Editorial

In early April this year, shortly before writing this editorial, the paper copy of 37–04 was delivered (4 months after the cover month of December). Upon receipt, several readers were prompted to write and share their concerns about the first paragraph of the editorial of that special issue entitled ‘Time to (re)-integrate Dissociation into Psychoanalytic Psychotherapy’. Writing in the first 10 days after the terrorist attack on Israel, Dr Shahar had described some impressions of the population’s response and his role providing psychological first aid. The intention was to add context to the special issue by providing a brief personal account of current clinical experience of dissociative responses to a trauma of which the readership would be very aware. Our correspondents were concerned that in providing this context the editorial did not comment on the broader situation in Gaza, which had become much worse by the time the paper copy of the journal was delivered.

We refute any suggestion that this was a deliberate and calculated decision to represent the discourse of the Israeli government or a Zionist perspective. However, we do recognise that the editorial made no mention of any context to the horrific attack of 7/10/23, such as the occupations of Gaza, the blockade or the illegal settler colonialism (Albanese, 2022). Nor was there any mention of the subsequent Palestinian deaths, which have now mounted to at least 34,622 and 77,867 injuries (OCHA, 2024). Kemp (2021, p. 37) argues that institutions such as this journal ‘have a responsibility to include in their reflections the constructive exercise of their public influence both in general terms and particularly in regard to the subjugation of the Palestinian people’. To this end, we would welcome the submission of articles that address these issues within an applied psychoanalytic framework.

We open this issue with an article entitled ‘Evaluating the 20-day Dynamic Interpersonal Therapy (DIT) training programme: a mixed methods investigation to identify characteristics associated with successful outcomes of DIT’. Jennifer Khalastchy, Deborah Abrahams, Rob Saunders and Peter Fonagy report on the new 20-day training format for DIT at the Anna Freud Centre in London based on the approved extended national curriculum for DIT training. This extended training is now being offered to counsellors and psychologists who do not meet the psychodynamic competencies required for the original five-day training. Trainees attend 20 face-to-face teaching days and receive close clinical supervision of three or four cases in order to acquire the required competencies to deliver DIT effectively. This study evaluated the 20-Day DIT training by investigating factors associated with the successful patient outcomes of a cohort of 28 trainees, each with three patients. Quantitative analyses found that reliable recovery and reliable improvement of patients was 69% and 90%, respectively. Patients who have positive outcomes were likely to have lower baseline Patient Health Questionnaire-9 (PHQ-9) scores and lower patient complexity. Trainees were also interviewed and thematic analysis of their responses suggested that they perceived the most important elements of DIT to be associated with successful patient outcomes clustered around four superordinate themes. These are as follows: aspects of the DIT model/training; characteristics of the patient; aspects of the patient–therapist relationship; and characteristics of the therapist. The authors conclude that the results of their study suggest that the DIT protocol can be acquired by therapists who are naive to psychoanalytic/dynamic methods and offer insight into the factors that may be associated with successful treatment outcomes.

Our next article, ‘Private Pleasures and the Damage Done: Asking the Unasked Question About Consumption of Online Pornography’, is a brief report by Alessandra Lemma. In February 2023, the All Party Parliamentary Group on Commercial Sexual Exploitation reported the findings of its Inquiry on Pornography. ‘Pornography Regulation: The case for Parliamentary Reform’ concluded that the proliferation of male violence against women and girls cannot be ended unless the Government confronts the role that pornography plays in fuelling sexual violence. In her Brief Report, Lemma focuses on the impact of internet pornography on sexual health and personal relationships. She draws on a psychoanalytically informed conceptual framework to argue that the online medium changes the user’s relationship to sexual materials by providing a virtual space within which sexual desire is gratified quickly and non-reflectively. She suggests that this undermines the user’s capacity to mentalize the sexual desire of self and others and also their ability to evaluate the prudential risks associated with their use of online pornography. These risks are particularly significant for the digital generation whose sexual development is likely to be shaped by online pornography. Lemma summarises the relevant research and concludes by outlining one key practice implication arising from the literature.

We continue with a research article by Rachel Hirschfeld, Scott Steen, E.L. Dunn, A. Hanif and L. Clarke. Their paper, ‘The effectiveness of psychodynamic therapy in an NHS psychotherapy service: outcomes for service-users with complex presentations’, reports on an NHS tertiary-level specialist psychotherapy service which offers Psychodynamic therapies to treat complex and enduring mental health problems and support sustained improvements in personality functioning. Using a naturalistic design, their study evaluated the effectiveness of Psychodynamic therapy by evaluating the scores on pre- and post-treatment patient rated outcome measures over a 10-year period, along with engagement rates and therapist assessments at intake. The results from 474 datasets demonstrate that Psychodynamic therapy was effective in reducing psychological distress. The authors note several limitations related to data quality and completeness which are a consequence of the naturalistic design. Despite these limitations, they conclude that the study provides evidence to support the use of Psychodynamic therapies within NHS mental health services for people with complex and enduring mental health problems.

The next article continues our growing evidence base for the provision of remote therapy. Stephanie Morgan and Casey Mace Firebaugh report their experiences in ‘Psychodynamic therapists treating patients with eating disorders during COVID-19: perceptions of the therapeutic relationship, patient experiences and symptomatology, and therapeutic processes’. In this qualitative phenomenological study, they describe the novelty of developing and sustaining a therapeutic connection with their patients whilst not inhabiting a shared physical space. Twelve participants engaged in a 30–45-min semi-structured interview. Four themes emerged from the data: Depth of content; Manifestations of patient distress; Therapist–patient relationship; and Implementation of techniques. Participants spoke about the challenges and resilience that they and their patients experienced. They described the complexities of navigating a global pandemic which required the rapid transition to telehealth and exacerbated their patients’ symptoms. The authors discuss practical implications for the remote delivery of relational and dynamic therapy for patients with eating disorders and consider directions for future research.

We conclude this issue with another brief report, this time by Eveliina Ilola and Andrew Howe. ‘Talking to the most reasonable voice: building rapport within a crisis service’ describes an intervention in a busy South London Home Treatment Team (HTT), where a psychodynamically informed approach was used in a crisis setting with a patient in psychosis. Ilola and Howe begin their report by reviewing the literature on the treatment of acute psychosis, before moving on to a discussion of psychodynamic thinking on psychosis and interactions centred around the theories of Carl Jung and Richard Lucas. They describe how they applied this to a young male patient who had been under HTT for an extended period of time due to an episode of psychosis that was not resolving. After initially struggling to interact with him, they adapted Lucas’ and Jung’s models in order to re-establish psychic rapport. This led to their patient finally agreeing to take medication that led to a resolution of his long-standing psychotic episode. Ilola and Howe suggest that this case highlights the power of psychodynamic thinking in acute, short-term settings where a more extensive psychodynamic intervention may not be appropriate or feasible.