competency Map Explained
The Competency Map
The competency map for each of the modalities organises the
competences into a number of domains and shows the
different activities which, taken together, constitute each
domain. Each activity is made up of a set of specific
competences. The maps show the ways in which the
activities fit together and need to be ‘assembled’ in order for
practice to be proficient. The descriptions below give details of
the competences associated with each of these activities.
Generic Therapeutic Competences
Generic competences are employed in all psychological
therapies, reflecting the fact that all psychological therapies,
share some common features. For example, therapists using
any accepted theoretical model would be expected to
demonstrate an ability to build a trusting relationship with their
clients, relating to them in a manner that is warm, encouraging
and accepting. They are often referred to as ‘common factors’.
Metacompetences
Metacompetences are common to all therapies, and broadly
reflect the ability to implement an intervention in a manner
which is flexible and responsive. They are overarching,
higher-order competences which practitioners need to use to
guide the implementation of therapy across all levels of the
model.
Competence Map Key:
- The competences in each of the framework maps are colour coded
under each of the headings above.
- The maps outline the competences under each heading and also group
some key competences, that are fundamental components in
demonstrating competence in that modality.
Basic Competences
Basic competences establish the structure for therapy and
form the context and structure for the implementation of a
range of more specific techniques. This domain contains a
range of activities that are basic in the sense of being
fundamental areas of skill; they represent practices that
underpin the modality.
Specific Techniques
These competences are the core technical interventions
employed in the therapy. Not all of these would be employed
for any one individual, and different technical emphases would
be deployed for different problems.
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Brief Dynamic Interpersonal Therapy for Depression (DIT) Competency Map
Ability to maintain an analytic attitude
Generic Therapeutic
Competences
Basic DIT Competences
Knowledge and understanding of
depression and mental health
problems
Knowledge of basic principles and
rationale of analytic/dynamic
approaches
Knowledge of, and ability to operate
within, professional and ethical
guidelines
Ability to assess the likely
suitability of an analytic/dynamic
approach
Knowledge of a model of therapy,
and the ability to understand and
employ the model in practice,
including the treatment of
depression
Ability to engage the client in
analytic/dynamic therapy
Ability to derive an analytic/
dynamic formulation
Ability to engage client
Ability to foster and maintain a good
therapeutic alliance, and to grasp
the client’s perspective and ‘world
view’
Ability to work with the emotional
content of sessions
Ability to manage endings
Ability to undertake generic
assessment (including relevant
history and identifying suitability for
intervention)
Ability to establish and manage
the therapeutic frame and
boundaries
Ability to work with unconscious
communication
Ability to facilitate the exploration
of the unconscious dynamics
influencing relationships
Ability to help the client become
aware of unexpressed or
unconscious feelings
Specific techniques
Ability to make dynamic
interpretations
Ability to work in the transference
Ability to work with the countertransference
Metacompetences
Generic metacompetences
Capacity to use clinical judgment
when implementing treatment
models
Capacity to adapt interventions in
response to client feedback
DIT specific metacompetences
Ability to recognise and work with
defences
Ability to work through the
termination phase of therapy
Ability to make use of the
therapeutic relationship as a
vehicle for change
Ability to apply the model flexibly in
response to the client’s individual
needs and context
Ability to establish an appropriate
balance between interpretative and
supportive work
Ability to identify and apply the
most appropriate
analytic/dynamic approach
Ability to assess and manage risk of
self-harm
Ability to work with difference
(‘cultural competence’)
Ability to make use of supervision
Ability to use measures to guide
therapy and monitor outcomes
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Ability maintain an analytic /
dynamic focus
Ability to identify and respond to
difficulties in the therapeutic
relationship
Ability to work with both the
client’s internal and external reality
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Generic Competences
Knowledge and understanding of depression and mental health
problems
•
During assessment and when carrying out interventions, an ability
to draw on knowledge of common mental health problems and
their presentation, particularly depression.
•
An ability to draw on knowledge of the factors associated with the
development and maintenance of mental health problems.
•
An ability to draw on knowledge of the usual pattern of symptoms
associated with mental health problems.
•
An ability to draw on knowledge of the ways in which mental
health problems can impact on functioning (eg maintaining
intimate, family and social relationships, or the capacity to
maintain employment and study).
•
An ability to draw on knowledge of the impact of impairments in
functioning on mental health.
•
An ability to draw on knowledge of mental health problems to
avoid escalating or compounding the client’s condition when their
behaviour leads to interpersonal difficulties which are directly
attributable to their mental health problem.
Knowledge of depression
•
An ability to draw on knowledge of the cluster of symptoms
associated with a diagnosis of depression:
•
•
•
•
•
•
•
•
•
•
•
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depressed mood most of the day
marked loss of interest or pleasure in daily activities
sleep problems
loss of appetite and significant loss of weight
fatigue/exhaustion
difficulties getting to sleep or excessive sleep
psychomotor agitation (feeling restless or agitated) or
psychomotor retardation (feeling slowed down)
feelings of worthlessness or excessive guilt
low self-confidence
difficulties in thinking/ concentrating and/or indecisiveness
recurrent thoughts of death, suicidal ideation, suicidal
intent (with or without a specific plan)
•
An ability to draw on knowledge:
• that a diagnosis of depression is based on the presence of a
subset of these symptoms
• that of these symptoms, depressed mood; loss of interest or
pleasure; and fatigue are central
• that symptoms need to be present consistently over time (e.g.
DSM-IV-TR criteria specify two weeks, ICD-10 criteria specify
one month)
•
An ability to draw on knowledge of the diagnostic criteria for all
mood disorders (including minor depression/dysthmic disorder and
bipolar disorder) and to be able to distinguish between these
presentations
•
An ability to draw on knowledge of the incidence and prevalence
of depression, and the conditions that are commonly comorbid
with depression
•
An ability to draw on knowledge of the patterns of remission and
relapse/ recurrence associated with depression
•
An ability to draw on knowledge of factors which are associated
with an increased vulnerability to depression e.g.:
•
•
•
•
•
•
•
•
developmental risk factors (e.g. temperament)
quality of early experience with parents or significant others
quality of relationships with partner, family and significant
others
quality of current social relationships
social isolation
major adverse life-events (e.g. childhood abuse or neglect,
financial loss, unemployment, separation from a partner,
bereavement, retirement)
major life-transitions (e.g. becoming a parent)
acute and chronic physical illness (both in the client and in
significant others)
Return to the
Competency Map
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
• competence to practice, and maintaining competent practice
through appropriate training/professional development
•
An ability to draw on knowledge of the impact of depressive
symptoms on the client’s functioning (e.g. in interpersonal and
work domains), and the fact that difficulties in functioning can (in
turn) contribute to depressive symptoms
•
An ability to draw on knowledge of the evidence for the
effectiveness of psychological and psychopharmacological
interventions for depression, and their effectiveness in
combination
•
• recognition of the limits of competence and taking action to
enhance practice through appropriate training/professional
development
• protecting clients from actual or potential harm from
professional malpractice by colleagues by instituting action in
accordance with national and professional guidance
• maintaining appropriate standards of personal conduct for
self:
a) a capacity to recognise any potential problems in
relation to power and ‘dual relationships’ with clients, and
to desist absolutely from any abuses in these areas
An ability to draw on knowledge of the ways in which depression is
conceptualised within the model of therapy being adopted
b) recognising when personal impairment could influence
fitness to practice, and taking appropriate action (e.g.
seeking personal and professional support and/or
desisting from practice)
Knowledge of, and ability to operate within, professional and ethical
guidelines
Knowledge of guidelines
•
•
An ability to maintain awareness of national and local codes of
practice which apply to all staff involved in the delivery of
healthcare, as well as any codes of practice which apply to the
counsellor as a member of a specific profession.
An ability to take responsibility for maintaining awareness of
legislation relevant to areas of professional practice in which the
counsellor is engaged (specifically including the Mental Health
Act, Mental Capacity Act, Human Rights Act, Data Protection Act).
Application of professional and ethical guidelines
• An ability to draw on knowledge of relevant codes of professional
and ethical conduct and practice in order to apply the general
principles embodied in these codes to each piece of work being
undertaken, in the areas of:
• obtaining informed consent for interventions from clients
• maintaining confidentiality, and knowing the conditions under
which confidentiality can be breached
• safeguarding the client’s interests when co-working with other
professionals as part of a team, including good practice
regarding inter-worker/ inter-professional communication
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Knowledge of a model of therapy, and the ability to understand and
employ the model in practice, including the treatment of depression
•
An ability to draw on knowledge of factors common to all
therapeutic approaches:
•
supportive factors:
•
a positive working relationship between counsellor and
client characterised by warmth, respect, acceptance and
empathy, and trust
•
the active participation of the client
•
counsellor expertise
•
o
opportunities for the client to discuss matters of concern
and to express their feelings learning factors:
advice
o
correctional emotional experience
o
feedback
o
exploration of internal frame of reference
Return to the
Competency Map
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
o
changing expectations of personal effectiveness
Ability to engage client
o assimilation of problematic experiences
•
•
•
While maintaining professional boundaries, an ability to show
appropriate levels of warmth, concern, confidence and
genuineness, matched to client need.
cognitive mastery
•
An ability to engender trust.
o
encouragement to face fears and to take risks
•
An ability to develop rapport.
o
reality testing
•
o
experience of successful coping
An ability to adapt personal style so that it meshes with that of the
client.
•
An ability to recognise the importance of discussion and
expression of client’s emotional reactions.
•
An ability to adjust the level of in-session activity and structuring of
the session to the client’s needs.
•
An ability to convey an appropriate level of confidence and
competence.
•
An ability to avoid negative interpersonal behaviours (such as
impatience, aloofness, or insincerity).
o
action factors:
o
behavioural regulation
o
An ability to draw on knowledge of the principles which underlie the
intervention being applied, using this to inform the application of the
specific techniques which characterise the model.
An ability to draw on knowledge of the principles of the intervention
model in order to implement therapy in a manner which is flexible and
responsive to client need, but which also ensures that all relevant
components are included.
Ability to foster and maintain a good therapeutic alliance, and to
grasp the client’s perspective and ‘world view’
Understanding the concept of the therapeutic alliance
•
An ability to draw on knowledge that the therapeutic alliance is
usually seen as having three components:
• the relationship or bond between counsellor and client
• consensus between counsellor and client regarding the
techniques/methods employed in the therapy
• consensus between counsellor and client regarding the goals of
therapy
•
An ability to draw on knowledge that all three components
contribute to the maintenance of the alliance.
Return to the
Competency Map
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Knowledge of counsellor factors associated with the alliance
•
An ability to draw on knowledge of counsellor factors which
increase the probability of forming a positive alliance:
•
•
Capacity to develop the alliance
being flexible and allowing the client to discuss issues
which are important to them
•
being respectful
•
being warm, friendly and affirming
•
being open
•
being alert and active
•
being able to show honesty through self-reflection
•
being trustworthy
Knowledge of counsellor factors which reduce the probability of
forming a positive alliance:
•
being rigid
•
being critical
•
making inappropriate self-disclosure
•
being distant
•
being aloof
•
being distracted
•
making inappropriate use of silence
•
An ability to listen to the client’s concerns in a manner which is
non-judgmental, supportive and sensitive, and which conveys a
comfortable attitude when the client describes their experience.
•
An ability to ensure that the client is clear about the rationale for
the intervention being offered.
•
An ability to gauge whether the client understands the rationale for
the intervention, has questions about it, or is skeptical about the
rationale, and to respond to these concerns openly and nondefensively in order to resolve any ambiguities.
•
An ability to help the client express any concerns or doubts they
have about the therapy and/or the counsellor, especially where
this relates to mistrust or skepticism.
•
An ability to help the client articulate their goals for the therapy,
and to gauge the degree of congruence in the aims of the client
and counsellor.
Capacity to grasp the client’s perspective and ‘world view’
•
An ability to apprehend the ways in which the client
characteristically understands themselves and the world around
them.
•
An ability to hold the client’s world view in mind throughout the
course of therapy and to convey this understanding through
interactions with the client, in a manner that allows the client to
correct any misapprehensions.
•
An ability to hold the client’s world view in mind, while retaining an
independent perspective and guarding against identification with
the client
Return to the
Competency Map
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Capacity to maintain the alliance
Ability to work with emotional content of session
•
An ability to recognise when strains in the alliance threaten the
progress of therapy.
•
An ability to deploy appropriate interventions in response to
disagreements about tasks and goals:
•
•
an ability to check that the client is clear about the rationale for
treatment and to review this with them and/or clarify any
misunderstandings.
•
an ability to help clients understand the rationale for treatment
through using/drawing attention to concrete examples in the
session.
•
an ability to judge when it is best to refocus on tasks and goals
which are seen as relevant or manageable by the client (rather
than explore factors which are giving rise to disagreement
over these factors).
An ability to deploy appropriate interventions in response to
strains in the bond between counsellor and client:
•
•
•
an ability for the counsellor to give and ask for feedback
about what is happening in the here-and-now interaction,
in a manner which invites exploration with the client.
an ability for the counsellor to acknowledge and accept
their responsibility for their contribution to any strains in
the alliance.
where the client recognises and acknowledges that the
alliance is under strain, an ability to help the client make
links between the rupture and their usual style of relating
to others.
•
an ability to allow the client to assert any negative
feelings about the relationship between the counsellor
and themselves.
•
an ability to help the client explore any fears they have
about expressing negative feelings about the relationship
between the counsellor and themselves.
•
An ability to facilitate the processing of emotions by the client – to
acknowledge and contain emotional levels that are too high (eg
anger, fear, despair) and contact emotions when levels are too low
(eg apathy, low motivation).
•
An ability to work effectively with emotional issues that interfere
with effective change (e.g. hostility, anxiety, excessive anger,
avoidance of strong affect).
•
An ability to help the client access differentiate and experience
his/her emotions in a way that facilitates change.
Ability to manage endings
•
An ability to signal the ending of the intervention at appropriate
points during the therapy (e.g. when agreeing the treatment
contract, and especially as the intervention draws to close) in a
way which acknowledges the potential importance of this transition
for the client.
•
An ability to help client discuss their feelings and thoughts about
endings and any anxieties about managing alone.
•
An ability to review the work undertaken together.
•
An ability to say goodbye.
Ability to undertake a generic assessment (including relevant history
and identifying suitability for intervention)
•
An ability to obtain a general idea of the nature of the client’s
problem.
•
An ability to elicit information regarding psychological problems,
diagnosis, past history, present life situation, attitude about and
motivation for therapy.
•
An ability to gain an overview of the client’s current life situation,
specific stressors and social support.
•
An ability to assess the client’s coping mechanisms, stress
tolerance, and level of functioning.
Return to the
Competency Map
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
An ability to help the client identify/select target symptoms or
problems, and to identify which are the most distressing and which
the most amenable to intervention.
•
An ability to help the client translate vague/ abstract complaints
into more concrete and discrete problems.
•
An ability to assess and act on indicators of risk (of harm to self
or others and the ability to know when to seek advice from
others).
An ability to gauge the extent to which the client can think
about themselves psychologically (e.g. their capacity to reflect
on their circumstances or to be reasonably objective about
themselves).
An ability to gauge the client’s motivation for a psychological
intervention.
An ability to discuss treatment options with the client, making
sure that they are aware of the options available to them, and
helping them consider which of these options they wish to
follow.
An ability to identify when psychological treatment might not be
appropriate or the best option, and to discuss with the client
(e.g. the client’s difficulties are not primarily psychological, or
the client indicates that they do not wish to consider
psychological issues) or where the client indicates a clear
preference for an alternative approach to their problems (e.g. a
clear preference for medication rather than psychological
therapy).
•
•
•
•
Ability to assess and manage risk of self-harm
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•
An ability to draw on knowledge of indicators of self–harm, and to
integrate research/actuarial evidence) with a structured clinical
assessment and the exercise of professional judgment in
appraising risk
•
An ability to draw on knowledge of the limitations of using risk
factors to predict self-harm:
• that risk factors identify high risk groups rather than
individuals
• that because suicide is a relatively rare event it is difficult to
predict at the level of the individual:
even where accurate systems of prediction are
employed these will incorrectly identify a substantial
number of individuals as possible suicides
that because most risk factors relate to long-term risk they
are less helpful in prediction in the short-term or immediate
clinical situation
o
•
•
An ability to draw on knowledge that individuals with a history of
prior suicide have a markedly elevated risk of self-harm
•
An ability to draw on knowledge of factors associated with an
elevated risk of self-harm that apply across the population:
• childhood adversity
• experience of a number of adverse life-events (including
sexual abuse)
• a family history of suicide
• a history of self-harm
• seriousness of previous episodes of self-harm
• previous hospitalisation
• mood disorders
• substance use disorder
• a diagnosis of personality disorder
• anxiety disorder (particularly PTSD)
• a psychotic disorder (e.g. a diagnosis of schizophrenia or
bipolar disorder)
• presence of chronic physical disorders
• bereavement or impending loss (where psychological
problems preceded the bereavement)
• relationship problems and relationship breakdown
• severe lack of social support
• socio-economic factors e.g.
o
people who are disadvantaged in socio-economic
terms
o
people who are single or divorced
o
people who are living alone
o
people who are single parents
Return to the
Competency Map
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
An ability to draw on knowledge that individuals with depression
have a significantly elevated lifetime risk of suicide
•
An ability to draw on knowledge that the risk of suicide is highest
relatively early in a depressive episode, and less likely during
periods of remission
•
An ability to draw on knowledge that hopelessness (negative
expectations of the future) may be a more important marker of
risk than the severity of depression
•
•
•
An ability to draw on knowledge that the combination of
depression, hopelessness and continuing suicidal intent
represents a marker of elevated risk
An ability to draw on knowledge that the risk of suicide is elevated
if the following factors are present, and the person:
• has a history of previous attempts
• used a violent method in their attempt
• left a suicide note
• is older (45 and over)
• is male
• is living alone
• is separated, widowed or divorced
• is unemployed
• is in poor physical health
•
An ability to assess the client’s strengths and resources by
asking them about:
• external resources (e.g. relationship with care services, self
help groups, local associations)
• supportive relationships (e.g. a partner or close friend who
they trust and can confide in)
• personal resources (e.g. ability to suggest ways of managing
their present difficulties)
• previous patterns of coping (i.e. how they coped with
potentially stressful events in the past)
An ability to undertake an assessment which aims
• to understand the social, psychological and motivational
factors specific to the act of self-harm
• to assess the degree of suicidal intent:
• to assess current suicidal intent and hopelessness
• to assess current mental health and social needs
•
An ability to convey a nonjudgmental and tolerant attitude when
discussing self-harm with the client
•
An ability, where required, to ask direct questions to clarify an
understanding of the attempt, and the extent of suicidal intent
•
An ability to work with the client to develop a detailed sequential
account of the period leading up to self-harm, in order to identify
the events which precipitated it
Assessing risk in individuals who have self-harmed
•
An ability to draw on knowledge that the risk of suicide is
particularly elevated in the three months following attempted
suicide, and that this risk remains elevated in the longer-term.
Return to the
Competency Map
13
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
An ability to work with the client in order to assess the degree of
suicidal intent e.g.:
• whether the event was impulsive or planned
• whether the client was alone, whether someone was present
or within easy access, whether the client was likely to be
found soon after the attempt
• whether any steps were taken either to prevent or to ensure
discovery
• if alcohol or drugs were taken prior to or during the attempt,
and the intent and/or impact of taking these substances on
the attempt
• client’s expectations regarding the lethality of the drugs or
injury
• presence of a suicide note (including recorded and text
messages)
• the client’s efforts to obtain help after the event
•
•
•
An ability to ensure that (so far as is possible) the client is
involved in decisions regarding any actions to be taken to
manage risk
•
An ability to draw up an appropriate plan of action which specifies
the ways in which risk will be managed, and is tailored to the
needs of the individual
•
Where there is a clear risk of repetition, an ability to draw up a
plan which is maintained over an extended period (e.g. 3 months)
and which includes:
An ability to ask about previous acts of self harm (including the
circumstances and the level of intent)
An ability to administer and interpret standardised measures for
assessing suicidality and hopelessness (e.g. Suicide Intent Scale,
Suicide Assessment Checklist, Beck Hopelessness Scale (etc))
Management of risk of self-harm
14
•
An ability to draw on knowledge of local and national protocols
(e.g. NICE 2004) for the management of self-harm, and an ability
to ensure that actions taken comply with these protocols
•
An ability to draw on knowledge of relevant legislation (e.g.
Mental Health Act, Mental Capacity Act) when considering
admission of a client who is considered to represent a significant
risk to themselves (but is not willing to receive treatment)
the management of actively suicidal clients who refuse
intervention
decisions regarding the involvement of relatives
•
•
•
•
•
Use of standardised scales to assess risk of self-harm
•
An ability to draw on knowledge that if a standardised risk
assessment scale is used to assess risk, this should be used only
to aid in the identification of people at high risk of repetition of
self-harm or suicide
•
An ability to identify and manage ethical issues in relation to risk
management e.g.:
frequent access to a therapist when needed
home treatment when necessary
telephone contact
outreach (which include active follow-up when appointments
are missed)
•
An ability to liaise with and refer to any relevant colleagues and
services who need to be involved in delivering the plan of action,
or who need to be aware of its content
•
Where plans for the management of risk are compatible with the
maintenance of the therapeutic contract, an ability to integrate the
management of risk with the current intervention
• an ability to make appropriate modifications to a treatment
contract in order to ensure that it includes elements focus on
the management of risk (e.g. a problem-solving orientation
focused on identifying potential crises and the strategies for
avoiding or resolving these)
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
An ability to seek supervision and/or consult with colleagues in
relation to decisions regarding risk-management
•
Ability to maintain a record of assessments and plans for managing
risk
•
•
An ability to maintain a clear and detailed record of any
assessments and of decisions regarding plans for managing risk,
in line with local protocols for recording clinical information
An ability to communicate (verbally and in writing) with relevant
clinicians and services in order ensure that all individuals or
services involved in the management of risk are appropriately
informed
• an ability to draw on knowledge of the conditions under
which confidentiality can be breached in support of the
management of risk, and the national and profession-specific
guidance which addresses this issue
•
An ability to maintain an awareness of the potential significance
for practice of social and cultural difference across a range of
domains, but including:
• ethnicity
• culture
• class
• religion
• gender
• age
• disability
• sexual orientation
•
For all clients with whom the therapist works, an ability to draw
on knowledge of the relevance and potential impact of social and
cultural difference on the effectiveness and acceptability of an
intervention
•
Where clients from a specific minority culture or group are
regularly seen within a service, an ability to draw on knowledge
of that culture or area of difference
•
An ability to draw on knowledge of cultural issues which
commonly restrict or reduce access to interventions e.g.:
• language
• marginalisation
• mistrust of statutory services
• lack of knowledge about how to access services
• different cultural concepts, understanding and attitudes
about mental health which affect views about help-seeking,
treatment and care
Ability to work with difference (cultural competence)
Although it is common (and appropriate) to think about ‘difference’ in
relation to specific demographic groups, this may be a somewhat narrow
perspective. There are many ways in which both therapists and their
clients could be ‘different’, partly because some areas of difference will not
be immediately apparent, and also because it is the individual’s sense of
their difference that is important. On this basis almost any therapeutic
encounter requires the therapist to consider the issue of difference.
In what follows the term ‘culture’ is sometimes used generically, so (for
example) referring to an intervention as ‘culturally sensitive’ means that
the intervention is responsive to the demographic group to which it is
applied.
•
•
15
An ability to draw on knowledge that the term ‘difference’ refers to
the individualised impact of background, lifestyle, beliefs or
religious practices
An ability to draw on knowledge that the demographic groups
included in discussion of ‘difference’ are usually those who are
potentially subject to disadvantage and/or discrimination, and it is
this potential for disadvantage that makes it important to focus on
this area
An ability to draw on knowledge that clients will often be a
member of more than one “group” (for example, a gay man with
disabilities, or an older adult from a minority ethnic community),
and that as such, the implications of different combinations of
difference needs to be held in mind by therapists
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
•
•
stigma, shame and/or fear associated with mental health
problems (which makes it likely that help-seeking is delayed
until/unless problems become more severe
stigma or shame and/or fear associated with being
diagnosed with a mental health disorder
preferences for gaining support via community contacts/
contexts rather than through ‘conventional’ referral routes
(such as the GP)
•
An ability for therapists of all cultural backgrounds to draw on an
awareness of their own group membership and values and how
these may influence their perceptions of the client, the client's
problem, and the therapy relationship
•
An ability to take an active interest in the cultural background of
clients, and hence to demonstrate a willingness to learn about
the client’s cultural perspective(s) and world view
•
An ability to work collaboratively with the client in order to
develop an understanding of their culture and world view, and
the implications of any culturally-specific customs or
expectations, for:
• the therapeutic relationship
• the ways in which problems are described and presented
by the client
o an ability to apply this knowledge in order to
identify and formulate problems, and
intervene in a manner that is culturally
sensitive, culturally consistent and relevant
o an ability to apply this knowledge in a manner
that is sensitive to the ways in which
individual clients interpret their own culture
(and hence recognises the risk of culturerelated stereotyping)
•
An ability to take an active and explicit interest in the client’s
experience of difference:
• to help the client to discuss and reflect on their experience
of difference
to identify whether and how this experience has shaped the
development and maintenance of the client’s presenting
problems
•
An ability to discuss with the client the ways in which individual
and family relationships are represented in their culture (e.g.
notions of the self, models of individuality and personal or
collective responsibility), and to consider the implications for
organisation and delivery of therapy
•
An ability to ensure that standardised assessments/ measures
are employed and interpreted in a manner which is culturallysensitive e.g.:
• if the measure is not available in the client’s first language,
an ability to take into account the implications of this when
interpreting results
• if a bespoke translation is attempted, an ability to crosscheck the translation to ensure that the meaning is not
inadvertently changed
• if standardisation data (norms) is not available for the
demographic group of which the client is a member, an
ability explicitly to reflect this issue in the interpretation of
results
•
An ability to draw on knowledge of the conceptual and empirical
research-base which informs thinking about the impact of cultural
competence on the efficacy of psychological interventions
•
Where there is evidence that social and cultural difference is
likely to impact on the accessibility of an intervention, an ability to
make appropriate adjustments to the therapy and/or the manner
in which therapy is delivered, with the aim of maximising its
potential benefit to the client
An ability to draw on knowledge that culturally-adapted
treatments should be judiciously applied, and are warranted:
• if evidence exists that a particular clinical problem
encountered by a client is influenced by membership of a
given community
• if there is evidence that clients from a given community
respond poorly to certain evidence-based approaches
•
Return to the
Competency Map
16
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
Where the therapist does not share the same language as
clients, an ability to identify appropriate strategies to ensure and
enable the client’s full participation in the therapy
• where an interpreter/advocate is employed, an ability to
draw on knowledge of the strategies which need to be in
place for an interpreter/advocate to work effectively and in
the interests of the client
Ability to make use of supervision
•
Capacity for active learning
•
An ability to act on suggestions regarding relevant reading made
by the supervisor, and to incorporate this material into clinical
practice.
•
An ability to take the initiative in relation to learning, by identifying
relevant papers, or books, based on (but independent of)
supervisor suggestions, and to incorporate this material into
clinical practice.
An ability to hold in mind that a primary purpose of supervision
and learning is to enhance the quality of the treatment clients
receive.
Capacity to use supervision to reflect on developing personal and
professional role
An ability to work collaboratively with the supervisor
• An ability to work with the supervisor in order to generate an
explicit agreement about the parameters of supervision (e.g.
setting an agenda, being clear about the respective roles of
supervisor and supervisee, the goals of supervision and any
contracts which specify these factors).
•
An ability to help the supervisor be aware of your current state of
competence and your training needs.
•
An ability to present an honest and open account of clinical work
undertaken.
•
An ability to discuss clinical work with the supervisor as an active
and engaged participant, without becoming passive or avoidant, or
defensive or aggressive.
•
An ability to present clinical material to the supervisor in a
focussed manner, selecting the most important and relevant
material.
Capacity for self-appraisal and reflection
17
An ability to use feedback from the supervisor in order further to
develop the capacity for accurate self-appraisal.
•
An ability to reflect on the supervisor’s feedback and to apply
these reflections in future work.
•
An ability to be open and realistic about your capabilities and to
share this self-appraisal with the supervisor.
•
An ability to use supervision to discuss the personal impact of the
work, especially where this reflection is relevant to maintaining the
likely effectiveness of clinical work.
•
An ability to use supervision to reflect on the impact of clinical
work in relation to professional development.
Capacity to reflect on supervision quality
•
An ability to reflect on the quality of supervision as a whole,
and (in accordance with national and professional guidelines)
to seek advice from others where:
•
there is concern that supervision is below an acceptable
standard
•
where the supervisor’s recommendations deviate from
acceptable practice
•
where the supervisor’s actions breach national and
professional guidance (e.g. abuses of power and/or
attempts to create dual (sexual) relationships)
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Ability to use measures to guide therapy and to monitor outcomes
•
Knowledge of measures
•
An ability to draw on knowledge of commonly used
questionnaires and rating scales used with people with
depression
Ability to integrate measures into the intervention
•
Ability to interpret measures
•
•
An ability to draw on knowledge of measurement to ensure that
procedures for self-monitoring are relevant (i.e. related to the
question being asked), valid (measuring what is intended to be
measured) and reliable (i.e. reasonably consistent with how
things actually are)
An ability to draw on knowledge regarding the interpretation of
measures (e.g. basic principles of test construction, norms and
clinical cut-offs, reliability, validity, factors which could influence
(and potentially invalidate) test results)
•
•
An ability to be aware of the ways in which the reactivity of
measures and self-monitoring procedures can bias client report
An ability to use and to interpret relevant measures at appropriate
and regular points throughout the intervention, with the aim of
establishing both a baseline and indications of progress
An ability to share information gleaned from measures with the
client, with the aim of giving them feedback about progress
An ability to establish an appropriate schedule for the
administration of measures, avoiding over-testing, but also aiming
to collect data at more than one timepoint
Ability to help clients use self-monitoring procedures
Knowledge of self-monitoring
•
•
•
•
An ability to draw on knowledge of self-monitoring forms
developed for use in specific interventions (as published in
articles, textbooks and manuals)
•
•
An ability to draw on knowledge of the potential advantages of
using self-monitoring
• to gain a more accurate concurrent description of the
client’s state of mind (rather than relying on recall)
• to help adapt the intervention in relation to client progress
• to provide the client with feedback about their progress
An ability to draw on knowledge of the potential role of selfmonitoring:
• as a means of helping the client to become an active,
collaborative participant in their own therapy by identifying
and appraising how they react to events (in terms of their
own reactions, behaviours, feelings and cognitions))
•
An ability to construct individualised self-monitoring forms, or to
adapt ‘standard’ self-monitoring forms, in order to ensure that
monitoring is relevant to the client
An ability to work with the client to ensure that measures of the
targeted problem are meaningful to the client (i.e. are chosen to
reflect the client’s perceptions of the problem or issue)
An ability to ensure that self-monitoring includes targets which are
clearly defined and detailed, in order that they can be
monitored/recorded reliably
An ability to ensure that the client understands how to use selfmonitoring forms (usually by going through a worked example
during the session)
Ability to integrate self-monitoring into the intervention
• An ability to ensure that self-monitoring is integrated into the
therapy, ensuring that sessions include the opportunity for regular
and consistent review of self-monitoring forms
• An ability to guide and to adapt the therapy in the light of
information from self-monitoring
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18
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Basic Competences
•
Knowledge of the basic principles and rationale for analytic/dynamic
therapy
Knowledge of developmental theory
•
An ability to draw on knowledge of the developmental factors that
shape an individual’s experience of themselves and others (i.e. the
importance of early relationships/attachments).
•
An ability to draw on knowledge of the different types of
personality organisations (i.e. neurotic, borderline, psychotic)
•
An ability to draw on knowledge of the operation of defences
throughout development
•
An ability to draw on knowledge of developmental
psychopathology
Knowledge of an analytic/ dynamic model of the mind
• An ability to draw on knowledge that we have a conscious as
well as a dynamically unconscious mental life
• An ability to draw on knowledge of the different structures of
the mind (ego, id, superego) and their contribution to
personality development
• An ability to draw on knowledge of an unconscious inner world
of object-relations that:
o mediates the way people experience themselves and
others
o informs how people act in the external world.
• An ability to draw on knowledge of, and respect for, the
importance of the client’s imaginative life (e.g. unconscious
fantasies, dreams, metaphors) as a vehicle for understanding
their unconscious experience of themselves and others.
Knowledge of the core principles of an analytic/dynamic therapeutic
approach
• An ability to draw on knowledge of the affective and
interpersonal focus of the therapy.
• An ability to draw on knowledge of the rationale for closely
tracking the therapeutic process (i.e. attending closely to microprocesses in the therapeutic relationship so as gain a detailed
understanding of the client’s internal world of relationships and
conflicts).
19
•
•
An ability to draw on knowledge of the rationale for adopting a
primarily receptive (i.e. non directive) stance in relation to the
client’s communications so as to facilitate the elaboration of
unconscious meaning.
An ability to draw on knowledge of the importance of
maintaining an open mind throughout therapy ( avoiding
premature closure and tolerating ‘not knowing’, so as to avoid
imposing assumptions about the client’s difficulties or the
direction of treatment)
An ability to draw on knowledge that the alleviation of
symptoms is not normally regarded as the primary target of the
therapy, but is considered to be the outcome of an
understanding of their unconscious meaning
Ability to assess likely suitability of analytic/dynamic therapy
Knowledge
• An ability to draw on knowledge that pre-therapy client
characteristics are not significantly predictive of outcome:
• an ability to draw on knowledge of factors that may be pertinent
to the ways in which an analytic/dynamic approach is
applied/needs to be adapted to meet the client’s needs:
• the client’s response to an exploratory approach (e.g. their
response to a relative lack of therapist direction, indicators
of an interest in reflection)
• the client’s interest in reflecting on how their relationships
with others work
• the client’s interest in working with interpersonal and
affective themes
• the client’s curiosity about their role in their difficulties
• the risk to the client of connecting with painful feelings
and/or memories, which could be difficult for them to
manage (e.g. increasing risk to themselves) balanced
against the benefits of exploring issues in therapy
• the external resources that could support the client during
the therapy
• the therapist’s experience with the client in the session
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
An ability to draw on practice-based knowledge of the contraindications for brief and more intensive analytic/dynamic
therapy (e.g. risk of exacerbation of problems)
An ability to draw on knowledge of other psychological
therapies as the basis for considering more suitable
alternatives for the client
presenting difficulties/symptoms to their past and current
relationships and behaviour
•
An ability to evaluate the client’s readiness and motivation at
this point in time to engage with the affective and interpersonal
focus of the therapy through relevant questions and
interpretations (e.g. a “trial interpretation”)
•
An ability to formulate the dominant transference theme(s) that
emerge in the assessment so as to gauge how the client
responds to a transference focus
•
An ability to help the client reflect on their experience of the
assessment by articulating their conscious and unconscious
experience of it
Application
Frame for the assessment
•
•
An ability to approach the assessment with an analytic attitude
so as to observe the client’s interaction with the therapist and
evaluate what adaptations may be necessary to support the
client’s capacity to work within an analytic frame:
• an ability to balance the need to gather information about
the client and their difficulties against the requirement to
assess how they manage without therapist imposed
direction in the session
An ability to realistically consider, with the client, their capacity
to work within an analytic frame in the context of an
assessment of potential risk (e.g. increase in self-harming
behaviour)
Ability to identify and take account of external resources available to
the client and to the therapist when planning interventions
• An ability to inform the therapeutic plan and consider the need
for additional resources by exploring the client’s external
resources (e.g. sources of support, stability of housing, etc)
•
An ability to appraise the appropriateness of the setting in
which the therapy will be offered relative to the client’s needs
(e.g. for additional support from other professionals)
Ability to engage the client in analytic/dynamic therapy
Listening: content and process
• An ability to listen both to the content of the client’s narrative
while taking into account the way in which they present
themselves (e.g. non-verbal communications)
•
An ability for the therapist to identify the emotional impact the
client’s presentation has on them
•
an ability to appraise the potential significance of the therapist’s
response to understanding the client’s interpersonal patterns
Intervention
• An ability to engage the client’s interest in this therapeutic
approach by making interpretations that connect the client’s
20
Ability to develop a therapeutic alliance
• An ability to respond to the client’s presenting problems in a
concerned, non-judgemental manner through:
• allowing the client’s narrative about their difficulties to
emerge without imposing a structure
• asking clarifying questions so as to understand the client’s
perspective without making assumptions
• communicating empathic understanding in response to the
client’s conscious and unconscious communications
• respecting the client’s need for defences
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
An ability to foster the development of a working relationship of
trust and rapport through:
o containing the client’s level of anxiety by engaging with
the client’s conscious and unconscious anxieties about
the therapy and the therapist
o tolerating the client’s distress and other feelings in order to
remain emotionally attuned to them
o adjusting technique with those clients who are
unproductively disturbed by a more passive stance in the
early stages of therapy
o communicating the boundaries and frame of the therapy
clearly
o providing some brief guidance on the differential
expectations of both therapist and client (e.g. to say what
comes to mind) so as to orient the client to the particular
style of therapy
o assessing which clients may require a strengthening of
the supportive aspects of the therapeutic relationship in an
explicit manner so as to engage them
Ability to help the client understand the rationale for
analytic/dynamic therapy
• An ability to provide the client with sufficient direct information
about the therapy (including its risks and benefits) so as to
make consent meaningful
•
•
21
An ability to use the assessment session(s) to give the client an
experience of an analytic/ dynamic approach and the
challenges this might present for them, for example through:
• showing interest in, and commenting on, the client’s
unconscious communications, especially about the
relationship with the therapist
• conveying an understanding of how the client’s presenting
symptoms/problems may be connected with unconscious
feelings and conflicts
An ability to encourage the client to reflect on their reactions to
the proposed therapy and its focus (i.e. primarily on feelings
and relationships)
Ability to identify and agree therapeutic aims
• An ability to share a tentative account of how the therapist
understands the client’s problems early on in the therapy so as
to provide the client with an opportunity to ask questions, clarify
and agree therapeutic aims
•
An ability to engage the client in articulating the aims for the
therapy through:
• enquiring explicitly about what the client hopes to achieve
• communicating understanding that in addition to the stated
aims there might be less conscious aims
• communicating understanding of the client’s resources and
vulnerabilities in relation to the stated aims
• helping the client to reflect on their expectations of therapy
so as to introduce some realism about what might and
might not be achievable
Ability to derive an analytic/dynamic formulation
Knowledge
• An ability to draw on knowledge that a psychodynamic
formulation takes into account the respective contribution of:
• relevant developmental deficits (including early traumata)
• unconscious conflicts, including unconscious anxieties and
the defences associated with their management (and
which may “oppose” change and pose challenges to the
therapy)
• recurring interpersonal patterns and expectations of others
• areas of resilience
•
An ability to draw on knowledge that the formulation will be
informed by the therapist’s observations about the quality of:
• the client’s presentation of their narrative
• the client’s relationship with the therapist in the session
•
An ability to draw on knowledge that formulation is not a “onceand-for-all” process, but requires regular revision in light of
client feedback and the therapist’s evolving understanding of
the client over time
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Application
• An ability to be curious about the client’s subjective experience
•
An ability to identify recurring interpersonal themes through:
• relevant questions and observations
• reflection on the transference-countertransference themes
that emerge in the session
•
An ability to develop hypotheses about:
• the unconscious meaning of the client’s presenting
symptoms
• the significance of the therapist’s emotional response(s) to
the client
•
•
Knowledge
• An ability to draw on knowledge that the therapist’s boundaries
and those of the therapeutic frame will have an idiosyncratic
meaning for the client and that this will inform how the client
experiences the frame and any changes to it.
•
An ability to draw on knowledge that the physical setting of the
therapy room is invested with an affective charge that is linked
to the relationship with the therapist
•
Knowledge that planned and unplanned interruptions in the
treatment may impact on the client and that this requires
acknowledgement and understanding when it occurs:
• knowledge of the dynamics of separation, loss and
mourning as the basis for understanding the client’s
subjective experience of breaks during the treatment
An ability to bring together information directly provided by the
client, as well as the experiential information derived from the
here-and-now of the therapeutic interaction, to arrive at a
provisional formulation of the client’s difficulties
Ability to elaborate and agree the formulation with the client
• An ability to work collaboratively with the client to promote a
sense of agency and participation in arriving at a formulation
that is meaningful to them:
• an ability to communicate in a clear manner the therapist’s
understanding of the client’s experience and difficulties
• an ability to engage the client in responding to the
therapist’s formulation and elaborating it or revising it
•
Ability to establish and manage the therapeutic frame and
boundaries
An ability to ascertain the formulation's relevance and/or any
threats it poses to the client's equilibrium from their response to
it.
An ability to revise the formulation (and hence the focus of the
therapy) in light of new evidence and/or the client’s response to
the therapy
Application
Ability to establish and maintain a consistent therapeutic frame
• An ability to establish clear parameters within which the
treatment will take place (setting; frequency and length of
sessions; use of the couch where applicable; limits of
confidentiality; expectations of the client [e.g. that they will say
what comes to mind/bring dreams etc]; arrangements/cover
over breaks)
•
An ability to maintain consistency in relation to the agreed
parameters and therapeutic stance so as to create a stable and
secure setting for the client through:
• maintaining the therapist’s analytic attitude
• being alert to the meaning to the client of any changes to
the agreed setting, whether planned or unplanned
• helping the client to explore their experience of any
changes
• attending to and interpreting the therapist’s understanding
of the client’s experience of separations/discontinuities in
the treatment frame
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22
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
An ability to be receptive to the client’s conscious and
unconscious experience of the setting and its boundaries and
to help the client to articulate this experience so as to:
o ensure that the client’s agreement to the therapy and its
boundaries is rooted in an exploration of their conscious
and unconscious feelings and fantasies about the therapy
o identify early transference patterns that will form the basis
for eventual interpretations
Ability to manage deviations from the established therapeutic frame
• An ability to evaluate the meaning of the client’s requests for
modifications to the parameters of the therapy as the basis for
responding to such requests
•
An ability to help the client explore unverbalised feelings and
unconscious conflicts to counter the pressure to act out and so
protect the viability of the therapy
•
An ability to maintain (or regain) a reflective stance when
managing forms of acting out in relation to the setting (by the
client, therapist or both)
•
through the emotional impact the communication has on the
therapist
•
Application
•
An ability to allow the emergence of spontaneous
communication of feelings, thoughts, fantasies, daydreams or
dreams so as to gain access to the client’s imaginative world
by:
• allowing the client to talk without imposing any formal
structure or direction in the sessions (e.g. by using
questions infrequently)
• communicating understanding to the client of the internal
obstacles to free association
•
An ability to tolerate uncertainty and ambiguity when trying to
understand the client’s communications so as to not foreclose
exploration through:
• helping the client explore their feelings about not being
understood or helped (e.g. when the therapist does not
provide practical advice)
• understanding and managing the therapist’s own feelings
of anxiety about ‘not knowing’ (e.g. about being perceived
to be incompetent)
An ability to set clear limits where necessary (e.g. if the client’s
behaviour undermines the viability of the treatment)
Ability to manage interruptions in the treatment
• An ability to prepare the client for planned interruptions (e.g.
holiday breaks) in the treatment by helping them explore their
conscious and unconscious responses to breaks
•
An ability to assess risk during breaks in the treatment and to
make arrangements for additional support when required
Ability to work with unconscious communication
Knowledge
• An ability to draw on knowledge that a client’s manifest
communications may contain a latent meaning
•
23
An ability to draw on knowledge that the latent content of any
communication may at times only become manifest indirectly
Knowledge of the principle that unconscious communication is
more likely to emerge in the absence of therapist-imposed
structure, and that remaining silent can facilitate this
Ability to listen to unconscious communication
• An ability to pay attention to the client’s imaginative life and to
use its manifestations
(e.g. conscious and unconscious
fantasies, dreams, metaphors) to further the understanding of
the client, and hence as the basis for a more focused
interpretation
•
An ability to note, and reflect upon, the latent meaning
conveyed through non-verbal communications (e.g. tone of
voice, body posture etc)
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
An ability to allow the therapist’s own subjective associations
and ideas to form in response to the client’s communications
Ability to respond to unconscious communication
• An ability to prioritise process over content when responding to
the client’s communications
•
An ability to consider the potential latent content in the client’s
communications by:
• being curious about what anxieties may lie behind the
client’s questions, even if ostensibly ‘sensible’, and drawing
the client’s attention to these
• identifying and helping the client to reflect on unverbalised
feelings
•
An ability to consider the possible meaning of the therapist’s
own emotional reactions to the client as a basis for an
intervention
An ability to help the client elaborate on their idiosyncratic use
of language/imagery/dreams, with the aim of facilitating the
experience and expression of their feelings and states of mind.
•
Ability to tolerate and make judicious use of silence
• An ability to tolerate and allow silence so as to permit the
emergence of the client’s uninterrupted flow of associations
and communications
• An ability to resist interpersonal pressure to break silences
(e.g. by asking questions)
• An ability to manage the anxiety evoked in the therapist by
silences
• An ability to communicate to the client an understanding of the
anxiety silence can generate, rather than responding directly by
filling the silence
• An ability to monitor the client’s level of anxiety in response to
silence, and limit silences if the client’s anxiety risks
undermining engagement with the therapy by:
o interpreting the anxiety
o increasing the therapist’s level of activity when appropriate
• An ability to engage the client in exploring the unconscious
meaning of silences as they occur in a session:
o exploring the client’s use of silence in the session
24
o
exploring the client’s response to the therapist’s use of
silence
Ability to help the client explore the unconscious dynamics
influencing their relationships
Knowledge
• An ability to draw on knowledge that the origins of the client’s
difficulties will normally lie in their early relational experiences
• An ability to draw on knowledge that both internal and external
forces shape the mind and therefore inform our perception of
ourselves in relationships with others
• An ability to draw on knowledge that unconscious projective
and introjective processes underpin the client’s subjective
experience of their relationships
Application
Ability to formulate the client’s internal world of relationships (as the
basis for helping them to understand their subjective experiences of
relationships)
• An ability to listen out for recurring interpersonal and affective
patterns in the client’s past and current relationships:
• an ability to identify recurring configurations of ‘self’ and
‘other’ representations
• an ability to identify areas of omission from the client’s
descriptions of their relationships (e.g. a pervasive
absence of conflict)
• An ability to make use of the experience and observation of the
client’s ways of relating within the session to inform the
understanding of the client’s internal world of relationships
Ability to help the client explore their feelings when in a relationship
• An ability to help the client identify and understand recurring
effective patterns in their relationships, particularly by exploring
how these play out in the relationship with the therapist
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Ability to help the client explore the defences mobilised in
relationships
• An ability to help the client identify areas of difficulty in their
relationships
•
•
An ability to help the client understand the unconscious
strategies they use to manage areas of difficulty in their
relationships
An ability to help the client reflect on behaviours and feelings
which perpetuate or exacerbate interpersonal difficulties
Ability to help the client become aware of unexpressed or
unconscious feelings
Knowledge
• An ability to draw on knowledge that the client may be troubled
by feelings and experiences other than those which they
consciously report
Application
Ability to facilitate the expression of unexpressed or unconscious
feelings by:
• communicating to the client that their feelings can be tolerated
and thought about by the therapist (i.e. through the therapist’s
understanding, empathic stance)
•
An ability to help the client explore internal and interpersonal
obstacles to the awareness, and expression, of particular
feelings (especially in the context of the relationship with the
therapist).
Ability to maintain an analytic/dynamic focus
Knowledge
• An ability to draw on knowledge that ‘maintaining an analytic
focus’ describes two distinct activities:
• maintaining the primary focus on the exploration of the
client’s unconscious experience (i.e. maintaining an
analytic attitude)
• remaining focused on a particular theme to the relative
exclusion of others for the duration of the therapy (which
typically applies to brief therapeutic approaches)
Application
Ability to approach all aspects of the work with an analytic attitude
• An ability to stay focussed on:
• exploring the client’s unconscious, “internal world” of
relationships
• identifying and responding to the transference and
countertransference
•
responding to non-verbal cues by the client and linking these to
unexpressed or unconscious feelings
Ability to engage the client in exploring unexpressed or unconscious
feelings
• An ability to help the client put into words what they feel, or fear
feeling, by:
• enquiring into the subjective meaning of the client’s use of
particular words, dreams, fantasies or non-verbal
behaviours
• encouraging the client to stay with a current feeling as it
emerges in the session and to articulate what they are
experiencing
25
•
An ability to prioritise the focus of the interventions on the hereand-now therapeutic interaction:
• an ability to identify when such a focus is not appropriate
so as to attend to other material that carries a strong
affective charge
Ability to “track” a specific dynamic theme/conflict
• An ability to relate the content of interventions to the
interpersonal and affective themes and unconscious conflicts
that the formulation identifies as the focus of the therapy
•
An ability to help the client explore themes relevant to the
agreed focus through the use of techniques such as
clarification, confrontation and interpretation
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
An ability to work on the agreed focus by exploring the
vicissitudes of the therapeutic relationship:
• an ability to help the client identify relevant interpersonal
and affective patterns through exploration of interpersonal
narratives and (where relevant) their elaboration in the
transference
An ability to help the client identify and explore the meaning of
diversions away from the agreed focus (e.g. because it is too
painful to address)
o
o
•
An ability to facilitate the client’s involvement in making sense
of the interpersonal behaviours that express opposition to the
therapist through:
• helping the client understand that the therapeutic
relationship (like any relationship) operates at different
levels such that positive and uncomfortable/negative
feelings towards the therapist can co-exist
• drawing the client’s attention to the feelings they may be
trying to avoid
•
An ability to recognise the importance of working with the
negative transference:
• an ability to make use of ruptures or impasses in the
therapy as opportunities for expanding the understanding
of the client’s subjective experience and of their difficulties
Ability to identify and respond to difficulties in the therapeutic
relationship
Knowledge
• An ability to draw on knowledge that a degree of resistance to
the painful nature of exploratory therapy is normal, and to be
expected in everyone
•
An ability to draw on knowledge that difficulties in the
therapeutic relationship may reflect the operation of the client’s
defences
•
An ability to draw on knowledge of the reasons for “negative
therapeutic reactions” and “flight into health”
•
An ability to draw on knowledge that enactments are inevitable
and require the therapist to work to regain a reflective stance
Application
Ability to engage the client in understanding the meaning of
difficulties between themselves and the therapist
• An ability to identify therapeutic ruptures or impasses:
• an ability to engage with the client in understanding what is
felt to have gone wrong in the therapeutic relationship,
through:
o conveying to the client that the relationship with the
therapist is something they can discuss
responding non-defensively to the client’s negative
experience of the therapeutic work and of the
therapist
helping the client understand the emotional impact
of the work, including the impact of the therapist’s
interventions (e.g. the client’s experience of
empathic failure as an abandonment)
Ability to reflect on the therapist’s contribution to difficulties in the
therapeutic relationship
• An ability to engage in self-reflection to clarify the therapist’s
possible contribution to a difficulty in the therapy and to
understand its meaning
•
An ability to consider the respective contributions of the
therapist and the client to the client’s perception of the therapist
•
An ability to distinguish between instances when resistance to
therapy is a manifestation of the client’s difficulties and
instances when the client is responding to an accurate
perception of differences of opinion between themselves and
the therapist
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26
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
Where the therapist identifies their contribution to a therapeutic
impasse, an ability to consider the most helpful way of using
this awareness to resolve the impasse (e.g. by openly
acknowledging an error)
An ability to identify the need for supervision/further personal
therapy in order to protect the client’s therapy
Ability to work with the client’s internal and external reality
Ability to work with differences between the therapist and client
• An ability to be curious about the meaning and impact of
differences in race, culture, age, socio-economic status,
religion, gender and sexuality between therapist and client
•
An ability to respond openly and sensitively to the client’s
experience of difference in the therapeutic relationship
•
An ability to explore with the client the unconscious use that
may be made of actual differences between therapist and client
•
An ability to be aware of, and reflect on, the significance of the
therapist’s countertransference in relation to difference(s)
•
An ability to critically self-reflect on assumptions, biases and
prejudices that may be operating consciously and
unconsciously in the therapist with respect to difference(s)
Knowledge
•
An ability to draw on knowledge that analytic/dynamic
approaches privilege the exploration of the client’s internal,
unconscious world of experience, but that this is not at the
expense of the exploration of, and sensitivity to, the client’s
external reality and value systems
Application
Ability to balance working with the client’s internal and external
reality
• An ability to attend and respond to the conscious as well as the
unconscious meaning of the client’s preoccupations:
• an ability to respond sensitively to the client’s current
preoccupations and distress
• an ability to evaluate when it is most productive to focus
primarily on the client’s external or internal reality
27
•
An ability to help the client to make connections between their
current, real-life preoccupations and their unconscious internal
world of subjective experience
•
An ability to respond openly and respectfully to the client’s
conscious and unconscious experience of race, culture,
religion, age, gender and sexual orientation:
• an ability to explore for the client the meaning of their
cultural, ethnic, socioeconomic and religious background
as well as their gender and sexuality
• an ability to explore the relationship, if any, between the
client’s external context and values and their difficulties
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Specific Techniques
•
Ability to make dynamic interpretations
Knowledge
• An ability to draw on knowledge of unconscious processes to
help the client become cognisant of aspects of emotional and
interpersonal experience that lie outside their immediate
awareness, and that are a source of conflict
•
•
An ability to draw on knowledge that the process of
interpretation is collaborative, so that the therapist:
• draws on their experience of the here-and-now relationship
with the client
• relates to their interpretations as hypotheses to be tested
with the client
• makes it clear to the client how they arrived at the
interpretation
• is open to client feedback about the helpfulness or
otherwise of an interpretation.
An ability to draw on knowledge that interpretation is best seen
as a process (i.e. based on a series of interventions over time,
rather than on a single comment):
• an ability to draw on knowledge of the use of clarification
and confrontation to gradually bring feelings, fantasies
and behaviours to the client’s attention and as the basis
for eventually making an interpretation
• an ability to draw on knowledge that interpretations are
hypotheses formulated over time and are normally shared
with the client gradually
• an ability to draw on knowledge that the process of
interpretation aims not only to capture the client’s
conscious and unconscious experience, but also to
introduce a new perspective on their experience
• an ability to draw on knowledge that the work of
interpretation is not a once-andfor- all process but
requires ‘working through’ to enable the client to gradually
apply their understanding of themselves
An ability to draw on knowledge that the aims of interpreting
are manifold:
• to bring together disparate aspects of the client’s
experience
• to bring unconscious conflicts and fantasies to
consciousness
• to provide the client with an experience of another person
who can think about their experience
• to contain anxiety
Application
Focus of interpretation
• An ability to maintain the primary focus of interpretations on:
• dynamically unconscious content
• the client’s interpersonal and affective experiences.
•
An ability to communicate to the client an interpretation that
captures multiple levels of meaning (i.e. it goes beyond what
the client consciously reports feeling)
Process of interpretation
• An ability to integrate information gathered from various
sources (e.g. accounts of external events, relationship with the
therapist, countertransference reactions) to arrive at
hypotheses regarding unconscious processes
•
An ability to help the client to explore and become more aware
of painful conflicts by pointing out unacceptable or
uncomfortable feelings (that are otherwise managed by being
kept out of the client’s conscious awareness)
•
An ability to draw the client’s attention to communication that is
unclear, vague, puzzling or contradictory, with the aim of
encouraging the client to elaborate on these elements
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Competency Map
28
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
•
•
An ability to help the client become aware of incongruent
elements in their communication:
• by pointing out and giving meaning to discrepancies and
incongruities in what is being communicated through
different “channels” (e.g. a contrast between verbal and
non-verbal communication)
• by bringing together conscious, pre-conscious and
unconscious material that the client may be experiencing
separately.
An ability to consider the potential latent content in the client’s
communications through:
• being curious about what anxieties may lie behind the
client’s questions, even if ostensibly legitimate, and to draw
the client’s attention to these
• identifying and pointing out to the client unverbalised affect
when it is manifested in the session
An ability to share with the client an interpretation in a manner
that is:
• clear (i.e. succinct enough for the client to be able to take
in what is being said)
• appropriately timed a) in relation to an assessment of what
the client can bear to think about at any given point and b)
relative to the amount of time left in a session (i.e. not
introducing new topics that may be unsettling to the client
too close to the end of a session)
• of appropriate depth (i.e. moving gradually from preconscious content to more unconscious content)
• pertinent to the affective and/or interpersonal focus of the
session
Client’s experience of interpretations
• An ability to assess the client’s capacity to make use of an
interpretation
• An ability to critically appraise the helpfulness and correctness
of an interpretation:
• by listening to the client’s conscious and unconscious
response to the interpretation
29
•
by responding non-defensively to the client’s experience of
an interpretation (including disagreement with it)
by incorporating this into an ongoing process of evaluation.
Ability to work in the transference
Knowledge
• An ability to draw on knowledge that a transference
interpretation makes explicit reference to the client-therapist
relationship so as to elucidate and encourage a joint
exploration of the client’s deficits and/or conflicts
•
An ability to draw on knowledge that working in the
transference relies primarily on interpreting the current
relationship between therapist and client (i.e. as opposed to
interpreting the childhood origins of the client’s current
interpersonal patterns)
•
An ability to draw on knowledge that the transference can take
many forms (e.g. positive, idealised, negative, sexualised)
•
An ability to draw on knowledge of the rationale and features of
the analytic setting and stance that encourage the development
of the transference
•
An ability to draw on knowledge of the emotional impact of
transference interpretations on the client so that their use is
“titrated” in a manner that reflects the client’s capacity to
receive them
•
An ability to draw on knowledge that the interpretation of
transference is core to an analytic/dynamic approach, but that
the therapist also needs to acknowledge and explore other
relationships and salient events in the client’s life.
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Application
Ability to facilitate the client’s exploration of the therapeutic
relationship
• An ability to encourage the client to discuss and explore:
o their perceptions of, and feelings about, the therapist
o how they think the therapist may feel or think about them
•
An ability to accept the client’s view of the therapist so as to
allow a particular experience of the client’s self in relationship
to the therapist to emerge in the session
Ability to maintain the focus of exploration on the transference
relationship
• An ability to help the client explore recurring patterns in their
relationship to the therapist
Ability to respond non-defensively and flexibly to the client’s
experience of a transference interpretation
• An ability to evaluate the impact of a transference interpretation
at any given point in time in light of:
• the client’s conscious and unconscious response to the
interpretation (e.g. what associations/understandings follow
an interpretation)
• the therapist’s evaluation of the quality of the working
alliance following an interpretation (i.e. a strengthening or
weakening of the alliance)
• the client’s level of distress following an interpretation
•
An ability to be open to the client’s view that the interpretation
may be incorrect or badly timed and to respond to this nondefensively
•
An ability to help the client make links and draw parallels
between their subjective experience with others outside the
therapy (past and present) and with the therapist (and vice
versa)
•
Ability to use the therapist’s experience of the transference
• An ability to use the therapist’s experience of the transference
in order to inform their understanding of:
• the client’s patterns of relating and of their defences
• the client’s capacity to work in the transference (i.e. to
make use of transference interpretations)
An ability to re-establish a focus onto the transference
relationship when the client, therapist (or both) are
unproductively pulled away from reflecting on the “here-andnow” of the therapeutic relationship
Ability to work with the counter-transference
Ability to understand and help the client manage the emotional
impact on them of the transference relationship
• An ability to help the client understand an increase in their
positive or negative feelings towards the therapist that may
result from the transference to the therapist
•
An ability to address and help the client understand the
meaning of erotic feelings they may experience towards the
therapist
•
An ability to recognise the client’s need to ‘test’ the relationship
with the therapist in the transference and to communicate this
understanding to the client
Knowledge
• An ability to draw on knowledge that countertransference
reactions are variously determined by:
• the therapist’s ordinary emotional response to the client’s
predicament
• the therapist’s own transference to the client
• the client’s projections into the therapist
•
An ability to draw on knowledge that enactments (by the client,
therapist or both) are inevitable in the course of treatment and
require understanding so as to regain a reflective stance:
• knowledge of the possible sources of countertransference
to understand and manage the pull towards immediate
action or enactment of particular roles with a client
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30
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Ability to recognise and work with defences
Application
An ability to make use of the therapist’s responsiveness to the client
as the basis for interpretation
• An ability to attend to the specific quality of the feelings,
thoughts, flow of associations and fantasies that are evoked in
the therapist during the exchanges with the client so as to
hypothesise about what the client may be expressing indirectly.
•
•
An ability to be open to experiencing transitory identifications
with the client’s projections (e.g. of particular roles) through:
• allowing the client to view the therapist in a manner
incongruent with the therapist’s own self-perception, so as
to understand the meaning of this for the client (i.e. not
interpreting this prematurely)
• being receptive to the client’s conscious and unconscious
needs and wishes in relation to the therapist
•
31
•
An ability to draw on knowledge that defences have both
adaptive and maladaptive functions
•
An ability to draw on knowledge that defences are often
unconscious mental processes that distort reality, and that
they:
• may exclude a feeling or thought from consciousness
altogether
• may consciously admit the disturbing feeling /thought but
detach it from its emotional significance
• may substitute one feeling for another
• may distort or confuse the perception of self and others
(thus fundamentally altering perceptions of external and
internal reality)
•
An ability to draw on knowledge that any behaviour or feeling
may be used defensively and that an important task in
analytic/dynamic therapy is to identify the defensive function of
a feeling, behavioural pattern or state of mind.
•
An ability to draw on knowledge that the nature of the defences
predominantly used by a client will reflect their level of
personality functioning (i.e. neurotic, borderline or psychotic)
•
An ability to draw on knowledge that interpretation of the link
between anxiety and defence is normally prioritised over the
interpretation of content.
An ability to appraise the relevance of the therapist’s own
thinking about, and affective responses to, the client and to use
this as a basis for an interpretation of what the client may be
struggling to articulate explicitly
An ability to reflect on the therapist’s involvement in the therapeutic
process
• An ability for the therapist to reflect on their emotional reactions
to the client so as to maintain an “observing distance” from the
part of themselves that is involved in the process.
•
Knowledge
• An ability to draw on knowledge that all individuals deploy
defences to manage uncomfortable and painful feelings, states
of mind (e.g. the experience of dependency) and forbidden
impulses
An ability to recognise erotic feelings towards the client and to
think through the meaning and implications for the therapist
and for their relationship with the client
An ability for the therapist to critically consider the meaning of
their emotional reactions to the client so as to minimise the risk
of unsubstantiated speculation or of misattributing to the client
feelings that belong to the therapist:
• an ability for the therapist to identify personal need for
further therapy/supervision.
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Application
Ability to help the client understand why and how they protect
themselves from painful feelings/states of mind
• An ability to accept the client’s style of relating and respect the
defensive needs that may underlie particular interpersonal
styles
•
•
•
•
An ability to help the client explore and become more aware of
areas of conflict by drawing attention to feelings/states of mind
that seem unacceptable or uncomfortable
An ability to help the client explore the meaning of their
defensive structures by:
• empathically pointing out how they may unconsciously
protect themselves (e.g. by becoming confused or unable
to think)
• helping the client understand why they need to protect
themselves from the experience of particular feelings
/states of mind
An ability to help the client become more aware of how they
manage problematic aspects of their relationships through an
exploration of defences as they arise in relation to the therapist
and significant others
An ability to help the client understand the ‘costs’ of the
defences used by pointing out their impact on their own
capacities and on their relationships
Ability to manage the anxiety generated by the exploration of
defences
• An ability to assess the client’s readiness to explore their
defences
32
•
An ability to be receptive to the client’s anxiety as it manifests
in the therapeutic relationship so as to facilitate the client’s
reflection on its meaning
•
An ability to contain the client’s experience of anxiety if they
feel too exposed
Ability to work through the termination phase of therapy
Knowledge
•
Knowledge that preparation for endings is an integral part of the
process from the outset, and not just a distinct phase
•
Knowledge of the dynamics of separation, loss and mourning as
the basis for understanding the client’s subjective experience of
endings/separations
•
An ability to draw on knowledge of the specific significance of
separation and loss in clients with different personality structures
(e.g. in borderline clients)
Application
Ability to be attuned
termination/separations
to
direct
and
indirect
references
to
•
An ability to systematically draw attention to, and address, the
client’s feelings, unconscious fantasies and anxieties about the
ending of therapy
•
An ability to systematically draw attention to, and address, the
defences the client uses to protect themselves from awareness of
endings or from the feelings associated with endings through:
• articulating the feelings that are triggered by endings (so as to
pre-empt acting out and premature endings).
• responding to the client’s decision to end prematurely by
helping them to consider whether unconscious factors may
be influencing such a decision.
• responding to the indications of regression near the end of
treatment (e.g. a symptomatic deterioration) by linking this
with the feelings and fantasies associated with endings.
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
•
•
An ability (throughout the therapy), to help the client become
aware of their subjective experience of separations as they occur
in the context of the therapy and in their life (with the aim of
helping them work through the feelings associated with
separations and loss)
When responding to a client’s expressed wish to terminate a
therapy before its agreed end, an ability to critically appraise
whether the therapy may have reached an unresolvable impasse
such that ending and/or referral onwards may be the most helpful
way forwards
Ability to prepare the client for the ending
33
•
An ability to identify clients who are likely to be adversely affected
by endings and the risks this may pose for them (e.g. risk of selfharm)
•
An ability to understand and work in the transference with the
significance for the client of the separation from the therapist:
•
an ability to tolerate and address the client’s anger and/or
disappointment about ending
•
An ability to maintain a focus on the experience of endings as the
treatment approaches its end
•
An ability to recognise the ending phase of treatment as an
opportunity to re-visit the core interpersonal patterns and conflicts
that have been worked on in the therapy
•
An ability to keep in mind, and help the client to reflect on, the
meaning of the time frame of therapy throughout the treatment:
• an ability to be aware of any specific countertransference
reactions to the time frame that may result in an enactment
(e.g. colluding with the client’s wish to create an atmosphere
of timelessness)
•
An ability to maintain the boundary created by the time-limited
nature of the therapy, particularly in response to interpersonal
pressures to extend the therapy (and hence avoid facing the
ending)
•
An ability to help the client review the therapy as a whole (e.g.
whether they have achieved their aims) and to help them express
gratitude and/or disappointment, as appropriate .
•
An ability to take responsibility for the personal resonances that
endings will have for the therapist so that this does not impinge
on the client’s exploration and experience of ending
•
An ability to make an assessment of the client’s clinical needs
post therapy, as part of the preparation for ending, including the
need for follow-up sessions or future therapy:
•
an ability to consider decisions about the client’s future
needs in light of the transferential implications of such
arrangements
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Metacompetences
Generic Metacompetences
Analytic Specific Metacompetences
Capacity to use clinical judgment when implementing treatment
models
•
•
•
Ability to make use of the therapeutic relationship as a vehicle for
change
An ability to implement a model of therapy in a manner which is
flexible and which is responsive to the issues the client raises,
but which also ensures that all relevant components of the
model are included
An ability to use clinical judgment in order to balance
adherence to a model against the need to attend to any
relational issues which present themselves
An ability to maintain adherence to a therapy without
inappropriate switching between modalities in response to
minor difficulties (i.e. difficulties which can be readily
accommodated by the model being applied)
Capacity to adapt interventions in response to client feedback
•
34
An ability to accommodate issues the client raises explicitly or
implicitly, or which become apparent as part of the process of
the intervention:
• An ability to respond to, and openly to discuss, explicit
feedback from the client which expresses concerns about
important aspects of the therapy
• An ability to detect and respond to implicit feedback which
indicates that the client has concerns about important
aspects of the therapy (e.g. as indicated by non-verbal
behaviour, verbal comments or significant shifts in
responsiveness)
• An ability to identify when clients have difficulty giving
feedback which is “authentic” (e.g. clients who respond in
accordance with what they think the therapist wishes to
hear, rather than expressing their own view) and
discussing this with them
• An ability to be aware of, and respond to, emotional shifts
occurring in each session, with the aim of maintaining an
optimal level of emotional arousal (i.e. ensuring that the
client is neither remote from or overwhelmed by their
feelings)
Knowledge
• An ability to draw on knowledge that the detailed tracking and
exploration of the vicissitudes of the therapeutic relationship is
the cornerstone of analytic/dynamic technique
Application
• An ability to establish and maintain emotional contact with the
client
•
An ability to prioritise the experiential focus of the here-andnow of the session as the basis for interventions:
• an ability to respond to the current state of the relationship
•
An ability to make use of the therapist’s experience with the
client to inform the therapy:
• an ability for the therapist to monitor their emotional
reactions to the client
• an ability to critically consider the relevance of the
therapist’s current experience with the patient as the basis
for furthering understanding of the patient
• an ability to self-reflect and where appropriate to identify
the need for further personal therapy and/ or supervision
(to protect the client from potential harm)
•
An ability to identify, and respond appropriately when the
client’s experience of close emotional contact with the therapist
leads to a deterioration in their functioning
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Ability to apply the analytic/dynamic model flexibly in response to
the client’s individual needs and context
Ability to respond flexibly to changes in the client’s presentation
• An ability to monitor the client’s experience of the therapy and
their state of mind
•
•
•
An ability to adapt the model, technique (e.g. interpreting the
negative transference), frequency of sessions or setting of the
therapy in response to:
• the individual needs of the client (including their level of
distress) at a given moment in the session and during
particular phases of the therapy
• the quality of the therapeutic alliance
• changes in the client’s external context
• changes in the treatment setting
An ability to systematically monitor any harmful impact of
therapy on the client:
• an ability to identify the need for consultation/supervision if
there are indications that the client is at risk
An ability to intervene to help the client manage anxiety that
would otherwise prevent exploration:
• an ability to help the client understand what may be making
them anxious
• an ability to adapt technique flexibly (e.g. by increasing the
therapist’s level of activity) so as to respond to
unproductive levels of anxiety in the client
Ability to tailor therapy to the time available
• An ability to identify the adaptations of the core
analytic/dynamic model required to work within a specified time
35
•
Ability to establish an appropriate balance between interpretative and
supportive work
Knowledge
• An ability to draw on knowledge that while the primary focus in
analytic/dynamic psychotherapy is on interpretative techniques,
supportive techniques facilitate the development and
maintenance of a working alliance
•
An ability to draw on knowledge of both interpretative and
supportive approaches, their overall objectives and different
technical emphases:
• that the aim of interpretative techniques is to engage the
client’s curiosity about, and understanding of, their
unconscious inner mental life and the ways in which this
informs their subjective experience of self and others
•
that the aim of supportive techniques is to alleviate the client’s
immediate problems by strengthening their resilience (i.e.
building “ego strength”) and focusing on conscious experience
An ability to monitor and explore the meaning for the client of
any adaptations to the originally agreed treatment plan
Ability to titrate the level of therapist activity in response to the
client’s levels of arousal
• An ability to closely monitor the client’s levels of arousal
•
•
frame (e.g. if brief therapy, regular reminders to the client of the
time-limited nature of the work)
An ability to adjust the level of therapist activity relative to the
length of treatment (e.g. greater activity if working on a
circumscribed focus within a time-limited frame)
An ability to appraise the risks and benefits for the client of an
open-ended or time limited approach
• where risks are identified, an ability to establish safe
parameters for the therapy (e.g. by organising additional
support)
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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Application
• An ability to evaluate and support the client’s ability to manage
the demands of interpretative work (both within a given
session, and as an overall treatment strategy during particular
phases of therapy) by:
• continuously monitoring the client’s level of distress
• listening to the client’s conscious and unconscious
communication about how they are experiencing the
therapy
• communicating to the client an understanding of why they
may be finding aspects of the work particularly challenging
at certain points
• responding flexibly to the client’s shifting capacity to
tolerate an interpretative approach
• regularly reviewing the client’s external systems of support
•
An ability to identify when it is appropriate to act on the anxiety
generated by the client in the therapist (i.e. not only reflect on
its possible meaning) so as to protect the client/others/the
therapy
•
Where the therapist shifts from an interpretative to a more
actively supportive stance, an ability to:
• identify the impact this may have on the therapeutic
relationship
• communicate to the client an understanding of the meaning
for them of this shift in style
Ability to identify and apply the most appropriate analytic/dynamic
intervention
Knowledge
• An ability to draw on knowledge of the various analytic/dynamic
models and techniques in order to identify the most appropriate
intervention for a given client
Application
• An ability to apply the chosen model skilfully
• An ability to consider the length, intensity and format of the
treatment (individual, group, family, couple) in light of:
• developmental factors (e.g. age)
• the client’s mental state
• the level of risk
• the setting in which the therapy will take place
• the nature of the problem
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36
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)
Acknowledgments
The competences for Brief Dynamic Interpersonal Therapy
(DIT)
have
been
adapted
from
the
Psychoanalytic/Psychodynamic framework (Lemma, Roth and
Pilling, 2008) the main adaptation is their focus on working
specifically with people with depression.
The full Psychoanalytic Competence Framework can be found
online at:
http://www.ucl.ac.uk/clinicalpsychology/CORE/competence_frameworks.htm
The work to devise the competences in this document was led
by Prof Alessandra Lemma.
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37
IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)