Interpersonal Therapy

PSYCHODYNAMIC-
PSYCHODYNAMIC-
INTERPERSONAL
INTERPERSONAL
THERAPY
THERAPY
MICHAELBARKHAM,
MICHAEL BARKHAM, ELSE
ELSEGUTHRIE
GUTHRIE
GILLIAN E HARDY AND FRANK MARGISON
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PSYCHODYNAMIC-
INTERPERSONAL
THERAPY
A CONVERSATIONAL MODEL
MICHAEL BARKHAM, ELSE GUTHRIE

SAGE Publications Ltd  Michael Barkham, Else Guthrie, Gillian E. Hardy and
1 Oliver’s Yard Frank Margison 2017
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This book is dedicated to the memory of Dr Robert F. Hobson MD with
gratitude for his inspiring vision and teaching.
1920–1999
Contents
List of Tables ix
About the Authors x
Preface xi
Acknowledgements xiii
Part I Theoretical and Research Foundations 1

1 Psychodynamic-Interpersonal Therapy in Context 3
2 The Efficacy and Effectiveness of

Psychodynamic-Interpersonal Therapy:
A 30-Year Overview 15
3 Client Change in Psychodynamic-Interpersonal

Therapy 33
Part II Practitioner Manual 51

Section A: Learning the Skills
4 Core Model and Introductory
Psychodynamic-Interpersonal Skills 53
5 Intermediate Psychodynamic-Interpersonal Skills 67
6 Advanced Psychodynamic-Interpersonal Skills 77
Section B: Applying the Skills 87

7 The Initial Sessions 89
8 The Intermediate Sessions 107

9 The Final Sessions 120
viii Psychodynamic-Interpersonal Therapy
Part III Learning and Developing the Model 135

10 Being an Effective Practitioner of
Psychodynamic-Interpersonal Therapy:
Developing Competence 137
11 Epilogue 153
Appendix: The Psychodynamic-Interpersonal Therapy

Rating Scale (PITRS) 157
References 176
Index 185
List of Tables
2.1 The (first) Sheffield Psychotherapy Project 18

2.2 The Second Sheffield Psychotherapy Project (SPP2) and
National Health Service Collaborative Psychotherapy Project (CPP) 20
2.3 Two-plus-one Project 22
2.4 Evaluations of PI therapy for patients with
medically unexplained symptoms 26
2.5 Other evaluations of psychodynamic-interpersonal
therapy 31
3.1 Listing of themes, their components and associated
research methods 34
3.2 Assimilation stages 48
4.1 The three competency stages and associated
skills for psychodynamic-interpersonal therapy 54
10.1 Examples of role-play cards 141
10.2 Example of systematic process notes 147
10.3 Developing levels of supervision 150

About the Authors
Michael Barkham is Professor of Clinical Psychology and Director of the

Centre for Psychological Services Research at the University of Sheffield. He
was Joint Editor of the British Journal of Clinical Psychology (2004—2011) and is
a Fellow of the British Psychological Society. He was the international Vice-
President for the UK chapter of the Society for Psychotherapy Research and,
with colleagues, developed the family of CORE outcome measures widely used
in practice-based evidence. He has led on several of the process-outcome stud-
ies in Sheffield and Leeds.
Else Guthrie is a Consultant in Psychological Medicine and Honorary Professor

of Psychological Medicine and Medical Psychotherapy at the University of
Manchester. She runs a busy liaison psychiatry service in Manchester and is a
clinician and researcher. She has conducted many of the research studies on PI
therapy in Manchester, including work on self-harm and persistent physical
symptoms. Her other research interests include the interplay between physical
and psychological disorders.
Gillian E. Hardy is Professor of Clinical Psychology and Director of the Clinical

Psychology Unit at the University of Sheffield. She was Joint Editor of the British
Journal of Clinical Psychology (2004–2011), and Associate Editor of the British
Journal of Medical Psychology (2000–2005). She worked as a therapist/researcher
on the Sheffield and Leeds research psychotherapy projects and has a particular
interest in psychotherapy process research and attachment theory.
Frank Margison is a consultant psychiatrist in psychotherapy and general adult

psychiatry working in Manchester. From 1978 he worked on the development
of the Conversational Model of psychotherapy with Bob Hobson and led on
developing teaching methods. His psychotherapy research apart from PI ther-
apy has been in assessing client change using the CORE measure. He was UK
Vice-President of the Society for Psychotherapy Research and was joint editor
of the British Journal of Medical Psychology.
Preface
This book has been through several iterations prior to publication. We began
with an attempt to write a definitive Handbook of Psychodynamic Interpersonal
Therapy, a type of therapy also known as the Conversational Model. After a
while we shifted focus and we have developed a much briefer book that
focuses mainly on the very pragmatic aspects of doing therapy in this way. In
many ways this goes back to the roots of the model in the very practical appli-
cations pioneered in the United Kingdom by Robert Hobson.
The opening chapter (Chapter 1) provides a brief introduction to how this
model of psychotherapy developed, and links to other books on how it can be
applied in the long-term therapy of serious, long-term personality difficulties
(through the work of Russell Meares and colleagues in Australia). The chapter
also introduces the theoretical basis of the model in outline.
Our original intention of summarising in detail the many research studies
of this model has crystallised into two chapters (Chapters 2 and 3), the first of
which summarise briefly the evidence that demonstrates that this approach is
effective, and then a chapter on the many process research studies that
together tell a story about how this approach may be effective.
The bulk of the book comprises six chapters (Chapters 4 to 9) that constitute
a manual for a generic form of the Conversational Model. It is written to be
suitable for beginners with little or no background in psychotherapy or coun-
selling and can form the foundation for a teaching programme.
Chapters 4 to 6 cover introductory, intermediate and advanced skills. The
introductory skills can stand alone as a generic approach to helping patients or
clients to focus on important feelings, while the intermediate and advanced
skills build incrementally to cover those skills needed to practise this model of
therapy, especially in its briefer forms.
Chapters 7 to 9 develop the skills as they emerge in the beginning, middle and
end of a therapy with some extended examples of an anonymised therapy based
on actual sessions with Robert Hobson. These are not intended as exemplars of
perfect practice, but rather as therapy conducted in real life, warts and all.
Hobson emphasised the importance of learning from and acknowledging mis-
takes and we have tried to represent a realistic approach to conducting a form
of therapy that is very easy to learn in its basics, but a life-long task to deliver at
its best.
The book is also intended for those who already have a solid background in
therapy or counselling who want to develop skills in this particular model.
Some of the basics of how to start a session may seem redundant, but those
aspects are arranged to lead logically into the fundamental skills and princi-
ples of the model.
xii Psychodynamic-Interpersonal Therapy
For therapists who are already experienced in working this way, the book
summarises not only the skills to be refreshed but also an introduction to how
a programme can be developed to supervise and encourage the learning of
others (Chapter 10) and finally Chapter 11 provides a brief overview of the life
and work of Robert Hobson.
The book can be read sequentially and is designed to give an initial ground-
ing in the model before the practice section, but it can equally be used initially
as a practical manual, starting at Chapter 4, and the earlier theoretical basis
reviewed later.
We have also included an adherence manual, where individual skills of PI
therapy are summarised, anchored in a rating scale with examples to help use
the manual in a consistent way. The scale can be used as part of training or in
supervision when reviewing recordings of therapy sessions.
There are some additional resources and tools within the book, and more are
available on the Psychodynamic Interpersonal Therapy website www.pit-sig.uk
Professor Michael Barkham (University of Sheffield)

Professor Else Guthrie (University of Manchester)
Professor Gillian E. Hardy (University of Sheffield)
Dr Frank Margison (University of Manchester)
April 2016
Acknowledgements
The whole of the development of this type of psychotherapy began with the
work of the late Dr Robert (Bob) Hobson and Professor Russell Meares, and
this book is our special thanks to them. Robert Hobson was active in much
of the research cited here and was a principal investigator on several pro-
jects. We have worked closely with Russell Meares to make sure that the
strand developed in the UK and the developments in Australia have kept
synergistic links.
So many people have contributed to the development of this model of
psychotherapy that it will be almost impossible to mention everyone, so we
have tried to give credit to groups of people with named individuals who have
contributed key developments.
Principal investigators of key research programmes

in the development of the model
Professor Sir David Goldberg and the late Professor Peter Maguire were joint
grant holders with Robert Hobson in the early definition of the model in the
UK. Professor David A. Shapiro was a major figure and programme leader for
the first process-outcome studies in Sheffield and we thank him for his involve-
ment in an early draft of this book. Professor Francis Creed was programme
lead on many of the early trials in Manchester.
International research collaboration

with external programmes
Professors William B. Stiles, Robert Elliott and Marv Goldfried have worked
extensively with the Sheffield programme and have contributed greatly to the
elaboration of the way the therapy works. Many colleagues from the Society
for Psychotherapy Research and other societies have contributed to our
developing understanding. Professor Peter Henningsen led work to develop
and test the model in a large multi-centre trial in Germany. Professors
Wolfgang Herzog, Marco Rigatelli, Thomas Hyphantis and Dr Gaspare
Palmieri have all been involved in significant European collaborations with
the Manchester team.
xiv Psychodynamic-Interpersonal Therapy
Key research collaborators at the

Universities of Sheffield and Leeds
We thank Dr Hannah Mackay who wrote an early compilation of process
research studies. The late Professor Mike Startup with Professor Shapiro devel-
oped an early version of a chapter on adherence. Dr Graham Paley contributed
work on approaches to training in the model. In addition, the following contrib-
uted to the delivery of the model in a range of process and outcome research
studies: Dr Roxane Agnew-Davies, Alison Culverwell, Dr Susan Field, Professor
Jenny Firth-Cozens, Dr Jeremy Halstead, Dr Heather Harper, the late Veronica
Harrington, Professor Sue Llewelyn, Professor Anna Madill, Professor Glenys
Parry, Ann Rees and Professor Shirley Reynolds.
Research colleagues in Manchester studies

We thank colleagues who have worked on the Manchester studies including
Professors David Thompson, Bonnie Sibbald, Nick Read, Alistair Burns, Nav
Kapur, Kevin Mackway-Jones and Caroline Chew-Graham, Drs Jane Hamilton,
Joy Ratcliffe, Lasmi Fernandez, Graeme McGrath, Steve Reilly, Helen Barker,
Jane Martin and Dan Beales. Stephanie Howlett has contributed not only to
the work in Manchester, but also to developing the model for people with
neurological presentations. Mrs Barbara Tomenson has been involved in the
statistical analysis of many of the Manchester projects. Mrs Wendy Clarke has
been responsible for the administrative support for many of the Manchester
research studies and all the training courses we have run over the years.
Without her support, very little would have been achieved.
Development of teaching methods

and training in Manchester
We thank Madeline Osborn, Terry O’Dowd, Hazel Seidel, Susan Fairbairn and
Steve Moss for their roles in developing the teaching materials, and many oth-
ers who volunteered to play parts in the teaching videos and early development
of role plays.
Malcolm Firth, Sarah Davenport, Roger Paxton, Dave Rhodes, Graham
Paley, Jane Nicholson, Malcolm Judkins, Graeme McGrath and others devel-
oped teaching and evaluation, and clinical methods in other settings.
We are indebted to Jim Moorey and Eileen Brierley who set up and have
been running training courses in PI therapy in Manchester for the last
20 years, and over that time have trained many hundreds of people. More
recently, Richard Brown and Rebecca Hughes have also been involved in
developing training in relation to a condensed form of PI therapy. Simon
Heyland has been involved in developing and using the model in a primary
Acknowledgements xv
care setting, and is currently playing a key role in the expansion of training in
PI therapy. Clive Turpin and Rita Jordan have made an enormous contribution
to training and using the model in the field of self harm.
We thank Professors Tony Roth and Steve Pilling, who have worked with
us to develop a competency framework for psychodynamic-interpersonal ther-
apy for people with persistent physical symptoms which can be downloaded
from the University College of London website (www.ucl.ac.uk/CORE/).
Theoretical development of the model

Jim Moorey and Richard Brown have both made significant contributions to
the theoretical basis of the model.
PIT Special Interest Group

We thank all the members of the PIT Special Interest Group which is geo-
graphically based in Manchester but covers the United Kingdom. We would
like to pay special thanks to Simon Heyland and Sarah Bartlett who originally
set up the group as well as Rebecca Hughes, Richard Brown, Mary Lewis, Kath
Sykes, Wendy Macdonald, Sheena Grant, Liz Murphy, Graham Cooper and
Clive Turpin.
Finally, Robert Hobson’s son, Professor R. Peter Hobson, who has developed his
own integration of therapist–patient relatedness from a psychoanalytic perspec-
tive (Hobson, 2016), has been an invaluable fellow traveller. We would like to give
special thanks to Marjorie Hobson for her support over many years, and to Robert
Hobson’s wider family for support through the long gestation of this book.
PART I
THEORETICAL AND
RESEARCH FOUNDATIONS
1
Psychodynamic-
Interpersonal Therapy
in Context
Introduction
This book contains the essential information about a model of therapy named
psychodynamic-interpersonal therapy that has been developed over the last four
decades. The book draws heavily on the extensive research base for psycho
dynamic-interpersonal (PI) therapy, which is summarised in Chapters 2 and 3.
But the overall text is designed to be a compact summary and overview of this
model of therapy that will enable practitioners, in conjunction with appropriate
supervision and training, to implement PI therapy. Accordingly, Chapters 4 to 9
comprise a detailed manual to allow therapists to develop their skills and tools
in practice. The model can be used as a development aid to existing skills in
psychological practitioners, or can be used as a stand-alone model for experi-
enced practitioners with more complex clients.
Psychodynamic-interpersonal therapy is relatively jargon-free and easy to
learn as PI practitioners use everyday language rather than technical language
to describe emotional experience. There is a strong emphasis upon ‘knowing a
person’ as opposed to knowing about a person, coupled with the development
of a strong therapeutic alliance. As feelings are re-experienced, they are linked
to images, thoughts or prior memories, and then to key relationships. This pro-
cess of linking feelings, thoughts, symbols and relationships occurs cyclically as
the therapy develops and solutions are found and tested out both in the therapy
and in the client’s life.
4 Psychodynamic-Interpersonal Therapy
The development of the model began in the 1960s when Robert (Bob)
Hobson, a consultant psychotherapist, was working at the Bethlem Royal
Hospital in London. Hobson ran a ward for patients with complex and enduring
problems, many of whom would now be considered to have borderline person-
ality disturbance. Hobson discovered that the traditional psychodynamic
approach of that time was not helpful and, with his colleague Russell Meares,
began formulating a new approach to treatment with much less emphasis upon
psychodynamic interpretation and a far greater emphasis upon ‘getting to know’
the person and finding solutions to problems in the context of ‘a conversation’.
Their essential idea was that the client’s primary fundamental disturbance
was a disruption or stunting of the ordinary experience of living. They viewed
‘self’ not as an isolated system but as part of a larger social organism. It follows
from this theoretical position that the ‘conversation of therapy’ should involve
a reciprocal shaping or picturing of the immediate central and emotional expe-
rience of the other, coupled with a re-working and re-processing of images,
ideas and feeling states to form a more coherently operating self-system.
Hobson published his thoughts about a new approach to psychotherapy in
a paper entitled ‘Imagination and amplification in psychotherapy’ (1971), and
this was followed by a preliminary account of some of the features of the
model in The Pursuit of Intimacy by Russell Meares (1977). Hobson then pub-
lished a fuller account of the therapeutic approach in his book Forms of Feeling:
The Heart of Psychotherapy (1985), by which time there was beginning to build
a body of research on the model (see Chapters 2, 3 and 10).
Meares has further elaborated and developed the theoretical underpinning of
the model (Meares, 1993, 2000). And a full exposition of his work with border-
line personality disorder has been published recently (Meares, 2012a). The text
is accompanied by a psychotherapeutic manual specifically for delivering the
model for people with borderline personality disorder (Meares, 2012b). The
model was originally known as the Conversational Model of therapy and this
term is still used widely and interchangeably with the term psychodynamic-
interpersonal therapy (abbreviated at times to PI therapy for convenience).1
The hallmarks of the model

This initial chapter introduces the four features that characterise the PI model
of therapy. We briefly summarise them here and then amplify each of them in
the subsequent sections.
1. Conversation – Psychodynamic-interpersonal therapy begins with the prem-

ise that personal difficulties can best be tackled within a relationship and
that developing a personal relationship requires the therapist and client to
‘discover a language that fits’ (Hobson, 1985: 192); that is, to shape a common
1
The term psychodynamic-interpersonal therapy is generally used as the name of this
model, particularly in scientific discourse. The (or a) Conversational Model was the
name preferred by Robert Hobson and Russell Meares. Throughout this book, the two
names are used interchangeably.
PI Therapy in Context 5
‘feeling language’. This is what Robert Hobson meant by a Conversational

Model of psychotherapy. The therapist and patient engage in a creative
process, a conversation in which shared understanding develops.
2. Forms of feeling – The notion of ‘forms of feeling’ is crucial to the PI model
approach. When Hobson referred to feeling, he did not mean a faculty of
emotion plus a faculty of cognition. Rather, he referred to a form of ‘emotional
knowing’ or imaginative emotion related to an idea. This requires a different
thought process to an intellectual way of thinking about problems and
requires a form of creative imaginative or symbolic attitude which links
together feeling states, symbols and ‘analogues’ to produce a sense of greater
coherence. This type of analogical relationship is described by Meares as
something providing a feeling of ‘fit’ or connectedness, showing the shape and
proportions of something being described whilst not being an exact copy.
3. Minute particulars – Hobson used the term ‘minute particulars’ to refer to the
ability of the therapist to pay especially close attention to the barely noticed
nuances of a conversation so that by a painstaking series of adjustments,
paying attention to minimal changes in inflection or gaze, the therapist starts
to share an understanding of the other’s inner state through a series of ten-
tative hypotheses. Few other models of therapy focus so intently on the
micro aspects of treatment.
4. Research and practice – The model has, from its inception, been grounded in a
synergistic relationship between research and practice. Firstly, the PI model
has a foundation in outcome research (see Chapter 2). This gives a clear
answer to the question: Does it work? But, it is equally grounded in process
research studying how people change in therapy – that is, research where the
question is: How does it work? Our account of research on PI therapy takes
the form of a developing story which progressively answers these key ques-
tions (see Chapter 3). In Chapter 10 we describe not only the research on
learning this model of psychotherapy but also some suggestions about how
process research methods can be used to enhance clinical practice by bringing
in a different perspective of observation.
1. Conversation
A central tenet of the model is that the development of cohesion of the self
depends upon a particular style of conversation, initially learned externally
and then progressively internalised. This form of conversation is one that car-
egivers naturally adopt when bringing up young children (see Stern, 1985: 43).
Some people are more naturally adept at this mode of relating than others. The
process involves engaging with the child in an intimate form of ‘emotional
play’. It is this natural style of relating and capability to ‘attune’ to someone
else that the model seeks to promote.
Hobson’s strong belief was that it is the stories that matter – and how they
are told. The skill of psychotherapists lies in their ability to learn and reflect
back the language of the client and thereby create a ‘mutual language’ – a
personal conversation. Hobson drew upon Wittgenstein’s concept of ‘language-
games’ (Hobson, 1985: 47). This is the notion that forms of language are
particular and specific to shared activities of living and Hobson argued it was
central to understanding the Conversational Model. The use of a form of
words in one context may have a completely different meaning in another
context. The important question is: ‘What is this language doing within a par-
ticular situation?’ (Hobson, 1985: 47).
The idea of ‘conversation’ as a principle is discussed further elsewhere in
this book, but in considering the personal roots of the model developed by
Hobson the actual conversations with colleagues over the years have had a
powerful influence. In writing Forms of Feeling, he acknowledges that there is
an inevitable bias towards the ideas that have arisen in conversations with
friends. Two contributors to the idea of ‘conversation’ as part of the core of
psychotherapy have been Russell Meares, who gives his own account of the
Conversational Model elsewhere (see Meares, 2012a), and Miller Mair (1989).
Russell Meares, in his subsequent work on child development and the idea
of the ‘secret’ as part of the development of a sense of a separate self, has
carried forward the ideas of the Conversational Model into specific theories
related to infant development (Meares, 1993, 2000). Meares was also acutely
aware of the risks of a therapist ‘knowing too much’ and hence invading the
personal space of the other in a therapeutic conversation. In their work on
‘The persecutory therapist’ (1977), Meares and Hobson specified the character-
istics of an anti-therapeutic conversation that has been crucial in developing a
teachable model of psychotherapy.
The conversational and rhetorical aspects of conversation and the ‘poetics
of experience’ have also been closely linked with Hobson’s work. He begins
the Introduction to Forms of Feeling (Hobson, 1985: xi) with a quotation from
Wordsworth:
The principal object, then, which I proposed to myself … was to choose incidents
and situations from common life, and to relate or describe them throughout, as far
as was possible, in a selection of language really used by men; and at the same
time throw over them a certain colouring of the imagination whereby ordinary
things should be presented to the mind in an unusual way … not standing on
external testimony but carried alive into the heart by passion. (Preface to the
Lyrical Ballads, 1805)
Robert Hobson draws extensively on quotations from literature, but in a series

of discussions he worked with the late Miller Mair2 (1989) in elaborating a ‘poet-
ics of experience’. Quoting George Eliot in Middlemarch, Miller Mair points out
that to be a poet:
2
The late Professor Miller Mair was a clinical psychologist who became Clinical
Director of Crichton Royal Hospital in Dumfries and Galloway. He worked closely with
Robert Hobson in a series of training workshops during the 1970s and 1980s. He
focused on the use of conversation and metaphor, and introduced the idea of a ‘com-
munity of selves’ with an internal conversation. These ideas and the emphasis on the
poetics of experience resonated closely with the work that was developing on the
Conversational Model at that time.
is to have a soul so quick to discern that no shade of quality escapes it, and so quick
to feel, that discernment is but a hand playing with finely-ordered variety on the chords
of emotion – a soul in which knowledge passes instantaneously into feeling and feel-
ing flashes back as a new organ of knowledge. (Mair, 1989: xi)
As Miller Mair reminds us, Eliot notes that ‘one may have that condition by fits
only’ – moments in psychotherapy – but Miller Mair, from his background in
personal construct psychology, is referring to the same core principle that Robert
Hobson espoused above. The emphasis on poetics of language was fundamental
to Robert Hobson’s understanding of therapeutic language.
For the purposes of simplicity, Robert Hobson and Russell Meares both
distinguished two basic forms of language in therapy. The first is the language
used to talk about ‘things’ that Hobson referred to as ‘jam-jar language’, and
the second is the language used to share personal experience, which Hobson
termed ‘feeling-language’. The former is language we use to describe being in
the world. It is literal and discursive and unconnected to feeling. It is the lan-
guage we would use to say: ‘That is a jam-jar’. The latter is characterised by a
sense of vitality, a feeling of connectedness and a sharing of emotional expe-
rience. Hobson referred to it also as ‘the language of the heart’. It is the lan-
guage we use when we are talking intimately with a friend, family member,
partner, or to ourselves.
Russell Meares developed this concept further by referring to ‘chronicles’
or ‘scripts’ to describe language that involves a catalogue of problems or symp-
toms, disconnected from the inner world. And he referred to ‘inner speech’
when describing figurative or emotional language (Meares, 2012b: 39).
Robert Hobson argued that a personal conversation, promoted in therapy,
involves the development of a ‘feeling-language’. This form of language
expresses, communicates and shares feeling that involves: a) an apprehen-
sion of, and staying with, immediate experiencing; and b) a process of dis-
criminating, symbolising and ordering experiences, especially by creative
expression in ‘living symbols’ (using figurative language and metaphor).
So, one of the main tasks of a therapist using PI therapy is to try to promote
or facilitate and share a kind of ‘feeling-language’; in other words, to try to
know and connect ‘with someone’ in therapy rather than talk about their prob-
lems or emotions. It is common for people to use ‘thing language’ to describe
their feelings – ‘it’s my depression back again’ – and this should not be mis-
taken for ‘feeling-language’. The important distinction is between talking with
someone as a person rather than talking about some experience they have had.
The work of therapy also includes owning experiences (thoughts, wishes,
feelings experienced in relation to persons) in a movement from passivity to
activity. This is characterised by accepting responsibility for actions and acts
which had previously been disclaimed as a way of avoiding conflict.
2. Forms of feeling
The terms ‘feeling’ and ‘emotion’ are often used interchangeably. But when
Hobson refers to ‘forms of feeling’ he is talking about elaborations of
presentational symbols – emotions that are connected to imaginative ideas –

as a kind of emotional knowing. Staying with feelings in the ‘here and now’
in therapy often leads to images, ideas, previous experiences, dreams,
memories or physical sensations. These presentational symbols or mental
pictures are elaborated, shaped and processed, dissolved and re-combined
to eventually produce a harmonious organization or ‘fit’.
Symbols enable people to elaborate ‘inner forms’; conceptions which can be
modified, combined, re-combined in the process of thinking and solving prob-
lems. Figurative speech, which involves symbolic language and metaphor, has
a sense of movement and direction: There is a sense of layered meanings and
complex connections.
The model emphasises the use of metaphor as one important way of
exploring creatively a relationship between hitherto unrelated ‘terms’. It is
the process of exploration between two people (therapist and client) and,
hence, the re-combination of meanings to create a new understanding, which
is key.
Hobson was very aware that this theoretical account, at first sight at least,
can seem hard to grasp, and he preferred to demonstrate the ideas in action.
When asked by a trainee for a recommendation about reading about depres-
sion, he might refer to Conrad’s Heart of Darkness rather than a psychiatric
paper, although he was very familiar with the technical language of psychia-
try as shown in his MD thesis on the physical treatment for depression.
3. Minute particulars
This concept of the ‘minute particulars’ arises originally from William Blake;
Hobson, (1985: 108) cites William Blake:
… he who would do good to another must do it in Minute Particulars: General Good

is the plea of the scoundrel, hypocrite and flatterer, For Art and Science cannot exist
but in minutely organized particulars (Jerusalem III, 55: 60–68)
A focus on the microscopic forms of therapy has been a crucial part of the
psychodynamic-interpersonal model from its inception. Russell Meares,
when training with Robert Hobson in the late 1960s, brought Hobson audio
recordings of sessions of therapy with a young man whom he was struggling
to help. Meares found he could not convey in sufficient detail to Hobson the
struggles he was experiencing without audio recording the sessions. Hobson
and Meares found that ‘within the minute particulars of the therapeutic con-
versation, systems of destruction and moments of aliveness were present in
microscopic form’ (Meares, 2012a: 13). They found a great deal can happen
within a very few minutes of a psychotherapy session. Hobson wrote: ‘The
important focus is how a conversation is developed in its minute particulars.
Broad psychodynamic theories are all very well: indeed, inevitably, they
guide what we observe. But any formulation of the problem that faces a
unique person must emerge from the manner of this conversation, here and
now’ (Hobson, 1985: 165).
PI therapy stands apart from many other modalities in its focus on the
‘micro’ interactions of therapy as opposed to the ‘meta’ world of understand-
ing. A crucial aspect of this process is listening. All therapists using any modal-
ity of therapy would say listening is important. However, when Hobson
referred to listening he meant more than simply attending to what is con-
veyed. Rather, Hobson referred to ‘an active process of perceiving and paying
attention to a multitude of verbal and non-verbal cues and by an imaginative
act, creating possible meanings which can be tried out and modified in a con-
versation, or dialogue, that aims at understanding’ (1985: 208).
Therapy involves a progressive, ever-varying exchange of information con-
veyed by complex cycles of action and perception. The challenge for the ther-
apist is to learn the ‘language’ of the client, which can only be accomplished
by ‘listening’ to what he/she is communicating in speech, gesture and feeling.
It is salutary to listen to or watch tapes of therapy and see the myriad different
ways in which clients converse, only to realise that we miss most of these
opportunities for conversation because we are not sufficiently attuned to what
the client is trying to tell us.
Although the audio recording of therapy sessions is now commonplace, in
the 1960s it was rare and many psychodynamic therapists were actively and
theoretically opposed to such forms of monitoring. But, Hobson and Meares –
in the same way that Carl Rogers and colleagues had done in counselling – were
pioneers as they realised that it is only by replaying and reviewing recordings
of therapy that therapists can improve their listening skills and begin to become
aware of the minute particulars of therapy.
4. Research and practice
A key characteristic of PI therapy is the way it draws together research and

practice as two faces of the same coin. Formal trials of whether a therapy is
effective are an initial step in building a therapeutic approach, but we describe
ways in which the detailed analysis of the process of change alters and updates
the model itself, and also the practice of individual therapists. The methods
used in teaching this model are similarly based on good research foundations.
But beyond this, we also encourage those learning to practise this model to use
research methods to increase their understanding of their own sessions as
described in Chapter 10.
This self-reflexive approach to practice can be strengthened by regular
review of progress in therapy. It is beyond the remit of this book to discuss this
in detail, but there is a complementary relationship between evidence-based
practice and practice-based evidence (Barkham and Margison, 2007; Margison
et al., 2000). This complementarity suggests that practitioners gain from look-
ing at their own practice and reviewing the progress of that therapy against
benchmarks derived from other practitioners through using simple, well-
established measures of therapeutic change.
Chapter 2 briefly summarises 30 years of research effort including evidence

that PI therapy is effective in mood disorders (depression), in some psychoso-
matic disorders (irritable bowel syndrome and functional dyspepsia) and per-
sonality disorder (studies of borderline personality disorder). In addition, the
model has also been shown to offer benefit to people who have not responded
to other therapeutic approaches. Further, the PI model has been shown to be
cost-effective in practice.
However, it is of limited benefit to show that a therapy works if we have no
idea what might be leading to that change. There needs to be a theory of why
a particular type of conversation can lead to change. We also want this model
of therapy to be grounded in what therapists actually do. So, the outcome
studies referred to above have been linked to qualitative and process studies
from which we have distilled some key lessons about how change occurs. This
work is summarised in Chapter 3 as part of an ongoing narrative about what
makes psychotherapy effective.
We also report in Chapter 10 studies showing that the basics of the
model can be learned quickly, that those skills persist in practice, that the
training has a positive impact on therapists and that trained therapists have
a distinctive style that maps onto the fundamental tenets of the model. In
our view there is no purpose in developing a new therapy without the con-
fidence that it is effective and that training can be provided that focuses on
the key therapeutic skills as efficiently as possible.
The theoretical and personal foundations

of psychodynamic-interpersonal therapy
Having set out the hallmarks of the psychodynamic-interpersonal model as
they are realised in therapy, here we consider both the theoretical concepts
that have contributed to the PI model and also the personal influences on
Robert Hobson that helped shape the formation and development of the
Conversational Model.
Hobson and Meares have been influenced by the ideas of Williams James
(1842–1910) – an American philosopher and psychologist – and Hughlings
Jackson (1835–1911) – a Yorkshire-born English neurologist – in relation to the
idea of ‘self’ as being a form of a stream of consciousness. Self is understood to
arise out of a relationship with others. The psychotherapist Harry Stack Sullivan
(1892–1949) – an American psychoanalyst – argued that ‘a personality can never
be isolated from the complex of interpersonal relationships in which the person
lives and has his being’ (1940: 10). Sullivan’s model has been very influential in
building an explicitly interpersonal model of the person.
However, there are areas in which Sullivan also retains a model of the
unconscious even though markedly different from that proposed by Freud.
He saw the contents of passion and conflict in ‘shifting and competing con-
figurations composed of relations between the self and others, real and
imagined’ (Greenberg and Mitchell, 1983: 80). This assumption that the self
is a property emerging in relationships (internal and external) underpins the

psychodynamic-interpersonal model and other modern theories of psycho-
therapy, such as Cognitive Analytic Therapy (Ryle, 1990; Ryle and Kerr,
2002: 34–36). And both approaches draw explicitly on the work of Vygotsky
(cf. Leiman, 1997; Stiles et al., 1997). For example, both models draw on the
idea of a ‘zone of proximal development’ (ZPD; see Zonzi et al., 2014 for an
example within PI therapy).
Vygotsky worked on cognitive development in children and described the
ZPD as the ‘distance between the actual developmental level … and the level
of potential development as determined by problem solving under adult
guidance, or in collaboration with more capable peers’. In working with
adults, the model is more like collaborative learning with no sense of hierar-
chy (see Chapter 3 for applications of ZPD in PI therapy). In addition, in PI
therapy we have developed the idea of working in collaborative peer groups
to extend the ZPD of trainee therapists as well as of clients (see Chapter 10
section on role-play groups).
As is common in relational approaches, PI therapy pays particular attention
to the infant’s development within a relationship (Meares, 1993). It is widely
recognised that the infant has an intrinsic need to relate. As Sullivan pointed
out, there are ‘needs for tenderness’ beginning with the need for bodily con-
tact, developing into a need for an audience, and later needs for competition,
co-operation and compromise. Failure to satisfy these needs at the appropriate
developmental point leads to ‘loneliness’. Hobson echoes this theme with his
distinction between the creative state of ‘aloneness/togetherness’ and the ter-
rifying state of ‘loneliness’ (Hobson, 1974). The theoretical underpinning for
this core state has been further developed by Meares (2012a) but the detail
goes beyond the scope of this book.
A complementary view of the early need for relationship is derived from
attachment theory (Mace and Margison, 1997). The process of therapy is seen
as an attempt to invoke an actual relationship with the therapist which is sta-
ble and responsive but within which the attachment representations can be
modified to allow alternative, less maladaptive, patterns of relationship to
develop (Holmes, 1996). Identifying and working with these patterns of attach-
ment is a key underpinning of psychodynamic-interpersonal therapy. A key
idea in monitoring whether these crucial conditions are being met is to con-
sider the degree of ‘attunement’ between therapist and client as described by
Stern (1985). Attunement is a concept widely used in counselling to mean
attending closely to another person’s state of mind. Here we mean something
closer to the sense in which Stern refers to attunement as a form of conversa-
tion between parent and infant. The caregiver apprehends the other’s affective
states and responds with behaviour that corresponds with the infant’s affec-
tive state, and finally the infant perceives a connection between the caregiver’s
statement and his or her own emotional state. This may be verbal or could be
in the form of vocalisation or non-verbal gesture leading to a state of affective
attunement. Stern conceptualised these states as the foundation for recognis-
ing that inner states are shareable.
Between adults, the same emotional exchange can occur and this experience
is crucial in PI therapy. In some cases a longer period of therapy may be needed,
as the belief that emotional states can be shared or even experienced directly
has never been developed. With reference to the practice of PI therapy, Stern’s
description of ‘amodal properties’ (Stern, 1985) are especially helpful as they
describe textural properties of a conversation such as intensity, rhythm, shape
and cadence which are part of the ‘minute particulars’ discussed earlier.
PI therapy also draws on Jungian principles and Robert Hobson acknowl-
edged the particular importance of Jungian psychology in developing his ideas.
Hobson’s own basic training as a psychotherapist was in analytical psychology
and there are many resonances of the Jungian tradition in his writing. He
acknowledges the influence of Fordham (1979), in particular his work on the
Self. But the most important links are with Jung himself, and particularly
Jung’s approach to the practical aspects of therapy.
A profound personal influence on Hobson was his personal meetings with
Carl Jung during the 1950s. Although by then a senior analytical psychologist
and President of the Society of Analytical Psychology, Hobson admits to being
surprised by the simplicity of some of the core elements of Jung’s actual clinical
work. Hobson distilled these principles and incorporated them into his own
model. Many casual observers pay most attention to Jung’s work with arche-
types and myth, which are, of course, important in their own right. However,
the central elements that Hobson drew from his conversations with Jung have
much in common with current models of brief therapy.
There are three that are particularly pertinent. First, Jung emphasised the
importance of a ‘symbolical attitude’ even in the briefest therapies and this
principle has clearly been carried forward in the centrality of metaphor in the
Conversational Model, and hence PI therapy. Second, Jung also used the imme-
diate present, the ‘here and now’, in a particular way which focused the ses-
sion in a, sometimes, challenging way. And third, Hobson’s central idea of the
‘conversation’ was drawn from Jung’s concept of the ‘dialectical meeting’: thesis,
antithesis and the synthesis embodied in the conversation itself.
For Hobson, this emphasis, drawn originally from Jung, has strong resonance
with the ideas of Harry Stack Sullivan (1953). Sullivan developed Interpersonal
Psychoanalysis. He saw the contents of passion and conflict in ‘shifting and
competing configurations composed of relations between the self and others,
real and imagined’ (Greenberg and Mitchell, 1983: 80). This approach, which
underpins the original Conversational Model, is fundamentally dialogical. This
assumption that the self is a property emerging in relationships (internal and
external) underpins other modern theories of psychotherapy drawing on the
work of Vygotsky and Bakhtin.
Core values
All of the elements of theory presented above are embedded in the notions of a
conversation, as described by Hobson and Meares. Hobson also invoked some
core values that need to be upheld by the psychotherapist. Hobson returns fre-
quently to the theme that psychotherapy is about ‘persons’ involved in a mutual
conversation. ‘[S]ix qualities of a personal relationship … are at the heart of

conversational therapy: it happens between experiencing subjects, it can only be
known from “within”, it is mutual, it involves aloneness-togetherness, its lan-
guage is a disclosure of private “information”, and it is shared “here and now”‘
(Hobson, 1985: 25). This approach is central to Hobson’s approach to therapy.
In those six qualities he sums up some of the key principles of practice that we
will expand in the subsequent chapters of this book.
A key paper from Meares and Hobson (1997; ‘The persecutory therapist’)
shows how even well-intentioned therapists can be experienced as damag-
ing and so the model of psychotherapy developed here is explicit not just
about what should occur in a therapy but also what is unhelpful. These
unhelpful aspects prevent the development of a therapeutic conversation.
Psychodynamic-interpersonal therapy as
an integrative model
Psychodynamic-interpersonal therapy, as the name implies, can be seen to draw
on several traditions within psychotherapy and can be seen as an ‘integrative’
model (Margison, 2002; Martin and Margison, 2000). One particular aspect of
integration that was developed alongside the research programme described
later is the assimilation model (Stiles et al., 1990; see Chapter 3). This illustrates
how different approaches by PI therapy and cognitive behaviour therapy (CBT)
can both aim to increase the assimilation of problematic experiences. However,
as described later, the way that assimilation occurs shows key differences
between an integrative relational approach like PI therapy and other models of
therapy. Integration suggests that the elements are part of one combined
approach to theory and practice, as opposed to eclecticism, which draws ad hoc
from several approaches in the approach to a particular case (Hollanders, 2000).
The diverse range of influences involved in PI therapy as an integrative model
have been discussed elsewhere (see Margison, 2002). In addition to psychologists
such as William James, Rogers’ person-centred counselling, self-psychology of
Kohut, systems theory and Bowlby’s attachment theory, Robert Hobson was
influenced by literary figures including Shakespeare, Wordsworth and Coleridge
in his approach to developing a ‘feeling language’. He was heavily influenced by
philosophers, especially Wittgenstein on language games, Christian writers
including Martin Buber on the ‘I–Thou’ relationship and phenomenology
through Rollo May on the experience of the self. These influences are explored
further in Forms of Feeling, especially in the Notes and Note on Sources (Hobson,
1985: 283–99) where the breadth of influence becomes apparent.
Conclusions
This chapter has outlined the main background to the development of the
Conversational Model and subsequently this model of psychodynamic-interper-
sonal therapy. It has complex foundations but now represents a distinctive
tradition within psychodynamic-interpersonal therapies. The psychodynamic
tradition is represented in the detailed attention to shifting states of mind, the

tendency to ward off painful or threatening experiences, the underlying drive to
form attachments and in the focus on disturbances of the self.
The interpersonal aspects are seen in the fundamentally dialogical approach
and the emphasis on repetitive relationship themes. Both of these are in a
context that draws on an explicit focus on optimising the therapeutic relation-
ship and facilitative conditions (Rogers, 1951). The model of psychotherapy
has been heavily influenced by the research that we, and others, have carried
out and this work is summarised in the next two chapters. We look at the
evidence that this approach is effective and also at the evidence that supports
our model of the change process.
2
The Efficacy and
Effectiveness of
Psychodynamic-
Interpersonal Therapy:
A 30-Year Overview
Introduction
Psychodynamic-interpersonal (PI) therapy, or the Conversational Model, as it
was and still is known in Australia, has been rooted in an ethos of scientific
enquiry. Robert (Bob) Hobson in the UK and Russell Meares in Australia were
both determined, from its inception, that the model should be teachable,
researchable and evidence-based. Scientific study of the model has been con-
tinuing for the past 30 years and covers not only outcome research but also
studies on the process of therapy and how the model is taught and practised.
It stands apart from other psychodynamic and relational models in terms of
the strength, breadth and depth of research that has been undertaken.
This chapter provides a brief overview of the outcome literature on PI ther-
apy. The work derives from two major research methods: trials, which test the
efficacy of a treatment under optimal research conditions, and effectiveness
research, where there is less rigour but the setting is more routine. However,
equally important as showing that a therapy is effective is building an
understanding as to how psychological therapies work and lead to client
change. The body of research focusing on the change process in PI therapy
is presented in Chapter 3.
The majority of evaluative studies that are discussed in this chapter involve
randomised controlled/comparative trials of PI therapy – that is, efficacy stud-
ies. Randomisation involves the allocation of the client by chance to a particular
treatment limb of a study. In other words, a client stands an equal chance of

receiving one treatment or the other. Although there are difficulties when this
kind of evaluative approach is applied to psychotherapy outcome, it remains the
gold standard and the main basis upon which influential bodies make recom-
mendations regarding the standing of treatments and whether they are viewed
as front-line treatments for specific conditions.
In other circumstances, evaluative data may have been gathered in routine
clinical settings, a research paradigm that has been referred to as practice-based
evidence or practice-oriented research (e.g. Barkham and Margison, 2007;
Castonguay et al., 2013). Research has also been carried out into teaching and
training the model (see Chapter 10). Such work is also included in this chapter
where it helps to build a more comprehensive evidence base of PI therapy.
One of the hallmarks of PI therapy is that it is transdiagnostic in its
approach and is potentially of benefit to a wide variety of different conditions.
However, the following sections about its evidence base are grouped according
to the main symptoms or presenting problems for which it has been evaluated.
Although some of these groupings include diagnostic categories (such as
depression or borderline personality disorder), others focus on problem behav-
iours (such as self-harm) or patients who are high service users who may have
several co-existing mental and physical health diagnoses.
Depression
The studies on depression have been carried out by the Sheffield–Leeds
Psychotherapy Research Programme, which has spanned almost
40 years of work carried out at the University of Sheffield (Social and Applied
Psychology Unit; 1977–1995), University of Leeds (Psychological Therapies
Research Centre; 1995–2007), and again at the University of Sheffield (Centre
for Psychological Services Research; 2007 onwards). The research programme
was founded by David A. Shapiro in 1977 and carried forward across much of
this time with Michael Barkham and Gillian E. Hardy – as well as with other
colleagues – together with the long-term international collaboration of William
B. Stiles (Miami University), Robert Elliott (Universities of Toledo and
Strathclyde) and Marvin Goldfried (SUNY).
The Sheffield team adopted a research model that contrasted the
Conversational Model (initially referred to as exploratory therapy before then
being termed psychodynamic-interpersonal therapy) with a psychotherapy
drawn from cognitive behavioural therapy (initially referred to as prescriptive
therapy in early studies). A feature of the designs adopted by the Sheffield
group was that the same therapist delivered both types of therapy. This model
of crossing therapists with treatments, rather than having different therapists
nested within each therapy, provides a control on non-specific therapy factors
and effects. However, some would argue that it is not possible for the same
therapist to offer two contrasting therapies to the same high standard.
Accordingly, the designs described here makes it crucial that therapists show
fidelity to the model – they must not only adhere to the model they are using
The Efficacy and Effectiveness of PI Therapy 17
at that time, but the therapies using these two approaches should be easy to
differentiate. The issues surrounding adherence are described more fully in
Startup and Shapiro (1993). However, the research team worked closely with
Robert Hobson to ensure that the implementation of the Conversational Model
was as close as possible to his understanding of the psychotherapy process.
Comparative outcome trials

A key impetus that set the research agenda for the Sheffield–Leeds pro-
gramme was a meta-analysis of 143 outcome studies published between 1975
and 1979 in which two or more psychological treatments were compared
with a control group (Shapiro and Shapiro, 1982). The central finding was
that the mean effect size for treatment approached one standard deviation,
meaning that approximately 84% of the control group scored below the aver-
age person in the treated group. The results also suggested that the relatively
modest differences between treatment methods were largely independent of
other factors and that outcome research, at that time, was not representative
of clinical practice. Further, the article concluded that the most promising
research design for outcome research lay in ‘same experiment’ data in which
studies compared contrasting conditions within the same experiment or trial.
The substantive and methodological yield of this meta-analysis provided the
rationale for a quartet of successive trials, all of which were designed to com-
pare two therapies – psychodynamic-interpersonal (PI) and cognitive-behav-
ioural (CB) – as representative of the range of clinical therapies practised in the
UK and elsewhere. While the studies held the comparison between PI and CB
therapies constant, they used differing durations of treatment sessions as a
further comparison – two, eight and 16 sessions. The reasoning behind the
contrasting durations was two-fold. First, from a research design perspective,
any experiment (or study) relies on a contrast being made and in three of the
studies the contrast used was eight versus 16 sessions. It might be that while
there would be no difference between PI and CB therapies for one of these dura-
tions, differences might appear when delivered in the other duration. Second,
there was beginning to be interest in devising and delivering cost-effective treat-
ments and an awareness that duration was a key factor in the design and delivery
of the psychological therapies.
The (first) Sheffield Psychotherapy Project

(SPP1; Shapiro and Firth, 1987)
The (first) Sheffield Psychotherapy Project compared prescriptive (cognitive-
behavioural) therapy with exploratory (psychodynamic-interpersonal) therapy
within the same experiment and used a crossover design in which clients were
randomised to either eight sessions of PI or CB therapy, and then after that
they received eight sessions of the other therapy with the same therapist
(hence the term crossover). This design controls for patient, therapist and
common factors. The aim was to maximise the sensitivity of the design to any
treatment differences that might exist and thereby address the claim that
equivalence in outcomes are found because true differences are obscured by
weak research design.
The study comprised 40 clients referred for depression who received eight
sessions of either prescriptive or exploratory therapy followed by eight sessions
of the alternate therapy. The two eight-session interventions were separated by
an assessment. The results are presented in Table 2.1. The main outcome study
showed a small advantage for prescriptive (CB) therapy. However, further anal-
ysis showed that the differential effectiveness of the two treatments was con-
fined to one of the two main therapists who had better outcomes for prescriptive
therapy whilst the other therapist showed equivalent outcomes. Interestingly,
this was an early investigation of the phenomenon of therapist effects using a
sample of just two main therapists whereas current studies of this phenomenon
would utilise samples of over 100 therapists (see Saxon and Barkham, 2012).
Table 2.1 The (first) Sheffield Psychotherapy Project
Summary of methods Implications for

Study and results Sample size practice
Outcomes Clients received eight 40 PI and CB therapy

sessions of prescriptive (CB) had comparable
(Shapiro and
therapy and eight sessions effects with a slight
Firth, 1987)
of exploratory (PI) therapy advantage to CB
in a crossover design, with therapy, with little
each client seeing the obvious from the
same therapist throughout. sequence of the two
The results favoured CBT therapies.
although this difference was of
moderate extent. The outcome
was largely unaffected by
the order in which the two
methods were offered.
Therapist One of the principal therapists 40 (as above) Therapist effects are
effects was responsible for most of an important factor
the reported advantage of even under carefully
(Shapiro
prescriptive (CB) therapy controlled conditions.
et al., 1989)
over exploratory (PI) therapy
(Shapiro et al., 1989).
One-year Clients completed outcome 31 (sub- Improvements were
follow-up measures at two-year sample of 40) well maintained after
follow-up. At both group and the sequence of PI
(Shapiro and
individual levels, outcomes and then CB therapy
Firth-Cozens,
were very similar to those or vice versa.
1990)
obtained at the completion of
treatment.
Follow-up at one year showed good overall maintenance of treatment

gains, but, of course, the two therapies could not be compared at follow-up
as all clients had received both therapies, so any effect would be totally con-
founded (Shapiro and Firth-Cozens, 1990). Clients were generally non-
specific about what elements of therapy had been most helpful, but where
they could identify factors they were often the more general behavioural
elements of relaxation and anxiety management rather than more complex
cognitive techniques or PI-specific elements.
The Second Sheffield Psychotherapy Project

(SPP2; Shapiro et al., 1994)
The larger Second Sheffield Psychotherapy Project (SPP2) employed a more
complex design utilising five therapists and compared CB and PI therapies
whilst also testing the impact of treatment length – eight or 16 sessions – and
severity of depression – low, medium, high – on outcomes with a sample of
117 clients presenting with depression.
More specifically, it focused on questions of therapy approach – is CB
therapy more effective and rapid in its effects than PI therapy when delivered
by investigators having no prior allegiance to CB or PI therapies? And of ther-
apy duration – is 16 sessions more effective than eight sessions? The effect of
initial severity was also considered as a key predictor. A battery of standard
nomothetic outcome measures was used that included the Beck Depression
Inventory (BDI), Symptom Checklist-90-R (SCL-90-R), and the Inventory of
Interpersonal Problems (IIP). The feature of nomothetic measures is that the
items are standard and there are norms for the scores drawn from clinical and
non-clinical populations. Hence, the score of a client can be located in terms
of either a clinical or non-clinical population.
In addition, an idiographic change measure (personal questionnaire: PQ)
was used which helped to differentiate the rate of change of different prob-
lems experienced within the overall depression diagnosis. A key feature of
idiographic measures is that the items are derived from the client’s personal
experience. Hence, a client might describe their depression in terms of
‘Feeling like I am in a black hole’ and this is then the item that they rate. It
provides a way of generating items with unique personal meaning to a client,
which is why the name personal questionnaire is used. A number of process
measures were taken after every session for use in subsequent analyses as
described in the next chapter.
Overall, the study yielded slight but not robust advantages to CB therapy
with only the BDI yielding a medium-size treatment effect against PI therapy
and no evidence that either therapy delivered a difference in rate of change.
Table 2.2 presents a summary of the results. There was some evidence that 16
sessions were more effective than eight sessions, but mainly for the severely
depressed clients.
Table 2.2 The Second Sheffield Psychotherapy Project (SPP2) and National
Health Service Collaborative Psychotherapy Project (CPP)
Summary of methods and Implications for

Study results Sample size practice
Outcomes Clients completed eight or 117 For more severe

(SPP2) 16 sessions of either CB or depression there is
PI therapy. Each of five a clear advantage
(Shapiro
clinician-investigators treated for the 16-session
et al., 1994)
clients in all four treatment therapy. Otherwise
conditions. On most measures, results are broadly
CB and PI therapy were equally similar after
effective, irrespective of the either eight or
severity of depression or the 16 sessions.
duration of treatment.
Follow-up At one-year follow-up, although 104 Gains from therapy
gains were, in general, well (sub-sample were reasonably
(Shapiro
maintained, only 29% of clients of 117) well maintained
et al., 1995)
were asymptomatic on all three but a majority of
occasions of testing without clients still retained
recourse to further treatment. symptoms.
Outcomes Clients were randomly assigned 36 The study supports
(CPP) to CB or PI therapy delivered in the effectiveness
either eight or 16 sessions. of PI therapy in
(Barkham
clinical settings,
et al., 1996) Gains in both treatment
although there
approaches were approximately
were advantages to
equivalent and were similar to
16-session length of
those achieved in SPP2 when
therapy in this study.
measured at the end of treatment.
However, clients did not maintain
their gains to the extent that
the SPP2 clients did at three-
month and one-year follow-up
assessments.
At one-year follow-up, eight sessions of PI performed worse than eight ses-

sions of CB and 16 sessions of PI or CB (Shapiro et al., 1995). This suggests
that for more severe depression where there is a clear client preference for a
PI approach, 16 sessions are more likely to be effective than eight sessions. Or,
conversely, in conditions where a maximum of eight sessions is available, CB
therapy would be preferable where depression is severe, although in practice
most practitioners would be considering, or obtaining an opinion on, medica-
tion as an adjunct for the severest forms of depression (see Elkin et al., 1989).
A sub-group of clients had a Cluster C personality disorder (that is avoidant,
obsessive-compulsive or dependent). There were enough clients in this cluster to
warrant separate analysis, which showed that for Cluster C clients with severe
depressive symptoms there was an advantage for CB therapy (Hardy et al., 1995b).
The NHS Collaborative Psychotherapy Project

(CPP; Barkham et al., 1996)
In the context of results from the Second Sheffield Psychotherapy Project,
there was interest in the extent to which findings obtained in a university
research clinic would generalise to routine practice settings. To test this, a
smaller effectiveness trial was carried out in clinical settings across multiple
sites to determine whether the outcome results could be generalised to NHS
outpatients. A total of 36 clients and four NHS therapists across three sites
took part.
Results showed that clients yielded high levels of improvement and equivalent
to those achieved in the SPP2 research clinic but gains achieved at end of therapy
were not maintained as well at one-year follow-up. However, the overall effective-
ness was comparable to that shown in other effectiveness studies. There was no
advantage of CB over PI therapy in this study. The results are summarised in
Table 2.2.
The Two-plus-one Project (Barkham et al., 1999)
The consistent finding of only small differences between differing therapies led
to the design of a trial that attempted to maximise the potential impact of techni-
cally specific treatment components by delivering a very brief intervention essen-
tially comprising two sessions with a follow-up session. The major challenge was
to deliver psychodynamic-interpersonal therapy in this format. To initially pilot
this format, Robert Hobson carried out several single cases from which the model
was then formalised.
This pilot work yielded two articles, one theoretical and one practical.
Barkham (1989) presented five central components of the model used for the
PI treatment in the two-plus-one study based on a detailed analysis of one of
Hobson’s cases: (1) focus on the client’s affect; (2) identification of a focal
issue; (3) personal meaning of dream content; (4) emphasis on the interper-
sonal process in the ‘here and now’; and (5) identification of a narrative point
of origin. The practical article – one of the pilot cases – presented a fascinat-
ing single case study using the two-plus-one model in which Robert Hobson
treated a thunder phobic (Barkham and Hobson, 1989).
The resultant trial compared psychodynamic-interpersonal therapy with cog-
nitive behaviour therapy delivered in two sessions (two-) one week apart fol-
lowed by a third session (plus-one) three months later (Barkham et al., 1999).
The rationale was to package these treatments to a plausible minimum in order
to maximise their impact as a cost-efficient intervention in which technical spec-
ificity would be the most prominent component at an early stage prior to the
cumulative effect of common factors, which had been seen as one explanation
for broadly equivalent results between therapies. A total of 116 clients were
randomly assigned to either PI or CB therapies and received treatment either
immediately or after a short delay (enabling a controlled evaluation of the short-
term impact of intervention).
This very brief treatment, albeit for subsyndromal depression, was effec-
tive. Client gains were greater in the CB than the PI treatment, but again any
advantage was modest. A summary of the study is presented in Table 2.3.
Table 2.3 Two-plus-one Project
Sample Implications for

Study Summary of methods and results size practice
Two-plus-one Clients with a range of subsyndromal 116 Brief therapies are

depression received three therapy effective for mild
(Barkham
sessions: two sessions one week symptoms. Client
et al., 1999)
apart followed by a third session three preference may
months later. Approximately two- be a rational basis
thirds of clients showed improvement. for treatment
There were no significant differences choice.
between CB and PI therapy, but
at one-year follow-up there was a
significant advantage for CB therapy.
Dose–effect relations
While these four studies held the comparison between PI and CB therapies
constant, they used differing numbers of treatment sessions considered as an
independent variable: two, eight, and 16 sessions. Studies have looked at the
dose–effect curve; that is how response varies with number of sessions
(Barkham et al., 1996, 2002). The results from two, eight, and 16 sessions was
aggregated and this suggested a greater degree of linearity than originally pro-
posed by the work of Howard and colleagues (see Shapiro et al., 2003). In approx-
imate terms, this means doubling the dose roughly doubles the effect, whereas
earlier work from Howard and colleagues (Howard et al., 1986) suggested that
extra sessions have proportionately less effect. However, these overall relation-
ships conceal the more specific point that more severe depression responds dif-
ferently and requires more sessions, especially in PI therapy.
Data comprised both nomothetic measures referenced against the general
population, for example the Beck Depression Inventory (BDI) and idiographic
questionnaires that reference internally, measuring improvement or worsening
against how things were previously, for example the personal questionnaire
(PQ). The extensive data set was used to investigate further detail about client
change.
Also, the PQ data, which was completed weekly throughout treatment,
showed broadly linear improvements. But, within that overall picture there
were differences such as the quickest improvement being in the area of symp-
toms, followed by relationship difficulties, and then self- esteem being the
slowest to change (Barkham et al., 1993).
Routine practice
Moving beyond the research clinic, data has been collected from routine prac-
tice settings in order to determine the effectiveness of PI therapy. One key
study – Paley et al. (2008) – focused both on showing that the PI model could
be taught to a broader group of professionals and that their outcomes would
be equivalent to those reported in the literature.
Data from 62 clients were assessed having received a course of PI therapy
(median = 16 sessions). The results were reported using the BDI-II and a more
generic measure of psychological distress, the Clinical Outcomes in Routine
Evaluation-Outcome Measure (CORE-OM; Barkham et al., 2001; Evans et al.,
2002). In addition, the results were reported for the percentage of clients meet-
ing the criteria of reliable and clinically significant change. This requires the
change in a client’s outcome score to: (a) make sufficient change for it to be
considered reliable (understood to be greater than the inherent unreliability of
the specific measure); and (b) for the post-therapy score to be located in the
range of scores that represent a non-clinical population.
Reliable and clinically significant change was achieved by 34% of clients on
the BDI-II and by 40% of clients on the CORE-OM. Clients with high
pre-therapy levels of interpersonal problems had poorer outcomes.
Benchmarking the results against both national and local comparative data
showed that these results were less favourable than those obtained where PI
had been used in efficacy trials, but were comparable with reports of other
therapies, including CB therapy, in routine practice settings. The results show
that PI therapy can yield acceptable clinical outcomes, comparable to CB ther-
apy in a routine care setting.
Psychodynamic-interpersonal therapy for depression:

summary and current context
In summary, across a programmatic series of research studies aimed to detect
treatment differences between PI and CB therapy, findings consistently
yielded broad equivalence between the two interventions even when the
design was optimised to detect differences (for summaries, see Barkham et al.,
2011). Where there were small advantages, they tended to favour CB therapy,
especially in severe depression where there was a definite advantage for CB
therapy over PI therapy when treatment length is restricted to eight sessions.
Where symptoms predominate and interpersonal problems are less salient
there is a case for offering CB therapy first, with PI therapy as an alternate
where clients do not respond well to a CB approach. The studies also support
longer therapies for clients with Cluster C personality disorder, interpersonal
problems or more severe overall symptoms. In service settings no differences
were detected between the two therapies, but these studies were not opti-
mised to pick up treatment differences in quite the same way as with the two
Sheffield Psychotherapy Projects.
The series of Sheffield studies and the subsequent routine practice studies
suggest that, for depression, there is very little difference between contrasting
or differing treatment approaches. A similar outcome for depression has also
been reported between counselling and CB therapy within the UK govern-
ment’s Improving Access to Psychological Therapies (IAPT; Layard et al.,
2006) programme (Glover et al., 2010). Indeed, considerably larger differ-
ences exist in the outcomes of clients who do not complete a course of psy-
chological treatment when compared with those who do complete a course.
In other words, enabling clients to remain in therapy is probably the best way
of ensuring the best outcome as opposed to pitting one therapy modality
against another.
Chronic and complex conditions

Depression has often been the initial focus for testing new models or applica-
tions of the psychological therapies as evidenced by the history of CB therapy
and also of the UK initiative regarding Improving Access to Psychological
Therapy (IAPT). Although the prevalence and burden of depression is huge,
there are presenting conditions that are generally viewed as more chronic and
complex. Logically, therefore, it is both a stringent test of the therapy and also
a necessity regarding wider applications that PI therapy is tested in these
settings. Such conditions include the following: chronic and intractable func-
tional bowel symptoms, chronic refractory depression and anxiety, deliberate
self-harm, Alzheimer’s disease and borderline personality disorder. Such
disorders are all relatively chronic and unremitting rather than episodic.
Correspondingly, they present a greater challenge to therapists and research-
ers alike and are the focus of the remaining sections in this chapter.
Much of the work reported here has been led by researchers at the
University of Manchester and were led by psychiatrists and clinical psy-
chologists who had been trained in psychodynamic-interpersonal therapy by
Robert Hobson (Else Guthrie, Frank Margison and James Moorey). Francis
Creed was the principal investigator for several of the projects. The chapter
also covers work carried out by Russell Meares’ group at the University of
Sydney in New South Wales, Australia, using the Conversational Model with
people with borderline personality disorder.
The Manchester outcome studies of PI therapy were mainly concerned with
the therapeutic evaluation of the therapy in a naturalistic setting. The principal
foci were on clinical outcomes and effectiveness. For this reason, the main anal-
yses were conducted on an intention to treat basis. Participants were recruited
from clinical populations and attempts were made to make the studies as clini-
cally representative as possible. In addition, the Manchester studies addressed
issues of cost-effectiveness with a view to evaluating the economic basis for the
implementation of a systematic psychological therapy such as psychodynam-
ic-interpersonal therapy with people with chronic and typically intractable dis-
orders that place substantial demands upon the healthcare system.
Medically unexplained symptoms

The term medically unexplained symptoms (MUS) refers to physical symp-
toms from which people suffer that do not have an obvious explanation for
their cause through structural pathology of bodily organs or body systems.
Such symptoms are unexplained and an organic cause is rarely found. As
symptoms become more severe, multiple and persistent there is an increas-
ing association with emotional and psychological factors (Henningsen et al.,
2011). The symptoms are real in that they are experienced in the body, and
causal mechanisms are multiple including a mix of genetic, physiological and
psychosocial factors, both past and present (Haustiner-Wiehle et al., 2011).
Data from the UK Department of Health indicate that MUS is the most
costly diagnostic category of outpatients in the UK and the fourth most
expensive category in primary care (Creed et al., 2011). Patients with severe
and persistent symptoms are the most costly to the health service and the
prognosis for this group is generally poor, without specific treatment.
There are five randomised controlled trials that have evaluated the
effectiveness of PI therapy for patients with medically unexplained symptoms
(see Table 2.4). Three have been conducted in Manchester and have focused
upon patients with unexplained bowel symptoms, and two have been con-
ducted in Germany with patients with mixed bodily complaints. Four of the
studies focused upon patients with severe and persistent symptoms (Creed
et al., 2003; Guthrie et al., 1991; Hamilton et al., 2000; Sattel et al., 2012),
who had not responded to conventional treatments and who had not been
helped by specialist medical care, whilst the fifth study involved patients in a
primary care setting (Schaefert et al., 2013). These studies are presented here
in chronological order.
Guthrie et al. (1991): The first study recruited 102 patients with severe and
intractable irritable bowel syndrome. Patients were recruited consecutively
from a gastrointestinal outpatient clinic and randomised either to brief PI ther-
apy or supportive therapy. All patients had had intractable symptoms, which
had failed to respond to conventional treatments. The PI group received one
long initial session of therapy lasting up to three–four hours followed by six
sessions of 45 minutes, spread over 12 weeks. Patients in the supportive limb
were seen on five occasions for 30 minutes per session. The supportive sessions
were used to control for the non-specific effects of therapy (for example, seeing
someone on a regular basis, and being listened to and supported).
The outcome of the trial showed that patients who received PI therapy
showed a significant reduction in both gut symptoms and psychological symp-
toms in comparison to the patients who received support. The improvement
in outcome was maintained over 12 months. Ratings were carried out by gas-
troenterologists who remained blind to the treatment groups.
Hamilton et al. (2000): In the second study patients were recruited with severe
and intractable functional dyspepsia (for example, patients with persistent
Table 2.4 Evaluations of PI therapy for patients with medically unexplained

symptoms
Condition Sample
and Study Design size Outcome
Severe, PI therapy versus 102 Greater improvement in IBS

intractable Supportive therapy symptoms for patients who
irritable bowel received PI therapy versus
RCT
syndrome controls. Improvement maintained
at 12 months.
(Guthrie et al.,
1991)
Severe PI therapy versus 83 Greater improvement in upper
functional Supportive therapy gastrointestinal symptoms for
dyspepsia patients who received PI therapy
RCT
in comparison with controls.
(Hamilton et al.,
Improvement maintained at six-
2000)
month follow-up.
Severe irritable PI therapy versus 257 Greater improvement in health
bowel syndrome paroxetine versus function for patients who received
usual care PI therapy and paroxetine versus
(Creed et al.,
controls at one-year follow-up
2003) Multi-centre RCT
post-treatment. Greater savings
in costs for PI therapy group
versus usual care group through
reductions in health-service use
over 12 months post-treatment.
Multisomatoform PI therapy versus 221 Greater improvement in health
disorder enhanced medical status for patients who received
care PI therapy in comparison with
(Sattel et al.,
controls at one-year follow-up. No
2012) Multi-centre RCT
effects on healthcare use.
MUS patients PI informed group 304 Significant improvement in mental
with persistent therapy versus health status for treatment versus
symptom for at usual care. controls at 12 months after
least six months baseline. No difference in physical
Cluster
health status. Number of GP visits
(Schaefert et al., randomised RCT
significantly reduced in treatment
2013)
versus control group.
upper gastrointestinal complaints). Patients in this study were randomised to

PI therapy versus supportive therapy. Patients who were randomised to the
supportive therapy received exactly the same amount of time with a therapist
and the therapy was again conducted over a 12-week period. The outcome
showed that PI therapy was superior to the supportive condition both at the
end of treatment and at follow-up six months later. As with the first study,
assessment of patient improvement was carried out by gastroenterologists who
were blind to the trial groups.
Creed et al. (2003): In the third trial, 257 patients with severe and persistent
irritable bowel syndrome were randomised to 12 weeks of PI therapy, or treat-
ment with an antidepressant or usual treatment. Detailed assessments of out-
comes and costs were undertaken. Both PI therapy and antidepressant
treatment resulted in significantly improved outcomes at 12 months
post-treatment in relation to both physical and mental health. PI therapy, how-
ever, was also associated with a significant reduction in healthcare use in the
12 months post-treatment, compared with patients who received usual care.
So not only did PI therapy achieve a better outcome than usual care, it also
resulted in significant cost savings. The average savings per patient over a year
were approximately £1,000 (≈$1,500/€1,250) at the time of publication and for
patients with the most severe symptoms, cost savings were approximately
£3,000 per annum per patient (≈$4,500/€3,750) (Creed et al., 2008). Significantly
more patients who received psychotherapy in comparison with the other two
groups were also able to come off incapacity benefits with a view to returning
to work.
Of interest, patients in the above study who reported a history of child-
hood physical or sexual abuse had a particularly good outcome following
psychotherapy (Creed et al., 2005), and also showed evidence of physiologi-
cal change in pain threshold levels post-treatment (Guthrie et al., 2004a).
Sattel et al. (2012): The fourth study of PI therapy for patients with MUS was
conducted in Germany and recruited patients with persistent multisomato-
form disorder. This disorder is characterised by severe and disabling bodily
symptoms of which pain is the most common symptom. The trial was a
multi-centre trial conducted in six different centres in Germany. A total of
211 patients were recruited to the study and were randomised to either
12 weeks of PI therapy compared with three sessions of enhanced medical
care; the best routine care that could be provided. Patients were followed up
six months post-treatment. The main findings were that patients who
received the PI therapy showed significantly greater improvement in physi-
cal and mental health function compared with the control group over the
course of the study. This is an important study as it showed that the results
from the English studies using the PI model could be generalised to other
countries and other healthcare settings.
Schaefert et al. (2013): The final study discussed in this section was also con-
ducted in Germany but recruited patients with MUS in a primary care set-
ting. Patients in the intervention group received ten weekly group sessions of
90 minutes plus two booster meetings in the follow-up phase. The groups
were run by a psychosomatic specialist and a GP, and were based upon a PI
approach to treatment with an aim to improve interpersonal relationships
both within and externally to the groups. Patients in the control limb received
usual care.
A total of 306 patients were recruited to the study. The main results were
that there was no difference between the two groups in terms of physical out-
come at the end of the 12-month assessment period. However, the patients
who received the PI informed group therapy reported significantly greater

improvements in mental health status compared with controls, and also signif-
icant reductions in depression and anxiety. Patients who received group ther-
apy also had significantly fewer family doctor (GP) visits over the 12-month
assessment period than did the controls.
Overall these five studies demonstrate that PI therapy is an effective treatment

for MUS. The trials had low drop-out rates, which meant that the therapy was
acceptable to patients and people were able to engage with the therapeutic
process. The benefits of treatment appeared to continue post-treatment in
several of the studies, with some patients making further gains in the six to
12 months post-treatment. In the UK, PI therapy resulted in a reduction in
healthcare use and substantial cost savings (Creed et al., 2003). The final
study by Schaefert and colleagues (2013) showed promising results for a
group-informed PI intervention in the primary care setting. This approach
did not appear to have a similar impact on the physical aspect of functioning
as the individual treatments that were delivered in the previous four studies,
but did show positive impacts upon psychological health and healthcare uti-
lisation. Overall, the evidence suggests that PI therapy is an effective and
cost-effective approach for treatment of MUS with various presentations.
Self-harm
Guthrie et al. (2001): There has been one randomised controlled trial that has
evaluated PI therapy as a treatment for self-harm. In this study 119 people
who had presented to a UK Emergency Department after an episode of
self-poisoning were randomised to four sessions of home-based PI therapy in
comparison with usual treatment. The therapists in the study were mental
health nurses who were trained to deliver PI therapy, but did not have any
formal psychotherapy qualification or prior training. The therapy was deliv-
ered at home to increase engagement and compliance.
Over 70% of people who self-harm cite an interpersonal problem as the main
precipitant of the self-harm episode, so there is a strong rationale for using an
interpersonal therapy with this group of people (Bancroft et al., 1977).
Participants who received the PI therapy had a significantly greater reduction
in suicidal ideation at six-month-follow-up compared with those in the con-
trol group. They were much more satisfied with their treatment and much
less likely to report further self-harm during the six-month follow-up period
than participants who received usual care.
This study showed that nurses with good interpersonal skills can be
trained to deliver PI therapy for self-harm and deliver this treatment effec-
tively. Following this study, a PI service for self-harm was established in
Manchester. Nurses in other hospitals such as Hull, in the East of the UK, and
the Wirral in Merseyside, Northwest England have been trained in the model
and have demonstrated good clinical outcomes with reductions in service use
(NHS Confederation, 2009).
High utilisers of mental health services

As PI therapy is a transdiagnostic treatment, it can be used to treat people who
present with complex, mixed mental health and physical problems. A small
number of people with mental health problems have chronic problems that
are difficult to treat and account for a disproportionate amount of healthcare
costs. They may find it difficult to engage with services, be unable or unwilling
to take medication, not respond to diagnostic specific therapies because they
have complex needs, or drop out of psychological treatment before it is com-
pleted. Many also have risk issues and may self-harm frequently or present to
services in acute states of distress. Very few studies have explored the benefits
of psychotherapy for people with complex disorders and enduring symptoms,
who are high service users. PI therapy, however, has been shown to produce
significant benefits for this group of service users.
Guthrie et al. (1999a): A sample of 110 people with complex mental health prob-
lems, who had been in treatment with specialist mental health services for at
least six months without improvement, were randomised to eight sessions of PI
therapy versus usual care from their psychiatric team. Those participants who
received PI therapy in comparison with controls reported a reduction in psycho-
logical symptoms, an improvement in health status and a reduction in health-
care costs during the six months post-treatment. Participants who received PI
therapy required less in-patient treatment, and less medication, GP time and
nurse practitioner time in the six months post-treatment than controls.
Participants in this study often had several co-morbid psychiatric diagnoses.
The most common was depression but this often co-existed with other forms
of anxiety disorders, substance misuse problems or personality disorder. PI
therapy was particularly well placed to help people with these kinds of prob-
lems because of its transdiagnostic approach.
Borderline personality disorder

Borderline personality disorder is a serious mental health problem, with signif-
icant mortality and morbidity. Individuals who are diagnosed with this condi-
tion report difficulties with distressing and extreme states of mind, problems
with making and sustaining relationships, self-harm and substance misuse. They
tend to lead chaotic lives and frequently report unhappy, unstable childhood
experiences including abuse and neglect. The series of studies reported here are
naturalistic studies and not controlled trials. They have all been conducted at
the University of Sydney by a team led by Professor Russell Meares.
Stevenson and Meares (1992): There have been two major evaluations of the
Conversational Model of therapy (the original term used for the PI approach
and further developed by Meares) for people with borderline personality disor-
der (BPD), the first of which was carried out in 1992. Treatment outcomes were
reported for 30 clients with BPD, treated with the Conversational Model of
therapy for 12 months with two sessions per week. These clients showed sig-
nificant improvements in mental health function over the year and marked
improvement on seven behavioural measures, which included self-harm behav-
iour, violence towards others, use of drugs (both prescribed and illegal) and
number of hospital admissions.
The clients who received therapy were compared with a matched group of
30 clients with BPD who were referred to the same clinic, but where no ther-
apist was available, and they remained on the waiting list for one year (Meares
et al., 1999). In comparison with this matched group, the clients who received
the Conversational Model of therapy showed significantly greater improve-
ments in mental health function. In a further analysis of costs, the use of health
are of the 30 patients treated with this form of therapy was examined for the
year prior to treatment and the year post-treatment (Hall et al., 2001). This
showed a saving of AU$670,000 compared with a cost of the psychotherapy of
AU$130,000, giving a net saving of AU$540,000 or AU$18,000 per patient.
Most of the cost savings were in terms of reductions in hospital admissions.
Korner et al. (2006): The second major study was carried out by the same group of
researchers, using a controlled design, in which patients with borderline personal-
ity disorder received 12 months of therapy compared with wait list controls. A
sample of 29 patients who received therapy were compared with 31 patients who
waited for 12 months without therapy but continued during that time to receive
ongoing mental care and crisis support. There were significant improvements in
mental health status and a reduction in self-harm for the patients who received
therapy in comparison with controls. There were also reductions in emergency
presentations for the patients who received therapy in comparison with controls.
Korner et al. (2008): In a further extension of this study, the researchers went on
to compare different lengths of treatment for borderline personality disorder.
They compared two groups of patients, one group received one year of Conver
sational Model therapy and the other group received two years of therapy. They
found that the patients who had longer treatment continued to make further
gains during the second year of treatment in comparison to the patients who
received 12 months’ treatment, particularly in relation to depression.
As stated earlier, none of the above studies involving patients with border-
line personality disorder were randomised controlled trials, so some caution
is required in the interpretation of the results. However, they provide prelim-
inary evidence for the value of the Conversational Model of therapy for peo-
ple with borderline problems, and point to the potential cost savings that can
be made by providing timely and appropriate treatment.
Other evaluations of psychodynamic-interpersonal

therapy
Shaw and colleagues (2001): An evaluation was carried out of inexperienced
therapists using the PI model with patients referred to an NHS psychotherapy
Table 2.5 Other evaluations of psychodynamic-interpersonal therapy
Sample
Study and condition Design size Outcome
Clients referred to an RCT PI therapy 40 Significant improvement

NHS psychotherapy versus wait list in those who completed
unit treated by therapy (before and after).
Pilot
inexperienced Non-significant trend towards
therapists improvement versus controls.
(Shaw et al., 2001)
Alzheimer’s disease RCT PI therapy 40 No difference between
versus usual care treatment and control for
(Burns et al., 2005)
patient outcome. Carer
Pilot
improvement PI therapy
versus usual care.
Complex clients Before-and-after 41 Significant improvement
treated by primary evaluation following treatment with
care counsellors PI therapy. Twenty clients
trained in PI therapy showed clinically significant
and reliable change.
(Guthrie et al., 2004b)
PTSD sufferers with Time-series 3 Improvement in all three
complex problems analysis subjects
(Guthrie et al., 1999b)
service. Clients were randomised to either psychotherapy or wait-list control.

Significant improvement was demonstrated in those patients who completed
therapy, and there was a non-significant trend towards greater improvement
in the immediate treatment group in comparison to wait-list controls.
Burns and colleagues (2005): Burns et al. assessed whether PI therapy could
benefit cognitive function and affective symptoms in patients with Alzheimer’s
disease. There was, however, no evidence of improvement on the main out-
come measures although there was some reduction in carer burden.
Guthrie and colleagues (2004b): An evaluation was carried out on the effective-
ness of PI therapy for common mental health problems in primary care in a
before and after design. Primary care counsellors were trained in the model (see
Chapter 10) and their treatment, using the model, was evaluated in
41 patients. The patients who they treated presented with a mix of complex
mental problems including mixed anxiety and depression, self-harm, alcohol
problems and past histories of abuse. There was a significant reduction in
psychological symptoms over the course of the treatment and 20 of the patients
underwent clinically significant improvement. This study again demonstrated
that the PI approach can be useful in helping people who present with a range
of co-morbid mental health problems due to its transdiagnostic approach.
Guthrie and colleagues (1999b): This study described how brief PI therapy
was provided to three people who developed post-traumatic stress disorder
after being involved in the Manchester bombing in 1996. All three showed
significant reductions in PTSD symptoms.
Summary
There is a robust evidence base for PI therapy in relation to other psychody-
namic or relational therapies. It has broad equivalence to cognitive behav-
ioural therapy for the treatment of depression and it is also effective for
patients who present mixed mental health symptoms, unexplained physical
symptoms and self-harm. There is also support for its beneficial effects for
people with borderline personality disorder. Work on the model has been car-
ried out in the UK, Australia and Germany. Three separate studies have pro-
vided evidence that PI therapy is cost-effective and can result in major cost
savings for healthcare services over time. Its transdiagnostic approach may
make it particularly suited to treat individuals who present with complex and
severe problems with mixed and varying presentations.
3
Client Change in
Psychodynamic-
Introduction
In the previous chapter we showed that when psychodynamic-interpersonal
(PI) therapy is compared with another active treatment, improvements are
broadly equivalent, and that PI therapy is helpful for many clients. However,
we know that not everyone is helped and that some therapists achieve better
outcome results than others. So, understanding what happens within a therapy
and not just the end result is vital in order to improve clients’ experiences and
outcomes, to train therapists better, and to make sure we are offering clients
the most appropriate treatment. This type of research – process research – seeks
to understand what is helpful (and unhelpful) about therapy, why it is helpful,
how clients change and make use of therapy, what is important to clients about
therapy and how they understand what helped them change. Even tentative
answers to these questions enable trainers to focus their training and practi-
tioners to improve their skills and be mindful of what they do and how they
are in therapy. Process research gives us a way of observing what we are
doing, how we do it and why.
In this chapter, we provide a brief overview of some key process research
focusing on PI therapy. The research has primarily been carried out using data
from Sheffield Psychotherapy Projects. To present the key results in an accessi-
ble format we have focused on the findings rather than the methods and used
the authors of studies as subheadings to avoid multiple references within the
text. A summary of the studies is provided in Table 3.1. The five main areas we
address are: the actions of PI therapists; the views of clients; the core elements
of PI therapy; therapist responsiveness; and the assimilation model. We summa-
rise the key learning points throughout the chapter.
Table 3.1 Listing of themes, their components and associated research

methods
Themes Components Research methods
yy Actions of PI yy Adherence Observer ratings of therapy transcripts using

therapists the Sheffield Psychotherapy Rating Scale
(SPRS; Shapiro and Startup, 1992)
yy Verbal Observer ratings of therapists’ speech using
response the Verbal Response Taxonomy (Stiles
modes et al., 1988)
yy Intentions Therapist completed post-session
questionnaire, Therapist Session Intentions
(TSI; Stiles et al., 1996)
yy Focus of Observer ratings of therapy transcripts
therapy using the Coding System of Therapeutic
Focus (CSTF; Goldfried et al., 1997)
yy Clients’ views of yy Helpful events Client post-session questionnaire, the
therapy Helpful Aspects of Therapy (HAT; Llewelyn
et al., 1988). Observers coded HATs
using the Functional Impacts of a Therapy
Session Coding Scheme
(FIT-CS; Goldfried et al., 1997)
yy Helpful and Observers coded HATs using the
unhelpful Therapeutic Impact Analysis System
events (TICAS; Elliott, 1985)
yy Impact of Client post-session questionnaire, the
therapy Session Impact Scale (SIS; Stiles, 1980)
sessions
Observer ratings of negative and positive
client speech (Mackay et al., 2002)
yy Core elements yy Aspects of Verbal response mode ratings (see above)
of PI therapy a feeling
Qualitative analysis of therapist language
language
during HAT identified significant events
(Hardy et al., 1999)
yy The here and Intensive qualitative analysis of one helpful
now therapy event (Mackay et al., 1998)
yy Mutuality and Client and therapist completed post-
relationships session questionnaire, the Agnew
Relationship Measure (ARM,
Agnew-Davis et al., 1998)
Client Change in PI Therapy 35
Themes Components Research methods
yy Alliance Quantitative comparison of outcomes using

ruptures and the ARM (see above) to identify patterns of
repairs alliance rupture and repair
yy Shared Discourse analysis of a single case
understanding (Mackay, et al., 1998)
yy Insight Comprehensive process analysis
of insight events identified by client
completed Session Impact Scale (SIS;
Stiles, 1980)
yy Therapist yy Interpersonal Analysis of patterns of client interpersonal
responsiveness style style (Inventory of Interpersonal Problems,
IIP, Hardy and Barkham, 1994), PI
adherence ratings using the Sheffield
Psychotherapy Rating Scale (SPRS;
Shapiro and Startup, 1992), Therapist
session intentions (TSI, Stiles et al., 1996)
yy Attachment Qualitative analysis of attachment issues
styles identified in transcripts of client identified
helpful session events (HAT forms, see
above)
yy Client Client completed Opinions about
expectations Psychological Problems (OPP, Pistrang
and Barker, 1992) before treatment and the
Treatment Credibility Form (TCI; Morrison
and Shapiro, 1987) before and after the first
therapy session
yy Personality Clients assessed before therapy using the
disorders Personality Disorders Examination (PDE,
Loranger et al., 1994)
yy Assimilation yy Assimilation See Table 3.2 for assimilation model
model stages
yy Movement Problematic experiences identified
through the in therapy transcripts, which were
assimilation then coded using the Assimilation of
stages Problematic Experiences Scale (APES;
Stiles et al., 1990)
The actions of psychodynamic-interpersonal

therapists
The first set of studies described below considers what PI sessions look like
or, perhaps more appropriately, how they feel, and whether it is possible to
distinguish this form of therapy from other therapies. These studies capture what
therapists do, their style, their intentions and the focus of therapy sessions.
Adherence ratings
Shapiro and Startup (1992); Startup and Shapiro (1993): These studies show that
therapists do indeed offer interventions that are consistent with the model of
therapy they are practising and that they can adhere to the model. When
independent observers rated PI and CB therapy sessions using a scale that
focused on behaviours specific to each therapy, as well as some facilitating
factors present in both (e.g. being empathic), almost all sessions were recog-
nised as the appropriate treatment and the interventions used were over-
whelmingly those appropriate to each model (i.e. PI or CB therapy).
Verbal response modes
Hardy and Shapiro (1985); Stiles et al. (1988); Stiles and Shapiro (1995): Another
approach to describing the content of therapy uses more general therapeutic
categories called verbal response modes (VRMs). These are general categories that
describe the differing functions of speech, for example: disclosure, question,
acknowledgement or reflection. Compared with CB therapists, PI therapists use
more simple reflections, interpretations and exploratory reflection, which is
what we would expect from the PI model. PI therapists also used more explor-
ing and interpreting verbal exchanges or conversations than CB therapists.
Box 3.1 Response modes

PI therapists use more reflection – both simple reflection back and more complex
reflection that goes beyond what the client actually said.
PI therapists also use more interpretation which, in this context, means
making an educated guess about the other person’s feelings.
Intentions
Stiles et al. (1989; 1996): In addition, two studies have focused on the intentions
of the therapist – that is, why a therapist was saying particular things. They
found CB therapists more often focused on reinforcing and encouraging change,
clients’ cognitions and behaviours, and getting information. By contrast, PI
therapists paid attention to feelings, insight and client–therapist relationship
problems.
Focus of therapy
Goldfried et al. (1997): In research centred on the focus of therapy, findings also
supported the expected differences between CB and PI therapists. For example,
PI therapy had a greater focus on interpersonal themes (within-session experi-
ences and a client’s past and current relationships) as well as emotional issues.
By contrast, CB therapy focused more on external situations and the future.
Box 3.2 Focus of PI therapy

PI therapists focus on interpersonal themes (in session, in the past and in the
external world) and emotional issues more than CB therapists.
So, these studies confirm that PI therapists offer a distinct therapy and use
interventions specified in the treatment manual. They have a different focus
to those using CB therapy and their intentions are firmly linked to the under-
lying principles of PI therapy.
Clients’ views of therapy

While the previous section considered how therapists and independent observ-
ers saw PI therapists’ actions, this section considers clients’ views of therapy.
There are two studies that address what clients found helpful or unhelpful in
therapy. The first study found that clients tended to identify similar helpful
events in both PI and CB therapy, whereas the second study found this was not
always the case.
Helpful events
Goldfried et al. (1997): Written descriptions were taken of events described by

43 clients from the Second Sheffield Psychotherapy Project that were identified
as being helpful after a therapy session. A framework was applied to the
accounts that took account of therapeutic change principles thought to be com-
mon to all psychotherapies: awareness, corrective experiencing, therapeutic
relationship and hope. They found that clients in both CB and PI therapy
sessions most frequently reported the category of awareness (58% of CB ses-
sions; 57% of PI sessions). This category was followed by the categories corrective
experiencing (25% in both treatments), the therapeutic relationship (16% of CB;
11% of PI) and, least frequently, hope (11% of CB; 6% of PI). There were no
significant differences between the frequencies with which each principle was
reported in each group.
Box 3.3 Four key change principles

Despite therapists being very aware of differences between therapies, clients tend to
see the impact of four key change principles as equally common features and do not
stress the differences between therapies:
zz Increased awareness
zz Corrective emotional experiences
zz The therapeutic relationship
zz Hope
Helpful and unhelpful events
Llewelyn et al. (1988): A similar approach to investigating helpful events used

another coding tool and found differences between the two contrasting ther-
apies. Clients in the Sheffield studies were asked to write down what they
found helpful and unhelpful after a therapy session and these independent
observers then coded these accounts. Findings showed that some positive
categories (awareness and personal insight) were more common in PI than CB
therapy, but also that clients experienced some unhelpful impacts more often
(unwanted thoughts, misdirection and repetition). By contrast, reassurance was
more commonly experienced in CB than in PI therapy events.
Impact of therapy sessions
Stiles et al. (1994): In these studies clients from the Second Sheffield
Psychotherapy Project completed a session impacts form (Stiles, 1980) after
each therapy session. Clients rated PI therapy sessions as less smooth and less
problem focused than CB therapy sessions.
Reynolds et al. (1996): Clients also reported more negative impacts early in PI
therapy compared with CB therapy. Changes in impact over the course of
the series of PI therapy sessions were significantly greater than those for CB
therapy. For example, although initial client ratings of session smoothness,
positive mood and therapeutic relationship were less positive for PI than for
CB therapy, this difference was not significant by the end of therapy. This
may reflect difficult early sessions in PI therapy, with an emphasis on an
uncomfortable emotional focus, and this became smoother over time along-
side a better client-therapist relationship. Problem-solving also showed a
similar slow start in PI therapy with more change as time went on. By con-
trast, in CB therapy, problem-solving occurred similarly across sessions.
Mackay et al. (2002): Clients in PI therapy experienced significantly more neg-

ative emotions than clients in CB therapy. However, outcomes were better
when associated with higher levels of negative emotions. The reverse was true
for CB therapy, where clients experienced less negative emotions in the ses-
sions and negative experiences were not linked to better outcomes.
Together these findings point to similarities and differences in client
experiences. One important difference is the reporting of negative client
experiences within PI therapy as contrasted with CB therapy, perhaps par-
ticularly in early sessions. From a clinical and indeed ethical viewpoint,
such potentially aversive experiences need to be justified. As we will discuss
later, these difficult earlier sessions may arise because clients are talking
with therapists about previously inaccessible feelings and memories that
other therapies do not bring into focus. This is consistent with clients expe-
riencing PI sessions as deeper, as the negative feelings associated with more
positive outcomes suggest that difficult material is being emotionally pro-
cessed in the sessions.
Box 3.4 Impact of PI sessions

PI therapy is rated as less ‘smooth’ especially in the early sessions when clients
experience difficulties, which have previously been partly warded off, coming into
awareness.
Core elements of PI therapy and outcomes

In this section we look at four key elements of PI therapy that are associated
with client outcomes. These are as follows: aspects of a feeling language
(finding the right language that captures the client’s experiences); experienc-
ing in the here and now; the relationship between the client and therapist;
and development of a shared understanding.
Aspects of a feeling language
Hobson emphasised some important aspects of the language used in the deliv-
ery of PI therapy. He talked about focusing on the ‘minute particulars’ of the
therapeutic conversation. This is very hard to research because such small
nuances are often missed in more global measures of therapy. However, there
is some support from one study that demonstrated the importance of very
small details.
Stiles et al. (1989): Differences had been found between the two main therapists
in the first Sheffield Psychotherapy Project in the use of verbal response mode
forms (i.e. the grammatical forms used for the utterances). They speculated that
even something as simple as how the therapist acknowledges something from

the client could have contributed to differences in the effectiveness of the dif-
ferent treatments. Therapist 1 tended to use the form ‘OK’ or ‘Right’ when
acknowledging what the client said. In this system these are called interpretations
in the service of acknowledgement. In contrast, Therapist 2 tended to use so-called
minimal encouragers such as ‘Mm-hm’ and ‘Yes’. The former style tended to
close down ongoing communication whereas the latter tended to facilitate it.
Therapist 1 was found to be less effective overall than Therapist 2 in PI treat-
ments. Showing a direct link between these differences and outcome is, of
course, a different matter. However, this study suggests that it is not only the
intent of the communicative act that is important but also that the precise
detail needs attention.
Box 3.5 Minute particulars [1]

Even minute differences in the therapist style may impact on the experience of the
client and influence the outcome.
Hardy et al. (1999): Another approach has been to consider the language of the
therapist during attachment-related events in PI therapy. Small sections of cli-
ent and therapist interactions were examined showing how therapist respon-
siveness enabled client progress. Both the content and form of the therapists’
language encouraged both exploration of clients’ feelings and containment for
the client.
Box 3.6 Minute particulars [2]

PI therapy is sensitive to minute changes in language and the precise choice
of words within a shared ‘feeling language’ may encourage exploration but also
containment.
The here and now
Mackay et al. (1998): An intensive analysis was carried out of one event in PI
therapy that the client described as helpful. The client found it helpful
because she was able to express her anger, something that usually she was
unable to do. The primary mechanism that enabled the client to do this was
the therapist encouraging the client the stay with her feelings that emerged
during the session.
Rudkin et al. (2007): Therapy sessions were examined in two good outcome
cases compared with two unchanged outcomes in PI therapies. Good outcome
sessions were characterised by high levels of client moment-to-moment
experiencing and the therapist and client working together to construct
meaning.
Box 3.7 The here and now

Relational therapies such as PI need to focus on the experiencing of feelings, ‘here
and now’ in the session.
Mutuality and relationships
Agnew-Davis et al. (1998); Raue et al. (1997); Stiles et al. (1998a, 2004): Hobson
emphasised the centrality of the relationship between the client and therapist
in promoting change. As with most therapies, the quality of the therapeutic
relationship in PI therapy has been associated with outcome; the better the
alliance the better the outcome. However, in the Sheffield studies, clients rated
the quality of their relationship with their therapist generally lower in PI than
in CB therapy. There was also greater improvement in the alliance over ther-
apy in PI than CB therapy. A question we cannot yet answer is whether it is
possible to stay with re-experiencing negative emotions as part of the focus
whilst also developing the good early therapeutic alliance that is so important
in brief therapies. Our suggestions based on other evidence would be that close
attention to potential alliance ruptures and their repair would be crucial as
discussed below.
Box 3.8 Centrality of the therapeutic relationship

The better the relationship between the client and the therapist the better the
outcome.
Alliance ruptures and repairs
Stiles et al. (2004a): Clients experience more negative events in PI than CB

therapy, particularly in the early sessions of therapy. This study developed
these findings and considered ‘ruptures’ in the therapeutic relationship.
Using a sessional measure of the alliance completed by clients, 17 clients
were identified who experienced an event with a ‘rupture and repair’ of the
alliance (11 PI and six CB therapy clients from the SPP2). The outcomes for
these clients were better than for clients who had not experienced an alliance
rupture at all. This finding fits with a key principle of PI therapy – the impor-
tance of working in the here and now within the client–therapist relationship.
Agnew et al. (1994): It is important to consider how therapists can best man-
age relationship ruptures. We studied two clients in detail using qualitative
research methods, and developed a model of repair that included six stages:
(1) acknowledgement; (2) negotiation; (3) exploration; (4) consensus and
renegotiation; (5) enhanced exploration; and (6) closure. This model of
repairing a rupture in the therapeutic alliance is a microcosm of the PI model
as the alliance repair includes some of the key features of the PI model
alongside one of its fundamental aims – for clients to develop new and
different ways of being in relationships.
Box 3.9 Resolving ruptures

Alliance breaches occur in all models of therapy, but when they do occur they
are linked to better outcomes when the alliance is repaired in the ‘here and now’
relationship.
Shared understanding
Madill and Barkham (1997): A discourse analytic approach was adopted to

study PI therapy and indicated that problems addressed successfully in PI
therapy tended to be ‘understood as belonging to the client’. Changes in the
ways in which the problems were described through the course of therapy
showed a shift towards an external attribution of blame in the two successful
cases studied. In the unsuccessful case, the client and therapist had different
ideas as to ‘the problem’; the client presented it in terms of her partner’s
behaviour, whereas the therapist located the problem as belonging to the client
(for example, relating the problem to her jealousy and low self-esteem). The
therapist stuck closely to the therapeutic model, but this did not help the cli-
ent, as little consensus was reached regarding the nature of the client’s prob-
lems by the end of therapy.
Box 3.10 Shared understanding

A shared understanding of the nature of the problem is crucial for change to be
enabled.
Insight
Elliott et al. (1994); Kerr et al. (1992): The work on insight brings together the
key aspects of PI therapy discussed so far: use of a feeling language, experi-
ences of emotion and a strong therapeutic relationship. In these studies client
insight occurred following therapists’ interpretation of clients’ recent difficul-
ties, delivered firmly, persistently and in a manner that encouraged feedback
from clients.
Elliott et al. (1994): In this study the general features of insight events across
therapies were found to include the following: the client is involved in recur-
rent, ongoing relationship difficulties; the therapist’s interpretations formu-
lated the client’s painful reaction as a problem to be addressed further, and as
relevant to a general interpersonal conflict theme; and the client’s first
response was to agree. Features of insight events that were specific to PI ther-
apy included: a core interpersonal theme was raised in an earlier session; the
therapist made appropriate and evocative use of a key word; and the client
experienced strong or painful emotion.
Kerr et al. (1992) found that PI therapists focused more on making interper-
sonal links, or hypotheses, than other types of links and the interpersonal
links were related to improved self-esteem.
Box 3.11 Effective focus on core themes

Relational therapies need a combination of a collaborative approach and firmness
in staying with the task focused on an interpersonal theme, often using a key word
or phrase both to signal and to contain painful emotions.
In this final section we introduce two models that have been developed out
of the Sheffield process research studies. These provide a framework for
thinking about how we adapt therapy interventions for individual clients.
The models are pan-theoretical, they are not specific to one therapy
approach, but they can help the therapist think about why a particular
approach may be helpful with a specific client. We introduce first the model
of therapist responsiveness and then the assimilation model.
Therapist responsiveness
Part of being competent in PI therapy involves being responsive in the devel-
oping relationship with the client. The PI principles of negotiation and recip-
rocation and of ‘aloneness-togetherness’ require the therapist to be aware of
and responsive to clients’ needs and ways of interacting. ‘Appropriate

responsiveness’ is used by Stiles et al. (1998b) to describe the behaviour of
an experienced therapist responding appropriately to differing client require-
ments, needs, abilities and circumstances.
Box 3.12 Appropriate responsiveness

‘Appropriate responsiveness’ is characteristic of experienced therapists who can
respond appropriately to different client needs.
Interpersonal style
Hardy et al. (1998c): Therapists’ responsiveness to clients’ interpersonal style

were investigated, hypothesising that such responsiveness may be one reason
why therapies produce equivalent outcome findings. It was hypothesised that
clients’ interpersonal styles would ‘pull’ therapists to respond differentially
even within theoretically pure, manualised therapies. SPP2 clients were clas-
sified either as over-involved, under-involved, or balanced in their interper-
sonal relationship style. It was predicted that therapists would respond to the
intense feelings of over-involved clients by using PI type interventions in both
CB and PI therapies. In contrast, it was expected that under-involved clients
would engage relatively slowly and therapists, therefore, would preferentially
use cognitive strategies.
The results showed that therapists tended to use more affective and relation-
ship-oriented interventions with over-involved clients, consistent with these
clients’ overriding concern about maintaining relationships. By contrast, thera-
pists tended to use more cognitive treatment methods with under-involved cli-
ents consistent with these clients’ more distant, cognitive approaches to
relationships. This latter finding was significant only for CB therapy. This may
be because therapists were able to use a greater range of interventions in CB
than in PI therapy and still be considered to be ‘in model’. PI procedures aimed
at maintaining the therapeutic alliance and dealing with affect may be easily
‘borrowed’ by CB therapists as part of the collaborative approach, whereas
addressing faulty cognitions and setting behavioural tasks are not easily woven
into PI therapy.
Box 3.13 Awareness of client attachment style

Being aware of the client’s attachment style is important as it evokes particular
styles of response from the therapist.
Attachment styles
Hardy et al. (1999): To further understand the process of responsiveness, a

qualitative study examining sections of therapy transcripts was conducted.
The transcripts contained events that clients indicated had been the most
helpful in the session. The researchers classified the clients’ attachment
style, attachment issues and therapist response to the identified attachment
issues. Attachment issues tended to focus on three themes: (1) concerns
about loss or rejection; (2) conflict and danger; and (3) the need for closeness
or proximity. It was hypothesised that therapists’ responses to clients’
attachment issues would be mediated by the clients’ attachment styles and
this was confirmed. Therapists responded to clients with preoccupied attach-
ment styles by using reflective interventions and to clients with dismissing styles
by using interpretative interventions. This finding confirms that therapists can
be pulled towards using particular styles of intervention in response to a client’s
attachment style.
Hardy and Barkham (1994): This study found that attachment style, mentioned
earlier in this chapter, also impacted on work problems in clients from the
Sheffield studies. The clients who were categorised as having an anxious-
ambivalent attachment style reported high levels of anxiety about their work
performance and work relationships. In contrast those clients with an avoidant
style were more concerned about the long hours they worked and their non-
work relationships.
Box 3.14 Therapists’ responsive reactions

Therapists tend to use more reflective responses (understanding hypotheses)
with clients who have an anxious attachment style and more interpretive
responses (explanatory hypotheses) to clients with an avoidant attachment
style.
Client expectations
Hardy et al. (1995a): It was found that the greater the client’s expectations of
treatment, both immediately before and immediately after their first session,
the greater their improvements in therapy. This latter finding was significant
only for clients who received the shorter of the two therapy lengths (eight rather
than 16 sessions), although it applied regardless of therapy type. For clients who
received 16 sessions of therapy, their expectations of treatment did not predict
outcome either in the middle or at the end of therapy. This suggests that the
influence of expectations on treatment outcome does not simply ‘wash out’, but
that it is important in those therapies when time for engagement or renegotiat-

ing the therapeutic relationship is limited. Socialising clients to therapy roles and
tasks, therefore, seems particularly useful when therapy is to be brief.
Box 3.15 Socialising the client about their role

When therapy is brief it is particularly important to socialise clients into the therapy
roles and tasks as that predicts a better outcome.
Personality disorders
Hardy et al. (1995a, 1995b): It has also been found that clients’ endorsement of
treatment principles and diagnosis of a Cluster C personality disorder differ-
entially predicted outcome. Cluster C personality disorders include depend-
ent, avoidant and obsessive-compulsive disorders, which are the personality
disorders most frequently associated with depression. In CB therapy, neither
clients’ endorsement of any treatment principles, nor a diagnosis of a person-
ality disorder, predicted treatment outcome. In contrast, clients who indicated
lower endorsement of either CB or PI treatment principles, or clients who had
a diagnosis of a personality disorder, did less well in PI therapy compared with
those clients who highly endorsed CB or PI treatment principles, or who had
no personality disorder diagnosis.
Box 3.16 Impact of Cluster C personality disorder

Cluster C personality difficulty predicts a poorer outcome for PI therapy.
The former findings suggest that maximum benefit from psychotherapy would
not be achieved by simply offering clients the therapy they preferred. What
appears to be more important, at least for PI therapy, is how strongly the client
endorses that particular treatment. This aptitude or knowledge enables clients
to make better use of the therapy. In contrast, CB therapies teach clients the
cognitive model at the outset of therapy. The impact of prior knowledge and
preferences may thereby be reduced.
Box 3.17 Client endorsement

Strength of client endorsement of the model is important as it predicts outcome
in PI therapy.
Hardy et al. (1995b): In addition, it has been found that the influence of a
diagnosis of a personality disorder on treatment outcome was also dependent
on the client’s severity of depression. It appeared that outcome was poor
only when clients were more severely depressed and had diagnoses of a
personality disorder. This suggests that the impact of these two disorders
may be interactive rather than additive. Also, it seems that brief PI therapy
may present some difficulties for clients with this type of personality disor-
der. This may mean that the type of work done in PI therapy cannot be done
in brief therapies with clients with such problems.
Assimilation model
Assimilation of problems
Stiles (2002); Stiles et al. (1990, 2004b): The assimilation model is a pan-theoreti-
cal model of change that conceptualises the process of change in therapy as
being specific to particular problematic experiences as opposed to a change in
the nature of the person as a whole. An important implication is that differing
problematic experiences may be located at differing stages within the assimi-
lation model as the changes relate to memories, wishes, feelings, attitudes or
behaviours within an individual person. Such experiences are problematic
because they comprise, for example, threatening or painful events or difficult
or destructive relationships. The model proposes that positive change is
reflected in clients following a regular developmental sequence of recognising,
reformulating, understanding and eventually resolving problematic experi-
ences. Subsequent articles have updated the model very slightly and we pres-
ent in Table 3.2 what is now considered the accepted model although some of
the research reported in this chapter used an earlier version.
Stiles et al. (1990): Effective targeting of treatment also depends, in part, on

clients’ presentation of their problems. The assimilation model describes how
clients present and may resolve their problems and how therapists’ interven-
tions assist in this process. The assimilation model argues that clients describe
their problems in a way that reflects the degree to which they have assimilated
a problematic experience into their own schemata. Schemata here represent
cognitive structures that provide meaning and, therefore, link together a person’s
experiences.
Stiles et al. (1992): The model proposes that, in successful psychotherapy of

any kind, the client’s problematic experiences become progressively assimi-
lated within their schemata, moving through eight specific levels, described
in Table 3.2. The sequence of levels was based on clients’ descriptions of the
impacts of helpful and unhelpful events in therapy (Elliott, 1985). The client’s
Table 3.2 Assimilation stages
Level Stage Description
0 Warded off/dissociated Content is unformed; client is unaware of the

problem.
1 Unwanted thoughts/ Content reflects emergence of thoughts associated
active avoidance with discomfort. Client prefers not to think about it;
therapist or external circumstances raise topics.
2 Vague awareness/ Client acknowledges the existence of a problematic
emergence experience and clearly describes uncomfortable
associated thoughts but cannot formulate the
problem clearly.
3 Problem statement/ Content includes a clear statement of a problem,
clarification something that could be worked on.
4 Understanding/insight The problematic experience is placed into a
schema, formulated and understood with clear
connective links.
5 Application/working The understanding is used to work on a problem;
through there is reference to specific problem-solving,
although without complete success.
6 Problem solution/ Client achieves a successful solution to a specific
resourcefulness problem.
7 Mastery/integration Client successfully uses solutions in new situations;
this generalising is largely automatic, not salient.
affective state (e.g. distress, as measured by standard symptom inventories) is

most negative at Stage 2, when the problem is emerging and most positive at
Stage 6, when the problem has just been solved.
Detert et al. (2006) compared the assimilation of problematic experiences in four

good outcome cases versus four poor outcome cases of very brief psychotherapy
(two sessions plus a follow-up) for mild depression. Half of the clients in each
group received a brief version of PI therapy and half received a brief version of
CB therapy. Results supported the theoretical expectation that reductions in the
intensity of depressive symptoms were associated with higher levels of assimi-
lation. There were no significant differences between the PI and CB treatments.
All of the good outcome cases reached assimilation Level 4 (understanding/
insight), whereas none of the poor outcome cases did so.
Box 3.18 Awareness of assimilation level

Awareness of the assimilation level of a client’s problem is a good indicator both of
progress in therapy and what aspects of the problem need to be addressed.
Movement through the assimilation stages
(Field et al., 1994; Hardy et al., 1998a; Rees et al., 2001; Shapiro et al., 1992; Stiles
et al., 1991, 1992, 1994, 1997, 2006): These studies looked in depth at individ-
ual stages of assimilation to understand better the therapeutic processes that
enable clients to move from one stage to another in PI therapy. Common
themes in these analyses suggest that therapists are both firm and collabora-
tive in helping clients assimilate problematic experiences. For example, in
helping a client move from the assimilation stage of vague awareness to prob-
lem clarification, the therapist was challenging and directive, whilst accepting
of the client’s distress and active in developing shared language.
Shapiro et al. (1992); Stiles et al. (1992, 1997): The assimilation model also sug-
gests that clients with poorly assimilated problems may do better in explora-
tory treatments such as PI therapy than in CB therapies. Therapists using PI
therapies often consider the client’s presenting complaints as reflecting expe-
riences that are not yet accessible or are avoided (APES Levels 0 to 2). In these
therapies, formulation of the problem and insight (APES Level 3 and 4) are often
the therapeutic goals.
These results suggest that CB therapy better targets and effects change
when the problem is relatively well defined. In contrast, PI therapy aims to
uncover problems that are causing distress and upset but which initially the
client is not able to describe clearly. For clients whose problems were rela-
tively clear, this uncovering process may have felt unnecessary and perhaps
not helpful, especially as therapy was time limited in the Sheffield projects.
These studies also show the value of therapists actively helping clients clar-
ify what is troubling them and then focusing interventions appropriately to
resolving these difficulties.
Box 3.19 Matching interventions

to assimilation level
PI therapy is effective when the client still has difficulty articulating the problem but
experiences distress, whereas cognitive approaches may be preferable when the
problem has already been clarified.
Summary
In this chapter we have used process studies to investigate a number of ques-
tions. Most of this research has come from the Sheffield studies, where therapy
sessions were audio recorded and clients and therapists completed question-
naires after each session.
Together the studies suggest that it is important for therapists to be flexible

and responsive to client needs, especially to the interpersonal or attachment
issues that confront clients. In addition, as attachment theory would predict,
clients did better in therapy if they were confident in their therapists. In
particular, assimilation of problematic experiences seems to occur when ther-
apists are firm, collaborative and challenging.
PI therapy appears to do best when the client is committed to a psycho
logical therapy prior to therapy starting. So, for example, both clients’ treat-
ment preferences and degree of psychological orientation predicted outcome
in PI therapy. These findings suggest therapists should socialise clients into
the treatment process with clearer exposition of what to expect during sessions
and a better explanation of how change may occur.
In addition, they should carefully assess clients’ needs and formulate their
problems so that therapy can both clarify and be targeted at key client prob-
lems. We have also seen that it is important for therapists to recognise the
impact of clients’ interpersonal histories on the treatment process itself, and
on the ability of clients to maintain the gains they make in treatment.
Finally, important and distinctive elements of PI therapy have been found
to focus on three main elements. First, finding the right language that captures
the clients’ experiences and is understood by both therapist and client is a
central component of PI therapy (Hobson, 1985) and highlighted by a number
of studies. Second, studies have linked change in therapy to the experiential
element, the experiencing of feelings, and events in the here and now, of PI
therapy. Finally, the centrality of the relationship between client and therapist
is evident in many studies.
PART II
PRACTITIONER MANUAL
SECTION A: LEARNING THE SKILLS
4
Core Model and
Introductory
Psychodynamic-
Interpersonal Skills
Introduction
This manual focuses upon the minute interactions between therapist and client.
It gives beginners to psychotherapy some answers to the following questions:
‘But what do I actually say now?’; ‘What do I actually do?’ For more experienced
therapists, it may provide an opportunity for reflection upon not ‘What do I
say?’ but ‘How do I say?’ something.
The model comprises three stages with 13 distinct but interlinked com-
ponents or competencies (see Table 4.1 for a listing). Some of these compo-
nents are generic to all psychotherapies but, when taken as a whole, they
constitute a specific and definable model of therapy. The competencies are
divided into the three stages according to the ease with which they can be
learned and practised independently. In this chapter, following a brief
description of the core components of the model, the Stage 1 competencies
of the model are delineated. The Stage 2 and 3 competencies are described
in the following two chapters – Chapters 5 and 6 respectively.
Once learnt, the competencies can be practised and refined, just as a musi-
cian practises scales. A key concept is that of deliberate practice formulated
by Ericsson (see Ericsson and Lehmann, 1996) in which he proposed that
people become experts by hour upon hour of very deliberate practice.
Evidence suggests that this also applies to being a skilled therapist (for example,
Chow et al., 2015). It might be supposed that this phenomenon is just a reflec-
tion of a practitioner’s cumulative caseload, making us all more skilled with
age. However, deliberate practice is more about the time and work put into
training outside the time spent with a client. That will invariably involve
repeated self-scrutiny and self-monitoring of audio files or video recordings of
therapy sessions; supervision; and individual rehearsal and practice for all
therapists, regardless of their level of competency.
Table 4.1 The three competency stages and associated skills for
psychodynamic-interpersonal therapy
Components within
Competency stage Competencies competencies
Stage 1: The four Stage 1

Introductory skills (4) competencies:
1.1 Statements
1.2 Picking up cues (4)
1.2.1 Verbal cues
1.2.2 Vocal cues
1.2.3 Non-verbal cues
1.2.4 Cues in the therapist
1.3 Negotiation
1.4 Understanding
hypotheses
Stage 2: The four Stage 2

Intermediary skills (4) competencies:
2.1 Focusing on feelings

(here and now)
2.2 Metaphor and living
symbols
2.3 Language of mutuality
(‘I and we’)
2.4 Linking hypotheses
Stage 3: The five Stage 3

Advanced skills (5) competencies:
3.1 Explanatory hypotheses

3.2 PI therapy rationale
3.3 Sequencing of intervention
3.4 Relating interpersonal
change to therapy
3.5 Patterns in relationships
Core Model and Introductory PI Skills 55
This should not jeopardise the genuineness of the therapeutic relationship;

rather it should enhance the therapist’s ability to tune into the person he/she
is ‘being with’.
The manual itself has existed as an informal document and previous ver-
sions have been used in research studies. These earlier versions were written
in collaboration with Robert Hobson, and this version also draws heavily upon
his book Forms of Feeling (1985). This manual focuses upon using the model in
a brief framework and is based upon our experience of using it in an intensity
of one session per week, usually in a 16, 12, eight, four or three session (i.e.
two-plus-one) format.
Russell Meares, who co-founded the model with Robert Hobson, has devel-
oped the model for use in a long-term and intensive format for clients with
borderline personality states, where there is a greater emphasis on reparative
work of the self and the development of a sense of coherence. Readers who
are interested in using the model in a long-term therapy and with an intensity
of two or three sessions per week, should consult Borderline Personality
Disorder and the Conversational Model: A Clinician’s Guide (Meares, 2012a).
The core psychodynamic-interpersonal

model therapy
PI therapy is designed for the therapy of clients whose symptoms and prob-
lems arise from difficulties or disturbances in interpersonal relationships. It
is, therefore, not problem-specific, and it can be used in its basic format to
help individuals with a variety of symptomatic complaints. The practical
workings of the model can be enhanced by tailoring it to certain conditions
(such as depression and medically unexplained symptoms), but the basic
underlying process is similar no matter which particular symptom complex
the client is experiencing. This is an advantage as clients rarely experience
one pure psychiatric disorder. Instead people commonly present with com-
plex multi-symptomatic complaints.
Hobson referred to the process of therapy as ‘personal problem solving’
(Hobson, 1985). By this he meant the discovery, exploration and solution of
significant problems that are brought alive in the therapy. The model assumes
that past emotional deprivation, hurts and failures result in difficulties in
expressing personal feelings in an appropriate way. Current and past hurt is
avoided, resulting in the development of troubling symptoms and behaviours.
Hence, PI therapy can be seen within the context of psychodynamic and rela-
tional therapies.
PI therapy has at its heart the development of a ‘feeling language’
between therapist and client. By this we mean a way of talking and explor-
ing emotions with people that ‘feels alive’ in the conversation and includes
symbolic resonances. As discussed in Chapter 1, Hobson differentiates
between the kind of language that we use to describe objects (which he
refers to as ‘jam-jar’ language), and the kind of language we use to describe
feelings (Hobson, 1985: 19). There is an important difference between a

client who talks ‘about’ things, and a client who talks ‘with’ the therapist
as a person, and shares with him or her ‘alive’ experiences and feelings,
and it is the latter form of communication that the model tries to
promote.
The term ‘forms of feeling’ that Hobson used as the title of his book refers
to more than an experience of raw emotion. Hobson referred to complex
images, thoughts, processes, memories and experiences that are linked with
specific feeling states and personal relating, and ordered in differing levels of
coherence. Staying with a feeling, which is one of the central actions of the
model (see later), is not just about sharing raw emotion. The intention is to stay
with the feeling to see what emerges; what images, memories and complex
experiences are linked or connected in some fashion to that particular feeling
state. Key problems with interpersonal relating often lie at the heart of these
processes, which are captured symbolically by a particular image or memory.
This aim of personal problem-solving occurs through the discovery, explo-
ration and solution of significant problems that are brought alive in the thera-
peutic conversation. A central feature of the model is the promotion of a
symbolic attitude, which is captured by helping clients to stay with feelings, and
through this to see what emerges. The emphasis is about how a conversation
is developed, rather than what is actually discussed. Key actions of the thera-
pist, described below, were developed by Hobson and his colleagues with the
specific intention of generating a feeling language from which previously
warded off feelings can be faced and assimilated and problems can be identi-
fied, explored and resolved. The process involves:
zz staying with immediate experiencing;

zz working with symbolic language, ideas and images to order and under-
stand experiencing in relation to others;
zz owning experiences, and responsibility for actions, and minimising avoidant
behaviour; and
zz active learning in sessions of different ways of ordering experiences, man-
aging feelings and relating to other.
The process is collaborative and progresses according to the client’s needs

and wishes, and at a pace that is therapeutic. Hobson used the term alone-
ness-togetherness to capture an ideal form of a collaborative relationship
(Hobson, 1985: 194). This is one where there is intimate sharing of feelings
and experiences between the therapist and client, yet both retain their indi-
viduality and their own inner space. The therapist will disclose little per-
sonal information or personal problems, but is an active participant in the
relationship with the client, sharing experience and using his/her own intu-
itive feelings to identify with the client’s feeling state. Hobson differenti-
ated aloneness from isolation and loneliness, and togetherness from
non-differentiation or fusion.
A great deal can occur between two people within a few minutes, but often
important signs or signals or opportunities to explore feelings are missed.
Audio or video recording sessions and playing them back enables the therapist
to identify and recognise these missed opportunities, and gradually over time
to become more receptive to the minute particulars of the conversation.
The three competency stages

The competencies are divided into three stages. Stage 1 competencies enable
the therapist to establish a close and supportive relationship with the client,
and begin to pick up and discuss feelings. Stage 2 competencies encourage
the development of a feeling language and a deepening of the therapeutic
relationship. Stage 3 competencies are concerned with interpersonal problem-
solving once a feeling language has been established.
zz Stage 1 competencies are relatively easy to learn and simple to execute. If

used collectively, they comprise a powerful tool for establishing a feeling
of being understood by the client. They can be used in low-intensity work,
without the other model components, to facilitate rapid development of a
problem, followed by problem solution. They can be taught to health pro-
fessionals with no prior knowledge or training in psychotherapy.
zz Stage 2 competencies involve a deepening of the relationship and more
intense work and can also be learnt quickly by individuals who have good
interpersonal skills. However, regular supervision involving recorded ses-
sions from several different clients is required to develop them fully.
zz Stage 3 competencies involve the layering and linking together of feel-
ings, ideas, relationships and problems in a cyclical and evolving process.
Supervision, using audio recordings, is necessary to develop these skills.
Health professionals with a prior training in therapeutic work (e.g. a
counselling diploma, or psychodynamic training or CB therapy training)
can often learn the components of the model quite quickly, provided
they feel a ‘natural affinity’ with this particular way of working.
Stage 1 competencies
1.1 Statements
The therapist uses statements rather than questions. Questions tend to make
the therapeutic situation more one-sided and also tend to push clients into an
intellectualised mode as they try to respond or struggle to find an answer. A
statement suggests a starting point, and it encourages the client to rest in an
experience from which something may emerge. These statements are made in
a tentative manner.
Box 4.1 Questions and statements

Using a question
CLIENT: Sometimes my sister just takes over, she’s so bossy.
THERAPIST: In what way is she bossy?
CLIENT: Well she tells me how I decorate my house, and she tells me which
men I should go out with, and she…
Using a statement
CLIENT: Sometimes my sister just takes over, she’s so bossy.
THERAPIST: That sounds difficult.
CLIENT: Yes it is…it makes me feel so frustrated…and…angry.
In the above example the use of a question results in the client giving the
therapist more information, whereas the use of a statement results in three
important benefits: the client feels understood, it creates an atmosphere of
reflection, and from this the client’s feelings regarding her sister emerge.
Further illustrations of the use of statements are given below:
Box 4.2 Using statements

Example 1
CLIENT: When I got home, I’d barely got through the door, and they [her par-
ents] said they were off to stay the weekend at friends, they just don’t
seem to care…
THERAPIST: …you felt very let down.
CLIENT: I so wanted to see them,…I felt so hurt.
Example 2
(Early on in the first session, after a long pause)
THERAPIST: It’s a bit difficult all this…coming to see someone like me…
CLIENT: Well, yeah, I didn’t know what to expect…I don’t know what I thought
it would be like…it just feels strange.
It is common when people start learning to use the model that they find using
statements, rather than asking questions, quite difficult. It is not that questions
are forbidden in this model, but rather that statements are generally preferred.
There may be times when it is appropriate to use a question if the therapist
requires a direct response from the client. Someone who is learning the model
should focus on trying to use more statements and fewer questions than they
do usually. As they do this, they often begin to see the value in using state-
ments as these help to keep the focus on feelings, and there is a natural shift
towards using fewer and fewer specific questions.
1.2 Picking up cues (listening and noticing)
In any model of psychotherapy, it is important that the therapist is vigilant and

attentive to what the client is experiencing. This means trying to appreciate,
understand and tune into what the client is saying in his/her words, tone of
voice and behaviour. In this model, listening is a major part of the work of the
therapist. Listening is ‘an active process of perceiving and paying attention to a
multitude of verbal and non-verbal cues and by an imaginative act, creating
possible meanings which can be tried out and modified in a conversation, or
dialogue, that aims at understanding’ (Hobson, 1985).
Verbal cues
Verbal cues refer to when the client alludes to how he or she is feeling.
Box 4.3 Picking up verbal cues

Example: Fails to pick up a verbal cue
CLIENT: Sometimes I just get so sick and tired of all the hassle.
THERAPIST: What kind of hassle?
CLIENT: Well…it’s someone at work…etc.
Example: Picks up cue

CLIENT: Sometimes I just get so sick and tired of all the hassle.
THERAPIST: You sound weary and fed up.
CLIENT: I just can’t stand work at present…I wonder if I can carry on…it’s just
awful!
In the first example above, when the therapist fails to pick up the verbal cue,
the client goes on to give an external account of the problem. In the second
example, by picking up the verbal cue, the client is encouraged to describe
how he/she feels.
Vocal cues
These cues refer to the tonal inflection used by the client when he/she speaks.
The client could make a relatively innocuous statement but the tone of his/her
voice might, for example, sound angry. There may be more subtle changes in
rhythm and intonation that stress particular aspects.
It is not possible to give examples of this kind of cue in written text, but
when the therapist responds to it, he/she should acknowledge the evidence on
which it is based. Instead of just saying, ‘you’re angry’ the therapist should say
‘…what you said just now – there was a real sting in your voice, I wonder if
you sometimes feel quite angry inside’. This will make more sense to the client
and will also make the client feel that the therapist is listening to him/her and
trying to understand.
Non-verbal cues
Non-verbal cues include all other kinds of behaviour that the client may exhibit
during the therapy. They include the client’s facial expression and demeanour,
eye contact, body language, clothing, personal items and behaviour outside the
therapy room. They can be fairly straightforward, for example the client look-
ing sad, or they can be much more complex, for example the client avoiding
eye contact whenever referring to himself or the therapist.
When the therapist comments on a non-verbal cue, it is important to gauge
how receptive the client is to such an observation. For some clients it can feel
very intrusive, for others it can be an enormous relief. Observations should
be couched in a tentative manner, particularly if the cue is rather complex and
subtle and also if the cue refers to the client–therapist relationship. If the
client appears receptive, then the therapist can go on to suggest possible feel-
ings that may underlie the client’s actions, but expressed in a tentative way.
Or, the client may spontaneously develop the theme.
Box 4.4 Responses to non-verbal cues

THERAPIST: You look really sad today.
THERAPIST: I can see that you’re screwing up your fists…you seem…very angry.
THERAPIST: When I confirmed just now we’ll be finishing meeting in six weeks’ time,
you looked…umh…you looked to me quite stunned…[pause to see if
client accepts this]…as if it was a surprise…
THERAPIST: I’m not sure, but when you said you were going to miss me during the
break…you turned your head away and looked down…as if…well…you
didn’t want to or couldn’t look at me…[pause to see if this is denied or
accepted and to see if client responds]…
THERAPIST: This may be quite difficult for you, but I’ve been aware that since
we’ve been meeting for these last four weeks, you’ve never really
been able to look at me…you know…look me in the eye…[pause
again to see whether client can tolerate this observation]…
Cues in the therapist
The ways that the therapist behaves or feels can, on some occasions, provide
clues as to how the client is feeling in the therapy session. This idea is based
upon the psychodynamic theories of counter transference. These theories sug-
gest that the therapist can sometimes act as either a resonating board and pick
up the same feeling as the client is actually feeling in the session, or act as a
depository so that the therapist experiences a feeling but the client has no sense
of experiencing it.
This is a highly complex area and supervision is important in disentangling
the different elements – even for very experienced therapists. The therapist
has to be able to distinguish his/her own personal feelings from feelings that
are more closely related to the client. This is difficult as there is usually a great
deal of overlap between the two, and the client’s feelings may well resonate
with some of the therapist’s own emotionally vulnerable areas.
For example, the therapist may begin to feel irritated with the client for no
obvious reason. This may not be related directly to the therapy and could be
related to the therapist’s own personal issues which have intruded into the
session. It is important, however, that the therapist reflects upon the unusual
feeling and asks himself/herself whether it could be intimating something
important about the interpersonal situation with the client too. It is possible
that, in this example, the therapist may be picking up that the client is actu-
ally very angry with him/her, but, is not expressing this directly. The therapist
is picking up the theme of anger, although this was initially experienced as
related to personal issues, but it may have several sources that are not mutu-
ally exclusive.
1.3 Negotiation
The ‘how’ of the therapist’s talk is crucial: the therapist should not imply that
he or she is right. The therapist is really trying to say to the client, ‘This is how
I see things now, but I might not be right; I may have misunderstood; I’d like
you to help me see things clearer’. This attitude produces an atmosphere of col-
laboration between the client and therapist where deeper understanding is
reached through a series of gradual adjustments of meaning which get closer and
closer to the client’s experience. It is also a way of pacing the therapy so that the
client does not feel either overwhelmed, or intruded upon, by the therapist.
The client should feel able to reject any suggestion from the therapist, even
if the therapist thinks that he/she is right. In some circumstances, the therapist’s
statement may be accurate but unacceptable to the client in the form in which
it has been presented. Accuracy is not always therapeutic.
Box 4.5 Illustrating negotiation

Example 1: Non-negotiating
CLIENT: I think if people are in professional jobs they should be trustworthy,
if they say they’re going to turn up [talking about a nurse not turning
up for a home visit], they should!
THERAPIST: I think that you feel angry because I was late today.
CLIENT: You what?…no I’m not angry with you.
Example 2: Negotiating
CLIENT: I think if people are in professional jobs they should be trustworthy,
if they say they’re going to turn up [talking about nurse not turning up
for a home visit], they should!
THERAPIST: You seem very upset about this…I wonder if your upset is also partly
about something similar to what you describe…in that I turned up
quite late today…I’m not sure.
CLIENT: I was annoyed with you.
THERAPIST: I thought that you were, but I wasn’t sure…it’s quite a big thing for
you.
CLIENT: Yes, when I was little my mother was always, always late…I cannot
stand it, I really cannot stand it.
In the first example above, the therapist’s statement is too direct. The client
cannot deal with it and blocks. In the second example the therapist first of all
acknowledges the client’s distress and then tentatively suggests a possible link.
The statement is phrased in such a way that the client could easily reject the
suggestion if it still seemed too intrusive. The use of phrases like ‘I’m not sure’,
‘I wonder’, ‘This may not be quite right’, etc. invite the client to subtly provide
corrections and refinements to the important details that are being discussed.
The first example could be salvaged if the therapist was able to acknowl-
edge that he/she had made a mistake.
Box 4.6 Acknowledging mistakes

CLIENT: I think if people in professional jobs should be trustworthy, if they say
they’re going to turn up [talking about nurse not turning up for a home
visit], they should!
THERAPIST: You feel angry because I was late today.
CLIENT: You what?…no I’m not angry with you.
THERAPIST: I’ve not got that right…it seemed as if it was a very important thing
for you, people not turning up or letting you down…
CLIENT: It is…
THERAPIST: …Something really gets to you inside.
CLIENT: Yes, when I was little my mum always, always turned up late…it was
a family joke…but…I can’t bear it.
THERAPIST: I thought it was really important for you…which is why I wondered
whether me being late this morning had an effect on you.
CLIENT: Well I was slightly annoyed by it…but I know you’re very busy… it’s
not like with my mother…she’s got all the time in the world.
THERAPIST: Well, let’s see, there’s something similar between how you felt this morn-
ing about me when I was late and how you feel about your mum,…but
also something that makes that feeling feel different.
By initially retracting the first statement, the therapist has now enabled the
client to explore the link between her anger towards the therapist and her own
mother. The client can go on to explore with the therapist her view that the
therapist is very busy and therefore cannot be blamed for being late. This will
be a rich and complex area for discovery and mutual understanding.
Negotiating is particularly helpful when it is used to explore issues involv-
ing the relationship between the client and the therapist. The following
example illustrates this. It is quite long as it attempts to convey the process
of negotiation.
Box 4.7 The process of negotiation

CLIENT: You’re bound to be judging me, no matter what you say, you can’t sit
there and not have an opinion.
THERAPIST: …Umh…well…I do have some impressions of you, but…you said
judging you…it implies possibly that you may think…or fear that
I’m…judging you in a bad light?…
(Continued)
(Continued)
CLIENT: …yeah…
THERAPIST: umh…criticising.
CLIENT: Yeah,…I think you must be sitting there thinking how dull and boring
I am.
THERAPIST: I’d like to understand this a bit more…it sounds…very painful.
CLIENT: Yeah, it’s really hard…
THERAPIST: You feel on edge with me,…not comfortable…at all.
CLIENT: I just feel you must think I’m pathetic.
THERAPIST …umh………weak?
CLIENT: Yeah, weak and pathetic and useless…
THERAPIST: Well, you want to know what I think of you…yet you fear what I think
of you…you feel criticised… you feel this weakness inside…it feels
sort of exposing?…
CLIENT: Yeah…
THERAPIST: Yes…and…I…wonder…this situation now…you and me…makes

you feel a bit cross?
CLIENT: Cross with myself…angry with myself for being so pathetic…
THERAPIST: Well… [hesitantly]
CLIENT: I know I don’t have to be here…no one’s forcing me to come here and
see you, but I couldn’t not just turn up…I should be able to…just not
let it bother me…just tell people to get lost.
THERAPIST: …and here, with me, suppose you felt you wanted to say…‘why
don’t you shut up and stop asking these questions…stop looking at
me…I’m not putting myself through this any more’…
CLIENT: No…no…[smiling]…no I couldn’t do that.
THERAPIST: Well perhaps could we look at that…I wonder what the feeling would
be…
1.4 Understanding hypotheses
Hypotheses in the PI therapy are ways of promoting exploration and under-

standing of the client’s feelings, especially in interpersonal relationships.
There are some similarities between hypotheses and interpretations – which
are also exploratory statements – as used in other kinds of interpersonal and
dynamic therapies. Hypotheses, however, are offered with much less cer-
tainty and conviction than interpretations commonly are, and they are usu-
ally couched in more subtle language than interpretations, which are
usually more direct and unambiguous.
The aim of a hypothesis is to engage the client in a dialogue concerning its
accuracy. It is always better expressed in a tentative manner so it can be
accepted, rejected or modified by the client. Of importance is the communi-
cation of a desire to understand, not necessarily to get it right.
These are statements made by the therapist that refer to how he/she ima-
gines the client is feeling. They are usually based upon subtle non-verbal
cues or are responses to verbal cues from the client. They are not mere
reflections of the client’s feelings but an attempt on the part of the therapist
to take the exploration of the client’s feelings a little further.
Box 4.8 Understanding hypotheses

Example 1
CLIENT: I’m edgy, I can’t settle…
THERAPIST: I’d like to hear a bit more about that…seems you feel sort of
wound-up.
Example 2
CLIENT: I feel dead inside.
THERAPIST: …it’s hard to feel anything at all…empty…
Example 3
THERAPIST: I wonder if you’re feeling a bit stuck right now.
Although the use of filling words like ‘sort of’ or ‘a bit’ may appear rather unnec-
essary in the examples above, they reduce the harshness and starkness of the
statements, making them more acceptable for the client.
Summary
The four Stage 1 competencies of PI therapy have been described above.
They are: using statements; picking up cues; negotiating style; and under-
standing hypotheses. They are relatively easy to learn and can be picked up
quickly by health professionals who have good interpersonal skills, and they
can be used together in a coherent form (Guthrie et al., 2004b). Cue response
is an area that can always be improved, as even the most experienced ther-
apists miss or fail to recognise important cues.
These basic skills lay the foundation for the development of a strong work-
ing relationship with a client. They encourage people to share how they are
feeling with the therapist, rather than talk about problems in a detached or
abstract way. They promote a feeling of being listened to and understood. The
next chapter will describe the four Stage 2 competencies.
5
Intermediate
Psychodynamic-
Introduction
This chapter describes the second stage competencies of PI therapy. They are
slightly more challenging to learn than the Stage 1 competencies but their use
leads to a deepening of the relationship between therapist and client. When
used collectively, they promote the development of a feeling language and
sharing of experience.
2.1 Focusing on feelings (‘here and now’)
This technique involves focusing on what the client is experiencing during

the session. Instead of talking about feelings in the abstract or as if they
belong only to the past, an attempt is made to re-create them or facilitate the
actual expression of them in the immediacy of the therapeutic environment.
The client experiences the feeling and is able to share it with the therapist.
Box 5.1 Here and now

Example 1: Not using ‘here’ and ‘now’
CLIENT: When my grandmother died, I didn’t say goodnight to her before she
went to bed, when I woke up the next morning, my mum came in and
told me she had died in the night…I know it seems a small thing…I
know she knew that I loved her…but it really used to upset me…that
I hadn’t said goodnight…and…that was the last time I saw her.
THERAPIST: You must have been very upset.
CLIENT: Yes I was, it seems such a long time ago though.
Example 2: Using the ‘here and now’

CLIENT: When my grandmother died, I didn’t say goodnight to her before she
went to bed, when I woke up the next morning, my mum came in and
told me she had died in the night..I know it seems a small thing…I
know she knew that I loved her…but it really used to upset me…that
I hadn’t said goodnight…and…that was the last time I saw her.
THERAPIST: And there’s something of that upset and sadness now…you feel it
now…here…with me.
CLIENT: Uh yes…
THERAPIST: Can we stay with that feeling.
CLIENT: [cries]
In the first example above, although the therapist acknowledges that the client
must have been very distressed, because the therapist uses the past tense the
actual feelings remain in the past and inaccessible. In the second example,
because the therapist focuses upon the present, the client is able to get in
touch with these feelings that previously have been buried.
This technique should only be used if the therapist senses that the client is
actually experiencing the feeling, even if it is only mild, although he/she finds it
difficult to acknowledge directly. If the client appears completely detached and
unemotional, such a response from the therapist would be inappropriate. In
these circumstances, it would be better for the therapist to contrast the distress
described by the client, with the lack of feeling he/she is actually experiencing,
although this needs tact as the client may not yet be aware of the discrepancy.
Another way of helping people get in touch with feelings is to ask them to
relive experiences as if they were happening ‘now’. The therapist asks the client
to use the present tense to describe something from the past, as if it were hap-
pening ‘now’. The event has already been identified as a significant one that the
client has remembered as having some specific meaning or importance for them.
Intermediate PI Skills 69
Box 5.2 Here and now (continued)

THERAPIST: I suppose…could you tell me…just let it come to mind…any time
when you were small…we when you were really wanting your mum to
be close to you.
CLIENT: Er…
THERAPIST: And were upset about it.
CLIENT: Er…I was eight. My mother had another child. When I came home,
she went into hospital. I knew she was going into hospital to have a
baby. That night she did go in. I can still remember it…five or seven
days…I’m not sure how long it was. It was when she did come home –
when she did come home, my mother was angry…and from that
point onwards I don’t think she treated me any different…because I
was always as my mother would say a sickly child, I would get a lot
of things, my other sisters felt sorry for me, but I didn’t know this
at the time. I’m not sure if I felt jealousy for my youngest sister.
I was eight then…
THERAPIST: But your mother was angry.
CLIENT: Yes I don’t know why…because she was always very kind. It took a
lot to get her angry. And I did walk in and she did have a lot of visitors
there that day, and I don’t know if I said anything but she appeared
to be very angry and that affected me for some reason and I’ve never
forgotten that.
THERAPIST: Yes…I wonder if we could go through that bit, almost as if it’s hap-
pening now. Conjure up a picture.
CLIENT: Yes I can still picture it.
THERAPIST: Right well now can you talk about it as if it’s happening now.
CLIENT: Right.
THERAPIST: Where are you? Can you say ‘I am’ not ‘I was’?
CLIENT: Well there were a few people.
THERAPIST: I am [indicates with hand]…There are…
CLIENT: Oh…I am…I walked into the room…
THERAPIST: You are walking…
CLIENT: I’m walking to the door…my mother and a few other ladies were
speaking…
THERAPIST: are…[gestures with hand]…there they are…
CLIENT: I’d say I’m in…In the lounge by this stage…and I must have said
something to my mother…I’m not sure…
(Continued)
(Continued)
THERAPIST: You see how hard you are finding it…to say as if it’s happening now…
it isn’t easy…to say it as if it’s happening now…I must have said
something…I don’t know what it is…but my mom…
CLIENT: She snapped.
THERAPIST: Snapped…as if she’s doing it now.
CLIENT: Yes…she snapped at me and that affected me…maybe because

she’d never snapped at me before the baby was born…so therefore
I took it very hard…that’s the only way I can describe that.
THERAPIST: Well when you say you took it very hard…let’s imagine what that
feeling was like.
CLIENT: A hurt feeling.
THERAPIST: Feels like I’m really hurt.
CLIENT: Very hurt…very hurt.
THERAPIST: Deep down inside.
CLIENT: Very hurt and I thought, she wasn’t like that before she had the baby.
THERAPIST: Well…stay with it now…stay with the feeling.
CLIENT: Yes very hurt…I feel that…… just comes over me…from here [points
to tummy] upwards. [Points to head]
[Therapist mirrors action]

CLIENT: This horrible hurt feeling, why did she snap at me?
THERAPIST: Aaaand…maybe she doesn’t love me anymore.
CLIENT: Right… [long pause]…yes I suppose that is the feeling.
In the example in Box 5.2 the therapist and client explore an important mem-
ory from the client’s childhood. The therapist encourages the client to try to
re-experience the memory, as if it is happening ‘now’. This approach is only
used for memories that are likely to have significant emotional meaning, and
where the client finds it difficult to get back in touch with feelings.
Note how, in the first part of the example, the client is gradually remember-
ing some facts about what happened, but seems hazy about what was experi-
enced. The client knows something important happened between her and her
mother that has stuck with her. The therapist pushes quite hard to help the
client relive the associated feelings.
There are two main reasons for trying to focus on feelings within the PI
model. First, some feelings may be difficult to acknowledge and share. For
example, someone who feels angry following the death of a loved one, may not
be able to acknowledge this feeling, as it may seem unacceptable. Other feelings

may be warded off because they are too frightening to acknowledge or embar-
rassing. Beginning to experience a warded off feeling in the presence of a sup-
portive other can be therapeutic and cathartic, and lead to change (Box 5.3).
Box 5.3 Getting in touch with a warded

off feeling
A young mother developed feelings of intense anxiety about her baby daughter and
was unable to leave her in the company of others (even her own mother) without
developing panic attacks. Brief cognitive behavioural treatment had not been success-
ful as she was too anxious to carry out the homework or tolerate any separation from
her baby.
Initially in the sessions, which she attended with her baby, she described herself
as having anxiety all the time. This started around the time her baby was born. She
said the birth had been difficult but she had got over it, and didn’t think it was con-
nected to her current problem. The therapist noticed that she used the word
‘anxiety’ to describe how she felt and never elaborated upon this: ‘It’s my anxiety, it
just stops me from doing anything.’
THERAPIST: Your anxiety…I’d like to try and understand more…get a feeling of

what it feels like for you…what you actually experience…
CLIENT: Anxiety…it’s my anxiety.
THERAPIST: A feeling inside?
CLIENT: Anxiety. [Client responds several times to gentle probes by the ther-
apist, each time responding with the word ‘anxiety’.]
THERAPIST: A feeling in your body…perhaps…a tenseness?
CLIENT: Yes…a shakiness…[Makes a fluttering gesture with her hands.]
THERAPIST: It’s there a bit now?…this shakiness [makes similar fluttering

gesture]
CLIENT: Yes…[client noticeably becomes more anxious]

THERAPIST: …with the tenseness and the shakiness…there’s a fear…
CLIENT: Yes…[breathing more heavily]…that she’s going to die…Hayley’s
going to die…
THERAPIST: Like it’s really going to happen…or you thought she had?
CLIENT: Like when she were born, I was out of it, it was forceps and she was
taken to the special care unit. But I didn’t know, so when I woke up,
she weren’t there, she weren’t there…and I thought she died…and I
just began wailing…until one of the midwives came in…but I couldn’t
(Continued)
(Continued)
stop shaking until they took me up to the unit to see her…it’s like I
didn’t believe them…
THERAPIST: You thought she’d died.
CLIENT: Yes…it were terrible…terrible. We’d been trying for ages…I’d kept mis-
carrying and I thought…all through the pregnancy…I thought I was
going to lose her. Like all the other babies…I just knew it.
THERAPIST: You’ve had a really terrible time…so many lost babies…it’s really
difficult to cope with all that loss.
CLIENT: I blame myself…[Client is connected and talking closely with the
therapist.]
In this example, the therapist is able to help the client get in touch with feel-
ings that lie behind her ‘anxiety’; the terrible fear that her baby had died and
that in some way she may be responsible for this.
The second reason for focusing on feelings in this model is to encourage the
connection between feelings and symbolic thought processes. The feelings
have to be present and experienced by the client for this process to happen,
otherwise it becomes an intellectual exercise. The notion of ‘forms of feelings’
has already been discussed in the first chapter in this book and in the intro-
duction to the manual (Chapter 4). It implies a complex system of connected
feelings and images, which arise from and are woven into the fabric of inter-
personal relating. As the person experiences and stays in touch with a feeling,
certain thoughts, images or ideas ‘come into mind’.
2.2 Metaphor and living symbols
Use of metaphor in literature refers to the fusing of two or more images and/or
ideas to bring a new experience and a new order and meaning. Metaphor is not
exclusive to PI therapy, but it is used commonly by PI therapists to bring vividness
to an idea, to expand understanding of an experience or concept, and to deepen
the level of emotional exchange between the client and the therapist. The therapist
should be alert to the language that the client uses to describe his/her experience.
It is often by ‘staying with’ immediate experience (focus on feelings) that
nascent images, symbols and ideas emerge. In this model, the emphasis is not
on what a symbol might mean, or why a particular metaphor has been used.
The interest is in where they might lead the conversation. The therapist aims
to convey and promote a symbolical attitude.
This means endowing words, gestures, experiences, and dreams with value; regard-
ing them not only as communications of formulated messages but also as living
symbols. They are intimations of, and means of apprehending, what is as yet
unknown. (Hobson, 1985: 199)
Box 5.4 Using metaphors

Example 1
CLIENT: I feel on edge all the time…I just can’t settle.
THERAPIST: Sounds as if you feel…sort of wound up.
CLIENT: I feel myself getting tighter and tighter inside…everything’s rigid…
THERAPIST: Feels a bit like you feel like a spring…that’s all coiled up…being
turned tighter and tighter.
CLIENT: Yeah, I think sometimes people do things deliberately to wind me
up…I’m sure I’m going to just snap.
Example 2
CLIENT: I feel trapped…there’s no way out…nothing to look forward to…noth-
ing’s going to change.
THERAPIST: It all feels quite hopeless…
CLIENT: Yeah.
THERAPIST: …as if you can’t move…stuck.
CLIENT: I can’t…I can’t do anything.
THERAPIST: It’s a bit like…you feel like almost caught in some kind of trap…like
perhaps an animal caught in a trap.
CLIENT: I always feel sorry for animals…like that…I hate hunting…it’s so
cruel…it’s so unfair, the animal hasn’t done anything wrong…it’s an
awful death…so painful and frightening…
THERAPIST: Hmm.
CLIENT: It’s so unfair…what have I done to deserve this.
In both of the examples in Box 5.4, the therapist picks up and extends the met-
aphor initially voiced by the client. There is a movement, a carrying forward.
In the first example, the extension of the metaphor leads to a deepening of the
feeling language, and to a new insight. That is, that the experience of being ‘on
edge’ is linked to an interpersonal dynamic (a feeling that people are deliber-
ately trying to upset the client).
In the second example, the feeling of being trapped is elaborated, and there
is movement from ‘stuckness’ to the client’s ‘here and now’ experience of
being an ‘innocent creature’ who is hunted and persecuted. Note at the begin-
ning the therapist is active in developing the metaphor, but later leaves space
with just a small encouragement for the client to stay with the exploration.
In Forms of Feeling, Bob Hobson describes seeing a client called ‘Joe Smith’
(Hobson, 1985: 33). Joe finds it difficult to describe how he feels and to put his
feelings into words. Hobson encourages him to stay with the difficulty of being in
touch with himself and Joe blurts out that there isn’t anything inside, there is ‘no
me’. After a longish pause, Joe says, ‘I feel queer’. Hobson asks Joe to stay with
the feeling, but Joe becomes very tense and begins to feel scared. He loses touch
with the feeling and then noticeably relaxes. Something, however, has been
shared. A few weeks later the feeling emerges again and this time he is able to
stay with it. Joe describes a ‘wobbly feeling’ and from this, he and the therapist
get to a feeling of ‘being wobbly like a child trying to walk’. A symbolic transfor-
mation has occurred. The original experience of ‘feeling queer’ has been trans-
formed into a shared personal feeling between the therapist and client, involving
fears about being little and vulnerable, and fears about ‘leaving mum’. This pro-
cess only occurred because the therapist adopted an attitude of expectant waiting,
what Hobson called a ‘symbolic attitude’ and encouraged Joe to stay with the
feeling of ‘queer’ (see Chapter 6 for further discussion of a ‘symbolic attitude’).
This example demonstrates that an important metaphor can hold together
an important theme across sessions. When looking in more detail at assimila-
tion in psychotherapy we found that this ongoing shared reference to a key
idea was highly characteristic of PI therapy and often the theme could be
brought back in a subsequent session just by either the client or the therapist
mentioning the key phrase as a shared reference point (Stiles et al., 1990).
2.3 Language of mutuality (‘I and we’)
The therapist explicitly refers to the relationship between therapist and client
in terms of first-person words ‘I’ and ‘we’. This indicates an active and mutual
involvement in exploration. It also facilitates a deepening of the relationship
between the therapist and the client, and accentuates a directness of commu-
nication. Some examples are given in Box 5.5.
Box 5.5 Examples of using a language

of mutuality
zz I’d like you to stay with that feeling if you can?
zz I can imagine how difficult that was for you.
zz I think that you’re feeling that a bit now, that feeling of upset…here with me.
zz I’d like to try and get a better understanding of how you are feeling.
zz Maybe it’s something that you and I can work together on?
This component of the model sounds simple and straightforward but it can have
a surprisingly powerful effect when used, and usually results in a deepening of
the conversation and a focus on what is happening between the client and the
therapist at that moment in therapy (see Box 5.6).
Box 5.6 Example of deepening the conversation

using ‘I and we’
Not using ‘I’ and ‘we’
THERAPIST: It seems like an effort to come here.
Using ‘I’ and ‘we’

THERAPIST: I wonder if you feel it’s an effort to come here and see me.
The shift in language is subtle, but the accumulated effect is significant as it

models personal language and avoids abstractions like ‘It’s’. The example also
shows the therapist being tentative at the same time, which is easier to achieve
when using personal language. It also focuses the therapy on the relationship
between the therapist and client, and on the ‘problem’, which is alive in the
session between the two people.
If the therapist starts to use passive or abstract language when referring to
the client–therapist relationship, it may be a sign in this model that the thera-
pist and client are not connected. It can even imply on occasions that the
therapist is avoiding uncomfortable or difficult feelings that he/she feels the
client holds towards him or her.
2.4 Linking hypotheses
Linking hypotheses are statements that link feelings that have emerged in the
therapy sessions to other feelings both inside and outside the therapy. They are
a way of drawing links between the client–therapist relationship and other
important relationships in the client’s life, past or present. In this respect, they
may refer to the transference relationship between the client and therapist,
although this is not always the case.
Box 5.7 Examples of linking hypotheses

THERAPIST: Maybe some of the feelings you’ve had here of worrying whether I
would take you seriously are a bit like feelings you’ve had at work
worrying whether people would believe you.
THERAPIST : I wonder if the way you feel now…a bit unsure of me…a bit worried
whether you can trust me…is a bit like…a little bit like…like you
were saying earlier…finding it difficult to trust your dad because you
didn’t know whether he’d hug you or beat you…
These examples show the link being made between the relationship between
therapist and client, to other relationships. The first example is to a current
outside relationship at work, and the second to a past experience with a rela-
tionship with the client’s father. At this point the therapist is simply establish-
ing the link but not drawing any general conclusions from it. That step could
occur later once the link has been established.
Linking hypotheses are used by the therapist to create a pattern of interlinking
relationships or themes, which gradually build as the therapy progresses. The
links can be vertical (i.e. referring to past or childhood relationships) or horizon-
tal (referring to current relationships outside therapy) or both. A more coherent
picture begins to emerge as the links that are made resonate with the present and
the current difficulties or problems facing the client.
Summary
The four Stage 2 competencies that have been described in this chapter are
powerful therapeutic tools, and care and experience are required to use them
appropriately and wisely. They enable the therapy to ‘come alive’ and for expe-
riences to be shared rather than talked about. In the next chapter, the Stage 3
competencies will be described that deal with the ways in which the session can
be used to help the client to structure their experiences into a coherent shape
and then begin to address their difficulties.
6
Advanced Psychodynamic-
Introduction
This chapter describes the remaining five key competencies of PI therapy:
explanatory hypotheses, PI therapy rationale, sequencing of intervention,
relating interpersonal change to therapy and patterns in relationships. These
help the therapist to explore the client’s problem in depth and facilitate the
development of a coherent and shared description of the problem. At the end
of this chapter we also discuss problematic behaviours that the therapist
should avoid. These are rarely discussed in therapy manuals, but we believe
a fundamental aspect of any therapeutic endeavour is not to do harm and we
include some guidance on what to avoid.
3.1 Explanatory hypotheses
These statements are more complex than understanding or linking hypotheses

(see Chapters 4 and 5) and are only made after the therapist has acquired con-
siderable information about the client. There will have been preparatory work
with understanding and linking hypotheses before extending to an explanatory
hypothesis. This type of hypothesis introduces the possibility of underlying rea-
sons for problems and difficulties in relationships. They usually relate to a
repeated pattern of maladaptive behaviour, both inside and outside of therapy,

and have often been present in the past – often detectable in some form even as
far back as childhood – as well as the present. The therapist tries to link the
client’s behaviour to some kind of underlying conflict or difficulty. This provides
an opportunity for the conflict to be acknowledged, owned and explored. It may
also lead to other ways of dealing with the underlying difficulty as the seemingly
blocked patterns become available for reflective thinking.
Box 6.1 Example of an explanatory hypothesis

THERAPIST: You were saying that it’s hard for you to feel angry with me…even
though it seems justified and appropriate, and…that I kept you wait-
ing this morning. You’ve also said that you find it difficult to feel angry
with other people even when they mistreat you. Your dad, of course,
was a very angry and violent man…I wonder if you’re afraid somehow
that if you were to get annoyed with me, you might lose control and
get very angry…or maybe that I would get very angry…a bit like your
dad used to…and either way…that’s very scary.
In the above example, before giving the explanation, the therapist provided
three pieces of information on which the hypothesis was based. This is impor-
tant, as otherwise it may sound as if the therapist is conjuring the hypothesis
out of thin air. The pieces of information, however, need not necessarily be
given in the one statement and may emerge in the context of a dialogue
between the client and therapist over several minutes. The client may well
contribute to the links too, and help to prepare the ground for the therapist to
pick out the pattern for further exploration. This example shows how an
exploratory hypothesis may be embedded within a conversation.
Box 6.2 Explanatory hypothesis in conversation

CLIENT: I feel as if I’ve always got to fit in…please others…I end up with no
say over my life…I don’t ever say what I want.
THERAPIST: You kind of adapt yourself to others.
CLIENT: Yeah I end up not knowing what I want, whether it’s something I really
want or something that she wants, or something my mother wants,
or something I’m expected to want.
THERAPIST: It’s all mixed up…your feelings…
CLIENT: Yeah.
THERAPIST: It seems one of the scary things about getting close…is you’re not
sure who is you and who is the other person…Sheila…your mother…
CLIENT: Yeah…
Advanced PI Skills 79
THERAPIST: …and…if you don’t fit in…please others…you could be hurt?

CLIENT: I don’t know if I let myself be hurt…I cut off…I say I don’t care.
THERAPIST: Umh…
CLIENT: I don’t know what to do…with…with feeling this…this hurt.
THERAPIST: It’s scary…scary staying with it a little while…with me.
CLIENT: Umh…
THERAPIST: It seems…you want to be close…but you’re scared of being close…
’cause you feel taken over…or you can’t tell, who is who, kind of…so
you cut yourself off…but then you feel awful inside…lonely?
CLIENT: People think I’m so easy going…so nice…yet they don’t see how
alone I feel.
THERAPIST: Alone because it’s so scary to be close.
In the above example, the client and therapist eventually reach an understanding of
why the client is scared of relationships, and why he keeps himself at a distance.
3.2 PI therapy rationale
An essential component of PI therapy is an understanding between the client and

therapist of the purpose of therapy. This may evolve during the first session as
the client’s experiences and problems are shared and explored. A strong rationale
for focusing on feelings and relationships should arise naturally from the shared
experiences and discussions between the client and therapist. Towards the end
of the first session, or earlier if appropriate, the therapist should make a connec-
tion between the importance of focusing upon relationships and sharing experi-
ences in the ‘here and now’ as a way of facing warded off fears and overcoming
problems. This shared rationale can help to build and maintain the therapeutic
alliance and provides the client with the beginnings of a model, to understand
his/her problems, which can grow and develop as therapy progresses.
Box 6.3 Example of an exploratory therapy

rationale
THERAPIST: Before we finish…can you just say something about your dad…we’ve
not mentioned him.
CLIENT: Well as a child he would give us a lot of things…but he would also get
very angry…at times, which would scare me a lot…and once when I
was 13…he came into the room…and was very angry…but he didn’t
(Continued)
(Continued)
hit me…he looked at me…and I was so white, I was that scared that
I froze…but I didn’t realise I had gone white and he just looked at me,
and it shocked him that I had got so scared, and he walked out…and
later on when he told someone about it…… shocked me that I had
got so scared…that’s all I can say about my father.
THERAPIST: This anger and violence comes in again.
CLIENT: Yes, but he was very loving…But, he would hit us…that’s all I can say.
THERAPIST: You’ve been able to share that with me.
CLIENT: Yes I have…I’ve never spoken about what we’ve talked about just
then…and I’m thinking about that now.
THERAPIST: Now we’re going to end. Things that are frightening…Often, if you can
look them straight in the face…they can often be a lot better…I’d
like to end by you telling me again about the dream with the dead
people.
CLIENT: Yes well there’s two kinds of dreams, one that I had to walk through a
road…a narrow road, and all dead people were lying everywhere and
behind that was a cemetery, and I was closing my eyes on either side
because I didn’t want to see the dead people, they were covered, I
couldn’t see their faces…and there was another time when I had
to walk into a room…and all dead people again, bodies…just lying
there…and I wake up very disturbed but I don’t understand why…why
always death?
THERAPIST: You’re very scared of death?
CLIENT: Yes.
THERAPIST: We’ve shared that a bit here.
CLIENT: Yes.
THERAPIST: I think there are important things to explore here…and it’s more
important to get in touch with that feeling…which I think you were a
bit just now…of loss…of fear…than any long explanations.
This extended example shows how encouragement to explore, giving a thera-

peutic rationale, and some preliminary attempts to link experiences, are all
arising within a conversation. The most important aspect of the work is to gain
the client’s trust and to enable the client to share something of what he or she
is feeling in the session. This does not have to involve an elaborate explanation
or formulation of the client’s problems. A simple, shared understanding that
there are difficult or upsetting things in the client’s life that may be helpful to
share and explore, is usually sufficient for a preliminary rationale. The key is
that the feelings, as in the above example (‘you are very scared of death’) are
actually experienced in the session, rather than discussed in an intellectual or
theoretical way. The therapist does not say, ‘you have a fear of death’ the
therapist says, ‘you are very scared of death’. This difference is subtle but
crucial in developing a therapeutic rationale as the former conveys an idea,
whilst the latter conveys a lived, current experience.
3.3 Sequencing of intervention
Psychotherapy is a creative process of personal problem-solving. Problems are

manifest and explored in the therapeutic conversation. This process begins
with the bringing of experiences and feelings into the ‘here and now’. Avoidance
actions are abandoned and a degree of conflict and stress is tolerated. The con-
nection between feelings and key relationships becomes apparent and possible
solutions are created through an imaginative feeling-language.
In PI therapy the sequence always begins with the client’s experiences
and feelings as they are experienced in the ‘here and now’. Sequencing may
happen over a few moments where there is clear movement from ‘here and
now’ feelings to their connection to an interpersonal relationship to the pos-
sibility of problem solution. However, the process can progress over a whole
session or several sessions. The key to this competency is that the therapist
is not looking for an immediate explanation for the client’s symptoms, so
statements like, ‘I wonder why you feel like this?’ would be out of model
behaviours as they are encouraging the client to think ‘about’ the problem
and its cause, rather than get in touch with the problem, and begin to face
warded off or difficult feelings.
In the previous example of Joe Smith (see the section on metaphor in
Chapter 5) there is a clear sequencing of events. An experience of feeling ‘queer’
is brought alive in the session. This is felt to be scary and the client moves away
from it, but its significance is noted and the shared feeling between client and
therapist has signalled a movement in the therapy. Some weeks later the feeling
re-emerges and again, by staying with the feeling, Joe describes feeling wobbly
in his middle. Hobson links this feeling to the experience of feeling ‘wobbly like
a child trying to walk’ and from this to the feelings of a small child in relation
to his mother, which can then be experienced and explored. The warded-off
experience that Joe found so threatening has been shared and the possibilities
of facing his fears of vulnerability and insecurity have begun. All this has hap-
pened in the context of the relationship with the therapist.
3.4 Relating interpersonal change to therapy
In PI therapy the problems are directly presented in the relationship with

the therapist as well as being enacted in the client’s personal life. Sharing of
experiences between the therapist and client and sharing a ‘new language’
open up fresh avenues of perceiving and acting in the world. As therapy
progresses these changes can be acknowledged and understood in a recipro-
cal and cyclical fashion. Such a process strengthens change and motivation
in the client.
Box 6.4 Example of relating interpersonal change

to therapy
THERAPIST: So…instead of giving in…in your usual fashion…you actually said
no?
CLIENT: Yes, I know…I can’t believe it…and when I said it…I thought he’d be
really angry [husband] and I got really panicky and for a moment I
nearly said…ok…let’s go and see her [husband’s mother]…but I just
didn’t say anything…
THERAPIST: It must have been very hard.
CLIENT: Yes…I thought my chest was actually going to burst…my head was
pounding…and I was just waiting for him to explode…but he didn’t…
and eventually I said…that I felt I needed a bit of time at the week-
end to sort out the things I need to sort out…and I wasn’t saying
I would never see his mother…just that…it was too much…and I
ended up with no time…to do all the other things…and he could go
by himself…
THERAPIST: This is a big…big step for you.
CLIENT: Yes.
THERAPIST: A big change…facing something you thought would result in Bill

being very angry…
CLIENT: Yes…but I think he knows…I’ve changed a bit…since coming to

see you…I think he’s aware I’m a little different…you know I almost
think…he’s a bit scared now of shouting at me…because…I’m not
as frightened anymore.
THERAPIST: Facing some of those fears with me…has helped?
CLIENT: Yes…yes most definitely.
The client is ready to acknowledge that new patterns are beginning to emerge,
and can see that the sessions are assisting that process.
3.5 Patterns in relationships
As the relationship deepens between the therapist and client and more of the
client’s life is known, repeated patterns in relationships often become appar-
ent. The therapist can use linking hypotheses to help foster the recognition of
similarities between relationships. Linking hypotheses may lead on to the
recognition of actual maladaptive patterns that occur in two or more of the
client’s relationships.
Box 6.5 Example of patterns in relationships

CLIENT: I don’t know where to start…
THERAPIST: There’s something difficult perhaps you want to say to me?
CLIENT: I suddenly realised when I walked out of this room last time that you
look like Helen. [Ex-girlfriend with whom client is still obsessed]
THERAPIST: That is curious.
CLIENT: F***ing curious!
THERAPIST: Also curious that it struck you just at the point you were leaving me
last week.
CLIENT: It’s been bugging me. I’ve been sitting down stairs in a real panic as
to whether you would turn up. It seemed a bit later this morning…I
was in a real panic…then I remembered I saw your light…another
thing…I realised I behaved towards Helen exactly the same way I’ve
behaved towards Dawn.
THERAPIST: You’ve seen a link between your relationship with Helen…and
Dawn…and I’m in there as well on some level.
CLIENT: When I got on the train, I made a list of my old girlfriends…all had
bad problems with relationships with blokes…all depressive…I knew
they were damaged from the word go. I want to know what’s that
about.
THERAPIST: You’ve seen a pattern in the type of women you are attracted to…
they have problems…there’s depression…there’s a sense you know
they are vulnerable…it’s not going to work…
CLIENT: Yes I just go round and round…
THERAPIST: Well…I wonder if we could go back to how you felt this morning…
before you saw me…there’s something of a connection between me
and Helen…you said you felt ‘panicky’…a fear I wouldn’t be there?
An important set of links has been made, with associated powerful feelings in
the client. The example ends with the therapist putting down a marker that
this has been important and suggesting that they go back and explore the links
more deeply.
Developing the conversation

The 13 competencies described in the last three chapters should be used seam-
lessly and interchangeably in developing a therapeutic conversation. The
intention is to move towards a ‘mutual dialogue and understanding’ with the
client. Psychotherapy involves, however, a special kind of conversation in

which the two participants have an asymmetrical relationship.
The therapist does not talk about the same things as the client, nor does the
therapist burden the client with his/her own difficulties or problems.
Psychotherapy, however, provides an unusually safe situation in which the
problems of everyday intimacy can be revealed, and solutions discovered. It
requires a genuineness and mutuality on both sides, as it is only in ‘real’ situ-
ations that new ways of tackling difficulties can be learnt.
The conversation needs to be developed at the right pace. Ideally it should
be progressed in a step-wise fashion. The steps must be the right height. The
pace should allow a person to remain in touch with feelings and bodily expe-
riences, without creating so much anxiety that the person cuts off and blocks.
In this therapy, the manner in which steps are taken is more important than
the content of the conversation. Discoveries are made in the actual ‘act’ of
relating, not in talking about a problem.
Doing no harm
The most important consideration for any psychotherapist is to do no harm.
Therapy can be life-changing, or it can alleviate unbearable distress, or it can
be moderately helpful, or of no help at all. It should not, however, be harm-
ful. The techniques described above that constitute a Conversational Model
of therapy if used inappropriately, or over-zealously or incompetently, are
capable of causing harm to the client who is being seen. The pace at which
therapy moves, the timing of interventions, knowing when and when not to
encourage someone to stay in the ‘here and now’, are all things that can only
be learnt through supervision, and meticulous self-scrutiny via the help of
audio recordings.
Therapists will make mistakes. Mistakes in themselves are not bad things,
and they are a normal feature of most relationships. If mistakes can be
repaired, the therapeutic relationship can often be stronger, as a result of the
reparative process. It is a mark of experienced and skilful therapists that they
can address and repair ruptures in the therapeutic relationship (Aspland et al.,
2008; Stiles et al., 2004a). Many aspects of the Conversational Model encour-
age the restoration of the therapeutic relationship if some form of dissonance
has occurred. Negotiation, basing interventions on cues, working in the ‘here
and now’, and the use of ‘I and we’ are all techniques, which if used naturally,
help the therapist to address misunderstandings or moments of conflict which
occur with a client.
However, therapists must be aware of common potential dangers and pitfalls
when practising psychotherapy – any form of psychotherapy. In a seminal
paper entitled ‘The Persecutory Therapist’, Meares and Hobson (1977) outlined
some of the key ways in which the therapist can unintentionally be drawn into
several different kinds of damaging behaviours.
Intrusion
In some therapies, this can occur when the therapist is too probing and asks
too many questions in an interrogative manner. Such questioning should be
unlikely in the Conversational Model, but therapists can also be too intuitive,
and even if correct, can propel the disclosure for the client at a pace which is
too fast and too exposing for him/her to bear. As discussed earlier, the thera-
pist can be quite active in encouraging the client to re-experience difficult
feelings, but, in extremes, it can feel to the client as if the therapist has
invaded his/her mind.
The Conversational Model is a collaborative enterprise in which the client
must feel safe, and only disclose or share personal information when he/she
wishes to. Hobson’s idea of aloneness-togetherness is particularly appropriate
in this context. All people need an ‘inner-space’ which is theirs and theirs
alone, and a ‘space-between’ which can be shared with others (Hobson, 1985:
201). The importance of picking up cues from the client to guide the thera-
pist’s interventions cannot be emphasised too strongly.
Derogation
This occurs when in subtle ways the client is made to feel patronised, ‘bad’ or
‘ill’. Some aspects of traditional psychotherapy theory include terms that can
seem derogatory and denigrating, whether by using a diagnosis to pin some-
one down rather than act as a reference point, or by the use of ‘clever’ tech-
nical language making the other person feel inadequate or stupid. In these
examples, there is a failure to understand the client from the client’s own
perspective. In subtle ways the client is made to feel inferior to the therapist.
Invalidation of experience
One of the most damaging things a therapist can do is to disaffirm what the
client thinks and believes. This again can arise from a false understanding of
traditional psychotherapy theory. The therapist assumes that the client does
not mean what he or she thinks and the ‘real’ meaning is being blocked. In this
scenario, the therapist is always right as, if the client tries to disagree, it can be
labelled crudely as ‘resistance’. In the Conversational Model, the therapist’s job
is to amplify the client’s feeling, and to extend awareness, not to dispute it.
In their paper, Hobson and Meares did not try to explain why these ‘perse-
cutory’ dynamics occur, although they give a vivid account of how things can
escalate into a persecutory spiral. They are drawing attention to the inevita-
bility that even the best therapists will at least occasionally fall into the trap
of being unhelpful. They stress that the therapist’s job is not to be perfect, but
to be able to listen actively for evidence that they have got something wrong.
The client may acquiesce rather than explore further; they may talk about a
parallel situation where an outside figure (dentist, tax inspector, traffic war-
den, thoughtless driver) is used to allude to the hurt being caused.
Very little has been written or acknowledged about the potentially harmful
aspects of psychological therapy, although it is achieving greater recognition.
PI therapy is one of the few approaches that acknowledged this problem, with
specific guidance about what and what not to do in any therapeutic situation.
Summary
In the last three chapters, the main components of PI therapy have been
described. The different competencies should be used seamlessly to create a
process of sharing and collaborating to facilitate interpersonal problem-
solving. In this form of therapy, the development of the relationship between
the client and the therapist is the key to revealing problems and difficulties in
the client’s interpersonal relationships, and it is also the main vehicle through
which change occurs.
The following three chapters will discuss in much greater detail how the
model is used in practice, going through from the beginning of a therapy,
through the work of the middle sessions and coming to a creative ending.
PART II
PRACTITIONER MANUAL
SECTION B: APPLYING THE SKILLS
7
The Initial Sessions
Introduction
The second section of this practitioner manual comprises three chapters (7–9)
that describe the application of the competencies in the overall process of a
course of brief therapy, including the initial, intermediate and final phase of
therapy. The chapters include practical advice about how to structure the pro-
cess, how to start a session of therapy, building theoretical models, using
goodbye letters, and ending. More experienced therapists may wish to pass
quickly through parts of these chapters as some of what will be said is generic
to all therapies, although the notion of deliberate practice would suggest that
these generic skills benefit from continual practice. However, the main empha-
sis in keeping with the PI model is to use these strategies to deepen the feeling
language between therapist and client, as will be discussed further in Chapter 8.
The present chapter will focus on starting therapy and the initial sessions.
The framework, settings, and facilitating conditions

Each session of therapy usually lasts for 45 to 50 minutes, but, whatever time
is available, the length of the sessions is agreed at the beginning of therapy and
normally remains the same for the duration of therapy. It is preferable that the
client and therapist meet on a weekly basis, at the same time and on the same
day each week. If changes to this structure do need to be made, they become
part of the ongoing conversation between the therapist and client.
This formal structure is important as it provides a sense of security and
reliability for the client. It also enables any changes in the routine of therapy
to be easily identified. These can sometimes be the first indication of signifi-
cant emotional tensions between the client and therapist. For example, a client
who feels angry or disappointed with his/her therapist may not tell the ther-
apist directly but may start coming late to the therapy sessions. This is more
evident when the scheduling of the sessions in terms of time is the same.
Box 7.1 Structure of brief PI therapy

Brief therapy
1. Initial sessions
a. The audio recording and supervision
b. Settling in
c. The problem
d. Plan of treatment
e. Link symptom development to interpersonal difficulties
f. Therapeutic alliance
g. Theoretical model and formulation
2. Intermediate sessions
a. Active exploration of the problem
b. Attend to moments of change
c. Testing solutions
d. Building an explanatory model
e. Passivity to activity
f. Deepening of a feeling language
g. Personal conversation and symbolic transformation
3. Final sessions
a. Explicit discussion of ending
b. Link ending to previous loss/dilemmas re intimacy
c. Review the main problem
d. Review significant changes
e. Review how work can be continued by the client although therapy will end
f. Involve client in the development and production of a farewell letter
g. Say goodbye
An example of how brief therapy is structured is shown in Box 7.1 and the
elements are covered in this chapter and in the following two chapters. It is
important that the therapist structures each session of therapy. Important
The Initial Sessions 91
information (e.g. the therapist going on holiday) is best discussed at the start
of a session and it is often helpful to let the client know when the session is
approaching the last few minutes, particularly if the client is distressed.
It is the nature of therapy that significant issues often emerge towards the end
of sessions. Therapy is not only about helping people to express feelings; it is also
about helping them to contain difficult feelings. Handling the ending of sessions
needs particular skill and tact, which is gained through practice and experience.
In brief, if the client is experiencing difficulty ending the session, these examples
show how a therapist can structure the end of each session, see the parallels
with managing feelings on a larger scale (such as the end of a relationship), make
tentative guesses about how the client is feeling and help to guide the client
towards ways of using structure to manage difficult feelings from the past.
Certain factors are common to most therapies. Although these factors may
be non-specific, they are often extremely important and help the therapy to run
smoothly. These include warmth, friendliness, supportiveness and empathy.
The purpose of these factors is to facilitate an understanding of what the client
is experiencing and try to develop a sense of feelings being shared between the
client and therapist. Empathic understanding is particularly important in the PI
model. However, there is an interesting conundrum captured by Robert
Hobson: ‘How dull life would be if we all had accurate empathy – there would
be nothing left to correct. Therapy is about the correction of misunderstandings’
(personal communication, circa 1980). So therapy is about the process of trying
to understand the client, but not always getting it right.
It is important for all inexperienced therapists to receive regular supervision from
a therapist who is trained and experienced. This can be on a one-to-one basis or in
a small group setting. Psychotherapy cannot be learnt just from a manual. It is a
skill that is acquired through closely supervised practice. We recommend that all
psychotherapy sessions are audio recorded (provided the client gives permission –
usually in writing); that the therapist listens to all sessions of the therapy; and that
audio recordings of sessions are played for at least part of each supervision ses-
sion as they provide a clear focus on the experience of the therapy and the inter-
actions between the therapist and client. The atmosphere of supervision should
be collegial and not hierarchical, with the more experienced therapist acting as
supervisor; providing a form of ‘scaffolding’ to help the therapist gain understand-
ing and perspective as effectively as possible. In a group setting the other thera-
pists in training, when adding their perspective, can not only assist the therapist
presenting but also internalise the model using a different form of learning.
The first five minutes

A lot can happen in the first five minutes of therapy. It will involve the initial
greeting of the client and a meeting of two people, previously unknown to
each other. Hobson noted the importance of the initial handshake or greeting,
noting the information held in the type of handshake offered by the client.
Although small, his point was simple: a handshake or greeting is one of the
initial contributions to the conversation, a minute particular, which provides
information for the therapist within the initial few seconds of meeting.
The therapist may have received detailed information about the client in the
form of a referral letter, or there may be a therapy questionnaire that the client
has completed, or the therapist may know nothing at all about the client.
Hobson preferred not to have any prior information about the person he would
see as he would say, ‘I want to know them. I don’t want to know “about” them.’
He was also concerned that his judgement may be biased or altered by hearing
other people’s concerns about the person he was about to meet.
It is difficult for therapists to see clients without receiving information
about them and gathering information to help record any risks. However, the
main purpose of the first session is still for the therapist to try to know some-
thing of the client, rather than know a lot of things about him or her.
So, how to start a session? Try to put yourself in the position of the client,
waiting in a waiting room, feeling anxious, waiting to meet a ‘therapist/coun-
sellor’, maybe with all kinds of mixed-up thoughts and feelings about why
you are there. Never forget just how anxiety-provoking this may be. Make
sure when you greet your client for the first time you are warm, welcoming
and sincere. Say clearly who you are, greet them, with an offer to shake their
hand if that is culturally appropriate, and show them to your room. Try to
speak to them as you both walk to the room. Try to avoid a forbidding silence.
Be aware of anything and everything they do or say. Therapy has already
begun. It is your job to look after your client. This involves making sure they
are seated in a comfortable fashion, their belongings are safe, their coat is
hanging up, you won’t be disturbed, the room is conducive to disclosure and
intimacy. That is, ensure there is no harsh or flickering fluorescent lighting,
chairs placed at an angle to each other so that making and breaking eye contact
is natural, they have water and tissues available, and they can see a clock.
Identifying shared sight of a clock is crucial – it is not a device to have behind
the client so that only the therapist can see it. If the client cannot see the time
and is too anxious to make overt use of their own watch, then at best their
attention will be distracted and at worse they will feel lost in time. The aim of
the therapist is to put all of your energy and empathy towards trying to under-
stand and help the client in the next 50 minutes such that they feel able to
return for the next session.
The audio recorder and supervision
Your client may have already been informed that the sessions will be audio
recorded, either at their psychotherapy assessment or during the referral pro-
cess, or they may know nothing. You need to explain the purpose of recording
the sessions, how you will safeguard the client’s identity and personal infor-
mation, who will have access to the recordings and how the recordings will be
stored securely. You will also need to obtain signed consent in most settings,
and we think this is good practice. You will also need to inform the client
about whatever supervision is in place.
It is our experience that the vast majority of people do not have a problem with
the sessions being audio recorded or with the therapist receiving supervision.
However, the example below is of a client who does have some initial misgivings.
Box 7.2 Explaining audio recording and

gaining consent
THERAPIST: Before we go any further, I must explain the recorder. As you can see
there’s a machine here and a microphone. I will use this to record our
sessions. It’s normal and good practice in psychotherapy. It enables
me to listen to the time we have spent together again, to see if there
are things I have missed,…and it generally helps me to be able to
help you…a bit more. I also meet with three colleagues for what’s
called supervision, where we discuss the clients we are seeing and I
may play parts of the tape, if I think it will be of help. My colleagues
will not know your name or be given any information that would iden-
tify you. I’d like to stress again that this is good practice and it’s like
quality control. I realise it’s quite a bit to take in…
CLIENT: It’s a bit off-putting. Who are these colleagues?
THERAPIST: Yes…it is off-putting…but most people settle and get used to it…but
for this treatment…important I spend time…to our discussions…
as well as meeting with you. The colleagues…there are three of
them…they are all psychotherapists/counsellors. They all work in
this department. If you want their names, I’m happy to tell you.
CLIENT: Umh…what happens to the recordings.
THERAPIST: Recordings are password protected [include the employing organ-
isation’s policies], and I use a code to identify them, so no one
knows your identity. At the end of the therapy, I will erase them…
or…well sometimes…people ask for them…and if you wanted
them…we could talk about that. Also…sometimes…people like to
listen to the sessions themselves…and again we could talk about
that…if you wanted.
CLIENT: I’m not sure…if I would want to do that.
THERAPIST: No…ok….do you have any other questions…anything else you are
not sure about?
CLIENT: No.
THERAPIST: Ok…I need to ask you to sign a consent form. This states that I have
explained all those things to you and that you consent to it?
CLIENT: What would happen if I didn’t give consent.
THERAPIST: That would be ok, we would still meet, but I wouldn’t be able to listen
to the sessions…and in this kind of treatment…that’s quite an impor-
tant part…You sound as if you are not sure.
CLIENT: No…I am ok with it…it makes sense.
As you will see from the above transcript, clients may sometimes want to listen
to sessions themselves. In most circumstances, in brief therapy, we think this is
helpful and it can result in some significant steps forward. It is, however, impor-
tant to discuss each arrangement regarding recording in supervision before any
agreement is reached. There may be a variety of reasons why the client asks for
recordings of the sessions and it is important in PI therapy to try to understand
the reasons underlying the client’s request. Is it that the client is frightened of
missing something? Are there hidden reasons why the client may want to have
recordings? What will the client do with the recordings?
Whilst there may be some concerns that the client may over-analyse por-
tions of the therapy, or focus on one small fragment of conversation, which
may or may not be helpful, the likely benefits probably outweigh any potential
harm. In the health sphere, it is becoming more common for patients to record
their contacts with doctors, and all therapists should be mindful that it is pos-
sible with modern technology for any client to audio record any session of
therapy. This is a relatively under-researched area of therapy, and all cases are
different. What is important is that any variation from the normal practice
should be carefully thought about and discussed in supervision.
Settling in
The client has had a lot to deal with in the first few moments of meeting. He/she
has sat down in a strange room, with a stranger, and most likely with an audio
recorder. How might the therapist respond to this situation? An example is shown
in Box 7.3.
Box 7.3 Settling in

THERAPIST: I reckon it all feels a bit strange…to come here…see someone…
like me…and the recorder…
A statement as in Box 7.3 often helps to ease anxiety and help settle the client
so he or she can relax a little better. This step is crucial as it is not helpful to
expect people to talk about themselves if they feel ill at ease and wary. Many
people are very fearful of seeking therapeutic help. They may feel they have
been told to come by their doctor, they may not see any value to it, or they
may be quite hopeful it will be of help. A statement like the one above allows
these things to be openly discussed. The therapist should be making every
effort to tune in to how the client is behaving and feeling in these opening
moments, via verbal and non-verbal cues.
The problem
In this model of therapy, we start with the client’s main problem and try to
get a shared understanding of the client’s experience. At this stage we are not
interested in facts about the problem such as how long it has been troubling
the client or when it started. We want to focus on the problem (i.e. the expe-
rience) itself. The problem may be any of the following: an intense worry
about something, a headache that won’t go away, dizzy spells, feeling low,
chronic tummy pains, a recent self-harm episode, no energy, etc. Whatever the
problem, the job of the therapist is to stay with the problem and explore it.
Box 7.4 Focusing on the problem

THERAPIST: It’s not easy to begin; some things are difficult to put into words.
Perhaps we could start if you could say something about what you
would most like help with…right now. [Emphasise this word]
Features of the model that help the therapist explore the nature of the problem
include: making statements, understanding hypotheses, ‘here and now’, negoti-
ating style, and using ‘I’ and ‘we’ as discussed in earlier chapters. Box 7.5 is an
example from the beginning of a therapy session.
Box 7.5 The first five minutes of a therapy

session
[Note: Bracketed, italic text indicates the model competencies.]
CLIENT: I hope I can answer your questions.
THERAPIST: Umh.
CLIENT: I hope I can answer your questions.
THERAPIST: Well we’ll go into that shortly…it’s not so much what I want to
know but I’m hoping to help you say the things you want to say…
[Statement]
CLIENT: Sometimes I can, but sometimes I can be…lost for words.
THERAPIST: So can I. We all can… When we are talking about things like feelings
it’s very hard to put words onto them. [I and we; Statement]
CLIENT: Yes…it’s hard to let go.
THERAPIST: I suggest we settle down a bit first.
CLIENT: Yes…
THERAPIST: I can imagine…you’re pretty much on edge…[Understanding
hypothesis]
(Continued)
(Continued)
CLIENT: Umh…all the time…more so now…

THERAPIST: It’s a strange situation…we’ll have 45 minutes, so we’ll finish on the
hour. There’s a clock on the side so you can see the time, so you
know how long we have so you won’t be left high and dry…But let’s
look if we can have a look at how you are now…you said it’s how you
normally feel but a bit more so…[Focus on feelings]
CLIENT: No I can get worse than I am now…I’m not too bad now, considering
what I’m doing…everything seems to hit me later on unless I try to
block it out completely…Even a telephone call…will hit me later…but
even now I’m just trying to really block it all out.
THERAPIST: I suppose what you’re saying is…Look what happens here might
be all very well but it might hit me when I get outside that door.
[Understanding hypothesis]
CLIENT: It will hit me…er…oh I’ll give you another example. If I hear some-
thing upsetting, I’ll just try and block it out. I don’t know how to
explain it.
THERAPIST: But it might happen if you discover something about you…it might hit
you afterwards. So you are saying it’s up to me, and it is in a way, to
have that in mind. [Understanding hypothesis]
CLIENT: Yes…umh…
THERAPIST: But in this interview you don’t have to put things in the right way…we
can wander around…
CLIENT: I’ll tend to do that to you. Sometimes I get straight to the point.
Sometimes I can’t answer at all. I say what I think. Sometimes I can’t
say anything at all.
THERAPIST: I would like to start if you could say something about what you would
most like help with right now. [Focus on feelings]
CLIENT: Right now.
THERAPIST: Right now, here and in your life at the moment. [Focus on feelings]
CLIENT: I’ve got that much tension, stuff inside my brain…when I start to
have a fainting or a dizzy spell or go off balance…that frustrates me
a lot. I want that to stop.
THERAPIST: Well let us stay with that…I’m not sure I heard all your words…(yes)
but I heard the word at the end ‘off balance’. [Focus on feelings,
Therapist picks up a potential ‘Living Symbol’]
CLIENT: Off balance…I get this off-balance feeling…I start to feel uneasy…
it could get worse than that…I have lost my balance completely for
nine months.
THERAPIST: And fall down? [Understanding hypothesis]
CLIENT: I don’t let it get to that stage, because I sit down before that happens
or it completely changes…I…er get faint but I don’t go right out to
it…I have all the symptoms of faint, I feel numb, horrible but I don’t
completely go out to it. That’s another side to me…I get quite a few
different symptoms.
THERAPIST: Umh…
CLIENT: Umh…That’s just one side of me…but the symptoms irritate me,
I’ve got a few phobias but these symptoms irritate me a lot.
THERAPIST: Umh…well perhaps we could stay with this. [Focus on feelings]
CLIENT: All right.
THERAPIST: The feeling as far as I’ve got it so far [right] …you might feel faint
[yes], you might feel unsure of yourself…with this comes a fear?
CLIENT: Yes it is a fear, yes.
THERAPIST: That you might fall? [Understanding hypothesis]
CLIENT: Yes, yes, because you feel that off balance…you know…I suppose it
comes down to I might fall, yes right and I don’t want to fall.
THERAPIST: We can talk can’t we about off balance…we can talk about it in a
bodily way like falling down or we can talk about the balance of the
mind and you might be also scared that somehow that you can’t get
your thoughts in order. [Beginning of an explanatory hypothesis]
CLIENT: The thoughts…how can I explain that…when I do feel like that I feel
uneasy and I don’t know what to…and if I’m laying down I don’t feel
safe at all.
THERAPIST: Not safe? [Focus on feeling]
CLIENT: No, I’d not feel safe at all. I like to know my feet are touching the ground
(sits with feet on ground and holds chair with both hands). I like to be
firm. So I what I do is sit very still and I hope I don’t have to lay down
and if I do have to lie down I can only lay on one side. This side here
[indicating left side] is completely out…I have to lie on this right side.
THERAPIST: If you lie on your left side? [Indicates left side]
CLIENT: No if I lie on my right I feel a lot safer than if I lie on my left.
THERAPIST: If you lie on your left? [Mirrors actions of client]
CLIENT: I don’t feel safe at all. Especially when things like that happen to
me……You’re going to ask me why.
THERAPIST: No I’m not…I’m not…I’m wondering if you get any different sensa-
tions from the different sides. [Focus on feeling]
(Continued)
(Continued)
CLIENT: Yes I do. [Sits forward] I feel I’ve got full control of this side of my
body [points to right side] [therapist leans forward]. This side here
[gestures to left side] seems to be a lot weaker. Yes even sitting
here now I can feel I’m a lot stronger in this half of me. This side
of me just follows, it’s useless. For some reason…I feel…I mean…
everything works.
THERAPIST: Umh.
CLIENT: And the balance feeling, even when I lie in bed I’m so tired by lying
on this side [left side] I turn over…like everybody does…and I start
to feel sick and very uneasy so I quickly have to turn back.
THERAPIST: Are you right handed?
CLIENT: Yes. I am right handed. That confuses me.
THERAPIST: Umm…ummh…Umm…your left side…sounds to me if it’s a more…
sort of unknown side. [Understanding hypothesis]
CLIENT: It is an unknown side. You’re right.
THERAPIST: Do you know we sometimes speak of the sinister side of ourselves
as at the left side, as if it’s dark and unknown. [Beginning of an
explanatory hypothesis]
CLIENT: Right…for example just before I came in I was just mucking about…
don’t know why…because I tend to be on the serious side because
I’ve been ill for so long and I threw my leg up [lifts right leg] and this
leg goes up quite all right but this leg [pointing to left leg] I couldn’t
get it as high…no matter how much I tried. I don’t know if that’s unu-
sual. [Therapist mirrors client’s movements with his legs as though
trying out how it feels]
THERAPIST: Umh…I’m not sure if you are scared whether there might be some-
thing really wrong with your body or not.
CLIENT: I’m very confused at this point. I keep saying to myself there has to
be something wrong for me to be like this. And they say to me. ‘It’s
all nerves. You’re unhappy.’ But would unhappiness do all this to me.
I’m very confused. And no one seems to be giving me any answers.
THERAPIST: Well let’s see if we can get at least an approach…we’re not going to
get the answer…But at least we might look at what things we might
explore. Yeah? [Beginning of exploratory therapy rationale]
The example in Box 7.5 illustrates how hard the therapist works to explore
and stay with the main problem by focusing on feelings. In this case the
client uses the term ‘off balance’. The therapist picks this up. The feeling is
associated with a fear of falling. This moves to a feeling of not being safe.
The client then describes this unusual experience of not feeling safe if she
lies on her left side. She then describes a weakness on her left side. The
therapist suggests the left side of her is ‘unknown’. The client agrees. There
is a stepwise movement occurring between the therapist and client as the
problem is explored. The therapist draws on some theoretical knowledge
about the left being the ‘sinister’ side, but that is not picked up by the client
and not pursued further.
The first five minutes of a session of therapy often contain key interactions
between the therapist and client, which will resonate throughout the whole
therapeutic endeavour. There are many interesting and revealing exchanges in
the above example, which would merit lengthy discussion and consideration in
supervision. Of most importance is that the client has felt understood and that
her symptoms have been taken seriously. There are the beginnings of a thera-
peutic bond and a collaboration to try to explore her problems in more detail.
Plan of treatment
It is the therapist’s task always to be aware of the time and to structure the
time accordingly. Towards the end of the first session, the therapist should try
to draw together the experiences that have been shared with the client in the
first session and if possible develop an exploratory therapy rationale (an example
of this has already been given in Chapter 6).
The therapist should set out a plan of meetings over the next few weeks. If
it is a very brief therapy (e.g. four sessions) it is best to set dates for each of the
meetings so the client is clear about the planned meetings. If the therapy is 16
sessions, then the therapist should give an approximate estimate of the likely
finish point (for example, ‘So we will meet for 16 sessions, so we will probably
finish some time in July.’).
Finally it is helpful to end the first session by saying something warm and
positive about the meeting. This must be spoken from the heart, so it is best
only to say something if it is genuinely meant: ‘Well…it’s been very nice to meet
with you…I think we’ve made a start…I will look forward to seeing you again.’
Linking symptoms to interpersonal difficulties

The aim of the initial sessions is to continue to develop the conversation in a
similar fashion to the first session. By tentatively suggesting hypotheses, the
therapist is hoping to promote dialogue, a dialogue involving inner feelings,
and a sharing of experiences from which meanings begin to form and links to
relationships emerge. There is a repeated process of sequencing of events (see
Chapters 1 and 6) so that patterns and forms emerge. Warded-off or avoided
feelings begin to be tolerated and with that comes new possibilities of chang-
ing previous maladaptive patterns of behaviour.
During this process the therapist will learn a lot about the client’s symp-
tom history and interpersonal relationships. The about, however, is not as
important as what is experienced and brought alive in the session. In the next
example in Box 7.6 the client is talking about problems with her husband and
particularly the difficulties she has getting on with her stepson. The therapist
focuses on her feelings and by doing this she is able to disclose the hatred
she feels for him and her fears that he will think she is a monster. This exam-
ple is from a session with the same client as discussed previously who had
feelings of being ‘off balance’. At the end of the section in Box 7.6, the ther-
apist makes a link between her feelings of hatred for her stepson and her
feelings of being ‘off balance’. He is using the term to denote both physical
feelings and off balance as in emotional balance.
Box 7.6 Link symptoms to interpersonal

difficulties
THERAPIST: And you said earlier that your husband didn’t understand you.
CLIENT: No, but he didn’t want to.
THERAPIST: I mean there are a lot of problems between you two.
CLIENT: Yes because he’s said to me, if you treat my son better, I’ll treat you
better.
THERAPIST: Sounds to me as if he treats you badly.
CLIENT: He can do. He can be very nice but he can also be…treat me badly…
And I found he had got very distant…we because I can’t be nicer to
his son as he puts it. It’s his guilt not mine.
THERAPIST: Uh.
CLIENT: He said to me you are not a proper mother to him. Meaning loving
him. Oh I dress him and feed him.
THERAPIST: I suppose there must be…you haven’t got the sense of the feelings
for your stepson, as for the others. [Understanding hypothesis]
CLIENT: I haven’t. I can admit it to you.
THERAPIST: To me. [I and we]
CLIENT: Yes to you. But I couldn’t say it to my husband as he would just pick
up and walk out, and use that as an excuse.
THERAPIST: Uh.
CLIENT: And use that as an excuse. He knows deep down that there is some-
thing there. I do feed him, dress him very well. I do a lot of things for
him but he hates the fact I don’t love him. He expected me to love
him from the word go and I’m not the type of person like that – I need
time. I don’t like to be pushed…so things got a lot worse.
THERAPIST: I was wondering whether sometimes you get worried about your feel-
ings about your stepson. [Focus on feelings]
CLIENT: I do.
THERAPIST: I mean, I wonder if you get mad with him sometimes. [Focus on
feelings]
CLIENT: I do…I do all of the time. I won’t deny it. I’m angry with him all the
time.
THERAPIST: Yes well…let us have a look at that. [Sits forward. Uses hands to
gesture a focus]. Stay with that (…all right…). You feel your husband
doesn’t understand and you were scared when you came in here that
I wouldn’t understand. [Linking hypothesis]
CLIENT: No…ok I accept…
THERAPIST: Now you sound as if you have to reassure me a bit. The thing is not
to give me what you think I want but for me to try to understand what
you are feeling. Now you say you feel angry with him the whole time.
CLIENT: Yes I blame him…because I’m blaming a child but I should blame my
husband really which I’ll do but I can forgive my husband when…he
is nice to me, but I can’t forgive my stepson.
THERAPIST: Because it’s really his fault? [Understanding hypothesis]
CLIENT: I blame my stepson yes…very much because he did come into my life
and my life did go down from that point. I wasn’t that healthy before that
but I could cope with a lot of things. But I wasn’t on tablets but I feel
he has changed my life completely for the worst. Not for the better. For
the worst. I do have a strong hatred for him. But I wouldn’t hurt him. I
wouldn’t do that.
THERAPIST: No…I wasn’t saying that. We’re staying with the feeling. [Focus on
feeling]
CLIENT: That is the feeling.
THERAPIST: And you…you feel…you get mad with him. [Focus on feeling]
CLIENT: I do now but at first I didn’t – he used to walk all over me and I didn’t
like that at all. I do feel awful afterwards.
THERAPIST: Could you say something about how you feel afterwards.
CLIENT: I feel guilty…I think he must feel I am a monster but I don’t feel that
at the time. At the time I don’t care because I am so angry.
THERAPIST: You feel that he must feel that you are a monster. [Understanding
hypothesis]
CLIENT: Yes…yes I do feel guilty that when he grows up and looks back he’s
going to really hate me. It does worry me. But as soon as I see him I
start getting very bitter.
(Continued)
(Continued)
THERAPIST: It isn’t easy is it to be hated or to hate. [Understanding hypothesis]
CLIENT: No.
THERAPIST: But it’s very strong…isn’t it. [Focus on feeling]
CLIENT: Very strong. I’ve tried to be nice but I can’t. The less I say to him the
better it is for me.
THERAPIST: And as I hear it there are times when you almost feel that he’s
responsible for your troubles…For your being off balance. [Beginning
of explanatory hypothesis]
CLIENT: I’ve never been right…since then. I’ve never been well.
This interview is the start of an exploration of her symptoms and the links to
her conflictual feelings about her stepson and her husband.
The therapeutic alliance

The strength of the bond between the client and therapist is an important
determinant of the overall outcome of therapy. Many of the individual compo-
nents of the PI model, if used competently, help foster a close bond between
the client and therapist. Negotiating, picking up cues, using a language of mutuality
and most of all sharing experience in a close and safe relationship strengthen the
therapeutic alliance. Therapists will get things slightly wrong, they will miss
certain cues, or they may push things slightly too far. What is important is that
therapists recognise these mistakes, acknowledge them and work hard to cor-
rect them – the correction of misunderstandings – in order to re-adjust and
re-align themselves with the client. The mistakes should not be catastrophic as,
within the model, we are looking for small steps forward. Suggestions made in
a tentative manner can be corrected, withdrawn, re-worded, and re-fashioned
if they are not helpful.
The theoretical model and formulation

Chapter 1 described the theoretical background to the model, which is rooted
in the domain of the interpersonal. The main approach involves helping the
client to find ways to manage and share warded off feelings and difficulties.
This involves developing a ‘feeling language’, a way of conversing which
allows feelings to be brought alive and images, memories, symbols to be
shared with the therapist.
There are differing approaches to formulation among experienced thera-

pists using this model. We would suggest that what is important is that there
is a shared understanding between the therapist and client as to what is the
main problems are, and how this can be addressed in therapy. Formulations
are important as all people strive to make sense of themselves and their lives.
The priority in PI therapy, however, is that the formulation arises from the
shared feeling between the client and therapist and not from an intellectual
process. In PI therapy the formulations that develop have a tendency to start
as micro in scale in that they arise from a focus on the minute particulars. These
micro understandings are slowly brought together so the client forms a more
coherent meta-understanding of his/her self. One can liken this process per-
haps to seeing a painting close up. You see only the brush strokes and parts of
an image. These small parts may begin to form a kind of patchwork with more
and more pieces linking together until finally you appreciate the whole can-
vas. Even when the canvas is seen as a whole, it is multi-layered and complex,
from which shifting meanings and emotions emerge. What is of most impor-
tance in this process of understanding or model forming is not the eventual
model alone, but how it was developed.
Through this process a working model begins to be shared with the client
and the development of this early constellation of ideas has a function that is
broadly similar to a formulation. It can be written down, as we show later in
the chapter, but its primary function is not intended to be a static statement
of how things are but a tentative working version from which therapist and
client can move forward.
There has been a lot of discussion across relational therapies about how
change comes about. Work with the assimilation model suggests assimilation
of warded-off experiences result in a change in the self that becomes more
cohesive and coherent. When PI therapy is used in an intensive long-term
format, there is much greater focus upon the self, but even in brief therapy,
changes to the self frequently occur. Theoretical constructs in relation to the
self and the role of PI therapy in reparative treatment of the self are dis-
cussed further by Meares (2012b). The assimilation model (Stiles et al., 1990)
suggests that the repetitive cycling through problems gradually allowing a
deeper understanding is characteristic of this type of relational learning
where warded-off experiences gradually emerge into awareness in a painful
way and then are gradually processed until the client finds tentative solu-
tions and eventually mastery of the difficulty.
Using the examples in Boxes 7.5 and 7.6 we demonstrate how the fragments
can be pulled together to form a more working formulation. The client and
therapist begin to develop a series of micro-models:
zz The client describes a coping strategy of trying to block out things she
finds upsetting.
zz A link is made between a physical feeling of being ‘off balance’ and a fear
of falling.
zz There are ‘two sides’ to the client in her experience and the several possi-
ble meanings of this phrase are held in mind.
zz The left side is an unknown and unsafe side.
zz The client describes two ways in which her husband treats her (nicely and
badly).
zz The client feels her husband doesn’t understand her. There is a possible link
to a fear that the therapist may not understand her either.
zz The client finds it difficult to love her stepson; more than that, she hates
him and treats him badly and fears that he will think she is a monster.
zz There may be a link between her problems with symptoms and the prob-
lematic feelings she has for her stepson.
zz She has begun to get in touch with feelings that normally she would try to
block out – like hatred for her stepson – while in the session with the
therapist.
As the therapy progresses, more pieces of the jigsaw will be added, so a more
coherent overall picture is realised. The therapist draws together some of the
micro models into a larger model when developing an exploratory rationale. In
the example discussed, the therapist goes on to draw a connection between the
client’s physical symptoms of shutting down and a fear of losing control and
becoming very angry. He draws a connection between her body and mind, and
suggests that just as the left side of her body feels ‘unknown’ to her, there is
a side of her mind that is also unknown. He suggests this dark side could con-
tain frightening things, feelings she cannot face. He also suggests, in keeping
with the model, that it is more important to get in touch with ‘these difficult
feelings’ so they are no longer warded off, than it is to have an intellectual
explanation about her symptoms or feelings.
One perhaps can see how many of the above micro-models may coalesce
together to form a coherent story about this client’s life. There is a persistent
theme of opposites – good and bad: her father and husband are both described
as loving and angry people. The client describes herself as having two sides.
A memory from childhood, which the client talks about later in the therapy,
becomes very important. She remembers the first time she felt ‘off balance’
was when her normally loving mother became unexpectedly and inexplicably
angry with her (see Box 7.5). Her mother had returned home from hospital,
after giving birth to a new baby. The client described that her mother was
seated in the living room of their house, surrounded by family, with the new
baby on her lap. The client remembered entering the room and immediately
sensing that she was not wanted and that her mother was angry with her. She
was thrown ‘off balance’. The feeling of ‘off balance’ now came to be under-
stood as being linked to this key event, when the client felt shocked by her
mother’s anger, and she felt that she was not wanted, and that the new baby
was preferred to her.
Maybe the client felt she was no longer loved? Maybe she shut off from
this sense of loss in relation to her mother, and her consequent anger about
being abandoned? Maybe she coped by pushing feelings out of awareness,
creating an experience of having ‘two sides’ to herself? Maybe this way of

coping worked until the client married and she then had to care for his
child? She, once again, had to face a ‘new child’ – her stepson – coming into
the home. The parallels between this situation and the scenario she
described as a child when her mother brought home a new baby are quite
striking.
There were many more interweaving links and patterns in the above ther-
apy, particularly ones involving feeling rejected and angry, and the client’s
tendency to try to please people to avoid any forms of confrontation, or any
possibility that would lead to anger.
As the conversation developed, the sense of coherence became stronger and
the requirement for feelings and fears to be warded off became less strong.
Perhaps what is most important is that the client experienced a change in the
experience of self. Her previously unknown, uncontrollable left side that
caused her to be off balance began to be seen as an aspect of herself. What
was dark and unknown and sinister has begun to be known and assimilated
as the experience of self has been enlarged.
The ‘alive’ problem in the room

In the PI model, ‘the problem’ should be manifest in the room at any point in
the therapy. By this we mean that the main problems or difficulties the client
is experiencing will inevitably be re-enacted in the relationship with the thera-
pist. This may only be evident in very subtle ways, or it may be prominent and
overt. Audio recordings of the therapy, which are played in supervision, can
help the therapist and supervisor identify ‘the problem in the room’ and this
should theoretically fit with the micro-models the therapist is developing with
the client.
In the example in Box 7.5, the client’s first words to the therapist are, ‘I
hope I can answer your questions’, which she then repeats. She then goes on
to say, ‘No I can get worse than I am now…I’m not too bad now, considering
what I’m doing…everything seems to hit me later on unless I try to block it
out completely…Even a telephone call…will hit me later…but even now I’m
just trying to really block it all out.’
We can now see that right at the very beginning of this therapy, the client
is showing that she is trying to be helpful to the therapist, to possibly avoid
any kind of conflict. The client also talks about having to block things out
completely or they ‘hit her’. This phrase can now be understood as being a
living symbol. Not only does it mean that things will jump out at her unex-
pectedly, but also that there is a suggestion of violence in the words that she
has chosen to use.
Any section of therapy can be used in this fashion for micro study, but the
first few minutes of therapy are often very illuminating because of the increased
anxiety that is present in any new encounter and it is well worth spending an
additional period of time, in micro study of these early interactions.
Summary
This chapter has discussed the initial sessions of a brief PI therapy, with
examples to illustrate specific points. Although the model focuses upon the
relationship between therapist and client, structure is very important as it
provides elements of order, safety, reliability and containment. By the end of
the first phase of therapy there should be a ‘working model’ or formulation
to build upon, and refine over the next phase. The following chapter will
discuss the intermediate sessions of PI therapy.
8
The Intermediate
Sessions
Introduction
This chapter focuses on the middle sessions of a brief course of psychodynamic-
interpersonal therapy. By this point, the client and therapist will have agreed
an area to work on together and they will have discussed a provisional explor-
atory rationale and preliminary working model. As emphasised earlier,
although models are important in helping individual clients develop a sense
of meaning and coherence, in PI therapy the greatest emphasis is placed on
the process of developing a shared model rather than the specific model itself.
Below are the seven key aspects of the middle phase of PI therapy. They
often occur interchangeably and simultaneously and in some respects it is
somewhat artificial to split them into separate entities. However, for the pur-
posed of a manual, it is easier to describe each aspect separately.
1. Active exploration of the problem

2. Attending to moments of change
3. Testing solutions
4. Building an explanatory model
5. Passivity to activity
6. Deepening of a feeling language
7. Personal conversation and symbolic transformation
1. Active exploration of the problem

The middle sessions of therapy enable the therapist and client to actively explore
the problem area. The model assumes that one of the most common problems
in connecting with others involves approach–avoidance conflict. The client
wants to be closer to people but at the same time fears being close. Avoidance
is constantly present and is manifest by talking about problems in an abstract
jam-jar language. The therapist can reinforce this avoidance by talking ‘about’
the difficulties and so avoiding exploration of them.
Box 8.1 Client and therapist using abstract

(jam-jar) language
CLIENT: I think my mother never really loved my father. She picked him because
she thought he’d be a good father, but she never showed any affection
towards him and basically just treated him like part of the furniture. She
always told us to mistrust feelings about people and think with your
head. She thought love was a silly emotion and people who fell in love
were idiots. I remember her criticising a friend of mine. She was 16 at
the time and had a boyfriend. My mum thought it was dreadful. She went
on and on about what a slut my friend was. It was the same with things
on TV. She would rubbish any films in which there were people who fell
in love. She just thought the whole thing was stupid. She didn’t get it.
THERAPIST: So she was quite judgemental and critical when it came to love.
In the example in Box 8.1 the therapist continues the conversation with the
client about the client’s mother. A more appropriate response in PI therapy
would be for the therapist to try to focus on the client’s feelings about her
mother. The therapist could have said something like, ‘When you describe
how your mother behaved, you sound…a bit annoyed…I’m not sure’.
Exploring a difficult problem involves developing a capacity to tolerate anxiety
and stress and to stand in ‘mysteries, uncertainties, and doubts’ (Hobson, 1985:
185). The ideal is a situation of relative safety in which frank and open conver-
sation can develop. Of course, it is unrealistic for the conversation always to be
in the here and now as the intensity of the therapy would be too great. However,
in some therapies most of the conversation between therapist and client may be
‘about’ something, rather than experiencing feelings in the ‘here and now’. A
balance between exploration and experiencing in the ‘here and now’ with time
to process and assimilate this kind of experiencing is the ideal scenario.
As discussed in the previous chapter, ‘the problem’ will be alive and enacted
in the therapy room between the client and therapist, even if it is not overtly
acknowledged by the therapist or owned by the client. In the example in Box 8.1,
the client is ostensibly talking about her mother as someone who mistrusted
feelings and thought with her head. She describes her mother denigrating a
teenage friend of the client’s for having loving feelings towards her boyfriend.
The Intermediate Sessions 109
As the client describes this event from her childhood, she is detached and
out of touch with her own feelings, and she uses jam-jar language. The cli-
ent’s problem is being enacted in the room and we can hypothesise that the
client may be having difficulty in feeling close to the therapist, as such
feelings will be inextricably linked to shame and humiliation (and possibly
other as yet unknown feelings). The focus of therapy will be to help the client
to connect and trust with feelings of closeness towards the therapist (and
key others in the client’s life), and to overcome the barriers to this, which
are so self-evidently present in the example shown. By actually tackling the
problem head on in therapy it is often easier then for clients to generalise
their experiences to scenarios and relationships in their own lives.
If we look at Box 8.1 again, we can also see that the client talks about her
mother not loving her father, and the inference from this is that the client may
also have felt unloved by her mother and the product of a loveless union. The
therapist in the first example responds to the client by using jam-jar language,
the language of the client’s mother: The language of reason and of the mind.
Even though we are focusing on only one response by the therapist, by staying
away from feelings, we can argue that in a micro sense, the therapist has inad-
vertently played the role of the client’s mother.
If the therapist responds using an intervention that picks up feelings, ‘When
you described how your mother felt…you sounded a bit annoyed’, this not
only brings feelings into the here and now, but at a micro level it is actually
tackling the client’s ‘problem’. The therapist is in effect saying to the client,
‘look feelings are actually really important and it’s really important that we try
to share them or something of them, rather than doing what your mother did
which was to rubbish, avoid and belittle them’.
2. Attending to moments of change

Growth or change in therapy occurs gradually as safety and trust are built up
between client and therapist. Change, however, can also occur through steps –
moments of insight, when something new happens. It is important that the
therapist is attuned and alive to these moments as they are important to build
upon, and if recognised can represent pivotal points of change.
Box 8.2 Example of a moment of change

CLIENT: I went for a walk at the weekend with the dogs. I should have known.
Got to the park and sat on a bench for a few minutes, then this mad
thing came careering over from nowhere and started a fight with Bliss
and then Mason joined in. I should have known. I had to drag my two
away and eventually it ran off. But I wish I’d never bothered. The idiots
round me don’t give a **** about their dogs. Just let them run wild.
(Continued)
(Continued)
Anyway, I thought, *** you, I’m going to let my dogs have a walk…so I
stayed out with them…and fortunately nothing else happened.
THERAPIST: As you were telling me this, I was trying to remember how long it’s
been since you went to the park.
CLIENT: Months…it was last year.
THERAPIST: You were anticipating that something bad was going to happen.
CLIENT: Yes…it always does.
THERAPIST: Yet you went out. You didn’t let it put you off and even when that dog
came over and attacked your dogs, you still didn’t let it put you off.
CLIENT: Well I thought about what you said last week…about being trapped…
feeling trapped. It’s partly in my own head…I mean I feel like I’m in a
prison…in my own house.
THERAPIST: What you did seems to me like a big thing…to go out…to try to
sort of break free a bit…and even though…you experienced all that
aggro…you stuck with it…
CLIENT: Umh…yes.
THERAPIST: And last week, with me…it sort of felt you had tried to break free a
bit…perhaps shared some things with me that you had not spoken
about before…or at least for a long time.
CLIENT: I knew you’d bring that up.
THERAPIST: Aarh…errr…Like you were worrying about us talking about it again…
CLIENT: Yes…and…no.
THERAPIST: It’s a very big thing for you…to share a secret…a secret like that. A
big thing…
CLIENT: I think I’m kinda pleased really.
THERAPIST: But…I wonder if you are also saying to me…look…go carefully…
I might feel hurt…or vulnerable…or got at.
CLIENT: Yes…
In the example in Box 8.2, the client had disclosed to the therapist that his
father abused him when he was a little boy and later he was raped when he
served a prison term for burglary. This represents a stepwise change in the
therapy as he had not disclosed such information before and indeed had not
been able to tell anyone previously about these experiences. There is a move
forward in the therapy and this is also mirrored by a change in the client’s
behaviour outside of therapy. He takes his dogs for a walk in the park. This is
something he has been unable to do for many months because of fears in
relation to going out and also low mood. The therapist acknowledges the step
forward he has made in a practical sense by daring to go out in the first place
and then coping with the dog attack when it occurred.
The therapist also realises the symbolic nature of the communication in that
the client is telling him a story about exposure, vulnerability and subsequent
attack. The therapist links this back into the therapy and the client’s feelings
of vulnerability following his disclosure the previous week. Moreover, the cli-
ent takes an extra step of indicating his conflicting feelings about disclosing and
together the client and therapist recognise the need to ‘pace’ things carefully.
Whenever change occurs in the course of brief therapy, it is important that the
therapist acknowledges it and provides support and positive feedback. If possible
clients should be encouraged to build upon changes, both within the sessions and
in their own lives. Where appropriate such changes can be linked to important
therapy conversations and moments of change as shown in the example above.
3. Testing solutions
As the problem becomes clearer and more and more pieces seem to fit together,
different ways of responding to feelings and events need to be tried out, both in
therapy and outside in the client’s world. Change is difficult for all of us, and the
therapist must understand how difficult it can be to change even small ways of
behaving and how tempting it is to fall back on routine patterns of avoidance.
In the example in Box 8.3, a different client has suffered from depression
and anxiety for several years. She is fearful of people and finds it easier to
avoid meeting people at all rather than have to interact with them socially.
Her father was a very severe, strict man who terrorised her when she was
little and she was also terrified of her teachers at school, who frequently used
the cane to punish children. Although she was never caned, because she was
always good, she lived in fear of punishment.
As the therapy has developed, the client has found it very difficult to stay
with feelings but at the same time has shown in a variety of ways that she
wants to please the therapist.
Box 8.3 Testing a solution

CLIENT: I try to think about the sessions…you know…in the week…and take
on board what you are saying…you know the advice you give.
THERAPIST: I’m not sure…errr…
CLIENT: Oh well…maybe it’s not advice…but I think about what you say…you
know I do try.
THERAPIST: Yes…I know you are trying…trying very hard…but I wonder if you feel
a bit wary of me at times…
(Continued)
(Continued)
CLIENT: I think you’ve been very nice to me.
THERAPIST: I wonder…although it feels as if you are trying very hard…I also

feel…er you feel…you seem…on edge.
CLIENT: No…not really.

THERAPIST: Umh..
CLIENT: I get terrible panics…downstairs…waiting to come up.
THERAPIST: When you are waiting to see me?

CLIENT: Yes…waves of panic and I just want to run away.
THERAPIST: Well…I wonder if you can get in touch with that feeling…as you felt it
this morning waiting to see me…but as if it’s happening now…and I
think it is…just a bit…
CLIENT: It’s awful…just dread…sickness…like I’m going to pass out.
THERAPIST: Like you’re going to faint…well…can you stay with that feeling…and see
what comes to mind.
CLIENT: It’s this awful feeling of waiting for my father to come home. Shaking
and trembling…trying to hide behind the sofa…hoping he won’t see
you.
THERAPIST: Try and stay with the feeling if you can.
CLIENT: It’s just scary…scared I’ll be shouted at again…hit again…terror…
praying he won’t see me…he’ll pick on my sister instead…[long
pause]…I hate him…absolutely hate him.
THERAPIST: Yes…and…
CLIENT: I would cheerfully kill him if he wasn’t already dead. All the pain and
misery he’s caused us…all the suffering and he didn’t suffer at all. I
hate him…he’s an absolute…
THERAPIST: Say it.
CLIENT: Bastard. He’s an absolute bastard.
Later in the session the therapist makes a link between the fear the client
experiences prior to seeing her (the therapist) and the generalised fear the
client has towards people, and the fear of her father. The therapist suggests
that one way of lessening the fear is to begin to try to face it, and points out
that the client has been brave enough to do that with her in the session. In
facing her fear, the client has also begun to get in touch with angry and
destructive feelings she harbours, and the hatred she feels for her father.
These feelings have previously been warded off. The therapist and client have
begun to test out possible solutions to her overwhelming fear and panic.
In another example, a client who has suffered from depression and anxiety for
many years has begun to explore and share her feelings in the session with the
therapist. She has always been a very submissive person who has found it diffi-
cult to challenge authority. She has been in an unhappy marriage for years and
is dominated by her husband, who she suspects has been having affairs through-
out their married life. She works full time, as does he, but she feels responsible
for carrying out all the household tasks, and he insists that the home is immac-
ulate. She has been frightened to challenge her husband in case he leaves her.
The therapist and client have explored her fears of abandonment through
the imagery of ‘having no anchor’. As a small child, her mother was intermit-
tently very ill (she had Crohn’s disease) and spent long periods in hospital.
During these times, the client had to live with various members of the family
(aunties and cousins) as her father did not feel he could work full time and
look after her as well.
An early memory from her childhood was one of coming home from school
when she was about seven years old to be told by her father that her mother
was ill again and she would have to stay with auntie. The feelings associated
with this memory were fear and dread at having to stay with auntie, who she
didn’t like, and also fears that her mum was going to die and she would never
see her again.
The client describes feeling empty inside and a terror of being alone. She
also begins to share with the therapist angry feelings about being dependent
upon her husband. She worries about the therapy ending and fears that she
will feel abandoned. She starts to be more assertive with her husband and
begins to take small measured steps towards redressing some of the imbalance
in their relationship. She faces the possibility he may leave her and begins to
wonder why she has been so frightened of this outcome. She begins to
acknowledge some of her strengths. In the relationship with the therapist
she is noticeably more alive, more connected with her inner self and more
connected with the therapist.
4. Building an explanatory model

As the therapy progresses, the client and therapist will continue to develop an
understanding of the problem. More and more links will be made between
symptoms, feelings and relationships. The therapist needs to hold together the
different threads as more and more pieces of the jigsaw are added. It can be
helpful for the therapist to summarise from time to time what has been shared
and discussed and to try to draw some of the threads together. This can be
done in the form of linking hypotheses, explanatory hypotheses, relating change to
therapy and patterns in relationships (see Chapters 5 and 6).
This process in itself can be a helpful learning experience for the client and
provides the basis for thinking about change. The therapist should also be
thinking about the end of therapy and the farewell letter (see next chapter) and
making notes about causal processes or aspects of the model that would be
appropriate to include in the letter.
Box 8.4 Building the model

THERAPIST: I suppose…the main thing we’ve shared is the difficulty you have in
trusting people. You immediately assume you will be treated badly
and we’ve talked about your hackles rising even before you meet
some in anticipation of how they are going to be.
CLIENT: That’s me all over. I’d rather get into a fight…cos I know I’ll win.
THERAPIST: …and it was hard to share things with me…one of things we’ve
talked about is how much initially you talked here, so there was no
space almost to feel anything…and the talking was like a big shield.
A big shield you held up against me. [Gesturing with hands]
CLIENT: Yes…I do that with everyone.
THERAPIST: But…in the last couple of weeks…you feel different with me…a bit
less guarded…you’ve talked about some important things…but then
gone away and worried that I wouldn’t want to see you again.
CLIENT: Why would you? No one wants to hear about shit do they? She didn’t
[meaning mother]. She didn’t care what he [father] was doing. She
didn’t care that we even had food. I had to go across the road to the
neighbours to ask if they had anything to eat because there’d be
nothing in the house. I’d even steal food if I could find it. I’d only be
eight years old.
THERAPIST: That’s an awful thing for a little boy to have to cope with and face.
There’s a kind of linkage however between some of these things…
how you were treated by your mum, how you had to fend for yourself
from an early age…how you expect people to hurt you…because
that’s how people treated you when you were little, and perhaps
how in someway…you’ve expected those things of me…to some
extent anyway…and you expect them of people who you meet in
everyday life…
CLIENT: I know it goes back to them…they screwed me up…[wry

smile]…when I was young…it didn’t matter. I was so hard…
I loved prison…It was safe and…people were scared of me…no one
messed with me…
THERAPIST: And being hard…tough…worked for a few years…kept these feelings

at bay…but it’s all kinda broken down…
CLIENT: Oh yeah…pack of cards…
THERAPIST: Well as we go on...perhaps we’ll return to these ideas…keep fitting

more things together…to try to make sense of things…the most
important thing I think…is for you to be able to face with me…
some of these deep fears…you kept at bay…for so long…behind
this front of being a really really hard man.
5. Passivity to activity
One of the most important tasks of the therapist is, by his/her responses, to pro-
mote a change from passivity to activity (Hobson, 1985: 189). By ‘activity’ Hobson
meant any kind of behaviour that was goal directed. This does not only refer to
outward observable movement but also to images, thoughts and emotions over
which the client takes ownership of, as opposed to feeling controlled by. The
emphasis is on moving from a state of passivity often experienced when distressed
or ill to an active state in which the client begins to use the word ‘I’. There is a
difference between someone who says, ‘the illness makes me angry’ to someone
who says, ‘I feel angry’. In this context illness can mean any psychological or
physical condition or combination of both regardless of the symptomatology.
Box 8.5 Example of passivity into activity

CLIENT: Ugh…It’s completely taken over my life. I don’t have a life anymore. I
used to be the life and soul of the party, bubbly, full of energy. Now it’s
just taken over. It just makes me feel so fed up. The pain is so bad in
the morning, I have to lie down. It just makes me feel utterly useless.
THERAPIST: Er…you’re feeling quite fed up now…as you speak. Can we try and
stay with how you are feeling…you feel as if you’ve lost a part of
yourself or who you are…
CLIENT: I…I’ve lost…who I used to be…I don’t feel like anything…like there’s
anything inside.
6. Deepening of a feeling language

Hobson used the term forms of feeling for his book about Conversational Model
therapy, or PI therapy as we now term it, in a very deliberate way. Hobson
drew on the work of Martin Buber who, when commenting on psychotherapy,
contrasted what he called ‘repair work’ with ‘the regeneration of an atrophied
personal centre’, the latter, he suggests, ‘can only be attained in the person–
person attitude of a partner, not by the consideration and examination of an
object’ (Buber, 1958: 133). Such a relationship involves a ‘feeling language’. The
term ‘feeling’ does not refer to a faculty of emotion as distinct from a faculty
of cognition. Rather feeling refers to a form of ‘emotional knowing’ or ‘imagi-
native, emotion influenced thinking’.
One of the key responsibilities of the therapist in the intermediate sessions
of therapy is to deepen the ‘feeling language’ between client and therapist.
This involves trying to stay with feelings and to explore and elaborate sym-
bolic images and metaphors. This is at the heart of PI therapy and is summa-
rised by Hobson (1985: xiii) as follows:
I am concerned with the centre, the basis, of my approach to psychotherapy: a devel-

oping relationship. What I say and do in therapy is aimed at promoting understanding:
a ‘conversation’, a meeting between two experiencing subjects (an I and a Thou), here
and now, in such a way that the learning can be effective in other relationships. If as I
believe, psychotherapy is a matter of promoting a personal dialogue, then we need to
know how to receive, express, and share feeling: how to learn a language of the heart
in its ‘minute particulars’.
This process is difficult to convey in a manual but we believe can be enhanced

by close scrutiny and rigorous attention to the audio recordings of therapy ses-
sions. It is by listening to the recordings that the therapist can ‘tune in’ to the
client, realise when he/she has failed to pick up cues, or responds in a way that
promotes a thinking ‘about’ rather than ‘sharing with’. Russell Meares has used
the term ‘empathic resonance’ and argues for a priority of value above meaning,
noting that a therapeutic approach that focuses on meaning will differ from that
which gives priority to value: ‘Privilege must be given to feeling tones and how
they arise in particular forms of relatedness’ (Meares, 2000: 75).
7. Personal conversation and symbolic

transformation
A central feature of PI therapy is the promotion of a symbolic attitude, a sort of
expectant waiting, for images, symbols, experiences to emerge from feeling states.
Emotional knowing rarely arises from logical thought processes, especially if
many unacceptable experiences, emotions and thoughts are warded off. Symbols
and metaphor provide a means for visualising the inner world (Meares, 2000:
125). This process of symbolic attention occurs in the context of an interpersonal
relationship and involves a sense of transformative looking which creates new
symbols and new understandings. The whole process involves an assimilation of
previously warded-off experience with a resultant change in the self.
It is important that the therapist listens out for key phrases or ways of
describing experiences or symptoms that may have personal meaning for the
client. The more deeply and personally an individual describes their experi-
ences, the greater the likelihood they will use personal meaning language.
Language that not only describes their physical or emotional experience but
language that also contains symbolic imagery. Although many people may
meet the criteria for clinical depression, no two individuals who are suffering
from depression will describe their inner feeling state using the same lan-
guage, providing they are encouraged to stay with and explore that feeling
state by the therapist’s holding symbolic attitude.
The same is true for physical symptoms, such as physical pain. It is not that
the depression or the physical problem is not real. It is real and experienced
by the client. What we are seeking is the elaboration of the client’s feeling
state and through this some access to their inner world. For a more detailed
account of this process, see Moorey and Guthrie (2003). In this paper, the
authors describe the therapy of a client seen by Robert Hobson for three ses-
sions of treatment, termed two-plus-one therapy (Barkham and Hobson, 1989).
The client who is described in this paper has suffered from an extreme fear of
thunderstorms for most of her life. Initially she uses jam-jar language to describe
her fear and is disconnected from the fear itself. She actively avoids any reference
to thunder and states that she wishes she was deaf and blind so she would never
have to experience a thunderstorm again. As the session continues the client
becomes more and more afraid as it begins to get dark outside. Hobson offers to
move her chair so she does not have to face the window, which particularly
unnerves her, as the sky is darkening and she fears a storm is approaching. She
is appreciative of Hobson’s offer to re-position the chairs and her anxiety falls.
As Hobson gently explores her symptoms using understanding hypotheses,
and focusing on her feelings, there is a change in her language and she is able
to talk in a different way. She describes a nightmare of being alone in her
house and the house being struck by lightning. She talks about her anger with
her daughter-in-law for leaving her children alone, and at her daughter-in-
law’s boyfriend for threatening to send the children away. As the session con-
tinues the fear of thunder begins to be understood as a symbol, not an
absolute. It begins to undergo a process of symbolic transformation. The fear
is large but it begins to be understood as a fear of something that is ‘large and
destructive’ rather than only a fear of a thunderstorm itself.
The client recalls a memory from childhood of a time when her mother
accused her of eating some ‘best butter’. In the memory, the client denies it
and becomes angry and swears at her mother. The memory is jumbled, but
the sense from the memory is that the client felt she had done something
really awful. In the retelling, the client remembers being sent to court and
having to appear before a judge because she had sworn at her mother.
Hobson doesn’t try to make sense of the memory in a literal fashion but
focuses upon the feelings and fears conveyed by the story. He stays with the
client’s immediate experience and uses the symbolic material to identify the
underlying emotion; that she had done something ‘dreadful’, as if she had
attacked her mother. Hobson then uses an exploratory rationale to link
together her fear of thunder with previously warded-off fears about anger
and destructiveness. There is an assimilation of these experiences and a
change of self, with a subsequent reduction in her fear of thunderstorms.
Adopting a symbolic attitude means that the therapist must actively listen,
recognise and take account of living symbols. This involves listening out for
descriptions that convey personal meaning. Words like ‘off balance’ open up
the possibility of movement and exploration as opposed to ‘dizziness’, which
does not hold the same possibilities. To say ‘I am depressed’ conveys a gener-
alised feeling state, but to say ‘I feel as if a cloud has cast a dark shadow across
my soul’ conveys a deeply personal individual form of feeling, from which
movement and exploration can occur.
The same process occurs with individuals’ descriptions of physical symptoms.
Many people may suffer from abdominal symptoms such as abdominal pain and
distension plus an altered bowel habit and receive a diagnosis of irritable bowel
syndrome. No two people with irritable bowel syndrome, however, will describe
their experience in the same way, provided they are encouraged to describe their
experience in depth, to a therapist who adopts a symbolic attitude.
Below are two brief descriptions of individuals describing their bowel

symptoms in a therapeutic situation. Note how different the two descriptions
are and the living symbols and turn of phrases that make each account unique.
Box 8.6 Example of a client describing her

symptoms of irritable bowel syndrome (1)
CLIENT: It just comes away…I’ve no control over it…it’s so smelly and disgust-
ing…if I’m out, I’m so ashamed…I wait in the toilet until I think no one’s
in, and then I sneak out. I can’t trust myself to be out.
In the example in Box 8.6, the client is conveying more than a description of
her bowel symptoms, which are real and disabling. She is also conveying
personal meaning by the choice of words she uses to describe her experience.
She feels disconnected from herself and her gut is described as an ‘it’ over
which she has no influence or power. She feels isolated and ashamed and uses
two key phrases: ‘I wait in the toilet until no one’s in and then I sneak out’
and ‘I can’t trust myself to be out’. The former implies a sense of living in
shadows and the latter implies a fear perhaps of losing control. The exact
meaning of these words is not important. In fact there isn’t an exact meaning.
What is important is that they open up an avenue of exploration that leads to
the self and the possibility of a dialogue between the therapist and client
which feels alive.
Box 8.7 An example of a client describing her

symptoms of irritable bowel syndrome (2)
CLIENT: It starts with a sickly feeling…and then I know I’m in for trouble…all
my insides begin to turn over…I have to rush upstairs…and then I’m
in the loo for hours…no one else can get in…
As with the first example, the client in the example in Box 8.7 also views her
bowel as separate from herself – a thing. However, apart from this, the descrip-
tion is entirely different. Key phrases include ‘I know I’m in for trouble’ and
‘no one else can get in’. The former could imply many things but resonates with
the image of a child realising he/she is going to be punished or told off. The
latter is perhaps about keeping people away, shutting people out. The impor-
tant thing is not to find any ‘true’ meaning, but that they open up opportunities
to explore feeling states with the client and links to personal relationships.
Through symbolic transformation, conversations about both psychological and

physical symptoms can lead to conversations about warded-off feelings with
subsequent assimilation and change in the self.
Summary
In many respects the intermediate sessions are the most crucial in any brief
therapy as there is a real chance to build the relationship, which is an essential
feature of this model of treatment. There can be a tendency sometimes to
coast in the intermediate sessions as a lot of the work involves returning again
and again to similar themes and problems but slightly re-working them on
each occasion. These building blocks of change are, however, crucial to the
overall outcome and the therapist needs to be as attentive and proactive as in
any other phase of the treatment. In the next chapter we will consider the final
sessions, ending therapy and farewell letters.
9
The Final Sessions
Introduction
We usually consider the final phase of therapy, depending on the overall length
of therapy, as comprising the last three or four sessions. In psychotherapy of any
length not all the client’s problems will be resolved by the end of therapy; the
emphasis though in brief work is on starting a process that the client can con-
tinue after the therapy and contact with the therapist has ended. The seven key
elements to consider are shown below and are outlined in the following
sections:
1. Explicit discussion of ending

2. Link ending to previous loss or dilemmas regarding intimacy
3. Review the main problem
4. Review significant changes
5. Review how work can be continued by client
6. Farewell letter
7. Say goodbye
Towards the end of the chapter, we will also discuss the role of review sessions
in the context of delivering brief psychotherapy and the potential changes that
can occur after psychotherapy has been completed.
The Final Sessions 121
1. Explicit discussion of the ending

In brief therapy, it is often usual to refer to the ending of the therapy right from
the beginning. This is obviously important in a three- or four-session therapy
but even if the therapy is due to last for 16 sessions or longer, the therapist
should provide the client with an expected ending time, right at the start of
treatment. This does not have to be a specific date, but an approximate time. For
example: ‘So…we are going to meet for 16 sessions which will take us through
until the middle of July.’
As the therapy reaches its final stage, which for a 16-session therapy will
probably be the last four sessions, discussion of the ending should become
explicit. Where there is a particular concern about endings, it can be flagged
up several times during the therapy, but the last three to four sessions would
be the minimum. Many patients develop deep attachments to their therapist,
even if the therapy is short. Even if some clients do not outwardly show any
concern, there is always the possibility that they may still have strong feelings,
fears and concerns about the ending. Skill, compassion and understanding on
behalf of the therapist are required to manage the ending successfully. It is
useful to agree an actual finishing date a few sessions from the end of therapy.
This automatically raises the spectre of ending and enables the therapist to
explore the client’s feelings about the ending.
2. Link ending to previous loss or dilemmas

regarding intimacy
The ending of therapy often resonates with previous experiences of loss in
the client’s life. The therapist will probably already be aware of these losses
and how the client has coped with loss in the past. Denial, anger, pain and
distress are common ways we all can react to losing someone who is close to
us. The whole approach of the model and specifically the Stage 2 competen-
cies, which involve working in the here and now, using I and we and using
linking hypotheses, provide a way of exploring and sharing with the client the
difficulties of ending.
Box 9.1 Raising the ending

THERAPIST: Er…before we go on today…er I just need to say that we’ve got four
sessions, including today, until the end of the therapy…er…I make
that Monday the 16th of April…unless you are planning to be away
before…or anything.
CLIENT: No…I’m not away.
(Continued)
(Continued)
THERAPIST: It’s a bit hard to think about…ending…us not meeting… [Understanding

hypothesis]
CLIENT: It’s just gone so fast…I can’t believe it’s gone so fast…we barely
seem to have started…
THERAPIST: Much…it is hard…and it sounds as if you feel…a bit short changed,

I’m not sure. [Understanding hypothesis]
CLIENT: I just feel I can talk to you and it’s going to be so hard to start
again…I just get passed from pillar to post.
THERAPIST: [pauses and leans forward] you feel a bit like a parcel…
CLIENT: I’ve always been let down…I just expect it…it doesn’t matter.
THERAPIST: Your feelings about this are important…you are feeling very let down.
CLIENT: It doesn’t matter, why should it matter?
THERAPIST: Ah…well…you’re are pulling away from me there…I think when we

stop meeting…it does matter I think…it matters quite a bit to you.
[I and we] …I wonder if you could stay with how you feel…now.
[Therapists gestures with hand] [Focus on feelings]
CLIENT: No one cares…it’s like no one cares…I feel I don’t exist…
THERAPIST: Almost like there’s nothing of you… [Understanding hypothesis]
CLIENT: Umh.
THERAPIST: and you’re feeling…I don’t care…and your mum didn’t care. [Linking
hypothesis]
CLIENT: It’s like…how can I go on…it’s just me…everything’s so hard.
THERAPIST: Well…it’s not easy…it’s hard…to feel your own mum doesn’t love
you… You feel like giving up…it’s not fair…
CLIENT: Why does it hurt so much…she’s been dead for ten years?
THERAPIST: I wonder if you can stay with the hurt feeling…because in a way…I
think if you can face that feeling or share some of it with me…there
isn’t such a need to keep it at bay… [Focus on feelings]
In the example in Box 9.1, the therapist raises the ending with the client and
is aware of the resonances of the ending of therapy with the loss the client
feels in relation to her own mother. The therapist tries to acknowledge the
understandable distress from the client and uses the model competencies to
try to stay with feelings.
3. Review the main problem

It is helpful to keep in mind the main problem or symptoms that the client
originally sought help for, and it is to be hoped there will have been some
improvement in this area. It is likely that this will have been continually dis-
cussed throughout the therapy but some overall review of the progress of the
client’s problem should be attempted. There may have been a gradual
improvement, or ups and downs, or an improvement followed by a relapse as
the therapy nears its conclusion.
It is important that the therapist presents a positive view of the future
regarding the client’s symptoms, with some acknowledgement that symp-
toms may return if the client experiences stress. Strategies or solutions
which have been worked out in therapy should be reviewed and thought
given to how the client may be enabled to react differently now.
As we have discussed before in several previous chapters, ‘the problem’
will be present in the final sessions, as it has been throughout the therapy,
and it is important that the therapist attends to the ‘here and now’ as well to
the overall bigger picture. In the example in Box 9.2 the client is talking
about what she will be doing the week following the end of her 16-week
therapy. She starts to talk about having her bathroom refurnished.
Box 9.2 Example of ‘the problem’ in a final

session of therapy
CLIENT: I’ve got a lot planned for next week. I am having a new bathroom
fitted, so I’ll have the builders in all week…it’s going to be chaos…
THERAPIST: Lots of mess. [Smiling]
CLIENT: Yes…but in a good way…I’ve got to pick the tiles…I haven’t done
that yet.
[Client looks at the therapist and smiles…there is a feeling of warmth between them]
THERAPIST: Sounds like you are going to be busy…

CLIENT: Yes…and I’m sure they will over run…builders always do…they set to
do one thing and then unearth some other problem that they then have
to sort…it always takes longer and of course…it always costs more that
you originally agree…[Client looks away…and there is a pause…the
therapist picks up cue and notices a sense of discomfort in the client]
In the example in Box 9.2, the task for the therapist is not to be drawn into a
lengthy discussion about bathrooms during the last session of therapy, but to try
to understand what the client is trying to say to the therapist, and to maintain
a symbolic attitude towards what is being discussed. We can only make

informed guesses. We do not know what the client wants to say to the therapist,
but it is likely to be something more than wanting to talk about bathrooms.
From the brief interaction shown in Box 9.2 we know that there is a shared
feeling of warmth between the client and therapist. The client is talking about
being busy and embarking on a project to ‘rebuild’ part of her home. This
might be a way of saying to the therapist, ‘Look…I am going to be ok…I am
going to keep myself busy and I am going to continue the work of therapy by
continuing to “rebuild” myself.’ On the other hand, it could be a way of saying,
‘look…it’s going to be really hard to stop seeing you…the only way I will
cope…is by keeping myself busy’. The client then goes on to talk about the
builders ‘unearthing problems’ that were not immediately apparent at the
outset of the work. Although it may seem fanciful, this next passage seems to
imply a clear reference to the work of therapy, particularly because the client
uses the word ‘unearth’.
In the PI model, we are not seeking the ‘real’ meaning of what the client is
saying, but to recognise that there is a deeper communication than that which
appears to be happening in relation to the conversation about bathrooms. The
problem is that the client cannot put the deeper communication into words,
and that is ‘the problem’ that is in the room. As we have reiterated throughout
the manual, the way a PI therapist would approach this problem would be to
try to get in touch with the feeling that the client is experiencing (and the
therapist may also be experiencing something of this as well) and to stay with
the feeling, to see what emerges. In the example in Box 9.3, the conversation
between client and therapist in Box 9.2 is continued.
Box 9.3 Focusing on feelings

CLIENT: Yes…and I’m sure they will overrun…builders always do…they set
to do one thing and then unearth some other problem that they then
have to sort…it always takes longer and of course…it always costs
more that you originally agree…[client looks away…and there is a
pause…the therapist notices a sense of discomfort in the client]
THERAPIST: [therapist leans forward towards client] I wonder if you could say a
little about how you are feeling now. [Emphasises the word now]
CLIENT: Er…a bit cut off really…
THERAPIST: A bit distant from me…
CLIENT: I think there are lots of things I want to say…will want to say…when
I walk out of here…but I can’t think of them now.
THERAPIST: Those things may be important things…but you can’t quite bring them
to mind…it’s frustrating when that happens…and I guess…it’s one of
the things that happens quite a lot with you…I wonder if we can just
stay with how you are feeling and see if some words come to mind…
[Pause]
CLIENT: I think I am going to miss coming here…I mean…I’m still finding it

hard to deal with things…
THERAPIST: Yes…of course…deal with things by yourself, without seeing me…
helping…to some extent but difficult…still difficult.
CLIENT: Yes…I think it’s helped…helped a lot…but…
THERAPIST: But…you feel let down…perhaps…
CLIENT: I feel that you’ve helped…and I’m grateful for that but…is that
it…I’ve still got to cope with everything…and you know I think I can…
THERAPIST: I think you can too…but it’s hard to stop meeting…and a big step
to carry on with what we’ve been talking about…and I think you are
feeling a bit let down by me?…
CLIENT: A bit…
THERAPIST: I come along and we talk about your problems, and share some very
difficult things…and then…I walk off…so to speak…at least that’s how
it might feel…exploited even…i’m not sure…maybe that’s a bit strong.
CLIENT: No…I think you mean well…I’m angry with myself…just angry it has
to end…I wanted to thank you really…I haven’t been able to say what
I wanted to say…because…it’s just naff really…but you have helped
me…a lot…[makes eye contact with therapist and smiles]…I am a bit
cross with you…[smiles]
In traditional psychodynamic therapy, the therapist may have offered an inter-

pretation linking aspects of the client’s story about the new bathroom suite
and the transference relationship between the client and therapist. There are
some obvious links, in particular the notion that the builders have come in,
produced chaos and unearthed hidden problems. There is also the notion that
the builders in some way may have exploited the client by charging more than
what was originally agreed for the bathroom work to be carried out.
In PI therapy, however, the therapist will try to focus on the interactions
and feelings between the client and therapist rather than the possible meaning
of what is being talked about. The problem in the room is that the client has
difficulty expressing her feelings towards the therapist. She has difficulty
expressing both positive and negative feelings. She feels simultaneously
warmth and attachment towards the therapist but also anger towards her that
the therapy is ending. This micro problem is indicative of the problem area
the therapist and client have been working on throughout the therapy, that the
client finds it difficult to ask for help, finds it difficult to trust and feel close
to people for fear of being rejected.
By staying with the client’s experiencing in the ‘here and now’, the therapist
is able to help the client express her feelings directly towards the therapist.
Instead of this leading to a negative outcome, there is a sense of the client being
able to face her difficulties, resulting in a more positive connection with the
therapist. The conversation continues in Box 9.4.
Box 9.4 Focusing on the problem

THERAPIST: [Picking up from Box 9.3] And you have every right to be cross with
me…it’s a very difficult thing to share things in the way you have…
and it’s a very difficult thing when that time for sharing comes to an
end…but in a way…I think…you are more able to talk about how you
feel and more able to manage difficulties…just like you have now…
CLIENT: Yes…I think I would have just put up with things. Not said anything. I
do feel more in control of things and the bathroom is a positive thing
for me. I’ve not done anything like this for a long time. I know I’m
going to be busy…but it’s a nice busy…rather than the frantic way I
used to feel.
4. Review significant changes

In the last few sessions, the therapist should highlight and revisit significant
changes that the client has made during the therapy. These will have been
discussed previously but should be reviewed in the context of ending. They
may well be included in the farewell letter (see later) and may be discussed in
that context. The intention is to build upon changes that have occurred in the
therapy so that these processes can continue when the therapy finishes, as
shown in Box 9.5.
Box 9.5 Reviewing changes

THERAPIST: I think when we first met, you felt very down and trapped. You talked
about not having any time for yourself and feeling put upon by others.
It was very difficult for you to talk about how you felt. You keep a lot
inside…and we talked about being a bit wary of people and afraid
that if you opened up a bit…people wouldn’t like you.
CLIENT: I think that’s changed quite a lot actually. I feel much more sure of
myself…and I don’t really know…it kind of seems silly now…how I
got into that state.
THERAPIST: Well it didn’t seem silly to me…it’s very hard to overcome things we
fear…and you have worked very hard to do that…a fear of not being liked
or not being likeable can become a BIG thing…it can become large…
CLIENT: I don’t think it will ever go…
THERAPIST: No…but I think…it doesn’t feel as big…and just now…when you

were talking about the end…I think you were able to say things to me
that you would not have been able to do before…
CLIENT: Oh…yeah…no…I wouldn’t have said anything at all. I feel a lot

more comfortable with people…and a lot less angry with my
mum…I think seeing you has helped me understand her problems
a lot more.
5. Review how work can be continued by the client

Our experience with this model is that continued change can occur and does
occur after therapy has finished. The intention is that small changes can con-
tinue to occur post-therapy and may even result in bigger changes. If the client
has begun to be more assertive in relationships and has recognised the bene-
fits of this change, the therapist needs to emphasise the importance of main-
taining this change. The same is true of a client who has become less defensive
and is more trusting of people, and indeed true for any major change in inter-
personal functioning.
Box 9.6 Maintaining changes

THERAPIST: I think one of the things that really moved things forward was the
dream you brought about being in an old house with a roof that was
peppered with holes, and light was shinning threw those holes. The
feeling in the dream was of intense unease and discomfort.
CLIENT: That helped me put into words how I felt.
THERAPIST: You used the word ‘leaky’.
CLIENT: Yes…like a leaky roof, I couldn’t somehow keep people out, or stop
them from hurting me…I couldn’t keep myself in…I felt exposed.
THERAPIST: And…you felt a bit of that here…
CLIENT: Yes…yes…but I haven’t had that dream…any more…
THERAPIST: When we finish after today…you are going to be in situations, where

some of those feelings…of being exposed…may come back…
CLIENT: Yes…I know…but in a way…thinking about the dream helps me…I
know that’s what’s happening and I somehow it doesn’t feel as
bad…I feel I can handle things differently…Yeah…I do feel that…
and if I have a fit…I have a fit…so what…
(Continued)
(Continued)
THERAPIST: The fear of having a fit has been bigger than the actual fits…you
have had…
CLIENT: Oh definitely…I was going to say…I had a fit last week…at football…
in front of all the kids…right at the side of the football pitch. One of
the parents apparently came over…she’s a doctor…and I was looked
after and taken to hospital…but it just hasn’t been a problem… For
me…I was back in school two days later…and it’s been fine…
THERAPIST: That’s amazing…
CLIENT: Yes…In the past…I would have been mortified…I wouldn’t have
been able to go back into school…to have a fit…right in the mid-
dle of football, with all the school watching…I would have died…
it would have been my worst nightmare…but it’s happened and it
was ok…
There are often significant events in people’s lives that are going to occur after
the therapy, which may benefit from discussion prior to ending, especially if
the client has made positive changes during the treatment. For example, it may
be helpful to go through with the client how he/she will cope with a key anni-
versary, or a family wedding, or similar event that resonates with the client’s
past difficulties and to contrast the new ways of coping with the client’s past
ways of behaving. An example of this is given in Box 9.7
Box 9.7 Anticipating future difficult events

THERAPIST: I know after we finish today…You are going to be facing Kika’s birth-
day next month…it’s the 9th…isn’t it…
CLIENT: Yes…I’m dreading it…but my sister is coming over and we are going
to get a lot of balloons and blow them up and take them to her grave.
My sister’s then going to stay over and we’ll probably have a takeaway
and a bottle of wine, after we’ve put the kids to bed.
THERAPIST: It’s a very difficult day for you…
CLIENT: I just have to get through it…but rather than hide away by myself…
which is what I’ve done…the last 2 years…I’m going to have my sis-
ter there…I think that’s a better thing to do. Plus I won’t drink myself
into oblivion like I did before…
THERAPIST: That’s been a really big thing you’ve done…to cut down how much
you drink…it’s taken a lot of strength and will power to do that…
CLIENT: I think I just got to a point, where I realised that I was just getting
through the nights…by drinking…not in front of the boys…after I
had put them to bed…but I think it’s affected them…because since
I’ve stopped doing that…they seem so much better…all the shout-
ing I used to do has stopped and I just thought the other day…I
actually really enjoy being with them…
THERAPIST: That’s a quite a special moment for you.
6. Farewell letter
Written communications between client and therapist are common in psycho-
therapy but relatively rare in psychodynamic and relational therapies. They
have been developed most explicitly in cognitive analytic therapy (CAT; Ryle
and Kerr, 2002).
Farewell letters in PI therapy were first used in 1996 in the context of a ran-
domised trial which was set up to evaluate the cost-effectiveness of PI therapy
versus an anti-depressant versus usual care in patients with severe and intracta-
ble irritable bowel syndrome (Creed et al., 2003). The rationale for using fare-
well letters was based on four assumptions. First, letters appeared to be of
clinical value in CAT (another form of relational therapy). Second, the patients
who were taking part in the trial were being asked to complete a variety of
formal measures of assessment, including diaries of symptoms and symptom
questionnaires, so the work was more active than traditional psychodynamic
models. Third, a key part of the therapeutic process was the exploration of the
patient’s physical symptoms, with a view to discovering connections with
important emotional and interpersonal issues. It was hypothesised that a letter
at the end of therapy may help to reinforce these associations. Finally, the ther-
apy was brief, and it was thought the letter might facilitate continuation with
the work of therapy after it had finished and also help with the actual ending
of therapy itself.
A one-year evaluation of the letters was carried out, which involved sending
out a questionnaire to clients who had completed therapy (Howlett and
Guthrie, 2001). All reported that they had kept the letter and most had read it
several times during the year post-therapy. Several people reported sharing the
letter with key people in their lives including partners, grown-up children and
close friends. The letter appeared to help people share their experiences with
others and increased possibilities of confiding. Clients reported consulting the
letter at times of difficulty and using it to aid problem-solving. Clients spoke
of the value of the letter in very positive terms, and there was clear evidence
that the letter had facilitated the work of therapy after the sessions had ended
(Howlett and Guthrie, 2001).
For a small number of clients who had not found therapy helpful, the let-
ter did not convey any additional value and one client reported that it had a
deleterious effect as it brought up memories she found distressing. In view

of this we recommend that letters are given to clients who are reporting ben-
efits from the therapy, but may be best left out if there has been little
improvement, unless there is a particular indication.
We suggest the therapist should introduce the idea of the letter during the
initial sessions of therapy. An example of how this might be done is given in
Box 9.8. The nature and purpose of the letter should be discussed and agreed.
The letter has been incorporated into the model and used in all forms of brief
therapy, even therapy as short as four sessions (Guthrie et al., 2001).
Box 9.8 Example: introduction of letter

THERAPIST: As we’ve met now on a couple of occasions I’d like to discuss with
you a letter that I write towards the end of therapy which will summa-
rise the things we have talked about over the course of our meetings.
We’ve found it’s helpful for people to take this letter away with them
when the therapy is over…er we have another ten sessions after
today…as it helps people remember the things we’ve talked about.
CLIENT: Ok.
THERAPIST: The letter is just for you and will not be sent to your GP or anyone
else…I usually include significant things we’ve discussed…which I
think may be helpful to keep in mind…I will discuss with you the kinds
of things that may be useful to put in the letter…and I will show you
a draft version which you can amend or change…before we agree the
final version…I will also write a more formal brief letter to your GP
about the outcome of the therapy…er…It’s good practice to do this…
but I won’t include any personal details in that letter…and you will also
receive a draft copy of this much shorter GP letter…before it is sent so
you can provide me with any comments etc.
CLIENT: So I get two letters?
THERAPIST: Yes…a long and personal one from me to you…and a copy of a brief
letter I will write to your GP…I should say at this point that if we
decide through discussions that you don’t wish to receive a letter
from me…or you don’t think it will be helpful etc.…then I won’t write
one…so any summary will be done through discussions between you
and me.
CLIENT: No…it sounds like a good idea.
The farewell letters are demanding and time-consuming to write. The thera-
pist should write the letter as the therapy progresses and not wait until the end
to try to do this. It is helpful if the therapist jots down notes when listening to
the audio recording after each session and where possible uses the client’s
own language to bring life to the words. The therapist should imagine what
the client may feel like when he/she reads the letter, and it should be couched
in such a way that the client will experience the letter in a positive way.
There should be a narrative that follows from the first session and tracks the
client’s progress during therapy. The letter should explicitly address the ending
of therapy with suggestions of how the work can continue even when the ther-
apy has actually stopped. There should be no surprises in the letter and
everything should be familiar to the client.
Each letter will be different and may vary slightly in the structure and con-
tent. What is important is to capture meaningful shared moments in the ther-
apy with which the client can re-connect, if they read it again some months
later. Box 9.9 summarises key things to include in the letter, but it is not an
exhaustive list and not all of these things need to be included in every letter.
The therapist will need to use judgement and discuss the content of the letter
in supervision.
Box 9.9 Content of the letter

zz A description of the problem, with which the client presented during the initial
session, using the client’s own words.
zz Moments of shared feeling, living symbols and metaphor, which should include
how these were explored.
zz An exploratory rationale which links symptoms, feelings and relationships,
including where relevant a model.
zz Problematic patterns in relationships and how these have impacted on the cli-
ent.
zz Avoided, painful or warded-off feelings.
zz Progress in therapy including reduction in warded-off feelings, closer sharing of
problems with therapist and changes in relationships outside therapy.
zz A timeline which refers to change over the course of therapy.
zz A timeline which refers to past, present and future.
zz Acknowledgement of the ending.
zz Reference to the changes that can be continued post-therapy.
A draft version of the farewell letter should be produced and discussed with
the client during the penultimate session of therapy, although as discussed
above, the therapist should be continually adding to it and changing it over the
course of the therapy. In the final session, the therapist can start the session
by reading out the amended version of the letter, or read the letter out when
it seems appropriate. It’s important, however, not to leave it until the end of
the session. It is important that the client has ownership of the letter and its
content, and the above process usually results in very positive and favourable
feedback. An example of a farewell letter is shown in Box 9.10.
Box 9.10 Example of a farewell letter

Dear John
This is a letter from me to you, and it will not be sent to your GP or any
other health professional. I would like to say from the outset how much I have
enjoyed meeting you and sharing time with you. This letter is intended as
brief summary and reminder of the things we have discussed over the last
few weeks.
I remember that you were rather puzzled at being referred to see me, and
were understandably hesitant and rather unsure when we first met. You had
seen your GP on several occasions in the last year for a variety of problems
including feeling tired and exhausted, pains in your tummy, headaches,
feeling sick, not being able to sleep and feeling down all the time. You told
me that your GP felt you were stressed and although you agreed with that
you could not see how talking about ‘it’ would help.
When I asked you what you most wanted help with, you said you just wanted
it all to stop. You felt you couldn’t settle, you couldn’t relax, and when we
stayed with that feeling, you told me you wanted ‘the pain’ to stop. You told me
the pain felt like there was a big wound inside you, a wound that couldn’t heal.
You felt it constantly and were never free of this awful feeling from the time you
woke up in the morning to when you fell asleep at night, usually having had to
drink a bottle of wine to ‘knock yourself out’.
You are a private person. You are someone who prefers to keep their
thoughts and feelings to themselves, so it was a new experience for you to
share something of how you were feeling with me. I remember you telling me
that it would be impossible to talk to your family about your feelings as you
were the person that they relied on to be strong, and indeed you are a strong
person and took responsibility from an early age for your little brother after
you were both taken into care and later adopted.
As we talked more, you were able to share some of the dreadful nightmares
you were experiencing and had experienced for many years. At first, you wanted
to know from me what these dreams meant as if there would be one explanation.
Instead, we found they were a way of exploring and sharing some of the fears
and feelings you had kept hidden inside for many years. You told me about the
feelings of panic you felt inwardly if ever you were asked to do something or face
something. You always faced it of course, and no one else would know except
you how dreadful you felt inside.
The more we talked, the more there seemed to be connections and parallels
between things that had happened in your life. Having to be strong for your
wife when so many awful things had happened to her seemed very like having
to be strong for your little brother.
The more you love someone, the more at times you can feel frustrated with
them, and angry with them, especially if they let you down in some way. In
the last couple of sessions, you have shared some of these difficult feelings
too. You do get angry at times and resentful and annoyed and ‘pissed off’
with people. You feel they always expect you to cope and be cheerful and
just breeze through life, yet until recently that is how you behave. We have
wondered together, how could they know that you get upset and angry and
fed up, when you never tell them or let them know. It’s almost as if you’ve
expected them to know, to know how you are feeling inside, even though you
never show it.
We have also touched on deeper feelings and fears. Your fear of
death which is very great and also your fear that others close to you
will die, and even the fear that in some way you may be responsible.
I have admired how resilient and ‘strong’ you have been and how even when
suffering yourself, you did care and have always cared for others.
As we are reaching the final session, it feels like a lot has changed. You
have felt physically a lot better over the last few weeks. You are more active,
and feel more refreshed. The dreams have stopped and you are actually
contemplating returning to work on a part-time basis. We have puzzled how
your physical health can be connected to your emotional world. It’s not clear
and it certainly isn’t straightforward. Your gut symptoms started with an
infection, so this would have triggered an inflammatory response in the bowel.
It really threw you physically and emotionally as for the first time in your life
you could not be strong when you felt you were needed. My feeling is that
this threw you into a state of panic, and some of the feelings you had buried
for many years began to emerge, if only in your dreams at first. The body and
mind are not separate and the more physically unwell you became the more
‘stressed’ emotionally until a vicious circle developed. You couldn’t sleep, you
felt exhausted, the physical and mental pain was unbearable, your resilience
was finally shattered.
It’s very hard to think that we will be meeting for the last time. Although we
have talked about ending during the therapy, it still can seem like a shock when
it finally happens. Because you have suffered such traumatic losses, any loss no
matter how small is significant. As we have discovered, loss for you is mixed up
with a lot of different feelings including panicky fears, distress, anger and upset
and deep pain. Most of all, it feels like a wound. A wound that has never healed
and for most of your life you have kept hidden.
I think you have made some big changes in the last few weeks and I hope
that you can continue to work on these in the next few months. As we have
discovered it’s not actually what you share and talk about that is always the
most important thing, it’s the feeling that you get from being able to share
things. May I take this opportunity to wish you and your family all the very best.
7. Say goodbye
It may seem obvious but it is very important to say goodbye to a client and,
just as a lot can happen in the first few moments of therapy, a lot can happen
in the last few moments. Saying goodbye is difficult for many people, includ-
ing therapists, which is why we have highlighted the importance of this basic
human transaction.
Brief therapy is about taking something of value forward. The significance
of warm words from the therapist at the end of treatment, including a warm
handshake, whilst looking the client in the eye, should not be forgotten.
Review sessions
The structure of some therapies includes a review session which takes place
6–12 weeks after the therapy has been completed. We have used this format
with very brief therapies for self-harm (four sessions) and found that an addi-
tional session a few weeks later helps to solidify gains from the therapy and
contain risk. Follow-up sessions are fairly common in many brief therapies and
they provide clients with an opportunity to come back and review their progress
after the end of therapy. Clients are often able to gain a greater perspective of
how the therapy has helped them and how they are putting into practice the
changes or things they have learnt from the therapy sessions.
Follow-up sessions can also act as an emotional life-line for clients who
have found ending difficult. The letter also helps with this aspect of ending
and the therapist and client will also use the time in the follow-up session
to reflect on the letter and how the client has used it. They may discuss that
the client has shown the letter to other important people in their lives and
their reactions to this.
Summary
The last three chapters have provided an overview of the therapy in practice. In
combination with Chapters 4 to 6, they convey, as best as any psychotherapy
manual is able to, the general approach of PI therapy when used in a brief for-
mat. In some of the studies on the model we have changed the length of the first
session so that it can last for up to two to three hours. We have found this of
benefit for clients who suffer from persistent physical symptoms or who are
difficult to engage. The fundamental approach of the model, however, is similar
no matter what the presenting problem and, for the purposes of this book, we
have preferred to include a generic manual that can be used for clients with a
wide range of presenting problems or conditions.
PART III
LEARNING AND
DEVELOPING THE MODEL
10
Being an Effective
Practitioner of
Psychodynamic-
Interpersonal Therapy:
Developing Competence
This chapter introduces some of the key elements that arise when helping thera-
pists to become effective practitioners of PI therapy. Therapists can adhere to a
manual of therapy but not be remotely competent and this chapter goes beyond
adherence to look at how competence and expertise can be developed. We are
concerned with helping therapists to become as competent and skilful as they
can be, and to be able to maintain those skills in the long term.
Unlike others who have developed schools of psychotherapy, Bob Hobson
was keen that the PI therapy maintained a principle that it can be used by a
non-specialist in psychotherapy such as a nurse working in physical medicine
or a psychiatrist working in a secure unit just as much as a psychologist work-
ing full-time as a psychotherapist. This does not mean that therapy cannot be
differentiated into different levels of expertise, but we have followed Hobson’s
principle that these are not organised as a hierarchy of importance.
Undoubtedly, some therapists are notable for having exceptionally good out-
comes. Others may be especially resilient in managing clients who challenge
boundaries and make great demands on the therapist. It follows from this
breadth that the mark of a good, safe PI therapist lies in knowing one’s strengths
and weaknesses. This chapter does not define a training programme to lead to
a specific qualification, but it does provide an overview and some suggestions
for developing expertise for individuals and groups of professionals.
As discussed in the manual section of the book, Hobson draws a useful
analogy here with playing ‘scales’ and improvisation (Hobson, 1985: 207).
A skilled musician can improvise based on a particular scale that has been prac-
tised previously. Each performance is different but the underlying structure is
shaped by the detailed knowledge of that particular scale. By analogy, a psycho-
therapist can become skilled in using a scale but does not need to be consciously
aware every second as the material is so familiar and well practised:
The procedures are akin to the scales of notes for a musician or to the words and
phrases of a literary artist. Broad theoretical ideas and psychodynamic formulations
are of importance only in so far as they are incarnated in the minute particulars of
what we do. We need to practise our scales. Technical accomplishment is essential
in achieving a unique ‘true’ voice of feeling. (Hobson, 1985: 207)
Before offering suggestions about developing expertise in this particular model

of therapy, we have briefly reviewed some key points about expertise in psy-
chotherapy more generally.
Adherence and competence

Adherence refers to the extent to which a therapist conducts a therapy as it is
described and defined in a manual (Waltz et al., 1993). These elements are
crucial in defining and differentiating an intervention in a research study but
may be less well suited to developing clinical skills in practice.The adherence
scale for PI therapy was originally developed in a research context (Startup and
Shapiro, 1993). It covers elements that differentiate this model from others, but
also includes some ‘facilitating conditions’ that are relevant to all therapists.
The scale has been modified so that the elements reflect closely the skills we
have discussed within the manual (Chapters 4 to 6) and only includes PI ther-
apy items. The modified version of the scale is available in Appendix 1 so that
therapists can monitor their level of skill development using audio recordings.
In contrast, competence is ‘the extent to which the therapists conducting the
interventions take the relevant aspects of the therapeutic context into account and
respond to those contextual variables appropriately’ (Waltz et al., 1993). Competence,
therefore, involves skills like timing of interventions; how to choose which possible
intervention; when to hold back; and also subtler skills related to the precise form
of language used in a conversation. These aspects are much more difficult to rate
reliably but are often the focus of clinical training as discussed later.
Learning PI therapy
Before the model was even described, Robert Hobson had already pioneered the
use of audio and video recording feedback for teaching and supervision. He
established the routine use of recordings in supervision and he was one of the
pioneers in the use of video recordings as a teaching medium to model how
therapists work. From the outset, learning from feedback was intrinsic to this
way of working. Hobson developed a repertoire of ways of introducing new
Being an Effective Practitioner 139
therapists to effective practice, and his systematic use of feedback from sessions
is still as relevant today.
The process of developing PI therapy in a research context is fully described
in the original reports (Goldberg et al., 1984; Maguire et al., 1984), but the
research is relevant here primarily in terms of the development of teaching meth-
ods. The research team had been influenced by the work of Ivey et al. (1968) in
the use of micro-skills teaching of counselling and therapy, but in this context it
applied for the first time to a relational form of therapy. The micro-skills method
involves the definition, modelling and practice of desirable therapeutic behav-
iours until there is mastery of each component. This was in part accomplished
through three teaching recordings introducing basic skills, putting the skills
into practice and rehearsing the key skills.
In summary the early phase of development of the model in terms of teach-
ing showed:
zz The model can be described clearly and rated with a measure that is reli-
able (Goldberg et al., 1984).
zz A simple micro-skills teaching package using inexperienced teachers had a
dramatic effect on changing trainees behaviour from an interrogatory style
to a negotiated style (Maguire et al., 1984).
zz Supplementary group teaching increased the trainees’ level of confi-
dence (Moss et al., 1991).
zz After two years there had been little if any change in the trainees’ ability
to use these skills (Moss et al., 1991).
zz The original teaching material (derived from actual therapies in a pilot phase)
was re-made with simulated interviews of high plausibility (Margison and
Moss, 1994).
zz The method has subsequently been used widely and replicated with nurse
trainees (Paxton et al., 1988).
zz A factor analytic study of the pattern of skills acquired was consistent with
the underlying model (Moss et al., 1991).
The research focused on the early stage of skills acquisition. To develop the
model beyond the initial training or research contexts, further work was car-
ried out using supplementary teaching methods to prepare practitioners for
the range and complexity of problems found in everyday use as described
below.
A further study (Guthrie et al., 2004b) showed that counsellors working in
primary care could be trained efficiently to deliver PI therapy using this
approach. As described in Chapter 3, 20 counsellors received a 12-week train-
ing course in PI therapy including supervised practice of cases from their
primary care settings. The client outcomes were good, with 50% showing
clinically significant and reliable change.
Performance was assessed using video recordings of sessions with simulated
patients at three points in time: before training, after an intensive first week of
training and at the end of 12 weeks of supervision. Counsellors’ adherence to
the model was assessed in relation to three patient scenarios: chronic depres-
sion, somatisation and suicidality. Validity of the simulated sessions was veri-
fied by reference to counsellor behaviour with actual patients using
audio-recorded sessions. After training, counsellors’ adherence to PI therapy
increased without affecting their basic counselling skills. Counsellors working
with patients with chronic depression or somatisation demonstrated improve-
ment in specific items; there was, however, less evidence of model application
among suicidal patients, where concerns about managing risk were predomi-
nant. Ratings of audio recordings of sessions with actual patients confirmed
that counsellors were able to apply the model in a real-life situation. The coun-
sellors also reported a positive experience with enhanced skills after training.
These teaching methods were also used in evaluating training in psycho-
therapy for social workers addressing PI behaviours among 14 core psycho-
therapeutic competences. This research showed the course to be effective
overall (Firth et al., 1999). The training methods for both short courses for
psychiatrists, nurses, counsellors, psychiatric social workers and clinical psy-
chologists (e.g. Margison and Moss, 1994; Moss et al., 1991; Paley et al., 2003a,
2003b; Paxton et al., 1988) and as part of longer training (Firth et al., 1993)
appear to be effective across professional groups.
Development of additional training

methods: role-play
Role-plays are another way of hearing feedback about performance as a ther-
apist. They have been used widely in developing therapist skills and aware-
ness for this model of psychotherapy and as an adjunct to supervision of
clinical experience. However, trainees are often worried that they will not be
able to cope with ‘difficult’ situations that occur outside the immediate train-
ing context. So, from an early stage we drew on the work of Kagan (1980) to
develop a way of addressing these therapist fears.
Kagan suggests that therapists typically ‘feign clinical naiveté’ with a super-
visor to avoid possible humiliation about their basic fears. He described these
as fear of being engulfed or engulfing (seducing) the other; or being attacked/
attacking the other. These are seen as the basic fears in any interpersonal
interaction, but they are amplified in the close observation characteristic in
learning psychotherapy. We used role-plays to set up a series of escalating
difficulties to desensitise the trainees to their fears and to help them to discuss
the difficulties they experienced in an open way. We developed four stages of
increasing complexity and challenge for the trainee therapists.
In our adaptation of Kagan’s methods, a standard format is used for all the
role-plays (Margison, 1991). A group, typically of about four therapists in
training and a facilitator, meet regularly. Two chairs are kept for the members
currently playing therapist and client. The ‘client’ is asked to prepare a couple
of sentences summarising the basic information about age, gender and main
problems. Sometimes the role-play will be based on an initial session but
role-players are also surprisingly adept at starting as though several sessions
into an ongoing therapy. Either the client or the therapist (or occasionally
both) are given cue cards which have a brief instruction explaining what
should be done. Typically this is a brief statement about what is the ‘agenda’,
such as assuming that the client has to be told that the therapist is going to be
away for three weeks’ holiday. The teacher stops the role-play after two or
three minutes in the early examples, or somewhat longer in the later, more
complex examples. After the role-play a standard sequence is followed with
the two role-players expressing their feelings about the interaction before
opening up the discussion to the whole group. It is crucial in this teaching
method to establish an atmosphere that is conducive to learning. Other group
members are encouraged to describe what they saw, heard or felt. Also they
are asked to comment about how they might have felt as the client or
responded as the therapist. Criticism of the ‘therapist’ is specifically discour-
aged. See Table 10.1 for examples of role-play cards.
Commonly trainees have had bad previous experiences of role-plays where
they have felt humiliated or exposed. So, it is important for the teacher to estab-
lish an atmosphere that allows exploration in depth for the role-players within
a safe framework. In a group that has been working together for only a few
weeks it is usually possible for the members to be quite open about their anx-
ieties as therapists. A reliable structure of the teaching session prevents inap-
propriate drift towards the training group becoming a quasi-therapeutic group.
Table 10.1 Examples of role-play cards
Role-Plays Level One: Examples
yyAvoid all eye contact with your client/therapist

yySpeak only technical jargon
yyAsk only direct factual questions
Role-Plays Level Two: Examples
yyYou are taking an unplanned three-week holiday after the next session
yyDiscuss your need to change the session time
Role-Plays Level Three: Examples
yyDo not accept what your client/therapist says at face value

yyComment in an emotionally neutral tone about some aspect of your client/therapist’s
appearance or clothing
Role-Plays Level Four: Examples
yyDiscuss with your therapist that you fear you might lose control and smash things/
harm yourself
yyDiscuss feeling embarrassed but that you need to tell your therapist how attracted you
are to him/her
yyTell your therapist that his/her habit of pausing before answering is driving you crazy
The training begins with low key examples of how sensitive the therapeutic
situation is to therapist behaviour. So, for example, a trainee may be given a
prompt card, which instructs the therapist to be ‘over-reassuring’, ‘lean too
close to the patient’, ‘avoid eye contact’ or similar undesirable behaviours.
The therapist can use these early examples to become sensitive to nuances in
the interpersonal situation and also become less anxious about the role-play
itself. This is preparation for the next phase when the sessions focus on how
to make practical arrangements about breaks, reviews of progress, session
times. These particular role-plays have a dual purpose: the experience allows
the therapist to be able to structure a therapy with confidence whilst develop-
ing sensitivity to the undercurrents of the therapy.
A common error amongst beginners is their tendency to equate listening
with passivity and as a result they may give insufficient structure. Whilst
learning these basic techniques of structure and contracts they also become
more sensitive to the emotional undercurrents involved in negotiating appar-
ently practical issues. For example, any issue related to timing or frequency
may be linked with separation issues or feeling neglected. Issues regarding
review of progress are often tinged with feelings of being criticised or, in
extreme cases, humiliation and narcissistic wounds. This second phase of the
role-play training prepares the therapist for the inevitable multiple levels
involved in any therapeutic conversation.
The third group of role-plays focuses on how easily the therapeutic alliance
can be damaged and persecutory dynamics established. For example, one role-
play simply asks both participants not to take anything the other says at face
value. As this is enacted the trainee becomes aware of the risk of invalidating
the other’s experience. This helps the trainee to understand the processes
described by Meares and Hobson (1977) as a ‘persecutory spiral’. By enacting
the patient role as well it is possible for the trainee to realise just how sensitive
the person in that position will be to minor discrepancies, ambiguities or
inconsistencies in the therapist. These examples also give practice in how to
repair ruptures in the therapeutic alliance.
Many beginning therapists in service contexts have had no experience of
their own personal therapy, which is a prerequisite for most trainees wishing
to practise primarily in psychotherapy. Whilst role-plays are clearly not capa-
ble of providing an equivalent experience, they can increase the trainee ther-
apist’s sensitivity to interpersonal nuances which otherwise are learned only
through therapeutic failures with actual clients.
In the fourth stage of the role-play training, a series of role-plays deliberately
simulates what Kagan described as ‘therapeutic nightmares’ such as being told
of intense suicidal or violent impulses, sexual feelings towards the therapist and
antagonistic and hurtful comments about the therapist. Kagan had developed a
number of ‘stimulus vignettes’ on video recordings, which the trainee could
watch and reflect on their emotional response. Our method draws on that tech-
nique, but uses a role-play situation to enact the challenging experience. The
therapists have to think on their feet and respond in ‘real time’, but in a safe
environment with no risk to clients. Most trainees find these sessions a demand-
ing but positive experience.
After the formalised sequence of role-play situations it is possible to extend

this model of training into actual clinical work. For example, in a supervision
group a trainee can role-play his or her client, or can ask another group mem-
ber to role-play the client whilst the trainee stays in the therapist role. The
advantage of this method is that it allows the therapist to become familiar with
‘What if?’ scenarios in dealing with particularly challenging material.
We evaluated the effectiveness of this role-play training in acquiring ther-
apy skills (Palmieri et al., 2007) and the findings suggested that role-play
training was effective in learning new skills. A 15-item role-play competence
measure was developed. Ratings by three judges of 34 role-plays from PI
therapy training showed good inter-rater and internal reliability. Validity was
supported as scores were statistically significantly associated with the length
of psychotherapy training experience. Most participants achieved satisfac-
tory ratings on the key skills of this model of therapy after the training.
These methods can be supplemented by the use of peer teaching groups first
described by Kagan (1980) when the members rotate roles between the roles
of commentator/time-keeper, facilitator, ‘patient’ and ‘therapist’. These tech-
niques are a particularly powerful way of getting across the idea of different
therapeutic perspectives. When teaching resources are scarce it is possible to
have several groups of more experienced trainees running simultaneously
with teachers moving between the groups to add an additional perspective.
We have used these sessions regularly with therapists at different levels of
experience and it is possible to develop new role-plays relevant to any specific
topic such as working with somatic distress or managing self-destructive
behaviour depending on the experience and clinical setting of the participants.
Participants include established PI therapists who take part in the sessions to
maintain their skills as part of continuing professional development.
With established therapists who want to progress to the role of supervisor we
have used the same structure to role-play the difficulties that arise in a supervi-
sory setting where members role-play supervisor and therapist and reflect on
experiences with different styles of supervision.
Learning to study by observing sessions

A wide range of process methods has been developed to analyse what is hap-
pening within a therapeutic session and many have been used with PI therapy
(see Chapter 3). In developing training for PI therapy we thought that it would
be valuable to develop these methods derived from research in a teaching
context. There is an almost infinite variety of ways in which such methods
could be developed and the examples given below are to be seen as examples
rather than definitive (see also Margison, 1991, 1999).
The first phase of this training encourages the trainee to listen closely to a
session by transcribing part of the session as accurately as possible annotating
the length of pauses, sections where both participants talk together, hesitations,
non-verbal vocalisations, dysfluencies and changes in intonation. This is a
time-intensive process, but it reminds the therapist of the complexity of what
is happening across many channels of communication in a session. There are

several systems in use for transcribing, and outside of the research setting it is
not critical that validated methods are used to write down the interchange
between therapist and client. However, it is a valuable skill to learn and we
recommend, where possible, using a standardised system such as the one
described by Mergenthaler and Stinson (1992).
After learning how to transcribe the session the trainee starts to write down
process comments. The exact order in which these are introduced is not criti-
cal, but a suggested sequence is given which follows a logical development of
skills (Margison, 1999) and this is reflected in the comments below.
What the therapist does
The therapist uses a method of describing the structure of what is said. Trainee
therapists can use the rating manual in Appendix 1 to assess their own inter-
ventions. There is also a variety of alternative models discussed by Elliott and
colleagues (1987) that can help a therapist see different ways of conceptualising
a session.
Describing the intention behind each intervention
It is useful to distinguish form from intent in analysing therapeutic interven-

tions. One option is to use a system that provides an accessible set of categories
to distinguish different reasons why a particular intervention might be used,
for example the List of Therapist Intentions (Hill and O’Grady, 1985).
Discussion of the intentions behind interventions can feel very uncomfortable,
but is helpful in developing self-reflective skills. They described some inten-
tions focused on the therapist focusing on feelings, new knowledge and insight,
whilst others concerned encouraging and maintaining change and setting lim-
its. These provide little challenge to the therapist other than mastering new
concepts. However, the final group focused on meeting the therapist’s needs
(whether to be liked, admired, respected or reassured) and these are much
more challenging for therapists to acknowledge. It requires considerable trust
to openly examine less honourable motives that may be driving some interven-
tions. Robert Hobson encouraged this degree of honesty from those working
with him but was always willing to share the experience by talking about diffi-
culties he encountered as a therapist (see, for example, Hobson, 1985: 261–81).
How the client responds
From the early development of the model by Hobson it has been clear that
mere acquiescence with the therapist’s point of view is insufficient and that a
fundamental test of an intervention is how far the client develops and extends
imagery and feelings in their subsequent narrative. In developing this thera-
peutic skill the focus of the observation is what the client says in response to
what the therapist says rather than the nature of the intervention.
Metaphor and therapy
Metaphor is an important concept in PI therapy and Hobson wrote extensively

on this topic (for example Hobson, 1985: 55–61). Sometimes a therapist may
use a metaphor or simile to illuminate a key point, but in this context we are
more interested in amplifying and giving back the metaphors that arise in the
client’s everyday language. However, it is easy to miss the significance of an
extended metaphor within a therapy and we need to develop our expertise in
listening for examples that develop a shared feeling language. Sometimes these
metaphors become important reference points that the therapist or client can
refer to as a form of shorthand for an important shared experience.
One strategy for learning how to listen at this level is to attend specifically
to every possible metaphor, even those which appear to have been used as
part of customary vernacular speech (a cliché or dead metaphor). By simply
listing such phrases from the transcript it is possible to draw up hypotheses
about hidden material. (For a fuller discussion of this technique see
Margison, 1995.) These words and phrases may be differentiated by being
expressed with more energy or affect, but sometimes the therapist just needs
to be aware of words like ‘burden’ or ‘wasting’ that can be picked up and
amplified to develop hypotheses about core feelings, or words such as ‘stuck’
or ‘wasted’ to identify themes that may be related to blocked progress in the
therapy. Metaphor (like the word transference) literally means to carry
across. Metaphors in therapy carry meanings from one context to another.
Case formulation
There are definite advantages to using a formulation: Having a formulation

shared with the patient can help maintain the therapeutic alliance during diffi-
cult re-enactments; or, in supervision, help understand potential re-enactments.
Also, the therapist can use the formulation after each session to ensure that the
agreed focus is being maintained (Margison et al., 2000). At the session level, it
is possible to link different sequences within the therapy to different elements
of the case formulation and to use the formulation to maintain focus (see
Margison, 1999).
There is an inevitable tension between different types of formulation. In
this approach a formulation that is shared and developed within the conversa-
tion is central. However, the therapist’s role is sometimes to help map out the
terrain by drawing on prior concepts and experience. Hobson was very aware
of this tension when he wrote ‘the form of a developing conversation often is
the diagnosis and also the treatment’ (Hobson, 1985: 177). He clarifies this
seeming paradox when referring to a case example, that:
In the interview we can formulate problems at different ‘levels’: in terms of the

minute particulars of non-verbal behaviour, the disturbances of his central relation-
ships and his struggle for identity in an adult world. A central and often difficult task
in psychotherapy is to decide which problems are to be tackled at what ‘levels’.
(Hobson, 1985: 178)
This choice can be determined by many factors such as the time available for
the therapy.
Modern approaches to psychotherapy are often ‘formulation-driven’ with a
description of the problems; psychological explanations based on theory about
the development and maintenance of these problems; a plan for intervention
based on the theory and principles used; and predictions about how the ther-
apeutic relationship will unfold (see for example, Johnstone et al., 2011).
PI therapy can be guided by this more formal approach to formulation,
and can draw on psychodynamic and relational theory freely. However, the
therapist needs to be aware of the potential to inadvertently depend upon
‘jam-jar’ thinking and block the collaborative aspects of the therapy by
being too distracted by a formulation based on theory: it is always tempting
to seek evidence to support a pre-existing theory.
A formulation can also be expressed in letter form as described in Chapter
9 and the letter can be a summary of the evidence discovered in the conver-
sation between client and therapist. A written formulation is a distillation of
what happens in the therapy, but it is best to see formulating as an ongoing
process, based upon the minutiae of the ‘here and now’, always open to
correction. So in the first five minutes the therapist needs to be especially
sensitive to cues that may only become clear later in the session. The
approach we recommend combines the formulation with the evidence sup-
porting it. So, as Hobson suggests, we are trying to summarise the ‘develop-
ing conversation’ in ways that help to progress the therapy in a mutual and
collaborative way.
The therapist is focusing upon ‘the problem’ that is alive in the session, and
gathering information about patterns in past relationships and those in the pres-
ent, both outside and inside therapy (described as the triangles of person and of
conflict by Malan, 1979: 80). In each of these areas there may be explicit prob-
lems or concerns, and the client may have already seen patterns between them.
The therapist is listening for key metaphors, phrases or symbols to summarise
these patterns in the words of the client, and is also looking out for the ‘minute
particulars’ – glances away, a catch in the voice – that may illuminate what is
happening for the client, and the therapist is also being alert for internal clues
such as bodily feelings – tension, nausea, tiredness, dry mouth – to give a fur-
ther perspective on the conversation.
When writing up the notes after the session it is worth spending time on
‘the first five minutes’ rather than rushing to record the middle section of
the session, as the early feelings and impressions may reveal an unexpected
perspective. From the information gathered, therapists can write down their
hypotheses about what is happening for the client, the therapist and their
interaction. There may be links between different relationships or themes in
the session (or to past sessions) and eventually the core of the formulation
can be expressed in the form of an explanatory hypothesis (see Chapter 9).
This process is much easier if there is a recording of the session, but it is
worth putting down initial impressions quickly first in what are often
referred to as ‘process notes’.
Process notes
In this model of therapy process notes are closely linked with formulation
building as described above. Initially therapists may simply attempt to
transcribe what was said with no attempt to make sense of the material
within a broader framework. It is helpful, as described in the section on
formulation, to guide the trainee towards writing down what was actually
said but then separately to generate hypotheses based on what the client
said, what the therapist said and their interaction. At the end of the process
notes the trainee can keep track of the overall therapy by commenting
about progress linked with core problems and reminders for the next session
such as themes to be monitored and predictions of what may happen in the
next session. Table 10.2 shows a possible structure for recording process
notes to assist in formulating the client’s difficulties and presenting sessions
in supervision.
The content relates to a brief therapy approaching half-way through. The
client is a 42-year-old woman who is experiencing blocked grieving after her
son was killed in a motorcycle accident. The therapist has listened to the audio
recording and has summarised some of the key issues on the proforma.
Table 10.2 Example of systematic process notes
Name Mrs AB
Therapist CD
Session 3rd of 8 sessions
Number
Date 17/02/16
Observations Hypotheses
yyWhat is said? yyExpress in everyday
yyHow is it said? language
yyBody language?
yyMetaphors?
yyHow do I feel?
Opening of The session felt very stilted Were we re-enacting the polite
session in the first few minutes. talk of a funeral where emotions
are being held in check?
Observation Mrs B was cutting over Perhaps struggling to contain
of client me whenever I tried to say feelings of loss?
anything.
[This sounds to be an
Her voice sounds very important metaphor and she
constricted and tight when keeps coming back to it –
she talks about ‘turning off possibly a reference to how
the life support’ she is feeling?]
(Continued)
Table 10.2 (Continued)
Observation I am also behaving Am I trying to avoid anger

of therapist very ‘politely’ – keeping directed towards me?
everything calm and being
almost deferential.
Observation She is not looking at me. Tension between us is not really
of interaction acknowledged perhaps because
Long pauses before she
anger could feel too much for
speaks.
both of us.
Sighs as though tired.
Progress She is angry at the world Looking for explanations outside
of core and needs an explanation herself or medical syndromes are
formulation for why her son died. She a way of avoiding thinking about
has been experiencing her bereavement and her guilt
difficulty swallowing and will that she argued with her son
not accept that the feelings about his choice of partner the
are part of her unresolved night before the crash.
grief.
Progress The session feels stuck and The session may be reflecting
with aims of we are not making progress blocked grieving.
therapy today as the room seems
I have ideas of what might be
full of strong feelings but
happening but they feel quite
exploration seems blocked.
separate from her experience.
Reminders
Administrative We are half-way through Try to summarise where we

next week. are – drawing attention to her
feelings about having half the
Check when her son’s
time left – possibly her avoidance
birthday would have been.
of this reflects her difficulty about
endings?
Themes to be yyLoss experienced as ‘being switched off’.
monitored yyHer voice constricts when she is experiencing loss.
Notes for There is a difficult section It will be helpful to think through
supervision at 14 mins 20 secs the levels of this:
where she talks about an
yyIs she angry with me for being
insensitive doctor who did
like the ‘doctor’?
not seem bothered about
yyIs she saying something
the life-support machine
about me becoming her
being turned off and just
life-support?
wanted to talk about taking
yyIs she experiencing me as
her son’s organs.
shut-off or is she telling me
she feels shut down?
How can I share these ideas with
her?
Competence
Understanding how to intervene in different and sometimes demanding con-
texts is a key ingredient of being a competent therapist. Competence can vary
between incompetent (actually causing harm) at one extreme to expert at the
other (Hill et al, 1992; Milne et al, 1999). It is important in assessing compe-
tence to look at what therapists do rather than what they think they do, so the
use of audio recording (or where possible video recording) is crucial.
One approach to developing competence is to look at the ability to stay
within model under challenging conditions such as the pressures experienced
when a client expresses persistently negative views about the therapy and hos-
tile or derogatory comments about the therapist. These can be developed
through role-plays as discussed earlier. With that example an incompetent ther-
apist would be paralysed by anxiety, or worse would retaliate and put their own
interests ahead of the client’s. A beginner therapist may try to respond but with
defensiveness and little or no awareness of the underlying relationship possibil-
ities. Increasing competence may be demonstrated by less defensiveness, but little
flexibility and no links to the ongoing formulation of the therapy. A therapist
who is competent, in contrast, would be flexible and non-defensive but may still
not have the overarching skills to then make a link to the overall patterns in the
therapy, whereas an expert response would go the extra step and be able to
sustain a collaborative working style despite sustained hostility, and make
meaningful links to ongoing therapy themes in a skilled and effective way.
This approach can be applied to other challenging settings such as a client
expressing suicidal ideas, experience of somatic symptoms (pain, dizziness,
etc.) and in-session challenges such as conflicts about confidentiality, and man-
aging intrusions into the therapist’s private life. Workshop settings where
mutual trust is established provide a good setting for developing and assessing
one’s own skills and competence in these challenging areas.
Supervision
Supervision for PI therapy has many similarities with supervision of other
relational therapies in that the setting and development of an atmosphere of
curiosity and exploration is crucial. Some professional bodies may require a
certain number of supervised hours of practice before independent practice,
but here we deal with the key principles that we have found particularly
important in supervising PI therapy.
The experience of supervision may be individual or group, but in either format
it is important to develop a collegial rather than hierarchical atmosphere, consist-
ent with the idea of a conversation. It is usual to have audio recordings available,
where possible, so that the focus of attention can shift easily between the material
of the session and the therapist’s recall of events. Supervision with Robert
Hobson was especially illuminating in listening for the ‘minute particulars’,
sometimes spending 30 minutes listening in detail to a tiny fragment of a session
and making hypotheses, developing imaginative capacity and considering alterna-

tive ways that the therapist might have intervened. Table 10.3 summarises the
main stages in developing the focus of supervision.
Table 10.3 Developing levels of supervision
Level of skill being Areas requiring Potential pitfalls for the

supervised supervisor attention supervisor
Basic technical
competence
Includes the ability to Clarifying basic techniques. Avoid moving to
use all main types of Ensuring clarity of complex skills before
intervention. intervention. basic competence is
established.
Ensuring interventions
are in response to
appropriate cues.
Responsiveness
and sensitivity
includes Timing of interventions. Possible to overload the
responsiveness Client capacity to deal with supervisee with more
to client need, emotional distress. material than can be
timing and tact of managed at that stage of
interventions. Tact and sensitivity of development.
responses including
intercultural, gender,
disability issues.
Ability to stay
in mode under
pressure
Being able to Identifying warning Need to tolerate
adhere to the model signs of therapist uncertainty for both
under challenging intrusiveness or retaliation therapist and supervisor.
conditions. when facing challenges
from the client.
Formulating material
at the session level
Analytic and synthetic Identifying narrative Imposition of supervisor’s
skills. structure at a session level. views before the therapist
has sufficient
understanding of the
therapeutic process.
Formulating at the
case level
Ensuring there is an Identifying appropriate Awareness of risk of
overall therapeutic level and type of case level supervisor carrying out
overview. formulation. therapy by proxy.
Level of skill being Areas requiring Potential pitfalls for the

supervised supervisor attention supervisor
Making sense
of interpersonal
anxiety or tension
Using re-enactments Identifying sources of Awareness of further
to therapeutic effect. interpersonal anxiety by re-enactment between
detailed exploration of therapist and supervisor.
sessions.
Re-enactments with the
therapist of pre-existing
patterns.
Distinguishing types of
counter-transference:
concordant and
complementary.
Recognising and
feeding back
therapist blind spots
Being aware of Attending to internal cues. Awareness of possible
therapist’s habitual Receptivity to ‘parallel shame or humiliation for
defensive strategies. communications’ the therapist.
from the client about
unacknowledged re-
enactments by the therapist
Recognising blocks
in the therapy
Has therapy become Identifying signs that Awareness of therapist
ineffective? the therapy has become fears of negative or
blocked. critical evaluations by the
supervisor.
However, in the early stages of supervision there is usually a focus on mak-

ing sure that the basic skills are there – identifying possible cues, ensuring the
trainee knows what different interventions are like and what alternatives
there were. The key areas of focus at this stage are to identify and develop
basic techniques and that they are in response to cues from the client. The
main risk for the supervisor at this stage is shifting onto other fascinating dis-
cussions before the basic skills have been covered.
Later the focus shifts to nuances of the therapy including timing and sensi-
tivity to the client’s experience. The main risk for the supervisor here is in
overloading the therapist with too much information so they become demoral-
ised. As the therapist progresses the emphasis often shifts to staying within the
model when under pressure and it is important then for the therapist to expe-
rience the difference between tactically shifting to keep the alliance as good as
possible and shifting defensively under pressure. The supervisor at this point
may also run the risk of intruding on the supervisee’s personal space whilst
exploring complex re-enactments.
As competence develops the supervisory focus can settle on the narrative
flow within the session and eventually an overview (or in some situations a
formulation) of the whole case. The risk for the supervisor here is in running
the case ‘by proxy’, for example by telling the therapist what is happening
and what to say rather than leaving space for the therapist to find his or her
own ‘voice’.
As the therapist matures it is possible to discuss sources of interpersonal
anxiety and to include those arising within the therapist. This is a related
concept to that of counter-transference. As with psychoanalytic models of
therapy the supervisor can help to distinguish counter-transference arising
from the re-enactment of a typical pattern of the client’s relationships (comple-
mentary type) from counter-transference where the therapist picks up and
starts to experience feelings of which the client may not yet be fully aware
(concordant type).
The therapist should gradually discover his or her own blocks – personal
themes that make it difficult for the therapist to ‘hear’ what is being said. The
risk the supervisor faces when identifying these blocks is analogous to the
risk for the therapist with the client – the insight may be valid, but if it is said
prematurely or insensitively it may cause the client, or in this case, the ther-
apist, to feel exposed or even humiliated.
The supervisor needs to be skilled to help the therapist identify internal
cues, and on occasion there may be parallel communications to discuss where
the conversation between client and therapist mirrors the conversation
between therapist and supervisor. With an appropriately mindful attitude the
supervisor can be ‘curious’ about the parallels allowing further exploration.
Conclusions
This chapter has given a brief account of the teaching methods based on exten-
sive research and presented some suggestions arising from the delivery of
training programmes. It should be clear from the discussion in this chapter that
we favour a self-directed, and peer-directed, approach to learning wherever
possible. When we consider the role of the supervisor or facilitator it should
reflect Vygotsky’s model of striving to provide the conditions for optimal learn-
ing by providing enough conceptual scaffolding for the developing therapist
always to be in their zone of proximal development (see Hess et al., 2008; Zonzi
et al., 2014); able to reach beyond what they already know by the judicious
input from a supervisor, mentor or facilitator, but not paralysed by anxiety.
11
Epilogue
In this last chapter we have included a brief section on Robert Hobson’s

background and development to put his work, which inspired this book, into
context.
Robert F. Hobson
Robert (Bob) Hobson grew up in Rossendale, Lancashire, UK. He was edu-
cated at Bacup and Rawtenstall Grammar School; Selwyn College, Cambridge;
and Manchester University Medical School where he graduated in medicine
in 1941. During his house jobs he worked as a house surgeon in neurosur-
gery at Manchester Royal Infirmary. Seeing patients with profound brain
injury, he was fascinated by the interplay of brain, mind and spirit. From
1944 to 1946 he served as surgeon lieutenant, RNVR (Royal Navy Volunteer
Reserve), on the Arctic convoys in the last two years of World War II. This
experience gave him a model of how a captain must lead from the front,
while also supporting from the rear – something he was to apply regularly
in his later work.
He trained in psychiatry at the Maudsley Hospital under Professor Sir
Aubrey Lewis and Professor Sir Denis Hill before developing a distinguished
career as a psychiatrist. His MD thesis in 1951 was on prognostic factors in
electroconvulsive therapy (ECT). In later years, colleagues who knew him as
a psychotherapist were amazed to learn that this seminal ECT study was by
the same Hobson. His breadth of experience would be difficult to match as
he worked extensively in the emerging fields of child and adolescent psychi-
atry, addiction psychiatry and in forensic psychiatry. He then extended the
role of the psychotherapist into community and pastoral developments with
a crucial report he wrote for the then Bishop of Southwark, pushing forward
the development of pastoral counselling services. He saw psychotherapy as
having a contribution beyond the consulting room and gave these ideas prac-
tical expression through his work with groups such as the Guild of Pastoral
Psychology and Westminster Pastoral Foundation. He counted among his
friends several notable theologians, including Michael Ramsey (Lord
Ramsey, former Archbishop of Canterbury) and David Jenkins, former
Bishop of Durham.
He developed an influential therapeutic community at the Royal Bethlem
Hospital, which ran for 20 years, but he warned subsequently of the dangers
of being drawn into a ‘charismatic leadership’ style. As a pioneer in the field,
he experienced considerable personal pain when his ideal of the community
passed through the inevitable cycles of growth, dissolution, profound despair
and rebirth. He was able to link this experience with his former role as Chair
of the Jungian Society for Analytical Psychology (where he had qualified as a
Jungian analyst in 1954) and his personal meetings with Carl Gustav Jung.
These prepared him to see that the cycle of dissolution and rebirth in a thera-
peutic community was not due to the personal failings of members of staff of
that community, but was part of a larger system.
In the 1960s, Hobson pioneered the use of audio and video recordings in
clinical supervision, arguing that therapists’ recollections of their own work
are a poor guide to the minute particulars of the encounter. In a supervision
group, he would stop the tape after a therapist statement and ask each mem-
ber to predict how the patient would respond. This was scientific method in
action, as each exposed their predictions (and accompanying rationales) to the
risk of Popperian disconfirmation. His tape-based supervision was a direct
precursor of subsequent research on strains and ruptures in the therapeutic
alliance. It was also during this period that his ideas about a new approach to
psychotherapy began to crystallise, and he worked with Russell Meares to
elaborate a model based less upon interpretation and more on developing a
‘conversation’ with someone; a real meeting of heart and mind.
Having achieved so much in a little over 20 years, he surprised many
London colleagues by returning to his roots in the north of England in 1974.
He shaped psychotherapy training in the north from a base in the Manchester
Royal Infirmary with sessions around the region. He ran a small in-patient
unit in Gaskell House, shared with Dr Sidney Benjamin. This provided a
remarkable experience for a generation of psychiatrists training in Manchester
as he showed how his conversational methods applied equally powerfully in
getting to know someone admitted for an acute psychosis as for someone
admitted from the adjacent psychotherapy clinic.
As the Regional Director for psychotherapy training, he persuaded the then
regional training director to let him use the staff training college at Brindle
Epilogue 155
Lodge for residential courses several times a year. Through those intensive
workshops he inspired a group of colleagues to develop advanced training in
psychotherapy in the north-west of England. Until a month before his death
he continued his work as a supervisor of senior staff in the area. As a super-
visor he modelled his own approach to therapy; being actively involved in a
supportive but searching conversation about personal experience.
Sometimes he needed to be convinced that he had something worth say-
ing, but a brief selection of his papers outlined below show the remarkable
breadth of his interests. He set himself ferociously high standards, but each
of his clinical papers, whether on ‘Loneliness’ (Hobson, 1974: developing
the concept of ‘aloneness-togetherness’) or ‘The Messianic Community’
(Hobson, 1979: on the risks of the charismatic leader) had a profound influ-
ence. Some of his papers drew on his love of literature and he wrote on
Coleridge’s The Rime of the Ancient Mariner (Hobson, 1984) and Arthurian
legend (Hobson, 1965) with equal ease. He was proud of his Lancastrian
background adding traditional poetry in Lancashire dialect to his immense
knowledge of folklore and myth, and he learned Welsh to study Arthurian
legends in their original form.
His fullest exposition is his 1985 book Forms of Feeling: The Heart of
Psychotherapy. Every therapist and counsellor can learn from it. It is
intensely personal, immediate, wise, theoretically rich, disarmingly direct
and free of jargon, and we draw heavily on that wisdom in this book. Forms
of Feeling reflects his unique ability to blend personal, literary, scientific,
psychodynamic, spiritual and philosophical themes and ideas, together with
finely drawn and succinct stories of therapeutic encounters.
It draws freely upon diverse ‘schools’ of psychotherapy, seeking a dynamic
synthesis rather than a mere eclectic compromise. The writing is poetic: every
word feels chosen for its textured meanings, resonances and associations,
every phrase crafted with intensely applied skill. Unusually for a psychother-
apy book, it attracted a positive review by the eminent American cognitive
psychologist George A. Miller.
Alongside his direct influence on the psychotherapy research carried out in
Britain, which earned him a Lifetime Achievement Award from the UK
Chapter of the Society for Psychotherapy Research, Hobson’s long-held central
ideas and beliefs about how psychotherapy helps people change – through
interpersonal learning grounded in a secure, open, responsive, interdependent
therapeutic relationship – have proved prescient, as they continue to gain sup-
port in the wider research literature. His approach also prefigured the trend
toward integration across the different approaches to psychotherapy.
Robert Frederick Hobson, psychiatrist and psychotherapist: born

Rawtenstall, Lancashire, 18 May 1920; Physician, Bethlem Royal Hospital
1954–74; Consultant Psychotherapist, Manchester Royal Infirmary 1974–
85; Reader in Psychotherapy, Manchester University 1974–85, Honorary
Emeritus Reader 1985–99; married 1946 Marjorie Brett (two sons, one daughter);
died Stockport, Cheshire, 13 November 1999.
Obituaries:
Margison, F.R., ‘Obituary Robert F. Hobson’, Guardian, Monday 29 November 1999.
Margison, F. and Shapiro, D.A. (2000) ‘Obituaries: Robert F. Hobson’, The Psychiatrist
(Bulletin of the Royal College of Psychiatrists), 24: 238.
Shapiro, D.A., ‘Obituary Robert F. Hobson’, Independent, Monday 29 November 1999.
Appendix: The
Psychodynamic-
Rating Scale (PITRS)
Introduction
This rating scale is an abbreviated version of the full scale which has more
detailed notes for raters. The rating rules are important if it is to be used in
research, so that good reliability can be maintained, but for use in learning the
model less formality is needed.
The PITRS is an adaptation of the Sheffield Psychotherapy Rating Scale
(SPRS), developed by Startup and Shapiro (1993).
Using the manual as an aid to learning the model

The adherence manual can be used as a useful tool to learn the model.
Therapists can rate their own recordings or role-plays to determine how in or
out of model behaviour they are. It is best to start with the basic skills first, as
PI therapists should use these items frequently. It is best not to progress to or
focus on the intermediate skills until the basic ones have been mastered.
It can be helpful to listen to portions of recordings, and stop the recording
at a point where a PI item has been identified or a PI intervention has been
missed. Try to think of ways to improve the PI item, if it gets a low score. If
a PI intervention has been missed, stop the recording and try to think of an
appropriate high scoring item that the therapist could have said.
The advanced items occur less frequently in therapy than the basic skills.
These are harder to learn and are best developed through practice, close
supervision and listening and re-listening to one’s own therapy recordings.
Specific items
Basic skills
1. Use of statements as opposed to questions

2. Picking up cues
3. Negotiation
4. Understanding hypotheses
Intermediate skills
5. Focusing on feelings (here and now)

6. Metaphor (living symbols)
7. Language of mutuality
8. Linking hypotheses
Advanced skills
9. Explanatory hypotheses
10. Exploratory therapy rationale
11. Sequencing of interventions
12. Relating interpersonal change to therapy
13. Patterns in relationships
Stage 1: Basic skills

1 Statements
Did the therapist use statements as opposed to questions when making an

intervention?
1 2 3 4 5 6 7
not at all some considerably extensively
The purpose of this item is to measure the extent to which the therapist’s interven-
tions are couched in the form of statements, as opposed to questions. The intention
in the model is to promote a feeling language, and the use of statements helps this
to develop. Some questions are necessary and the therapist should not be marked
down for using questions where it is appropriate (e.g. sorting out a practical issue,
arranging a different time to meet or some aspects of a risk assessment). This item
should be occurring very frequently throughout the session. A high rating would be
achieved if over 80% of the therapist’s utterances are in the form of statements.
Examples
The following are examples of interventions that are phrased in the form of
statements:
T: It’s been a difficult time for you.

T: I imagine it’s a struggle to keep going.
T: I wonder perhaps…you could say a bit more.
Appendix 159
If the therapist used a lot of questions as opposed to statements he/she would

be marked down on this item. The following are examples of interventions
that are not in statement form for contrast.
T: How have you been feeling?
T: Why do you think you feel like that?
T: Is it a struggle?
2 Picking up cues
Did the therapist explicitly base his/her interventions on cues (verbal and
non-verbal) supplied by the client?
1 2 3 4 5 6 7
The purpose of this item is to measure the extent to which the therapist’s inter-
ventions are explicitly based on verbal and non-verbal cues supplied by the
client during the session. These cues include choice of words as well as the
content expressed. They also include non-verbal cues such as posture, gestures,
facial expression and tone of voice. Cues in the therapist can also be included
if the therapist specifically refers to a cue-based response in him/herself. There
should be several instances of this item in a session of PI therapy.
Examples
The following are examples of interventions that are explicitly cue-based:
T: As you tell me about what’s been happening at home this week, you’re looking
like you’re ready to cry. I suppose you’ve been feeling pretty desperate about it.
T: And yet, the words you’re using to tell me this seem to put a distance between you
and what’s been happening. Words like ‘expectations’, ‘goals’, and so on, as if you
feel a bit cut off.
T: It seems you are a bit subdued today…not your normal self.
No doubt there are degrees of explicitness with which a therapist might base
his/her interventions. If it seems likely that a given intervention is based on
cues provided by the client but it is not certain, then some credit on this item
should still be given. In the following example it seems likely that the thera-
pist is referring to something in the client’s manner of telling a story, such as
the tone of voice or facial expression:
T: There’s something sad in those memories.

It may become apparent that the therapist is missing many cues from the client.
C: I’ve felt so anxious and worried I haven’t had a wink of sleep.
T: Can you tell me more about your sleep?
In this example the therapist has missed the verbal cue about the client feel-
ing anxious and worried and instead focuses on the client’s sleep. If this is
typical of a lot of the session, the therapist would receive a low score.
3 Negotiation
Did the therapist express his/her views concerning the patient’s experiences
and circumstances as tentative statements, open to correction, and inviting
elaboration and feedback?
1 2 3 4 5 6 7
This item assesses the ‘how’ of the therapist’s talk. It is concerned with the
extent to which the therapist, rather than implying ‘this is right’, conveys the
message, ‘I am trying to understand how you are feeling and this is how I
think you may be feeling…based upon what you have told me and how you
appear…but maybe I am wrong.’ To be tentative is not to be vague. Therapist
statements in a session rated highly on this item may well be definite (i.e.
clearly ‘owned’ by the therapist) and often specific (i.e. referring to particular
experiences and making quite detailed comments or observations concerning
these). These qualities of definiteness and specificity follow from the therapist
doing his or her best to be accurate, to really attend to the cues from the client
and the minute particulars of the conversation. The therapist conveys his or
her wish to be corrected, expressing a hope for communication which will
lead on to dialogue, with an adjustment of misunderstanding. This wish is
expressed in words, constructions and turns of phrase, as well as in the way
they are spoken. The rater should watch for such indicators of tentativeness
as ‘maybe’, ‘it’s almost as if’, ‘I’m not sure about this, but…’, ‘I wonder if…’,
etc. The ideal scenario is when a therapist makes a suggestion, which is then
further shaped and modified by the client. There should be several instances
of this item in a session.
Examples
The following illustrates a response typical of a therapist scoring very low on

this scale.
Appendix 161
C: I think I’ve been spending more money lately because I just need to cheer myself up.
T: That’s not the best way to cope with feeling down; you have fallen back into behav-
ing like a small child.
A medium rating would be obtained by a therapist using responses similar to

the following:
T: I’m not sure about this, but maybe, in a way, when you feel miserable and alone, buy-
ing things helps comfort you. It’s almost as if you’re feeling again like that a child who
needs treats, as if having things for yourself helps you feel comforted, and maybe loved.
A high rating is reserved for therapists skilfully adopting the negotiating style
in relation to issues within the relationship between therapist and client:
C: That’s just it, you see, you don’t seem to want me to get over it.
T: That feels pretty important to me. I wonder if what is happening between us…I’m
not sure…it feels to me as if you’re disappointed, as if you feel I’m not really with
you, not really on your side.
C: I thought I was doing really well in the last week. I’ve got out much more, I’ve been
meeting friends, I’ve been playing the guitar again.
T: I wonder if it feels when we try to look at what’s happening, the huge efforts you
are making to change are being ignored by me, and you don’t feel valued…I’m not
sure…almost that I want you to remain unwell. [Pause]
C: I don’t know…
T: How you feel is very important…and it’s important to me…to really under-
stand…I wonder if we could stay with that feeling you have…you said…‘you don’t
seem to want me to get over it’.
C: I was looking forward to telling you today what I had achieved in the week, but
when I told you…you just seemed disinterested…I was disappointed…
T: Frustrated…annoyed…can we stay with these feelings
C: Very annoyed…
In this example, by adopting a negotiating style, the therapist is able to help

the client explore his feelings of anger towards the therapist, whilst deepening
the conversation between them.
4 Understanding hypotheses
Did the therapist offer statements of empathic understanding that helped to

deepen the conversation?
1 2 3 4 5 6 7
This item measures the extent to which the therapist offers empathic and
imaginative statements of what he/she feels that the client is experiencing
right now in the relationship. Empathy is conveyed in such a way as to call
forth a response; to achieve a dialogue with increasing mutual understand-
ing, in which the desire to understand is communicated. This involves more
than simple repetition or reflection of the client’s message; that something
more comes from the therapist’s own perspective on the experiences
reported by the client, and is derived from the therapist’s understanding
and best guess of what the client is experiencing. This requires the therapist
to pay close attention to cues from the client as to how he/she is feeling.
One important aim of understanding hypotheses is often to contribute to
the resolution of misunderstanding. Another is to deepen the conversation
in a way that feels acceptable and safe for the client. Item 1 (using state-
ments) can also be scored if the hypothesis is couched in the form of a
statement. There should be many instances of this item in a session of PI
therapy.
Examples
The following is a simple example of an understanding hypothesis that tries

to take forward the client’s self-awareness, and invites a response:
C: I get really fed up at times and…[client sighs]…I just don’t know what to do.
T: Perhaps you are feeling quite unsure…lost?
C: It’s like everyone I’ve known couldn’t care less…
The next example is directly concerned with the resolution of

misunderstanding.
C: I don’t see the point of coming here. My doctor told me to come…but I don’t see
that talking is going to make any difference. I thought you would be able to actually
do something.
T: Mhm…It sounds as if you feel you’ve been sent here…to see me…under some kind
of false pretences…you’re understandably feeling aggrieved and frustrated…it
wasn’t what you had in mind…
C: Yes, well, my wife thinks I should be here…she’s worried I’m going to top myself.
Understanding hypotheses are not reflections (when the therapist repeats

back to the client what he/she has said). Below is an example of a reflection
which is an empathic statement, but it would receive a low score on this
item, but a high score on item 1 as it is not a question.
C: I get really fed up at times and…[client sighs]…I just don’t know what to do.
T: You get very fed up…
Appendix 163
Stage 2: Intermediate skills

5 Focusing on feelings (here and now)
Did the therapist focus on the here and now experience of the client in the
session, encouraging the client to stay with feelings to see what comes to mind?
1 2 3 4 5 6 7
This item measures the extent to which the therapist promotes the client’s
experiencing, acknowledgment and recognition of feelings, whether or not
these have been expressed, and whether or not the client is aware of them. The
therapist must act to promote this awareness, rather than respond to the client’s
expression of feelings by seeking to explain or dispel them. This encouragement
of the client to stay with the experience of a particular situation as it arises
during the session may require explicit guidance to the client, using instruc-
tions or suggestions. Particularly highly rated are efforts by the therapist to
focus on the physical sensations and inner experiences associated with feelings,
particularly if these feelings are aroused in relation to specific other people,
notably the therapist. There should be several instances of this in a session of
PI therapy.
Examples
The following are examples of the therapist focusing on the client’s here and
now experience:
C: It’s just rather frustrating, I suppose, to realise how much time I’ve spent marking
time in a way, not really getting anywhere at work.
T: Let’s just stay with that frustration, and try to get in touch with what it makes you
feel, inside.
C: You never seem to come out with what you think of what I’ve said or done, so I
just have to try and figure it out for myself. So, yes, I do wonder what you think,
and that’s not very comfortable.
T: Well I wonder if you could stay with that feeling of discomfort…it’s here now…just
stay…let’s see what comes to mind
C: John said I was wrong to react like I did, but I just couldn’t help it, somehow. I
just had to tell them that I wasn’t in a position to help out yet again, that they’d
been taking it for granted that I would, but that it just wasn’t possible. It hap-
pened again on Tuesday. Bill said that his section were short-staffed, and could I
let them have an extra person for the day, despite their already having had extra
help the previous day, which is much more than any section would normally ever
have in a week.
T: You’re feeling pretty tense as you tell me about all this…I wonder if we could stay
a bit with how you are feeling inside…right now…
6 Metaphor (living symbols)
Did the therapist encourage and elaborate the client’s use of metaphor?
1 2 3 4 5 6 7
This item is designed to measure the extent to which the therapist deliberately
aims to convey and promote a symbolical attitude. This means endowing
words, gestures, dreams, etc., with value – regarding them not only as com-
munications of formulated messages but also as living symbols.
The therapist rated highly on this item encourages the client to use meta-
phoric communication, and elaborates or builds upon metaphors introduced
by the client, in order to make greater integration of the client’s experience,
and to heighten or intensify the client’s experiencing and expression of feel-
ings. However, the rater should be alert to the possible use of metaphor as
an adornment rather than as direct and vivid communication. There should
be some instances of this item in a session of PI therapy.
Examples
In the following example, the therapist achieves a rating above ‘1’ by the use
of figurative language. However, this is not based on the client’s material in
this session, and so the rating would not be above ‘2’.
C: There’s so much to do at work that I often feel I cannot carry on.

T: You sound to me like Samson or Charles Atlas bearing the world on your shoulders.
The following examples would secure moderate to high ratings on this item, as
the therapist promotes the client’s use of metaphor, teasing out and elaborating
metaphoric content of which the client is scarcely aware:
C: It seems such a heavy burden when I am the one who always has to take respon-
sibility for things.
T: The weight of that burden feels really overwhelming, maybe to the point where
you feel crushed by it.
C: I find it very difficult to do my job. There is very little guidance laid down. I’m all
at sea with the work, especially at this time of year.
Appendix 165
T: No guidance, all at sea. It feels like there’s no one to steer you, and you’re at the
mercy of the waves, buffeted around by the waves, by things you can’t control.
C: I don’t really feel anything inside…just empty.
T: Empty…a void…that’s a powerful image.
C: I do feel that, a chasm, I suppose, opening up between me and everything or every-

one around me.
T: A great vastness of the distance between you…
7 Language of mutuality
Did the therapist use the language of shared endeavour (‘I’ and ‘we’)?
1 2 3 4 5 6 7
This item measures the therapist’s use of language conveying his or her full
participation in the therapeutic conversation. The use of first-person words ‘I’
and ‘we’ affirms the aim of a conversation between two separate and yet
related responsible persons who, alone and together, claim their actions. The
message of this language is that ‘we’ are separate people, yet there is a sharing.
Use of ‘I’ and ‘we’ often has the effect of deepening the conversation as the
focus is placed directly on the client–therapist relationship. There should be
several instances of this item in any session of PI therapy.
Examples
The following illustrates the therapist’s use of ‘I’ and ‘we’ to affirm the thera-
peutic conversation:
T: I feel that what we’re coming to grips with, here, is a big part of what happens
when you are trying to get to feel closer to someone …there’s a fear… And with
that comes…a moving away…a moving away from me…I think …we can both feel
that tension that fear…now…
T: When you say that, you look away from me, I feel it would be difficult for you to
hold my glance…because of the strong feelings between us.
In contrast, the following would be consistent with a rating of ‘1’, because the
therapist avoids using ‘I’ or ‘we’.
T: It sounds as if it was difficult for you to come to the session this morning?
Whereas the statement below would receive a high rating on this item.
T: It sounds as if it was difficult for you to come to see me this morning? It feels that
difficulty’s between us now…in the room here.
The use of ‘you’ can have a rating above ‘1’ on this item if this is accompanied
by use of ‘I’ and ‘we’:
T: This is a big part of what happens when you try to get close to someone, you both
want it and yet, I feel as we’re talking together, we’re finding it pretty scary, too.
8 Linking hypotheses
Did the therapist link the client’s present feelings with feelings in other con-
texts and at other times, with the central link being between each of these and
the ‘here and now’ of the therapeutic relationship?
1 2 3 4 5 6 7
This item measures the therapist’s use of observed recurrent patterns in the
client’s experiences and behaviour to make links and draw parallels, using a
tentative style. The therapist helps the client to make sense of experiences
by creating greater cohesion and thus to counter fragmentation and loss of
integration. Links may be (a) between events within therapy at different
times: perhaps during one interview, perhaps relating what is happening
now to previous sessions; or (b) between patterns in the present therapeutic
conversation and those in other areas of life (especially ways in which rela-
tionships are defective and distorted). This item would receive a ‘1’ if there
is no reference to the therapy or the therapeutic relationship. Instead a link
between relationships that did not include the therapist–client relationship
would be rated under item 13 (Patterns in relationships). There should be
some examples of this item in a session of PI therapy.
Examples
The following example would yield a high rating, because the therapist made
links between patterns in the therapeutic relationship and those in other areas
of life.
C: I really find it difficult when he asks me about my movements over the next few
days. He seems to want to tie me down, and that annoys me. I just wish he
wouldn’t hassle me so much, and just let me decide for myself how to allocate
my time.
Appendix 167
T: This feeling of being hassled by your boss reminds me, in a way, of what happens
here, when you feel I’m trying to tie you down too, when I want to know how
you’re feeling about things. You seem to find it really hard, and to get pretty uptight
and angry, whenever someone, perhaps especially someone with power or author-
ity, wants something from you.
Stage 3: Advanced skills

9 Explanatory hypotheses
Did the therapist introduce possible reasons or explanations for the client’s
behaviour and experiences, particularly in respect of disturbances in relation-
ships within and outside therapy?
1 2 3 4 5 6 7
This item refers to an intervention by the therapist that offers a reason or some
form of explanation as to the basis of the client’s feelings or behaviour. It rarely
occurs as a stand alone intervention but often follows a series of linking or under-
standing hypotheses. The term hypothesis implies that the therapist should pres-
ent it in a tentative fashion to be agreed, modified or rejected by the client.
Often there is reference to a present action that is carried out in order to
avoid a particular kind of relationship that would result in some catastrophe
or feared outcome. This fear of catastrophe may or may not be completely
outside awareness. In the conversation, it may or may not be explicitly linked
with past experience (like ‘I was abandoned by my mum’). It is desirable that
the client should contribute some or all of the explanation themselves, so that
client contributions to this are ‘credited’ to the therapist in making the rating,
provided that there is evidence that the therapist has contributed to the cli-
ent’s arrival at the explanation. This item does not occur frequently in a ses-
sion and may not be present in every session of PI therapy.
Examples
To aid rating, consider four ways in which therapists may attempt to explain
the client’s current issues:
(1) Fears of intimacy and abandonment

T: So although you would really like to feel close to someone, you’re scared of getting
close and find yourself often running from the possibility of an intimate
relationship.
(2) Events or motives rooted in the client’s past

T: I wonder if your indecisiveness regarding the possibility of separating from your
wife is in some way connected to that deeper conflict we’ve talked about – the trou-
ble you had earlier in your life around leaving your home and your mother.
(3) B
asic patterns which influence the client’s reactions
to the therapist
T: You feel cross now and frustrated…with me…[pause]…and a pressure from me…and
we have talked a lot about how angry you feel with your father because he was con-
stantly making demands…I wonder if these feelings are connected in some way…and
you feel I am making demands on you…
(4) M
otives or tendencies which serve to reduce anxiety or avoid
warded off feelings
T: It’s hard to face things we are scared of…very hard…it feels sometimes…that you
are a bit afraid of showing a bit more of yourself to me…the inside you…maybe
because…there’s a fear…that I won’t like you…with that fear…comes a feeling
of not being likeable…I wonder…and that seems to stem from…the very difficult
times when you were little…and were constantly told how bad and horrible you
were.
Note that reasons or causes deriving from the client’s thought patterns do not
increase ratings on this item, unless reference is made to origins of those thought
patterns in emotions, problematic or conflictual motives, or relationships with others.
Thus, the following example is compatible with a rating of ‘1’ for the session:
T: You are thinking about this in very negative terms. I have noticed a general ten-
dency you have to blame yourself when things go wrong, and yet never to take the
credit when things go well.
If the therapist were to proceed to link the problematic thought pattern to emo-
tions, motives or relationships, however, then a medium rating would be achieved.
T: You are thinking about this in very negative terms. I have noticed a general tendency
you have to blame yourself when things go wrong, and yet never to take the credit
when things go well. Perhaps this goes back a long way, and maybe it relates to the way
your parents seemed to judge you quite harshly at times…I’m not sure.
A high rating would be to give explanations that include some aspect of the
therapeutic relationship.
T: You are thinking about this in very negative terms. I think you have a tendency to
blame yourself when things go wrong, and yet never to take the credit when things
go well. Perhaps this goes back a long way, and maybe it relates to the way your
parents seemed to judge you quite harshly at times…and maybe it explains last
week when we had that mix up…you felt you were to blame…but it was really
probably to do with both of us getting mixed up…
Appendix 169
10 Exploratory therapy rationale
Did the therapist provide a rationale which suggested that working on under-
standing and changing the client’s characteristic patterns of feeling and action
in relationships, would help overcome the client’s difficulties and symptoms?
1 2 3 4 5 6 7
The purpose of this item is to measure how extensively the therapist discussed
the importance of focusing on relationships, especially the therapeutic rela-
tionship, for the purpose of overcoming the client’s problems. This connection
need not have been explicit, but it must have been strongly implied. This item
should be present in the initial sessions of a PI therapy, and may occur again
through the course of the therapy, but may not be present in every session.
Examples
The following is an example of a therapist statement that should receive a

medium rating as there is an implied link between relationships and the cli-
ent’s depressive symptoms. A high rating would be given if there was a specific
link to the therapeutic relationship:
T: Since so much of what’s happening with you at the moment has to do with your
relationships with other people, I think that as you begin to understand and work
out some of those things, you will feel less depressed.
In the following example, the rationale offered by the therapist explicitly

refers to the therapeutic relationship and so secures a high rating:
T: Since so much of what’s happening with you at the moment has to do with your
relationships with other people, I think that as you begin to understand and work
out some of those things, especially as they come up between us, you will feel less
depressed.
11 Sequencing of interventions
Did the therapist present interventions within a given episode in the sequence
of staying with feelings => thoughts/symbolic material => relationships?
1 2 3 4 5 6 7
This item should occur repeatedly over the course of a therapy although not
always in its entirety. The therapist should be encouraging the client to access
or focus on feelings and working then from that point with the material that
develops. This material usually involves a connection with relationships at
some level. The sequencing may sometimes involve an explanation at the end
in the form of an explanatory hypothesis, but this is less frequent.
The main emphasis in rating should be on the therapist abstaining from
offering causes or reasons for a behaviour or experience without first facilitat-
ing, experiencing in the here and now, and staying with that experience, which
may then lead on to relationships.
Examples
The following illustrates material that should be rated low on this item:
C: I don’t feel like talking today, it just feels too much of an effort.
T: Maybe that’s because you don’t want to get involved with the difficult feelings we
talked about last time.
A higher rating would be given if the therapist responded as follows, interpos-

ing an empathic reflection before proceeding to offer an explanation:
C: I don’t feel like talking today, it just feels too much of an effort.
T: Mhmm, you are feeling weary… [feelings]
C: Yeah…fed up…
T: Errr…I can feel that you do [gesturing with her hands] …it’s palpable…I wonder if
you could stay with this feeling…fed up…weary…stuck…can’t be
bothered… [staying with feelings]
C: [Sighs] It feels really hard to get started today. I’ve had a lot of bad dreams in the
last week. About dying…and dead bodies…horrible… [thoughts, symbolic
material]
T: Umh…dying…we spent most of last week talking about your mum’s death…I know
you found that very hard…I wonder if you feel that discussion between us has
stirred things up in you…fears…nightmares… [relationship with mother]
In the above example there is a clear sequence of staying with a feeling –

seeing what emerges – and then linking that to a problematic relationship.
The therapist would receive a low rating if he/she attempted to explore and
provide an explanation without this arising from an initial focus on feelings.
This kind of intervention is not using feeling language and is an intellectual
approach to the problem. The principles of this item are most readily demon-
strated at the microscopic level. However, in rating a session on this item, at
least as much attention should be paid to larger units of analysis. During an
episode (i.e. a portion of the session devoted to a single topic or closely related
set of topics or issues) lasting several minutes or even taking up a substantial
proportion of the hour, the therapist’s activities may shift between staying with
feelings, symbolic material, relationships and explanatory activities.
Appendix 171
12 Relating interpersonal change to therapy
Did the therapist relate changes in the client’s interpersonal relationships to the
emphasis in therapy on understanding and changing the client’s ways of relat-
ing to others, including in particular the therapist?
1 2 3 4 5 6 7
In order for this item to be rated greater than ‘1’, the therapist must have made
a connection between the focus on relationships in therapy and changes that
have occurred in the client’s relationships. This item will not occur in all sessions
of PI therapy.
Examples
The following is an example of the therapist having clearly related interper-

sonal change to therapy. This example would warrant a medium to high rating
depending on how this discussion continued.
T: We’ve spent a lot of our time together looking at your relationship with your wife
and on some of the things that were making it hard for you to spend more time
with your children. These relationships seem to be very much better for you now
than when you first came here. It seems to me that our looking at these issues
together has helped you feel quite different about them. I’m wondering how much
you feel this too.
The following example should be rated medium on this item because the ther-
apist helped the client to relate what was discussed in therapy to her resolu-
tion of a specific relationship problem. It does not get a very high rating as it
is not related to the ‘here and now’ or the therapist–client relationship.
T: Last week we discussed a problem you were having with your brother. I’d like to
know how you’re feeling about him now.
C: I do feel it’s a bit easier to talk to him now, somehow he doesn’t irritate me as much
as he did before.
T: When we talked about him last week, you seemed to come to realise that it wasn’t
so much what he said that got to you, as how you felt he was trying to carry on
controlling you the way your dad did when you were little. Maybe that new way
of looking at it has made it easier to feel OK with him.
Were the previous example to include reference to work done on the client–
therapist relationship, it would warrant a higher rating:
T: Last week we discussed a problem you were having with your brother, and how a
similar problem came up between us as we were looking at how you felt about
him. You’ve spent some time with him this week.
C: I do feel it’s a bit easier to talk to him now. Somehow he doesn’t irritate me as
much as he did before.
T: When we talked about him last week, you seemed to come to realise that it wasn’t
so much what he said that got to you, as how you felt he was trying to carry on
controlling you the way your dad did when you were little. And our conversation
seemed to be going in much the same way, with you feeling that I was a bit con-
trolling…perhaps which reminded you a bit of how it was with your dad…Maybe
that new way of looking at it has made it easier to feel OK with me, and with your
brother too.
13 Patterns in relationships
Did the therapist draw parallels or point out patterns in two or more of the cli-
ent’s relationships for the purpose of helping the client understand how she/he
functions in interpersonal relationships?
1 2 3 4 5 6 7
The purpose of this item is to measure the extent to which the therapist helps
the client explore past or present relationships for the purpose of identifying
patterns which occur in two or more of those relationships. This item may not
occur in all sessions of PI therapy.
Examples
The following are examples in which the therapist pointed out a pattern in the
client’s relationships (Example (a)) and a parallel between two of the client’s
relationships (Example (b)).
(a) T: It appears to have been very easy for you, both in your present relationship and
in [past significant other relationships], to bend to meet the other person’s needs
and to neglect yourself.
(b) C: I really get angry when my friend starts telling me what to do. Whenever we get
together she has advice for me on how I ought to do this or how I ought to do that.
T: That sounds similar to the reaction you have when your boyfriend gives you
advice. It might be helpful for us to understand a bit more about that.
The parallels and links yielding high ratings for this item – ‘Patterns in relation-
ships’ – need make no reference to the therapeutic relationship. If a link is
made between a pattern in one of the client’s relationships and the therapeutic
relationship, the item ‘Linking hypotheses’ should also be scored more than ‘1’.
Appendix 173
Psychodynamic-Interpersonal Therapy Rating Scale

Basic skills
1. STATEMENTS: Did the therapist use statements as opposed to questions

when making an intervention?
1 2 3 4 5 6 7
2. PICKING UP CUES: Did the therapist explicitly base his/her interventions
on cues (verbal and non-verbal) supplied by the client?
1 2 3 4 5 6 7
3. NEGOTIATING STYLE: Did the therapist express his/her views concern-
ing the patient’s experiences and circumstances as tentative statements,
open to correction, and inviting elaboration and feedback?
1 2 3 4 5 6 7
4. UNDERSTANDING HYPOTHESES: Did the therapist offer statements

of empathic understanding that helped to deepen the conversation?
1 2 3 4 5 6 7
Intermediate skills
5. FOCUSING ON FEELINGS: Did the therapist focus on the HERE AND
NOW experience of the client in the session, encouraging the client to stay
with feelings to see what comes to mind?
1 2 3 4 5 6 7
6. METAPHOR: Did the therapist encourage and elaborate the client’s use of
metaphor?
1 2 3 4 5 6 7
7. LANGUAGE OF MUTUALITY: Did the therapist use the language of

shared endeavour (‘I’ and ‘we’)?
1 2 3 4 5 6 7
8. LINKING HYPOTHESES: Did the therapist link the client’s present feelings
with feelings in other contexts and at other times, with the central link being
between each of these and the ‘here and now’ of the therapeutic relationship?
1 2 3 4 5 6 7
Advanced skills
9. EXPLANATORY HYPOTHESES: Did the therapist introduce possible

reasons for the client’s behaviour and experiences, particularly in respect
of disturbances in relationships within and outside therapy?
1 2 3 4 5 6 7
10. EXPLORATORY THERAPY RATIONALE: Did the therapist provide a

rationale which suggested that working on understanding and changing
the client’s characteristic patterns of feeling and action in relationships
would help overcome the client’s difficulties and symptoms?
1 2 3 4 5 6 7
11. SEQUENCING OF INTERVENTIONS: Did the therapist present inter-

ventions within a given episode in the sequence of: staying with feelings
=> thoughts/symbolic material => relationships?
1 2 3 4 5 6 7
Appendix 175
12. RELATING INTERPERSONAL CHANGE TO THERAPY: Did the

therapist relate changes in the client’s interpersonal relationships to the
emphasis in therapy on understanding and changing the client’s ways of
relating to others, including in particular the therapist?
1 2 3 4 5 6 7
13. PATTERNS IN RELATIONSHIPS: Did the therapist draw parallels or

point out patterns in two or more of the client’s relationships for the pur-
pose of helping the client understand how she/he functions in interper-
sonal relationships?
1 2 3 4 5 6 7
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Index
abstract language, 108 clocks, positioning of, 92

adherence to the PI model, 36, 138, 140, 151 Cluster C personality disorder, 20, 23, 46
advanced PI skills, 77–86, 157–8, 167–75 cognitive analytic therapy (CAT), 11, 129
affective states, 11 cognitive behaviour therapy (CBT), 13, 16–23,
Agnew, R.M., 42 32, 38–9, 44, 46, 49
Agnew-Davis, R., 41 cohesion of the self, 5
aloneness–togetherness, 56, 85, 155 Coleridge, Samuel Taylor, 13, 155
‘amodal properties’ (Stern), 12 collaboration between therapist and client,
approach–avoidance conflict, 108 11, 56, 85, 99, 149
Arthurian legend, 155 competencies of therapists, 53–4, 138, 149,
assimilation model, 13, 35, 47–9, 103 152
attachment theory and attachment styles, 11, advanced, 77–86, 157–8, 167–75
44–5 stages in the development of, 57, 65–6
attunement, 5, 9, 11, 55, 59, 94, 109, 116 complex disorders, 29
audio recording of therapy sessions, 9, 57, continuing professional development, 143
91–4, 105, 116, 130, 138, 140, 146, 149, Conversational Model of therapy, 4–7,
154, 157 10–13, 15–17, 24, 29–30, 84–5; see also
used in teaching and supervision, 138 therapeutic conversation
core values, 12–13
Bakhtin, Mikhail, 12 cost-effectiveness of treatment, 17, 24, 32
Barkham, Michael (co-author), 16, 21, 42, 45 counter-transference, 61, 152
basic skills for therapists, 151, 157–62, 173 Creed, Francis, 24, 27
Benjamin, Sidney, 154 cue cards, 141
Blake, William, 8 cues
bodily feelings, 146 picking up on, 59–61, 66, 146, 152, 159–60,
borderline personality disorder, 4, 24, 173
29–32, 55 in the therapist, 61
Bowlby, J., 13
brief therapy, 120–1, 133–4 deeper communication, 124
structure of, 90–1 depression, 10, 16–17, 23–4, 32, 116
Brindle Lodge, 154–5 derogatory treatment of clients, 85
Buber, Martin, 13, 115 Detert, N.B., 48
Burns, A., 31 dialectical meaning, 12
disclosure by clients, 110–11
change, moments of, 109–11 dose-effect relations, 22
changes happening in the course of therapy, duration of therapy, 17–22
review of, 126
chronic disorders, 24 eclecticism in therapeutic approach, 13
‘chronicles’ (Meares), 7 effect size, 17
clients effectiveness research, 15
confidence in the therapist, 50 efficacy studies, 15
endorsement of treatment, 46 Elliott, Robert, 16, 43, 144
expectations of, 45–6 ‘emotional knowing’, 115–16
views on the therapy, 34, 37–9 ‘empathetic resonance’ (Meares), 116
Clinical Outcomes in Routine Evaluation– empathy and empathetic understanding, 91,
Outcome Measure (CORE–OM), 23 161–2
ending of sessions, 91 Hill, C.E., 144

ending of therapy, 113 Hobson, Robert F., 4–13, 15, 17, 21, 24, 39,
content of final sessions, 120–34 41, 55–6, 59, 72, 74, 81, 84–5, 91–2, 108,
explicit discussion of, 121 115–17, 137–8, 142–6, 149, 153–5
linked to previous experiences of loss, 121–2 Howard, K.I., 22
Ericsson, K.A., 53 hypotheses in therapy, 64–5, 99, 146, 149–50,
evidence-based practice, 9 161–2, 167, 173; see also explanatory
expert therapists, 149 hypotheses; linking hypotheses
explanatory hypotheses, 77–9, 146,
167–8, 174 ‘I’, use of, 74–5, 121, 165
explanatory models, building of, 113–14 idiographic measures, 19, 22
exploratory therapy and rationale, 16–17, 99, Improving Access to Psychological Therapies
104, 169, 174 (IAPT) programme, 24
infants’ development, 11
farewell letter, 129–33 ‘inner forms’, 8
example of, 132–3 ‘inner speech’, 7
first use in PI therapy, 129 insight, 43
feedback, learning from, 138–40 integrative therapeutic practice, 13, 155
‘feeling language’, 7, 13, 39–40, 55–6, 81, 89, intermediate-level PI skills, 67–76, 163–7,
102, 115–16 173–4
feeling states, 116, 118 intermediate sessions of PI therapy, 107–19
feelings, focusing on, 67–72, 124–5, 144, 173; interpersonal change linked to therapy, 81–2,
see also bodily feelings 171–2, 175
Field, S.D., 48 interpersonal difficulties, symptoms linked to,
figurative speech, 8 99–102
final sessions of therapy, 120–34 interpersonal model of the person, 10
finishing date for therapy, 121 interpersonal problem-solving, 88
first few minutes of therapy, 91–2, 95–9, Interpersonal Psychoanalysis, 12
105, 146 interpersonal situations, 142
first session of therapy, 92 interpersonal style, 44
focus of therapy, 37 ‘interpretations’ made in therapy, 64–5
follow-up sessions, 134 intrusion, 85
Fordham, M., 12 invalidation of clients’ experience, 85–6
‘forms of feeling’, 5, 7–8, 56, 72, 115 irritable bowel syndrome, 25–7, 117–18
formulation of a case, 103, 145–7 Ivey, A.E., 139
types of, 145
‘formulation-driven’ approaches to Jackson, Hughlings, 10
psychotherapy, 146 James, William, 10, 13
future prospects, positive view of, 123 ‘jam-jar language’, 7, 55, 108–9, 117, 146
Jenkins, David, 154
generalisability of research findings, 21 Jung, Carl Gustav (and Jungian psychology),
goal-directed activity, 115 12, 154
Goldfried, Marvin, 16, 37
goodbyes, 133 Kagan, N., 140, 142–3
greeting clients, 91 Kerr, S., 43
Guthrie, Else (co-author), 24–5, 28–32, ‘knowing the client’ as distinct from ‘knowing
116, 139 about the client’, 3–4, 92
Hamilton, J., 25–6 ‘language-games’ concept, 5–6, 13

handshakes, 91, 133 language of mutuality, 74–5, 165–6, 174
Hardy, Gillian E. (co-author), 16, 36, 40, 44–8 language used in therapy, two basic
harm caused to clients, 84, 87–8, 149 forms of, 7
helpful events after therapy sessions, last few moments of therapy, 133
37–40, 45 linking hypotheses, 75–6, 82, 121, 166–7, 174
‘here and now’ experiencing, 41–2, 50, 68–70, listening, 9, 59, 142, 145
73, 79, 81, 108–9, 121, 123, 125–6, 146 Llewelyn, S.P., 38
Index 187
Mackay, H.C., 38–40 process research, 5, 15, 49

Madill, A., 42 nature of, 33
Mair, Miller, 6–7 psychodynamic-interpersonal (PI) therapy,
Malan, D., 146 3–14
Manchester Royal Infirmary, 154 characteristic features of, 4–5, 9
Margison, Frank (co-author), 24 compared with CBT, 17
matched groups of clients, 30 core elements of, 39–43, 50, 55
May, Rollo, 13 foundations of, 10–13, 15
Meares, Russell, 4–13, 15, 24, 29–30, 55, as an integrative model, 13–14
84–5, 103, 116, 142, 154 microscopic forms as a crucial part of, 8–9
medically unexplained symptoms (MUS), structure of, 90–1
25–8, 32 psychodynamic-interpersonal therapy rating
Mergenthaler, E., 144 scale (PITRS), 157–75
metaphor psychodynamic theory and tradition, 4, 14,
literal meaning of, 145 55, 61, 125
use of, 8, 72–3, 116, 145, 164–6, 174
micro-models and micro-study, 104–5 questions, use of, 57–9
micro-skills teaching, 139
Miller, George A., 155 Ramsey, Michael, 154
‘minimal encouragers’, 40 randomised controlled trials, 15–16
‘minute particulars’, 5, 8–9, 12, 39–40, 57, 91, rationale for therapy, 79–81, 99, 104, 169
103, 116, 145–6, 149 Raue, P.J., 41
mistakes, acknowledgment of, 63 recording of therapy see audio recording
models of therapy, 53 Rees, A., 48
Moorey, James, 24, 116 relationship, need for, 11
multi-symptomatic complaints, 55 relationship-building, 119
mutuality see language of mutuality relationships, patterns in, 82–3, 146, 172, 175
reliving experiences, 68–70
‘negotiation’, 62–4, 160–1, 173 ‘repair work’ (Buber), 115
nomothetic outcome measures, 19, 22 research in relation to practice, 5, 9–10
responsibility, acceptance of, 7
observation of sessions, 143–4 reviewing
O’Grady, K.E., 144 after therapy has been completed, 134
outcome studies, 5, 10, 17–18, 24, 34–5 of how work can be continued by the client
without the therapist, 127–8
pain, 116 of progress in the course of therapy,
Paley, G., 23 123, 126
passivity, 115, 142 Reynolds, S., 38
peer-directed learning, 152 Rogers, Carl, 9, 13
peer teaching groups, 143 role-plays, 140–3, 149
personal meaning language, 116 Royal Bethlem Hospital, 154
‘personal problem-solving’, 55–6, 116; see also Rudkin, A., 41
interpersonal problem-solving
personality disorders, 46–7 ‘same experiment’ data, 17
post-traumatic stress disorder, 32 Sattel, H., 27
practice-based evidence, 9, 16 ‘scaffolding’, 91, 152
practice-oriented research, 16 Schaefert, R., 27–8
practice of skills by therapists, 53–4, 89 ‘scripts’ (Meares), 7
prescriptive therapy, 16–18 self-directed learning, 152
‘problem in the room’, 124–5 self-harm, 28, 32
problematic experiences, 47–50 self-reflexive approach to practice, 9
problems sequencing of interventions, 81, 169–70, 174
exploration of, 108–9 Shakespeare, William, 13
focusing on, 95, 146 Shapiro, David A., 16, 36, 48, 157
‘levels’ for tackling of, 145–6 shared feelings and understanding, 42, 103, 145
process notes, 146–8 Shaw, C.M., 30–1
Sheffield–Leeds Psychotherapy Research therapists cont.

Programme, 16–17 development of competence and expertise,
Sheffield Psychotherapy Projects, 17–21, 24, 33 137–52
socialisation of clients about their role, 46, 50 needs of, 144
Startup, M., 36, 157 responsiveness to client needs, 35,
statements used in preference to questions, 43–7, 50
57–9, 173 ‘thing’ language, 7
Stern, D., 11–12 timing of therapy, 89–92, 99
Stevenson, J., 29–30 trainee therapists, 144
Stiles, William B., 16, 36–41, 44, 47–8 training methods,
Stinson, C., 144 effectiveness with regard to new skills, 143
story-telling, 5 extended into clinical work, 143
Sullivan, Harry Stack, 10–12 see also teaching of therapists
summarisation by the therapist, 113 transcription of therapy sessions, 143–4, 147
supervision of therapy, 91–2, 149–52 transdiagnostic therapy, 16, 29, 32
risks for supervisors, 151–2 trust in the therapist, 80
symbolic attitude, 12, 72, 74, 116–17, 123–4 ‘tuning in’ see attunement
symptoms two-plus-one therapy, 116
description of, 117–19
linked to interpersonal difficulties, 99–102 unconscious mind, 10
possible recurrence of, 123
verbal and non-verbal cues, 59–60, 65, 159
teaching of therapists, methods for, 138–43, 152 verbal response modes (VRMs), 36
tentative suggestions, 5, 33, 57, 60, 62, 65, 75, video recordings as a teaching medium, 138
91, 99, 102, 167 vocal cues, 60
testing of solutions, 111–13 Vygotsky, L.S., 11–12, 152
theoretical background to the PI model, 102
therapeutic alliance/therapeutic relationship, Waltz, J., 138
3, 14, 44–6, 55, 79, 102, 145–6, 168 warded-off feelings and fears, 71–2, 79, 81,
ruptures in, 41–2, 84, 142, 154 99, 102–5, 116, 119
therapeutic conversation, 13, 83–4, 165 ‘we’, use of, 74–5, 121, 165
therapeutic interventions, form as distinct Wittgenstein, Ludwig, 5–6, 13
from intent in analysis of, 144 Wordsworth, William, 6, 13
‘therapeutic nightmares’ (Kagan), 142 working models for therapy, 103, 107
therapists workshop settings, 149
actions of, 34–7
blocks of their own, 152 zone of proximal development (ZPD), 11

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What are some of the characteristic features and core elements of psychodynamic-interpersonal therapy?

What are some of the characteristic features and core elements of psychodynamic-interpersonal therapy?

What are some of the theoretical foundations of psychodynamic-interpersonal therapy?

What are some of the theoretical foundations of psychodynamic-interpersonal therapy?

PSYCHODYNAMIC-

Los Angeles | London | New Delhi | Singapore | Washington DC | Melbourne

MICHAEL BARKHAM, ELSE GUTHRIE

Editor: Susannah Trefgarne

Part I Theoretical and Research Foundations 1

2 The Efficacy and Effectiveness of

3 Client Change in Psychodynamic-Interpersonal

Part II Practitioner Manual 51

5 Intermediate Psychodynamic-Interpersonal Skills 67

6 Advanced Psychodynamic-Interpersonal Skills 77

Section B: Applying the Skills 87

8 The Intermediate Sessions 107

Part III Learning and Developing the Model 135

Appendix: The Psychodynamic-Interpersonal Therapy

2.1 The (first) Sheffield Psychotherapy Project 18

Michael Barkham is Professor of Clinical Psychology and Director of the

Else Guthrie is a Consultant in Psychological Medicine and Honorary Professor

Gillian E. Hardy is Professor of Clinical Psychology and Director of the Clinical

Frank Margison is a consultant psychiatrist in psychotherapy and general adult

Professor Michael Barkham (University of Sheffield)

Principal investigators of key research programmes

International research collaboration

Key research collaborators at the

Research colleagues in Manchester studies

Development of teaching methods

Theoretical development of the model

PIT Special Interest Group

The hallmarks of the model

1. Conversation – Psychodynamic-interpersonal therapy begins with the prem-

‘feeling language’. This is what Robert Hobson meant by a Conversational

Robert Hobson draws extensively on quotations from literature, but in a series

presentational symbols – emotions that are connected to imaginative ideas –

… he who would do good to another must do it in Minute Particulars: General Good

4. Research and practice

A key characteristic of PI therapy is the way it draws together research and

Chapter 2 briefly summarises 30 years of research effort including evidence

The theoretical and personal foundations

is a property emerging in relationships (internal and external) underpins the

conversation. ‘[S]ix qualities of a personal relationship … are at the heart of

tradition is represented in the detailed attention to shifting states of mind, the

treatment limb of a study. In other words, a client stands an equal chance of

Comparative outcome trials

The (first) Sheffield Psychotherapy Project

Table 2.1 The (first) Sheffield Psychotherapy Project

Summary of methods Implications for

Outcomes Clients received eight 40 PI and CB therapy

Follow-up at one year showed good overall maintenance of treatment

The Second Sheffield Psychotherapy Project

Summary of methods and Implications for

Outcomes Clients completed eight or 117 For more severe

At one-year follow-up, eight sessions of PI performed worse than eight ses-

The NHS Collaborative Psychotherapy Project

The Two-plus-one Project (Barkham et al., 1999)

Table 2.3 Two-plus-one Project

Sample Implications for