GUTHRIE AND MOGHAVEMI

PSYCHODYNAMIC-INTERPERSONAL THERAPY

Psychodynamic-Interpersonal Therapy:
An Overview of the Treatment Approach
and Evidence Base

Elspeth Guthrie and Amir Moghavemi

Abstract: This article describes the development of Psychodynamic-Interper-

sonal Therapy or the Conversational Model of therapy, as it is also known. It
includes a brief description of the approach to therapy, a review of the evidence
base, and a brief description of qualitative and psychotherapy process research
that has been conducted on the model.

The Conversational Model or Psychodynamic-Interpersonal Thera-

py, as it is also known, has been routed in an ethos of scientific enquiry,
from its inception. The model was developed by Dr. Robert Hobson
in the U.K. and Professor Russell Meares in Australia, who were both
determined that the model should be teachable, researchable, and evi-
dence based. Scientific study of the model has been continuing for the
last 30 years, and covers not only outcome research but also studies on
the process of therapy, linguistics, and how the model is taught and
practiced. It stands apart from other psychodynamic models in terms
of the strength, breadth, and depth of research that has been under-
taken.

Elspeth Guthrie, Honorary Professor of Psychological Medicine and Medical

Psychotherapy, University of Manchester, U.K.
Amir Moghavemi, Specialist Registrar, Manchester Mental Health and Social Care
Trust.

Psychodynamic Psychiatry, 41(4) 619–636, 2013

© 2013 The American Academy of Psychoanalysis and Dynamic Psychiatry
620 GUTHRIE AND MOGHAVEMI

The role of outcome research in psychodynamic

therapies

The double blind randomized controlled trial is the gold standard

for the evaluation of medical treatments, and a modified form of this
has become the accepted standard for the evaluation of psychological
therapies. However, there are many difficulties and challenges related
to the formal evaluation of psychological therapies. Clients/patients
cannot be blind to the treatment they are receiving, so studies can only
have a single blind design. Psychological treatments depend upon an
individual relationship between client and therapist, so each therapy is
unique, which makes it difficult to generalize or standardize the treat-
ment approach. There can be difficulties determining the most appro-
priate outcome measure, and therapists may have legitimate concerns
regarding the way assessments may be carried out (e.g., using indepen-
dent researchers to interview clients).
Understandably, therapists can feel that what is essentially an inti-
mate, private endeavor between two people, becomes distorted and
homogenized. They may also fear that the process of evaluation may
distort or impede the developing relationship between therapist and
client, and this may be of particular concern for transference-based
therapies.
Despite these legitimate concerns, to not evaluate a treatment poses
much greater problems. It is essential that any “treatment,” if it is to
be provided as part of a health service, with the purpose of “treating”
mental health conditions, requires some form of independent formal
evaluation. Funders need to know whether treatments are effective in
alleviating symptoms or distress in those who receive them. Achieving
a “better understanding of oneself” may be of great value, but unless it
is coupled with an improvement in symptoms or behavior, it is unlikely
to be regarded as a hard treatment outcome by a health service funder/
provider. Providers also need to know that the treatments they fund,
not only alleviate distress, but also do not cause significant harm.
In the U.K., the government has established a National Institute of
Clinical Excellence which reviews the evidence of efficacy and effec-
tiveness of treatments for specific conditions, and provides recommen-
dations concerning which treatments have a sufficient evidence base
to justify delivery via the National Health Service (NHS). As a result
of this development, the strong evidence base of cognitive behavioral
therapy for a variety of conditions and the relative lack of an evidence
base for psychodynamic therapy, has resulted in a dramatic reduction
of psychodynamic therapy services within the NHS. The U.K. is not
PSYCHODYNAMIC-INTERPERSONAL THERAPY 621

the only country to witness a rapid expansion in evidence-based psy-

chological treatment, and a reduction in non-evidence based therapies.

Unconscious Processes

It is obviously difficult to conceptualize how certain aspects of psy-

chodynamic therapy, for example, the unconscious, can be measured.
However, this is not essential or relevant to the issue of outcome. Un-
conscious mechanisms may be theoretically identified and addressed
in psychodynamic therapies, and as a result, bring about change. It is
the change, however, which is of interest to health providers, rather
than the mechanism by which change is brought about. There are many
examples of treatments being used in medicine long before their mech-
anism of action was understood.
It is of course highly relevant to psychotherapists and researchers to
understand the mechanisms of change within psychotherapy, and sev-
eral investigators have made attempts to study unconscious processes,
for example, the symptom context method developed by Luborsky
(1996; Luborsky & Curtis-Christopph, 1998) and the Core Conflictual
Relationship Theme (Luborsky & Auerbach, 1969). Piper and colleagues
have shown that the number of interpretations in a dynamic therapy
is inversely related to outcome (Ogrodniczuk & Piper, 1999). Meares
and colleagues have used linguistics to study dissociative mechanisms
during sessions of therapy (Butt, Moore, Henderson-Brooks, Meares, &
Haliburn, 2010). A greater understanding of the mechanisms of action
and process of therapy is essential, as it provides avenues for modifica-
tion and improvement.

Theoretical Basis

The project of the Conversational Model began in the 1960s when

Robert Hobson was working as a consultant psychotherapist at the
Bethlem Royal Hospital in London, and Russell Meares travelled from
Australia to study with him. Hobson ran a ward at the Bethlem Hospi-
tal for patients with complex and enduring problems, who would now
be considered to have borderline personality disturbance.
Hobson and Meares rapidly discovered that the traditional psycho-
dynamic approach of that time was not helpful, and could be potential-
ly harmful to the people on the ward they were trying to help (Meares
& Hobson, 1977). Hobson and Meares’s essential idea was that the pa-
622 GUTHRIE AND MOGHAVEMI

tients’ primary fundamental disturbance was a disruption or stunting

of the ordinary experience of personal existing. They viewed “self” not
as an isolated system but as part of a larger social organism.
Hobson published his thoughts about a new approach to psychother-
apy in a paper entitled, “Imagination and Amplification in Psychother-
apy” (1971), and this was followed by a preliminary account of some
of the features of the model in, “The Pursuit of Intimacy” by Meares
in 1977. Hobson then published a fuller account of the therapeutic ap-
proach in his book, Forms of Feeling in 1985. The notion of “forms of feel-
ing” is crucial to the conversational model approach. When Hobson re-
ferred to feeling, he did not mean a faculty of emotion plus a faculty of
cognition, 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.
Meares has further elaborated and developed the theoretical un-
derpinning of the model in relation to borderline personality disorder
(Meares, 2012b). A full exposition of his work has been published re-
cently, and a psychotherapeutic manual for delivering Conversational
Model for people with borderline personality disorder is also available
(Meares, 2012a).
Meares argues that the central disturbance of BPD is a disconnect-
edness of the complex neural function, which is necessary for higher
order consciousness or self (Meares, 2012b, pp. 301-302). This failure in
the integration of consciousness results in unpredictable shifting mood
states, relatedness, and behavior. These can range from being mild and
barely perceptible in some people to severe and disabling in others.
Core mood symptoms are characterized by feelings of emptiness and
fears of being alone.
The lack of integration influences mind and body with accompa-
nying disturbances in autonomic arousal, pain sensation, and bodily
awareness. A key component of Meares’s theoretical model relates to
the role of unconscious traumatic memories, which he suggests operate
as memories largely split off from everyday consciousness, as forms of
psychic life sensed as alien. These intrude periodically into conscious-
ness resulting in inexplicable breaks or intrusions into the fragile zone
of the self, creating confusion, disruption, and unpredictable behavior.
Meares suggests that there are two main aetiological factors to con-
sider in relation to a theoretically based treatment. The first is to fos-
ter the emergence of a coherent operating self system. The second is
to address the effects of traumatic impacts on the person’s experience
of self. The “conversation” of therapy should therefore involve a re-
PSYCHODYNAMIC-INTERPERSONAL THERAPY 623

ciprocal shaping or picturing of the immediate central and emotional

experience of the other, which he has termed “analogical relatedness”
(Meares, 2012b, p. 307). A detailed account of the model when used on
a long-term basis, twice weekly, is available (Meares, 2012a).

Practice

The model has been used in a variety of different formats includ-

ing long- and short-term individual work. In its short form, a problem-
solving approach is utilized, involving the use of “forms of feeling” to
link together specific emotions, memories, and symbolic experiences
with significant relationships and problem patterns in relationships in
the client’s life. The focus is on experiencing in the “here and now” in
the session, rather than talking “about” feelings.
One of the unique aspects of the conversational model is its focus on
the “minute particulars” of language. Hobson argued that a personal
conversation, promoted in therapy, involves the development of a cru-
cial form of language he termed, “feeling- knowing” (Hobson, 1985).
This form of language expresses, communicates, and shares feeling that
involves:

(a) an apprehension of, and staying with, immediate experiencing;

(b) a process of discriminating, symbolizing, and ordering experi-
ences; especially by creative expression in living symbols (using
figurative language and metaphor).

The work of therapy also includes owning experiences (thoughts,

wishes, feelings-experiencing in relation to persons) in a movement
from passivity to activity, characterized by accepting responsibility for
actions and acts which, formerly, have been disclaimed by means of
avoidance, usually associated with conflict.
The model is relatively jargon-free and tries to use “everyday lan-
guage” rather than technical language to describe emotional experi-
ence. There is a strong emphasis upon “knowing a person” as opposed
to “knowing about a person,” with the development of a strong thera-
peutic alliance. As feelings are re-experienced, they are linked to im-
ages, thoughts, or prior memories, and then to key relationships. This
process of linking feelings, thoughts, symbols, and relationships occurs
cyclically as the therapy develops and solutions are found and tested
out in the therapy and the client’s life.
624 GUTHRIE AND MOGHAVEMI

Outcome and Evaluation

Depression

The first evaluations of the model were undertaken in Sheffield, Eng-

land by a group of researchers led by Professor David Shapiro. The
group carried out a series of studies in which Psychodynamic Inter-
personal Therapy (PIT) was compared with Cognitive Behavioural
Therapy (CBT) for the treatment of depression. The first study (Shapiro
& Firth, 1987) involved a cross-over design in which 8 sessions of PIT
followed by 8 sessions of CBT were compared with 8 sessions of CBT
followed by 8 sessions of PIT. There was broad equivalence between
the outcomes of the two therapies and overall approximately 60% of
clients achieved a good outcome.
Further studies by the group compared 8-session PIT and CBT
with 16-session PIT and CBT for clients with depression (Barkham et
al., 1996; Shapiro, Rees, Barkham, & Hardy, 1995). There was broad
equivalence in outcome between the two treatments on most measures,
with CBT showing a better outcome on the Beck Depression Inventory
(BDI). The group also evaluated a very brief form of therapy (2+1) for
treatment of subclinical depression (Barkham, Shapiro, Hardy, & Rees,
1999). Both therapies performed well (better than wait-list) and again
showed broad equivalence, with outcome favoring CBT on the Beck
Depression Inventory.

Medically Unexplained Symptoms

The term medically unexplained symptoms (MUS) refers to physical

symptoms from which people suffer that do not have an obvious expla-
nation 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 per-
sistent, there is an increasing association with emotional and psycho-
logical factors (Sattel et al., 2012). The symptoms are real in that they are
experienced in the body and causal mechanisms are multifactorial in-
cluding a mix of genetic, physiological, and psychosocial factors, both
past and present (Hausteiner-Wiehle et al., 2011).
Data from the U.K. Department of Health indicate that MUS accounts
for the most costly diagnostic category of outpatients in the U.K. and
the fourth most expensive category in primary care (Creed, Henning-
sen, & Fink, 2011). Patients with severe and persistent symptoms are
PSYCHODYNAMIC-INTERPERSONAL THERAPY 625

the most costly to the health service and the prognosis for this group is
generally poor, without specific treatment.
There are four randomized controlled trials, which have evaluated
the effectiveness of PIT for patients with medically unexplained symp-
toms. Three have been conducted in Manchester and have focused
upon patients with unexplained bowel symptoms, and one has been
conducted in Germany with patients with mixed bodily complaints.
All the studies focused upon patients with severe and persistent symp-
toms, who had not responded to conventional treatments and who had
not been helped by specialist medical care.
The first study was published in 1991 and recruited 102 patients with
severe and intractable irritable bowel syndrome (Guthrie et al., 1991).
Patients were recruited consecutively from a gastrointestinal outpa-
tient clinic and randomized either to brief PIT or supportive therapy.
The PIT group received one long initial session of therapy lasting up to
3–4 hours followed by 6 sessions of 45 minutes, spread over 12 weeks.
Patients in the supportive limb were seen on 5 occasions for 30 min-
utes per session. The supportive sessions were used to control for the
nonspecific effects of therapy (e.g., seeing someone on a regular basis,
being listened to and supported). The outcome of the trial showed that
patients who received PIT showed a significant reduction in gut symp-
toms and psychological symptoms in comparison to the patients who
received support. The improvement in outcome was maintained over
12 months.
The second study recruited patients with severe and retractable func-
tional dyspepsia (i.e., patients with upper gastrointestinal complaints;
Hamilton et al., 2000). Patients in this study were randomized to PIT
versus supportive therapy. Patients who were randomized to the sup-
portive therapy received exactly the same amount of time with a thera-
pist and the therapy was again conducted over a 12-week period. The
outcome showed that PIT was superior to the supportive condition
both at the end of treatment and at follow-up six months later.
In the third trial, 257 patients with severe and persistent irritable
bowel syndrome were randomized to 12 weeks of PIT, or treatment
with an antidepressant or usual treatment (Creed et al., 2003). Detailed
assessments of outcomes and costs were undertaken. Both PIT and an-
tidepressant treatment resulted in significantly improved outcomes at
12 months posttreatment in relation to both physical and mental health.
PIT however was also associated with a significant reduction in health
care use in the 12 months posttreatment, compared with patients who
received usual care. So not only did PIT achieve a better outcome than
usual care, it also resulted in significant cost savings. The average sav-
ings per patient over a year were approximately £1000 at the time of
626 GUTHRIE AND MOGHAVEMI

publication and for patients with the most severe symptoms, cost sav-
ings were between £2–3000 per annum per patient.
The fourth study of PIT for patients with MUS was conducted in Ger-
many and recruited patients with persistent multisomatoform disorder
(Sattel et al., 2012). Multisomatoform disorder is characterized by se-
vere 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. 211 patients were recruited to the study and were
randomized to either 12 weeks of PIT compared with 3 sessions of en-
hanced medical care; the best routine care that could be provided. Pa-
tients were followed up six months posttreatment. The main findings
were that patients who received the PIT showed significantly greater
improvement in physical and mental health function compared with
the control group over the course of the study.

Self-Harm

There has been one randomized controlled trial which has evaluated
PIT as a treatment for self-harm (Guthrie et al., 2001). In this study 119
patients who had presented to a U.K. emergency department after an
episode of self-poisoning were randomized to 4 sessions of home-based
PIT in comparison with usual treatment.
The therapists in the study were mental health nurses who were
trained to deliver PIT, but did not have any formal psychotherapy
qualification or prior training. The therapy was delivered at home to
increase engagement and compliance.
Participants who received the PIT had a significantly greater reduc-
tion in suicidal ideation at six-month follow-up compared with those in
the control 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 PIT for self-harm and deliver this treatment effec-
tively. Following this study, a PIT service for self-harm was established
in Manchester. Nurses in other hospitals such as Hull and the Wirral
have been trained in the model and have demonstrated good clinical
outcomes with reduction in service use (NHS Confederation Service).
A pilot project to deliver the therapy in prisons has been conducted and
a full evaluation is now underway.
PSYCHODYNAMIC-INTERPERSONAL THERAPY 627

High Utilizers of Mental Health Services

As PIT is a trans-diagnostic treatment, it can be used to treat people

who present with complex, mixed mental health and physical prob-
lems. A small number of people with mental health problems have
chronic problems that are difficult to treat and account for a dispropor-
tionate amount of health care costs.
Very few studies have explored the benefits of psychotherapy for
people with complex disorders and enduring symptoms, who are high
service users. PIT however has been shown to produce significant ben-
efits for this group of service users. 110 patients with complex men-
tal health problems, who had been in treatment with specialist mental
health services for at least six months without improvement were ran-
domized to 8 sessions of PIT versus usual care from their psychiatric
team (Guthrie et al., 1999).
Patients who received PIT in comparison with controls reported a
reduction in psychological symptoms, an improvement in health sta-
tus, and a reduction in healthcare costs during the six months post-
treatment. Patients who received PIT required less inpatient treatment,
less medication, GP time, and nurse practitioner time in the six months
posttreatment than controls. The total healthcare costs incurred by pa-
tients who received PIT were significantly lower than controls for the
six months posttreatment. So not only did the therapy result in signifi-
cant improvements in mental health, it also resulted in cost savings.

Borderline Personality Disorder

Borderline personality disorder is a serious mental health problem,

with significant mortality and morbidity. Individuals who are diag-
nosed with this condition report difficulties with distressing and ex-
treme states of mind, problems with making and sustaining relation-
ships, self-harm, and substance misuse. They tend to lead chaotic lives
and frequently report unhappy, unstable childhood experiences includ-
ing abuse and neglect.
There have been two major evaluations of PIT for patients with
borderline personality disorder (BPD; Korner, Gerull, Meares, & Ste-
venson, 2006; Stevenson & Meares, 1992) and there is one randomized
controlled trial currently in progress which is comparing PIT with dia-
628 GUTHRIE AND MOGHAVEMI

lectical behavior therapy (personal communication from Drs. Bendit

and Walton, Centre for Psychotherapy, Newcastle, New South Wales,
Australia). In these studies the original preferred term, “conversational
model” is used to describe the therapy.
Stevenson and Meares (1992) reported the treatment and outcome of
30 patients with BPD treated with conversational model therapy for 12
months with two sessions per week. These patients showed significant
improvements in mental health function over the year and marked im-
provement on 7 behavioral measures which included self-harm behav-
ior, violence toward others, use of drugs (both legal and illegal), and
number of hospital admissions.
The patients who received therapy were compared with a matched
group of 30 patients with BPD who were referred to the same clinic,
as where the trial was based, but no therapist was available, and they
remained on the waiting list for one year (Stevenson & Meares, 1992).
In comparison with this matched group, the patients who received con-
versational model therapy showed significantly greater improvements
in mental health function. In a further analysis of costs, the use of health
care of the 30 patients treated with conversational model was examined
for the year prior to treatment and the year posttreatment (Hall, Caleo,
Stevenson, & Meares, 2001). This showed a saving of $670,000 (Aus-
tralian dollars) compared to a cost of the psychotherapy of $130,000,
giving a net saving of $540,000 or $18,000 per patient. Most of the cost
savings were in terms of reductions in hospital admissions.
The same team recently carried out a replication study in which cli-
ents with borderline personality disorder were allocated to treatment
or wait-list depending upon the availability of a therapist (Korner et
al., 2006). This was not a randomized controlled trial but as close to
randomization as the team could get in a clinical setting. The results
were very similar to the first study with significant improvements in
the treatment group in comparison with the wait-list controls.

Other Randomized Controlled Trials of PIT

Shaw and colleagues (Shaw, 2001) carried out an evaluation of in-

experienced therapists using the PIT model with patients referred to
an NHS psychotherapy service. Patients were randomized to either
psychotherapy or wait-list control. Significant improvement was dem-
onstrated in those patients who completed therapy, and there was a
nonsignificant trend toward greater improvement in the immediate
treatment group in comparison to wait-list controls.
PSYCHODYNAMIC-INTERPERSONAL THERAPY 629

Burns and colleagues (2005) assessed whether PIT could benefit cog-
nitive function and affective symptoms in patients with Alzheimer’s
disease. There was however no evidence of improvement on the main
outcome measures.

Service Evaluations

There have been several evaluations of PIT using before and after
designs in clinical service settings. Unlike trials, these studies provide
information about how PIT functions in “the real world.”
Guthrie and colleagues (2004) evaluated the effectiveness of PIT for
common mental health problems in primary care in a before and after
design. Primary care counsellors were trained in the model (see chapter
on training) and their treatment, using the model, was evaluated in 41
patients. The patients who they treated presented with a mix of 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 50% of
the patients underwent clinically significant improvement.
Kellett and colleagues (Kellet, Clarke, & Matthews, 2007) compared
the outcome of 176 clients referred to a clinical psychology service who
were offered either group psychoeducational cognitive therapy (n = 43),
individual cognitive therapy (n = 68), or individual psychodynamic-
interpersonal therapy (n = 65). All three treatments showed equivalent
outcomes on most measures. The percentage of patients who showed
clinically significant change on the Beck Depression Inventory was 47%
for group CBT, 49% for individual CBT, and 62% for PIT.
Paley and colleagues (2008) evaluated the outcome of 67 patients
who received PIT in a routine NHS clinical setting. Outcomes were
assessed using a range of measures. Clinically significant change oc-
curred in 40% of clients, which is equivalent to the reported outcomes
of 41% achieved by cognitive behavioral therapies in the national psy-
chotherapy program rolled out recently in the U.K., called Improving
Access to Psychological Therapies (IAPT; Richards & Borglin, 2011).
Guthrie and Wells (1999) described providing brief PIT to three peo-
ple who developed posttraumatic stress disorder after being involved
in the Manchester Bombing. All three showed significant reductions in
PTSD symptoms.
630 GUTHRIE AND MOGHAVEMI

Process Research

There have been a variety of studies on PIT that have used psycho-
therapy process research methods to provide researchers with a way of
observing what therapists are doing in sessions and why. These studies
were carried out in Sheffield, principally involving data from the ran-
domized controlled trials comparing PIT with CBT for the treatment of
depression. Therapy sessions were audiotaped and patients and thera-
pists completed questionnaires after each session. The key researchers
involved in this work were David Shapiro, Michael Barkham, Gillian
Hardy, Robert Elliott, Bill Stiles, and Mike Startup.
Startup and Shapiro (1993a, 1993b; Shapiro & Startup, 1992) found
that when independent observers rated PIT and CBT sessions using
a system that defined behaviors of both therapies, the majority of ses-
sions were correctly assigned to the appropriate treatment. In further
observer-rated studies, therapists’ speech was coded using what are
called verbal response modes (VRMs). VRMs are categories of speech,
such as Disclosure, Question, Acknowledgement, and Reflection. PIT
therapists used more Simple Reflection, Interpretation, and Explorato-
ry Reflection, which are highly consistent with the PIT model (Hardy
& Shapiro, 1985; Stiles, 1989; Stiles & Shapiro, 1995; Stiles, Shapiro, &
Firth-Cozens, 1988).
This work established that therapists using PIT carry out interven-
tions during therapy consistent with the model. In other words, that
therapists generally behave in sessions according to the model of thera-
py they are delivering. Although this may sound a fairly obvious state-
ment, it is important to establish that therapists actually do what they
say they do.
Other studies have also supported the expected differences between
CBT and PIT therapists in their focus during sessions. For example, PIT
has a greater focus on within session experiences and the client’s past
and current relationships and emotional issues compared to CBT that
tends to focus on external situations and the future (Goldfried, Caston-
guay, Hayes, Drozd, & Shapiro, 1997).
PIT appears to require patients’ commitment to psychological ther-
apy prior to therapy starting. So, for example, both patients’ treatment
preferences and degree of psychological orientation predicted outcome
in PIT. These findings suggest therapists should socialize patients into
the treatment process. In other words, we should explain in detail to
clients how the therapy works, what to expect and what they can do to
maximize potential benefit.
PSYCHODYNAMIC-INTERPERSONAL THERAPY 631

Important and distinctive elements of PIT have been found to focus

on two elements. First, finding the right language that captures the pa-
tients’ experiences and is understood by both therapist and patient is
a central component of PIT (Hobson, 1985) and highlighted by a num-
ber of studies (i.e., Elliott & Shapiro, 1992; Hardy et al., 1999). Second,
studies have linked change in therapy to the experiential element, the
experiencing of feelings, and events in the here and now, of PIT (Drozd
& Goldfried, 1996; Mackay, Barkham, & Stiles, 1998). These studies sup-
port the theoretical basis of the model and its clinical therapeutic ap-
proach.
The process of therapy has also been studied using linguistic re-
search methods to track consistencies and departures in meaning in
therapy sessions to help therapists understand significant aspects of
their clients’ state of mind. The “outer” language can be used to explain
changes in the clients’ inner state. This work has been lead by Professor
David Butt in collaboration with Russell Meares.
Using the study of language to illuminate the process of therapy is
particularly suited to the conversational model of therapy, where “the
conversation” provides such a pivotal role. Language is embedded in
our most formative and earliest relationships with carers. The choice
of language that we use, in terms of structure, grammar, and content,
reflects our personhood and the personalization of our brains. Butt and
colleagues have shown that subtle dissociative states can be identified
in patient-therapist discourses (Butt et al., 2010). Speech can be grouped
into chains that connect together by chain interactions (or bridges). “Is-
lands” of speech that appear in a therapy conversation without a con-
nection or bridge to other chains of speech, suggest a failure of connect-
edness or cohesiveness. It is suggested that these “islands” represent
episodes of dissociation.
Butt and colleagues have also characterized what they believe are
the essential discoursive elements of a therapeutic conversation (Butt
et al., 2010). They have suggested that each move in a therapeutic con-
versation is motivated by a distinct dimension of the social process, and
that there is an overarching move toward a potential future freer state
of “aliveness.” In terms of the model this would be characterized as a
state of aloneness-togetherness, a state of coming together between the
client and therapist in which an imaginative feeling state can be shared.

Summary

There is a strong evidence base for PIT, in relation to other psycho-

dynamic or relational therapies. It has broad equivalence to cognitive
632 GUTHRIE AND MOGHAVEMI

behavioral therapy for the treatment of depression and it is also effec-

tive for patients who present mixed mental health symptoms, unex-
plained 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 carried out in the U.K., Australia, and Germany.
Three separate studies have provided evidence that PI therapy is cost-
effective and can result in major cost savings to healthcare over time.

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E. A. Guthrie, M.D.
Professor of Psychological Medicine and Medical Psychotherapy
Rawnsley Building
Manchester Royal Infirmary
Oxford Road
Manchester M 13 9WL U.K.
[email protected]