Lemma, A; Fonagy, P; (2013) Feasibility study of a psychodynamic online group intervention for depression,
Psychoanalytic Psychology, 30 (3) 367 – 380. 10.1037/a0033239
1
RESEARCH ARTICLE
Feasibility Study of a Psychodynamic Online Group Intervention for Depression and
Anxiety
Alessandra Lemma
Tavistock and Portman NHS Foundation Trust
Peter Fonagy
Anna Freud Centre
Alessandra Lemma, Psychological Interventions Research Unit, Tavistock and Portman
NHS Foundation Trust, London, UK; Peter Fonagy, Anna Freud Centre, London, UK.
Peter Fonagy is also at Department of Clinical, Educational and Health Psychology,
University College London, UK.
Correspondence concerning this article should be addressed to Alessandra Lemma, E-
mail: alemma@tavi-port.nhs.uk
Lemma, A; Fonagy, P; (2013) Feasibility study of a psychodynamic online group intervention for depression,
Psychoanalytic Psychology, 30 (3) 367 – 380. 10.1037/a0033239
2
Abstract
Dynamic Interpersonal Therapy (DIT) was originally developed as a brief psychodynamic
intervention for the treatment of depression and anxiety. More recently it has become the
psychodynamic protocol for depression within Improving Access to Psychological
Therapies services across the UK. The aim of the present study was to pilot and evaluate
the feasibility of a group online version of DIT – Online Group Dynamic Interpersonal
Therapy – and the perceived helpfulness of psychodynamically informed self-help
materials. Twenty-four participants were randomly assigned to three groups. Participants
in Condition A (N = 8) took part in an online DIT group, with self-help materials, facilitated
by a therapist. Participants in Condition B (N = 8) were given access to a closed virtual
group space where they could interact with each other and were supplied with the same
self-help materials used by participants in Condition A, but without online therapist
facilitation. Participants in Condition C (N = 8) received no instructions or facilitation, but
had access to an online mental well-being site where they could meet virtually in a large,
open, moderated virtual group space to discuss their psychological difficulties. This
feasibility study was underpowered to detect significant differences in rates of change
between facilitated and unfacilitated provision of material, but decline in symptoms was
significantly superior to control only for the facilitated group when the groups were
considered separately. The encouraging superiority of the combined treated groups
against control also suggests that the DIT self-help materials are helpful and appear to
support the process of change.
Keywords: anxiety, depression, dynamic interpersonal therapy (DIT), online therapy,
psychodynamic therapy.
Introduction
In 2009, the updated NICE Guideline (CG90) on the management and treatment of
adults with a primary diagnosis of depression in primary and secondary care stated that for
Lemma, A; Fonagy, P; (2013) Feasibility study of a psychodynamic online group intervention for depression,
Psychoanalytic Psychology, 30 (3) 367 – 380. 10.1037/a0033239
3
patients with mild to moderate depression who decline other treatment modalities, the
clinician may consider brief psychodynamic psychotherapy. In light of this revision, brief
psychodynamic therapy has now been recommended as one of the therapeutic
approaches provided through the Improving Access to Psychological Therapies (IAPT)
initiative in England. Dynamic Interpersonal Therapy (DIT) has been selected as the
protocol for its delivery (Lemma, Target & Fonagy, 2011a, 2001b).
DIT is a time-limited (16 sessions) intervention that is specifically designed to
address depression and other mood disorders (Lemma et al., 2011a, 2001b). In order to
explore DIT’s potential as a “low-intensity” type of intervention, and to address the need to
consider both more accessible and more cost-effective early interventions given current
economic pressures on mental health services (Kazdin & Blase, 2011), here we discuss
the application of DIT in a modified format for delivery online in a group setting. We do not
consider that this is a viable alternative to face-to-face therapy for many patients.
However, for those individuals who find it hard to contemplate face-to-face interaction with
a therapist. either for reasons of accessibility or by virtue of their own psychological
difficulties, online therapeutic interventions have a potentially significant role to play in
increasing access to psychological therapy.
Traditionally, the psychoanalytic community has been highly skeptical of online
interventions, concerned that any alteration to the standard analytic frame compromises
the analytic relationship. Yet, several psychoanalysts over the years have been using
various forms of communication for treatment, including correspondence (e.g., Hofling,
1979), telephone, (e.g., Leffert, 2003; Lindon, 1988; Rosenbaum, 1977), and more
recently e-mails, videos and Skype. A survey of psychoanalysts’ practice in the UK (N =
62), carried out by the British Psychoanalytical Society, revealed that 31% of respondents
had conducted analysis via telephone/Skype (Fornari-Spoto, 2011). Those analysts who
do use new technologies to communicate with patients, for example via texts, or those
Lemma, A; Fonagy, P; (2013) Feasibility study of a psychodynamic online group intervention for depression,
Psychoanalytic Psychology, 30 (3) 367 – 380. 10.1037/a0033239
4
bold enough to have braved Skype analysis, are nevertheless careful not to advertise the
fact too widely, with a few notable exceptions (Carlino, 2011; Dini, 2009; Ermann, 2004;
Fiorentini, 2011; Lingiardi, 2008). Consequently, the psychodynamic psychotherapy
literature in this area is very scarce. Practitioners of other therapeutic modalities have
been far more enterprising in this domain, not least cognitive behavioral therapists, who
have developed a range of guided self-help resources and made creative use of new
technologies to deliver online interventions (e.g., Hedman et al., 2011).
From a psychoanalytic point of view, the emphasis with regard to new technologies
has been placed on the requirement to understand more about how these technologies
interact with the prerogatives of an individual’s internal world, how they may alter psychic
structure itself in fundamental ways, and the implications of this for the individual’s
functioning (Lemma and Caparrotta, in press). Equally important, however, is the
exploration of how new technologies could help individuals with mental health problems to
access help informed by psychoanalytic views and the extent to which online adaptations
of psychodynamic treatment models may be feasible and effective.
There are some encouraging signs that, as technological advances fundamentally
alter the way we relate to each other in our daily lives, a more active and open
engagement with new technologies, and how they may be integrated within
psychodynamic ways of working, is emerging. It is in this spirit of openness that we set
about to study whether facilitated internet applications of DIT are possible.
Online Group Dynamic Interpersonal Therapy
The assumptions informing the online group DIT (OLDIT) protocol are similar to those
of the standard face-to-face protocol, and are the same as those that underpin other brief
dynamically oriented approaches: (i) that behavior is unconsciously determined, (ii) that
internal and external influences shape thoughts and feelings and therefore inform our
Lemma, A; Fonagy, P; (2013) Feasibility study of a psychodynamic online group intervention for depression,
Psychoanalytic Psychology, 30 (3) 367 – 380. 10.1037/a0033239
5
perception of ourselves in relationships with others, (iii) that adult interpersonal strategies
and ways of relating are generated by childhood experience, particularly within the family,
(iv) that unconscious processes including defenses and identifications (projective and
introjective processes) underpin the subjective experience of relationships, (v) that thinking
about behavior and emotional experience in terms of mental states has significant
therapeutic effects, and (vi) that therapy should focus on the patient’s current
relationships, including the relationship with the therapist (Fonagy & Target, 2008; Lemma
et al., 2011a).
DIT’s starting point is interpersonal. It is based on the common clinical observation
that patients who present as depressed and/or anxious invariably also present with
difficulties in, and distress about, their relationships. The approach focuses on presenting
distress/symptoms, which are jointly formulated as possible responses to interpersonal
difficulties/perceived threats to attachments (loss/separation) and hence also as threats to
the self. In the course of these discussions it is recognized that perceived threats can both
result from, and cause, difficulties in thinking clearly and realistically, not only about the
external world, but also about the internal world, one’s own thoughts, feelings, and
experiences with others. It is assumed that improving the patient’s ability to reflect on his
own and others’ thoughts and feelings will improve his ability to understand and cope with
current attachment-related interpersonal threats and challenges (Allen, Fonagy, &
Bateman, 2008; Bateman & Fonagy, 2012). Mentalization is one of a family of concepts,
drawing on social cognition research, that is increasingly finding its way into the
psychotherapeutic lexicon (Dimaggio, et al., 2011; Lecours & Bouchard, 2011; Liotti &
Gilbert, 2011; Lysaker, et al., 2011; MacBeth, Gumley, Schwannauer, & Fisher, 2011;
Vanheule, Verhaeghe, & Desmet, 2011).
We can envision that this type of discourse may be implemented in the context of
group as well as individual treatments, face-to-face or across digital media. Lemma
