Dynamic interpersonal therapy as experienced by young adults

Abstract

The purpose of the present study was to investigate young adults’ experiences of brief dynamic interpersonal therapy (DIT). Six young adults (19–25 years old) who had undergone DIT at the Psychology Clinic at Stockholm University and the Erica Foundation in Stockholm were interviewed about their experiences of therapy and the changes that therapy may have brought about. The results showed that after therapy the respondents had better understanding of their feelings and better capacity to set and manage boundaries in relationships. The changes described by the respondents mainly concerned relationships and were perceived as highly important for them. Regarding specific aspects of DIT, their views diverged. In future research, we suggest that DIT’s interpersonal affective focus may be of particular interest, especially in relation to the therapeutic alliance.

Keywords:

• short-term psychodynamic therapy
• youth
• patient perspective
• qualitative research
• psychotherapeutic change

Introduction

Dynamic interpersonal therapy (DIT)

DIT is a psychodynamic manualised short-term therapy developed for adults suffering from anxiety and depression. It was developed by Lemma, Target, & Fonagy (2011a) and is intended to be used by experienced psychodynamic therapists from various theoretical schools. However, DIT differs significantly from many traditional variants of psychodynamic therapy with regard to length, structure of treatment, and not least the therapeutic approach (Lemma et al., 2011a). In a few clinics in Sweden, teenagers and young adults are currently treated with DIT. The present study is based on an interest in investigating young adults’ experiences of DIT as a therapeutic method, as no such research has been published before.

Theoretical thinking from several psychoanalytic schools is integrated into DIT and it builds on concepts and ideas that have proven fruitful in both research and practice. The therapeutic stance in DIT is active, and aims to create a collaborative therapeutic relationship. The main theoretical schools informing DIT are object relations theory, mentalization, attachment theory and interpersonal theory (Lemma et al., 2011a). A basic assumption behind DIT is that early interpersonal experiences shape the individual’s mental development, and create internal representations of oneself and others. These inner representations govern how the individual experiences and behaves in new interpersonal situations. It is assumed that these inner representations are the mechanisms that need to be changed in therapy for depression and anxiety (Lemma et al., 2011a). Sullivan (1953) believed that depression and anxiety should be understood as manifestations of individuals’ interpersonal relationships, interactional patterns and interpretations of interpersonal situations. The interpersonal affective focus in DIT is to a large extent informed by Kernbergs’ model of psychopathology. The focus consists of internal working models of the self and others which are based on early representations of the self and an attachment figure in interaction, connected by affects. These images are interconnected in such a way that they reflect each other. For example, a child with internal working models of attachment figures as dismissive could also have a corresponding self-representation, such as being unworthy of love or boring (Lemma et al., 2011a).

The attachment figure’s capacity to perceive, interpret and reflect upon the child’s feelings shapes the child’s self-understanding. In the theory of mentalization, Fonagy and co-authors (2002) relate both to Winnicott’s (1960) and Bion’s (1963) thinking about holding and containment; in order for the child to understand his own feelings and learn how to regulate affects, attachment figures must help the child to do this (Bion, 1963). Fonagy and co-authors (2002) propose that mentalizing ability develops intrapsychically through the individual constructing multiple internal constellations of representations based on interpersonal experiences. In DIT, it is assumed that patients suffering from anxiety or depression organise social experiences based on underlying unconscious assumptions and expectations of themselves and others, and these trigger specific affects. These unconscious interpersonal configurations create inner conflicts and lead to maladaptive psychological and behavioural defence strategies, creating and maintaining anxiety and depression. Therefore, work with an interpersonal affective focus is essential in DIT.

According to the manual, DIT spans over 16 sessions divided into an initial phase, a middle phase and an ending phase (Lemma et al., 2011a). In the initial phase, the main task is to formulate the patient’s problems as a recurring interpersonal pattern that dominates the patient’s functioning and explain the symptoms. The therapy will subsequently circle around this interpersonal affective focus (IPAF). Inner conflict is conceptualised as the result of a clash between specific representations of self and others, usually associated with specific affects (Clarkin, Yeomans, & Kernberg, 2006). The IPAF is based on the self-representation that appears to be causing most of the patient’s problems. An example of such self-representation would be that the patient sees himself as demanding, and sees significant others as dismissive. The linked affect may be fear of being left alone when the need for others is the greatest. The configuration has a defensive function – in this example it may be to avoid seeing one’s own aggression and tendency to reject, by seeing oneself as the one who is always rejected. These representations may be more or less conscious (Lemma et al., 2011a).

In the middle phase, the IPAF is explored through the patient’s interpersonal narrative, focusing on situations in current relationships. The therapist makes interventions linked to the interpersonal and affective themes that constitute the IPAF. One of the most important therapeutic interventions is to repeatedly show the patient how the IPAF manifests itself in current relationships and how it is associated with the symptoms. Sessions 13–16 constitute the ending phase. The separation from the therapist evokes associations to other experiences of separation, such as losing someone or moving away from home. In a successful ending phase in DIT, the patient is able to express disappointment, sorrow and gratitude, indicating that the patient has reached the depressive position (Lemma et al., 2011a). In this phase, the therapist writes a ‘goodbye-letter’ to the patient, an idea borrowed from cognitive analytical therapy. The letter becomes a concrete way for patients and therapists to reflect on what therapy meant, and what has and has not been achieved. It also functions as a kind of transitional object (Lemma et al., 2011a). The therapist writes a first draft of the letter, which the patient can comment on before the therapist writes the final version. In this way, the letter becomes a joint effort.

The research base for DIT is still small, but a recent RCT on DIT for moderate to severe depression (n = 147) showed that DIT was superior to low-intensity treatment and equal to CBT in reducing depressive symptoms, with 51% of the DIT patients showing clinically significant change at termination (Fonagy et al., 2019). Prior to that, two small naturalistic pilot studies were conducted in the UK (n = 16 and n = 26 respectively), both showing significant improvements (Lemma, Target, & Fonagy, 2011b; Wright & Abrahams, 2015). In the smallest study, 15 out of 16 patients were significantly improved (Lemma et al., 2011b). In the slightly larger study, 75% of patients were improved (Wright & Abrahams, 2015).

Young adulthood

Through history, the road to adulthood has become increasingly complex, with more and more choices to make (Arnett, 2014). Many authors in the field agree that the time between the teenage period and adulthood has been prolonged (Arnett, 2014, 2016; Briggs, 2003; Wong, 2018). ‘Emerging adulthood’ (Arnett, 2014) and ‘contemporary adolescence’ (Briggs, 2003), are two common research concepts regarding young adults: the first concept refers to the period between 18 and 25, and views the interval as a specific development period, while the other concept describes the same period as an extended teenage period. The last decades have been characterised by a growing gap between physical maturity (puberty) and psychological maturity, which develops from new cognitive and emotional experiences but is also influenced by social factors. Physical changes in the body greatly affect the youth’s basic sense of what Stern (1985) calls ‘the core self’. Part of the core self is the continuity of the self – to be able to feel like the same person throughout life. This ability is subjected to severe stresses during adolescence, as it becomes difficult for the youth to recognise him- or herself as the child her or she used to be. Some young people handle changes and contradictions by searching for already familiar situations, while others are more open to the unknown.

Emotional experiences tend to intensify during adolescence, and negative feelings in particular appear to dominate (Rosenblum & Lewis, 2006). Coping with all the uncertainty surrounding the long road to adulthood can be a challenging task; Arnett (2014, 2016) believes that the life of young adults is often characterised by turbulence. During this period in life there is a high risk of internalising problems such as depression but also of externalised problems such as drug abuse and behavioural problems. Moving towards greater independence causes different reactions; young people with insecure attachments, who have been subjected to greater emotional stress growing up, may find it harder to achieve independence (Allen, 2008).

Recently, the National Board of Health (2017) in Sweden published a report on the development of mental disorders among children and young adults in Sweden through 2016. The report, based on a register study, shows that mental ill-health among children and young adults is increasing. About 10% of girls, boys and young men have some form of mental disorder, and for young women the rate is around 15%. Depression and anxiety disorder are the most common diagnostic categories.

Research on psychotherapy with young adults is limited. A few patient-centred studies on teenagers and young adults have been conducted in Sweden. A number of studies from the Young Adult Psychotherapy Project have been published (e. g. Lilliengren & Werbart, 2005; Philips, Werbart, Wennberg, & Schubert, 2007; von Below & Werbart, 2012). Bury, Raval, & Lyon (2007) examined six adolescents’ (aged 17–21 years) experiences of psychodynamic long-term therapy. In the study, the participants described the process of understanding therapy and what was expected of them, which could be difficult. They also described the power balance between themselves and the therapists; several experienced that the therapists had more power than themselves in therapy and that it was difficult to contradict the therapist. The participants appreciated that the therapist was active and asked questions, which is also reflected in other interview studies with young people in psychotherapy (e.g. Lilliengren, 2014; von Below, 2017). Briggs and Lyon (2012) argue that it is noteworthy that there are so few psychodynamic short-term models for young people; they claim that short interventions would suit this group of patients, as young adulthood is characterised by change and relocation. Time-limited psychodynamic therapy can provide structure and focus within the therapy, things that a young person may miss in daily life.

Method

Given the scarcity of previous research on psychodynamic therapy for young adults and the lack of previous studies on DIT for this age group, we chose an exploratory approach with a broad research question. The main question was: ‘How do young adults experience dynamic interpersonal short-term therapy?’ In particular, we aimed to explore how young adults experienced any changes the therapy may have brought.

A qualitative inductive interview study was chosen as the most suitable research method. Following an experiential qualitative research approach (Braun & Clarke, 2013), and inspired by a phenomenological perspective, we wanted to explore the participant’s subjective experience of therapy and its impact on their lives (Kvale, 1997). The goal of the present study was to come close to the respondents’ views without letting our basic assumptions get too much in the way (Braun & Clarke, 2013). Therefore, data-driven thematic analysis was considered an appropriate method for our analysis.

The patients in the study were recruited from two different settings; the Psychology Clinic at Stockholm University and the Erica Foundation in Stockholm. The DIT therapies at the university clinic were conducted under supervision once a week. The therapists were psychology students with a psychodynamic orientation, and were in the last or penultimate year of their master’s education in psychology. The student therapists were thus novices, conducting their first DIT treatment. Their training in DIT was integrated in their psychotherapy courses, with a teacher (a Swedish licensed psychologist, licensed psychotherapist, and psychotherapy supervisor) who was a certified DIT practicioner and DIT supervisor, trained at Anna Freud Centre (AFC). Their training encompassed four half days of education and one half day of examination. The training included role plays and watching video demonstrations of DIT. The training of the psychologist students covered approximately the same theoretical material as in the DIT training at the AFC, but there were fewer practical exercises. Their psychotherapy supervisors were all well-versed in the DIT manual and most of them had undergone the basic DIT training at AFC. However, as these prerequisites described above may not fully reach the AFC’s criteria for training in DIT, it may be more accurate to describe the therapies as DIT-inspired (and fully following the DIT manual) rather than DIT proper.

The Erica Foundation offered various forms of psychotherapy and treatment for children, teenagers, young adults and families. The therapists at the Erica Foundation were highly experienced psychodynamic licensed psychotherapists, and they had all completed the five day DIT training at AFC. The therapists received qualified DIT supervision from supervisors at AFC. Six young adults participated; one was 19 and the others were aged between 23 and 26; five were females and one was male. The data collection was conducted in February 2018 and the respondents had terminated their therapies between one and two years prior to the interviews. The respondents were interviewed in an undisturbed environment. All interviews were audio-recorded and were about 60 minutes long. The interviews and the data analysis were performed by the two first authors under the supervision of the third author.

All respondents were informed that their participation was voluntary and that they were free to interrupt their participation at any time. They received this information both in written letters and orally. Both the interviews and the qualitative analysis were conducted in such ways that individual respondents could not be identified. The recorded material was protected by password and was not stored via the internet. After the interviews were transcribed, the audio recordings were permanently deleted.

As an interview guide, we chose the semi-structured ‘Change Interview’ (Elliott, 1999), adapting it slightly to our study. The Change Interview consists of eight question areas that revolve around change connected to therapy as well as helpful aspects of therapy. The participants were asked during the interviews to write down one to three changes that they had experienced in connection to therapy, estimating how expected and significant they had been, as well as the likelihood of the changes happening without therapy. We removed questions about medication and added questions regarding the respondents’ experiences of the length, focus and goodbye letter of the therapy.

The data analysis followed Braun and Clarke’s (2006) principles for inductive thematic analysis (TA). TA is a flexible method of analysis aimed at identifying, analysing, and reporting patterns in data. In TA, a theme is supposed to capture something essential about the material in relation to the study’s research question. In accordance with Braun and Clarke (2006), the process of the analysis encompassed the following phases: 1) Familiarising oneself with the data, including transcribing the interviews, 2) Generating initial codes, 3) Searching for themes, 4) Reviewing themes, 5) Defining and naming themes, and 6) Producing the report.

In accordance with Malterud’s (2001) guidelines for qualitative research, we have sought a transparent and systematic procedure in our work. The two first authors coded each other’s interviews in order to supplement the interview material with a look from the outside. They also compared our coding to make sure they were using the same strategy. During the ongoing joint work, categories and themes were continually tested against the quotes. As part of the interviews, the participants also made quantitative estimates of perceived changes in therapy. The complementary quantitative measurements meant there was a sort of method triangulation. Throughout the process, we strived for reflexivity about our understanding, in accordance with guidelines (Malterud, 2001). The two first authors’ interest in DIT as a method and in the specific patient group (young adults) was based on their experience of practical work as well as their theoretical understanding of the psychodynamic field. During their psychology education at Stockholm University, they were trained in DIT therapy under the supervision of an experienced psychologist. The third author was a psychodynamic psychotherapist, but without specific training and practice in DIT.

Results

The thematic analysis resulted in the following themes: Experienced Demands, Turbulence, The Therapist as an Expert, The Therapist as a Safe Point, A Flexible Focus, Insight into Relationship Patterns, Wider Repertoire, The Letter, Intensive Separation Work and To Stand on Ones’ Own Two Feet. Wider Repertoire has two subthemes: Wider Internal Repertoire and Wider External Repertoire. The Letter also has two subthemes: The Intellectual Letter and The Emotional Letter.

Experienced demands

The respondents consistently described themselves as ambitious with regard to everything, from work and studies to sports and social situations. The respondents labelled themselves as ‘a perfectionist who can’t accept making mistakes’ (R2), or as having a life ‘built on performing’ (R3). Many of the respondents said that they cared a great deal about their relationships and about being a positive and energising person among their friends. In general, many talked about a wish and ambition to be social and outgoing and to have the ability to be friends with many different types of people. They adapted to what they thought others expected of them, and they preferred to be diplomatic rather than to take a clear stand. All of the respondents said that they had realised during therapy that their perceived demands had limited their actions and thoughts, and thus the demands brought on suffering and impaired their life quality. Many respondents had tried to live up to others’ ideas of who they were.

Turbulence

The time of therapy was described as intense and marked by big changes. One respondent said that ‘there were many dramatic things going on at the same time’ (R5); another said ‘those were the most action-packed six months of my life … there was a lot at the same time’(R2). A recurrent theme was that the respondents had ended romantic relationships before, during or after therapy. Many described having had destructive relationships during the time of therapy: ‘I had a lot of “decadence” in my life back then that now I don’t have at all: destructive relationships, a destructive approach to sex and alcohol, a lot. Today I feel “Oh God! I can’t even remember what I was thinking!”’ (R6).

Several respondents described therapy as a sometimes painful experience, and a part of the turbulence. One respondent described it as an upheaval to go from feeling nothing to feeling a lot – all emotions that had been previously turned off emerged. Therapy was also described by the respondents as a safe place in a turbulent time of life; as one respondent put it: ‘During that period I went through big changes that I would not have been able go through without the therapy. It was the right time in my life for it all to happen’ (R6). Some respondents said that during therapy so much happened in their life that they could not fully take in what their therapist said, and instead many insights came after the therapy was over.

The therapist as an expert

The respondents repeatedly depicted their therapist as an expert or teacher who could provide new understanding about the respondent. Many saw their therapist as an outsider, an expert with an objective perspective who could shine a light on their difficulties and relationship patterns and make them understandable. ‘It felt good that it was someone outside who could have this helicopter perspective. It is hard to get that from your friends’ (R1). ‘It felt good to have a space to talk about oneself and ones’ difficulties’ (R2). Many appreciated that the therapist focused on emotions, and some described the importance of the therapist educating them about their feelings: ‘It was as if she gave me a map of my emotions´ (R1). Many described the therapist’s ability to understand them and their problems and how the therapist’s interventions led to greater self-awareness. However, one respondent described how the therapist repeatedly misunderstood or made interpretations that did not appeal to the respondent, but the therapy still led to new insights and changes. Some respondents wished that they had been given more hands-on strategies to use in the future after therapy.

The therapist as safe point

Another aspect of therapy that came up in the interviews was the therapeutic relationship. The therapist was described as both an outsider and as a close friend, someone they felt safe with. Many respondents said that they felt a lot of insecurity in the early stage of therapy. Several felt uncertainties concerning the therapeutic setting. Some reported that as therapy proceeded they felt less insecure and started to look forward to sessions. Many respondents described the limits and continuity of therapy as something positive: ‘All of the sessions were pretty similar, I remember that she even wore the same clothes … ’ (R1). The therapist became an important source of support, and therapy became a safe place during a turbulent time in life to many respondents as they underwent major changes. They described the importance of opening up to their therapist – talking about and experiencing emotions together. Many also stressed the importance of therapy being only about themselves: ‘It was only about me. I had never been good at taking that space with friends’(R5).

The respondents diverged in their ways of describing the therapeutic relationship, and some emphasised it more than others. Many described feeling close to their therapist; some viewed their therapist as a trustworthy, non-judgemental friend.

A flexible focus

The majority of the respondents did not initially remember the focus (the IPAF) of the therapy when first asked about it during the interviews. However, shortly thereafter most of them could remember that they had agreed upon a relational affective focus with the therapist and they remembered the focus as helpful. One respondent said that it felt as if they had a plan for what the sessions would be about: ‘[…] but that rule was sort of erased, because it became natural after a while […] in my mind it felt more like I just got there and started talking’ (R1). Several respondents stressed that the focus was both narrow and broad at the same time, as one respondent put it: ‘Our focus was kind of our feelings in relation to other people, which is a bit non-specific. But that was also a good thing, because I think if it had been super concrete then I would probably have felt a bit restricted’ (R4). In general, the respondents described the therapists’ ability to return to the focus and connect events and thoughts in order to make them understandable. At the same time, all of the respondents described the therapist as flexible and the conversation as free-flowing. A few respondents found that as they underwent personal changes, the focus initially chosen was no longer relevant later in therapy. The time limit was also described as an important factor: ‘When the time is limited it is necessary to define a focus’ (R3). A few respondents said that the focus made therapy feel more manageable.

Insight into relationship patterns

The respondents generally talked about insights regarding their relationship patterns, which for many had been partly visible in romantic relationships. Many described how they could identify these patterns when working with the therapist in the initial phase of therapy. Most of them described a close connection between the therapeutic work and ending their relationships – often because of their new awareness concerning how certain negative behaviours and emotions had been repeated in the their close relationships.

Many respondents said that during periods when they felt anxious or sad, they had tolerated behaviours from their partners that in hindsight they thought were unacceptable. One respondent said ‘I met a guy during that period and I accepted things I wouldn’t normally. If he said something mean I would think “Alright, I guess he’s right”’(R1). Another respondent described how the devaluing comments from a partner made it hard both to understand and be herself. Another respondent said that therapy made the separation with a partner possible as therapy provided the insight that a pattern was repeated over and over again in romantic relationships: ‘I realised that I was in the same kind of relationship again; that I was treating myself badly in the same way that I had done before. And I don’t think I would have realised that if I had not been in therapy’ (R6). These respondents felt that therapy had facilitated and accelerated the changes they were going through in life.

All the respondents expressed a greater awareness regarding the importance of prioritising their own needs and not only pleasing others. One respondent met a new partner during therapy, and she said ‘I needed someone who was nice and stuff. He was really good for me. I don’t think I could have really appreciated him if I hadn’t been in therapy, talking’ (R2). A few of the respondents described how adapting to others had led to a suppression of emotions that in turn caused outbursts of anger towards people close to them. For these respondents the difficulty in managing this anger was one of the reasons they had applied for therapy: ‘I had these emotional outbursts because I hadn’t been standing up for myself. I didn’t do what I actually wanted to do, but instead I had constantly put myself down. It created a build-up of anger because I never got what I wanted. And I haven’t had those outbursts of anger since going to therapy’ (R5).

In the interviews, none of the respondents revealed any details about relationships within their family; one respondent expressed resentment towards talking about childhood in therapy, and another one described it as very hard to remember life as a child. However, a few respondents did say that they could trace their problems in romantic relationships back to childhood problems.

Wider repertoire – internal and external

The respondents described changes that had taken place in connection to therapy, external changes such as making new decisions or spending time with new people, and internal changes such as questioning old patterns of thinking and changing their perceptions about themselves. Wider repertoire refers to greater flexibility in both thoughts and actions.

Internal repertoire

All of the respondents described having low self-esteem at the beginning of therapy. Many talked about a struggle to understand and express their needs, and to allow themselves to be vulnerable and cry. Later in therapy, they began trying to stand up for themselves and set boundaries, and had more self-compassion. All of the respondents talked about problems caused by a lack of self-esteem or sense of self. Many described having lived fast paced lives as a way to avoid thinking about problems. In addition, many described difficulties to hold their own in relationships in the past, and that they had been stuck in negative thinking patterns about themselves. Several respondents described how they started to change their self-image at the end of therapy, and said that this led to a more flexible relationship with their own feelings and thoughts. The change in thinking ‘unlocked many hidden things’ (R6), or therapy resulted in ‘a better relationship with myself’ (R2) or ‘made it possible to cry again’ (R3).

Several described the road to insights and changes as challenging. One respondent said ‘It was really an uphill battle to go through everything and tell certain things, but you have to feel something in order to move on’ (R1). Many respondents said that they could now analyse and reflect more on their choices, and that because of this they now had better relationships. Even if many respondents said that they still had many negative thoughts about themselves, they all said that they now had a different inner self-dialogue: ‘I now have a different dialogue with myself, between self-compassion, old assumptions and intellect’ (R6). ‘I can now sort out my emotions […] Before I didn’t realise the importance of reflection’ (R1). A third respondent described how the way feelings could be expressed in relationships had begun to change: ‘Now I am not as afraid to have an open and vulnerable relationship that is mutual’ (R4).

External repertoire

The respondents went through several life changes in connection to therapy, mostly to do with close relationships and in particular with romantic partners. Many said that during therapy they had discovered that many problems were related to setting themselves aside: ‘Now I understand that I need to prioritise myself. I was very surprised by this – it led to me breaking up with my partner because I realised I was treated badly’ (R5). Some of the respondents said that it was hard to make changes at the time of therapy: ‘Maybe we didn’t get that far then because it was a behaviour I had had all of my life – pushing feelings down – the change came later’ (R3). Another respondent described how the new insights had to be tried out in real life.

The letter

The respondents’ descriptions of the importance of the letter they received from the therapist in the final phase of therapy fall into two subthemes: The Emotional Letter, and The Intellectual Letter.

The Emotional Letter

The Emotional Letter was seen as an extension of the therapist’s care for the respondent. Many respondents said they appreciated that the therapist had taken the time to write the letter to them. Many said that they were moved by the letter. ‘I felt seen’ (R3), ‘It made me so happy that she wrote the letter’ (R1), ‘I felt as if the therapist really had understood me’ (R5). However, one respondent felt that the therapist had used the respondent’s own words in the letter in a way that the respondent disliked: ‘I want to say the things I say myself and not have someone else saying them for me’ (R4).

The Intellectual Letter

The letter was also described as a summary of the therapy and the respondents’ problems, and as an aid to continue improving after therapy: ‘It was like a proof that you’d gotten somewhere’ (R6), ‘If I didn’t have the letter it probably wouldn’t be as easy to see the changes, but now I could really see the differences between the first session and the last’ (R2). How helpful the respondents perceived the letter differed greatly. A few did not find the letter very useful: ‘It was a bit weird, it didn’t really have a function, it was sort of a waste of time’ (R4). One respondent would have preferred if the letter had been written with a more objective stance. On the other hand, another respondent described the summarising function as very helpful, since the letter clearly described the respondents’ progress: ‘I’m slow to see changes, so the letter was important. And it was with the letter that I understood what great progress I had made. […] It was good to take the letter home; otherwise it would be easy to forget. I have read it again and been reminded of what I need to keep working on’ (R5).

Intensive separation work

The respondents had vivid memories of the termination of therapy; many described it as stirring up mixed emotions. Ending therapy was associated with both feeling as if one had come a long way, and wishing to continue in therapy. ‘I actually had some anxiety prior to the last session, because I felt like it was right then that I started to become a bit more stable. […] The last time was so emotional. […] Still, we were both happy; we had been through so much. But I wanted even more’ (R1). Termination was consistently described as a positive experience even if some respondents felt anxiety prior to it or wished to continue therapy. ‘It was pretty hard towards the end. Therapy made me vulnerable, and that can be pretty hard for someone who has never been vulnerable with others before … to be vulnerable all of a sudden. […] Old feelings came back in the last week’ (R4). The same respondent said that much had changed and improved: ‘I had managed to get to the stage I wanted to’ (R4). Other respondents also said they had felt ready to end therapy: ‘The therapist and I were done and satisfied at the last session. She could let me go; I felt better’ (R3).

To stand on one’s own two feet

The respondents said that after therapy they had greater independence and reflective function, while at the same time many had wished for more therapy. They described both the struggle to stand on one’s own two feet and a greater ability to do precisely this: ‘I had acted in a certain way earlier … now I hate those words, but well submissive or whatever you’re supposed to call it. A bit of a victim, I didn’t really claim my space. Now it’s definitely not like that! […] I’ve become more aware of my decisions and needs’ (R2).

Many respondents found the therapy to be short. Some respondents said that when they were in the termination phase they felt more comfortable in therapy and because of that they wanted to continue. Some respondents said that they had wished to have more guidance regarding future struggles: ‘Perhaps I needed to explore a bit what my new strategies would be. I have a few strategies, but perhaps I needed some help with the whole reorientation thing’ (R6). Some wished to have more therapy with the same therapist later on in life. Many described the importance of making changes on their own: ‘Afterwards it felt great that I had made all the changes by myself – that I hadn’t had very much guidance, but it felt like I had talked about and figured things out by myself’ (R5). Several respondents described how change processes that started during therapy continued well after termination. Many described how they had continued to work with their problems after therapy: ‘It’s an ongoing process – I’m still working with these things’ (R5).

The change model

We discovered a general pattern in the respondents’ descriptions of changes connected to therapy, illustrated in Figure 1. At the start of therapy, they experienced high demands on themselves, particularly in interpersonal situations. They did not prioritise their own needs and feelings enough and adjusted to others in various ways. Many had a hard time setting boundaries with others in relationships. Therapy gave the respondents space to discover their needs and feelings, and to obtain new insights concerning relationship patterns and the demands the respondents had put on themselves. These insights contributed to a growing ability of the respondents to express needs and emotions, to more effectively set boundaries in relationships, and be less compliant towards others. In parallel, their experienced demands on themselves diminished.

Figure 1. Model representing the change processes within the respondents in connection to therapy. The arrows represent evolving processes over time.

Discussion

The purpose of the current study was to explore young adults’ experiences of DIT. The results showed that at the beginning of therapy the respondents experienced high demands on themselves, particularly regarding close relationships. They adjusted themselves to others, had trouble setting boundaries and prioritising their own feelings and needs. The respondents said that after therapy they could understand their own emotions and needs better, and handle them in more flexible ways, and could also manage interpersonal situations better. The therapist was described from two perspectives: partly as a competent expert and partly as a safe point that provided emotional support during a turbulent change process. The respondents valued the importance of these two aspects differently. The views also varied regarding other aspects of the therapy such as the letter and the length of the therapy.

The respondents all described the time of therapy as a turbulent period in life that included eventful love lives, which is in line with research on young adulthood (Arnett, 2014) as well as psychodynamic theories of development. The respondents’ eventful love lives could be interpreted through Kernbergs’ theory of object relations dyads, as the internal object representations of the young person are tested with new partners. An internal restructuring takes place that can require challenging work that involves coping with both painful memories and painful experiences (Clarkin et al., 2006). The fact that the respondents were focusing on new relationships is also in line with Blos’ (1967) theory on how teenagers start to dismantle their parents as primary love objects. A recurring narrative among the respondents concerned difficulties in adjusting to others while simultaneously not losing the core of one’s self – the challenge was hence to create mutual relationships, which is a narrative that fits well with Briggs’ (2003) theory on subject positions.

The fact that many respondents emphasised the expert role of the therapist is consistent with the findings of previous qualitative studies on young persons’ expectations about psychotherapy (Midgley, Isaacs, Weitkamp, & Target, 2016; Philips et al., 2007). This could be understood as part of an attempt on the young persons’ part to avoid once again being dependent on an adult, in this case the therapist (Philips et al., 2007). Overall, the respondents emphasised both technical and relational aspects of therapy, which suggests that these aspects together contributed to the therapeutic alliance (Bordin, 1979). To view the therapist as mostly an expert could mean seeing the therapist as a knowledgeable adult, whose competence might be crucial for fulfilling the role as a secure base in an attachment relationship (someone stronger and wiser). Some may argue that the therapist being perceived as an expert is discordant with the ‘not-knowing stance’ advocated in DIT (Lemma, Target, & Fonagy, 2011a). But we consider the realistic humility, as well as the curious and explorative therapeutic approach characterising ‘not-knowing stance’, not being at odds with the patient perceiving the therapist as someone with knowledge and competence. It is noteworthy that even the novice student therapists, some of them being not much older than their patients, were perceived as experts.

The respondents still being young and in the midst of psychological development and a majority of the therapists being novice student therapists with DIT training not fully corresponding to the formal DIT training at AFC, may explain why some of our results were not in line with ideal DIT theory and practice. For example, the respondents could only with difficulty remember that there was focus (the IPAF) for the therapy.

Some respondents wanted more advice and guidance, which is also a recurring theme in other qualitative interview studies with young adults (Lilliengren, 2014; von Below, 2017). Several respondents found the therapy to be short, but still experienced improvements in mood and interpersonal functioning. Perhaps therapy was too short for some of them, but for some this experience could be seen as an expression of an intensive separation process in therapy. According to the creators of DIT such a process always entails mourning what could not be achieved in therapy (Lemma et al., 2011a).

DIT was developed for adults who have reasonably stable internal representations of self and others. There is variation in the age at which these internal representations are mature enough so that an unmodified DIT treatment can be used. The respondents’ descriptions of their relationship patterns and related insights suggest that their internal representations were stable enough to formulate a working interpersonal affective focus. When using DIT with young people, the therapist needs to consider the degree of maturity and stability of the young persons’ internal representations before deciding if the approach is suitable. Briggs and Lyon (2011) have developed a model for short-term therapy aimed at teenagers and young adults which is similar to DIT but has an additional developmental focus. As an example, the above-mentioned authors describe how young people may handle transitions such as starting university or working life in various ways, and therapists are recommended to assess the young person’s readiness to meet such developmental challenges.

There are several reasons why DIT in this study appears as suitable for young people. The interpersonal focus on current relationships and relationship patterns fits young people who are in a phase in life where old relationship patterns are tested out in new relationships. The DIT approach requires an active therapist as well as collaboration between patient and therapist around the focus of the therapy, an approach that is concordant with research on what young people experience as helpful in therapy. Our findings suggest that the IPAF is not perceived as limiting but as a natural part of therapy. DIT is shaped to suit public health care, and we believe that the short format developed for depression and anxiety could help increase access to high-quality psychological interventions and better meet the needs of the growing number of patients suffering from depression and anxiety. It is possible that DIT needs to be modified to suit teenagers and young adults with less maturity than our respondents. Briggs and Lyon (2012) suggest that prior to therapy the therapist should assess where the young person is in the process of separating from his or her original family. Teenagers are in a process of separation and they may come to see the therapist as a parental figure, which might obstruct the therapeutic process. Furthermore, an awareness of the young person’s attachment style is probably important since this provides information about how the patient will react to separation in therapy – a crucial question in DIT.

Research on DIT is still limited. Randomised controlled trials on DIT specifically for adolescents and young adults would be of great interest. Future research could also focus on more specific aspects of DIT, such as the IPAF. For example, it would be interesting to study whether the IPAF contributes to creating the therapeutic alliance.

Limitations

The present study was explorative since there was no previous research on young peoples’ experiences of DIT. The change factors identified are frequently seen in both psychotherapy research and theory. The results could be valid not only for DIT but for psychodynamic psychotherapy in general. All of the respondents who took part in our study had mainly positive experiences of therapy. It is possible that satisfied patients are more likely to accept participating in an interview study about their therapy. The majority of the respondents were young adults. It is possible that teenagers faced bigger obstacles to taking part, both emotional as well as practical. One limitation of the study is that the student therapists at the Psychology Clinic at Stockholm University had not undergone the formal DIT training and supervision at AFC. The small sample size and the small proportion of teenagers and males are the major limitations of the study. Our aim was to recruit ten to fifteen respondents, but despite repeated attempts to establish contact with more patients we were only able to recruit six. To avoid further limitations, we followed established guidelines for qualitative research highlighting researcher reflexivity throughout the whole research process (Malterud, 2001). Our strategy to work close to the data material reduces the risk of preconceptions overly affecting the thematic analysis.

Conclusions

The young adults interviewed had mainly positive experiences of being treated with DIT. They were helped with achieving greater understanding of their own emotions and needs, which enabled them to better manage their emotional stress and interpersonal situations. During their DIT treatment, they moved from overly adjusting to others and living in turbulent interpersonal relationships to growing ability to express their needs and emotions, and to set adequate boundaries towards others. Thus, DIT appears as a promising treatment for young adults.

Acknowledgements

Warm thanks to the respondents who participated in this study. Many thanks also to the Psychology Clinic at Stockholm University and the Erica Foundation in Stockholm for making this study possible.

Disclosure statement

No potential conflict of interest was reported by the authors.