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Brief Dynamic Interpersonal Therapy for Depression (DIT) Competency Framework

September 2010

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.

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. 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 clients 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 clients interpersonal difficulties. DIT has a dual aim: 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 clients 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 Clinicians 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. 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.

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 therapists 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 clients needs and cultural contexts.

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. 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.

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.

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 Knowledge and understanding of depression and mental health problems Knowledge of, and ability to operate within, professional and ethical guidelines 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 client Ability to foster and maintain a good therapeutic alliance, and to grasp the clients 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 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

Basic DIT Competences

Specific techniques

Metacompetences

Knowledge of basic principles and rationale of analytic/dynamic approaches Ability to assess the likely suitability of an analytic/dynamic approach Ability to engage the client in analytic/dynamic therapy Ability to derive an analytic/ dynamic formulation Ability to establish and manage the therapeutic frame and boundaries Ability to work with unconscious communication

Ability to make dynamic interpretations Ability to work in the transference

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 work with the countertransference 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 clients 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 facilitate the exploration of the unconscious dynamics influencing relationships Ability to help the client become aware of unexpressed or unconscious feelings Ability maintain an analytic / dynamic focus Ability to identify and respond to difficulties in the therapeutic relationship Ability to work with both the clients 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 clients condition when their behaviour leads to interpersonal difficulties which are directly attributable to their mental health problem. 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)

Knowledge of depression An ability to draw on knowledge of the cluster of symptoms associated with a diagnosis of depression: 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)

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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 clients 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 An ability to draw on knowledge of the ways in which depression is conceptualised within the model of therapy being adopted 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 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 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 opportunities for the client to discuss matters of concern and to express their feelings learning factors: advice correctional emotional experience feedback exploration of internal frame of reference

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 clients 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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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)

changing expectations of personal effectiveness

Ability to engage client While maintaining professional boundaries, an ability to show appropriate levels of warmth, concern, confidence and genuineness, matched to client need. An ability to engender trust. An ability to develop rapport. 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 clients emotional reactions. An ability to adjust the level of in-session activity and structuring of the session to the clients 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 assimilation of problematic experiences


o o o o o o action factors: behavioural regulation cognitive mastery encouragement to face fears and to take risks reality testing experience of successful coping 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 clients 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.

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9 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: 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

Capacity to develop the alliance An ability to listen to the clients 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.

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

Capacity to grasp the clients 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 clients 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 clients world view in mind, while retaining an independent perspective and guarding against identification with the client

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10 IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)

Capacity to maintain the alliance 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.

Ability to work with emotional content of session 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 clients 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 clients current life situation, specific stressors and social support. An ability to assess the clients coping mechanisms, stress tolerance, and level of functioning.

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11 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 clients 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 clients 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).

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

Ability to assess and manage risk of self-harm An ability to draw on knowledge of indicators of selfharm, 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:

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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 assess the clients 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 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 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.

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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 clients expectations regarding the lethality of the drugs or injury presence of a suicide note (including recorded and text messages) the clients efforts to obtain help after the event An ability to ask about previous acts of self harm (including the circumstances and the level of intent)

An ability to identify and manage ethical issues in relation to risk management e.g.: the management of actively suicidal clients who refuse intervention decisions regarding the involvement of relatives

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: frequent access to a therapist when needed home treatment when necessary telephone contact outreach (which include active follow-up when appointments are missed)

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 administer and interpret standardised measures for assessing suicidality and hopelessness (e.g. Suicide Intent Scale, Suicide Assessment Checklist, Beck Hopelessness Scale (etc))

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)

Management of risk of self-harm 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)

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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

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 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

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

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 individuals 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.

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

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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)

to identify whether and how this experience has shaped the development and maintenance of the clients 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 clients 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

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 clients 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 clients experience of difference: to help the client to discuss and reflect on their experience of difference

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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 clients 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

An ability to use feedback from the supervisor in order further to develop the capacity for accurate self-appraisal.

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.

Ability to make use of supervision An ability to hold in mind that a primary purpose of supervision and learning is to enhance the quality of the treatment clients receive.

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 to use supervision to reflect on developing personal and professional role 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 supervisors recommendations deviate from acceptable practice where the supervisors actions breach national and professional guidance (e.g. abuses of power and/or attempts to create dual (sexual) relationships)

Capacity for self-appraisal and reflection An ability to reflect on the supervisors 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.

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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

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)

Ability to integrate measures into the intervention 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 interpret measures 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

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 clients 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 clients 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 individuals 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 clients 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 clients internal world of relationships and conflicts). An ability to draw on knowledge of the rationale for adopting a primarily receptive (i.e. non directive) stance in relation to the clients 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 clients 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 clients needs: the clients response to an exploratory approach (e.g. their response to a relative lack of therapist direction, indicators of an interest in reflection) the clients interest in reflecting on how their relationships with others work the clients interest in working with interpersonal and affective themes the clients 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 therapists 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 clients 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 clients interaction with the therapist and evaluate what adaptations may be necessary to support the clients 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 clients 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 clients 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 clients 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 clients presentation has on them an ability to appraise the potential significance of the therapists response to understanding the clients interpersonal patterns Ability to develop a therapeutic alliance An ability to respond to the clients presenting problems in a concerned, non-judgemental manner through: allowing the clients narrative about their difficulties to emerge without imposing a structure asking clarifying questions so as to understand the clients perspective without making assumptions communicating empathic understanding in response to the clients conscious and unconscious communications respecting the clients need for defences

Intervention An ability to engage the clients interest in this therapeutic approach by making interpretations that connect the clients

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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 clients level of anxiety by engaging with the clients conscious and unconscious anxieties about the therapy and the therapist o tolerating the clients 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 identify and agree therapeutic aims An ability to share a tentative account of how the therapist understands the clients 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 clients 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 therapists observations about the quality of: the clients presentation of their narrative the clients 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 therapists evolving understanding of the client over time

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 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 clients unconscious communications, especially about the relationship with the therapist conveying an understanding of how the clients 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)

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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)

Application An ability to be curious about the clients 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 clients presenting symptoms the significance of the therapists emotional response(s) to the client 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 clients difficulties

Ability to establish and manage the therapeutic frame and boundaries Knowledge An ability to draw on knowledge that the therapists 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 clients subjective experience of breaks during the treatment

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 therapists understanding of the clients experience and difficulties an ability to engage the client in responding to the therapists formulation and elaborating it or revising it 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 clients 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 therapists 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 therapists understanding of the clients experience of separations/discontinuities in the treatment frame

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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)

An ability to be receptive to the clients 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 clients 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

through the emotional impact the communication has on the therapist 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

Application An ability to allow the emergence of spontaneous communication of feelings, thoughts, fantasies, daydreams or dreams so as to gain access to the clients 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 clients 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 therapists own feelings of anxiety about not knowing (e.g. about being perceived to be incompetent)

Ability to manage deviations from the established therapeutic frame An ability to evaluate the meaning of the clients 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) An ability to set clear limits where necessary (e.g. if the clients 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 clients manifest communications may contain a latent meaning An ability to draw on knowledge that the latent content of any communication may at times only become manifest indirectly

Ability to listen to unconscious communication An ability to pay attention to the clients 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 therapists own subjective associations and ideas to form in response to the clients communications

exploring the clients response to the therapists use of silence

Ability to respond to unconscious communication An ability to prioritise process over content when responding to the clients communications An ability to consider the potential latent content in the clients communications by: being curious about what anxieties may lie behind the clients questions, even if ostensibly sensible, and drawing the clients attention to these identifying and helping the client to reflect on unverbalised feelings An ability to consider the possible meaning of the therapists 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 help the client explore the unconscious dynamics influencing their relationships Knowledge An ability to draw on knowledge that the origins of the clients 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 clients subjective experience of their relationships Application Ability to formulate the clients 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 clients past and current relationships: an ability to identify recurring configurations of self and other representations an ability to identify areas of omission from the clients descriptions of their relationships (e.g. a pervasive absence of conflict) An ability to make use of the experience and observation of the clients ways of relating within the session to inform the understanding of the clients 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

Ability to tolerate and make judicious use of silence An ability to tolerate and allow silence so as to permit the emergence of the clients 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 clients level of anxiety in response to silence, and limit silences if the clients anxiety risks undermining engagement with the therapy by: o interpreting the anxiety o increasing the therapists 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 clients use of silence in the session

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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

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 clients 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 clients unconscious, internal world of relationships identifying and responding to the transference and countertransference 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 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 therapists understanding, empathic stance) 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 clients 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

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)

responding non-defensively to the clients 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 therapists interventions (e.g. the clients experience of empathic failure as an abandonment)

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 clients 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

An ability to facilitate the clients 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 clients 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 clients subjective experience and of their difficulties

Ability to reflect on the therapists contribution to difficulties in the therapeutic relationship An ability to engage in self-reflection to clarify the therapists 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 clients perception of the therapist An ability to distinguish between instances when resistance to therapy is a manifestation of the clients difficulties and instances when the client is responding to an accurate perception of differences of opinion between themselves and the therapist

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

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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 clients therapy

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 clients 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 therapists 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)

Ability to work with the clients internal and external reality Knowledge An ability to draw on knowledge that analytic/dynamic approaches privilege the exploration of the clients internal, unconscious world of experience, but that this is not at the expense of the exploration of, and sensitivity to, the clients external reality and value systems

Application Ability to balance working with the clients internal and external reality An ability to attend and respond to the conscious as well as the unconscious meaning of the clients preoccupations: an ability to respond sensitively to the clients current preoccupations and distress an ability to evaluate when it is most productive to focus primarily on the clients external or internal reality 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 clients 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 clients 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 clients 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 clients 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 clients 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 clients 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 clients conscious awareness) An ability to draw the clients 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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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 clients communications through: being curious about what anxieties may lie behind the clients questions, even if ostensibly legitimate, and to draw the clients 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

by responding non-defensively to the clients 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 clients 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 clients 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 clients 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 clients life.

Clients experience of interpretations An ability to assess the clients capacity to make use of an interpretation An ability to critically appraise the helpfulness and correctness of an interpretation: by listening to the clients conscious and unconscious response to the interpretation

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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)

Application Ability to facilitate the clients 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 clients view of the therapist so as to allow a particular experience of the clients self in relationship to the therapist to emerge in the session

Ability to respond non-defensively and flexibly to the clients 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 clients conscious and unconscious response to the interpretation (e.g. what associations/understandings follow an interpretation) the therapists evaluation of the quality of the working alliance following an interpretation (i.e. a strengthening or weakening of the alliance) the clients level of distress following an interpretation An ability to be open to the clients view that the interpretation may be incorrect or badly timed and to respond to this nondefensively

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 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) 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 use the therapists experience of the transference An ability to use the therapists experience of the transference in order to inform their understanding of: the clients patterns of relating and of their defences the clients capacity to work in the transference (i.e. to make use of transference interpretations) Ability to work with the counter-transference Knowledge An ability to draw on knowledge that countertransference reactions are variously determined by: the therapists ordinary emotional response to the clients predicament the therapists own transference to the client the clients 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

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 clients need to test the relationship with the therapist in the transference and to communicate this understanding to the 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 therapists 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 clients projections (e.g. of particular roles) through: allowing the client to view the therapist in a manner incongruent with the therapists own self-perception, so as to understand the meaning of this for the client (i.e. not interpreting this prematurely) being receptive to the clients conscious and unconscious needs and wishes in relation to the therapist An ability to appraise the relevance of the therapists 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 therapists 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. 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. 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 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.

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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 clients 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 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 clients 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 clients 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 clients 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.

Ability to manage the anxiety generated by the exploration of defences An ability to assess the clients readiness to explore their defences An ability to be receptive to the clients anxiety as it manifests in the therapeutic relationship so as to facilitate the clients reflection on its meaning An ability to contain the clients experience of anxiety if they feel too exposed

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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 clients 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

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 clients exploration and experience of ending An ability to make an assessment of the clients 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 clients future needs in light of the transferential implications of such arrangements

Ability to prepare the client for the ending 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 clients 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 clients 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)

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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 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) Ability to make use of the therapeutic relationship as a vehicle for change 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 therapists 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 therapists 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 clients experience of close emotional contact with the therapist leads to a deterioration in their functioning

Capacity to adapt interventions in response to client feedback 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)

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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 clients individual needs and context Ability to respond flexibly to changes in the clients presentation An ability to monitor the clients 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 clients 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 monitor and explore the meaning for the client of any adaptations to the originally agreed treatment plan

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)

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 clients 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 clients immediate problems by strengthening their resilience (i.e. building ego strength) and focusing on conscious experience

Ability to titrate the level of therapist activity in response to the clients levels of arousal An ability to closely monitor the clients levels of arousal 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 therapists 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

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IAPT Programme - Competency Framework for Brief Dynamic Interpersonal Therapy (DIT)

Application An ability to evaluate and support the clients 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 clients level of distress listening to the clients 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 clients shifting capacity to tolerate an interpretative approach regularly reviewing the clients 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 clients 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)

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