PIT SIG

Latest news: November 2019

Dates for 2019 PIT SIG meetings announced. Click here for further details.

NEW LEVEL 1 PIT CPD COURSE LAUNCHED! PIT SIG UK is delighted to announce a new five-day introductory course in PIT, developed in collaboration with the University of Manchester. The course is taking place on the 9th-13th September 2019 at the University and will provide attendees with a basic knowledge of the approach, including the ability to use Level 1 PIT practical and formulation skills as an adjunct to other therapeutic models (including CBT). Click here for further information.

New Level 2 PIT course recently approved and due for launch soon. The University of Manchester have recently approved a new course offering advanced training and clinical supervision in PIT for people who wish to use the model as a standalone therapy in their clinical role. We will be releasing further information about this shortly.

NIHR gives 4m funding boost to research on PIT. NHS funding body the National Institute for Health Research has recently invested nearly 4m in two projects investigating the efficacy of PIT. The FReSH START study is investigating PIT as one of several treatments for people with a history of self-harm, while WORSHIP-III is a pragmatic trial of PIT for women offenders with repeat self-harm.

Information about PIT for professionals

This section provides technical information about PIT that is mainly likely to be of interest to clinicians, academics and other professionals.

Theoretical influences on the conversational model

Hobson was influenced by a wide range of clinical and theoretical perspectives whilst developing his approach to psychotherapy (see Figures 1a and 1b). In Forms of Feeling, Hobson presents a detailed, systematic model of psychotherapy that draws on these influences but is unique in its combination and application of them.

Figure 1a: Influences on PIT Influences on PIT

 

Figure 1b:Key concepts informing PIT and their origins

Key concepts informing PIT

Core theoretical concepts

In attempting to understanding the origins of psychopathology (or what he prefers to call "personal problems"), Hobson draws on traditional psychodynamic concepts like conflict, avoidance of painful feelings, and the re-enactment of problematic patterns of relating, acquired early in life, in current relationships. In this sense, the model lends itself to use of the so-called triangles of conflict and persons (popularised by David Malan in his 1979 book Individual psychotherapy and the science of psychodynamics published by Butterworths) when formulating clients' problems from this perspective. This is not an explicit part of Hobson's approach, however, and it is possible for clinicians to incorporate ideas from other traditions when formulating.

Hobson's description of these concepts and processes (mainly outlined in Chapter 14 of Forms) dispenses with much of the theoretical baggage and jargon of previous psychodynamic approaches, making his approach refreshing in its simplicity and accessibility. Particular emphasis is placed on two basic needs that are often in conflict: (i) the need for a coherent and positive sense of self; and (ii) the need to retain relatedness with other people, particularly attachment figures. Subsequent theoretical writings by Russell Meares, which are particularly aimed at accounting for the development of borderline personality disorder, have focused more on early experiences and their affect on the development of the self, including the ability to represent emotional experiences and relate to others.

Persons, I-thou relationships and aloneness-togetherness

According to Hobson, the quality of our relationships rests on our ability to relate to others and ourselves as 'persons' (i.e., unique, experiencing, feeling beings), which he distinguishes from how we relate to 'objects' like jam jars. For Hobson, this is not a given. Indeed, depending on our experiences in relationships, we may relate to others and ourselves more like jam jars than as sentient beings. The goal of PIT is to foster a particular kind of conversation that enables the therapist and client to relate to one another as people: a so-called 'meeting between persons'. Hobson follows Martin Buber in calling this an 'I-thou' relationship (as opposed to the 'I-it' relationship that characterises how we relate to objects). In so doing, it is hoped that the client will become more able to relate to themselves and other people in their life as persons rather than objects, thereby improving their self-esteem and relationships with others.

Throughout the therapy, the therapist is seeking to create an optimum balance between having an emotional connection with the client whilst respecting their separate identity and autonomy; Hobson refers to this as a state of aloneness-togetherness. This concept can be applied to all personal relationships, although the therapy relationship is special in that it is necessarily characterised by mutual asymmetry; in other words, the relationship is meant to be equal (i.e., both parties are afforded equal value and 'authority') but focused on the client's problems rather than the therapist's.

One implication of this theoretical stance is that the therapist must 'be a person' during the therapy. This entails being genuine, human and 'present' in the relationship (rather than thinking about other things), holding in mind and being responsive to the other person's feelings, seeking to understand the other person but not being 'the expert', and having humility.

Staying with feelings and symbolical transformation

The psychodynamic aspect of the model asserts that part of the cause of the individual's difficulties is their estrangement from, and avoidance of, feelings, thoughts, impulses and other mental contents that are too threatening or painful to acknowledge and accept. Creating a safe and trusting relationship enables the client to tolerate their anxiety about recognising these 'hidden' feelings and contents and begin to accept them as part of their experience. Many of the interventions in PIT are aimed at helping clients notice and 'stay with' difficult feelings as they arise in the therapy rather than avoid them. This fosters a process of symbolical transformation (akin to the concept of 'emotional processing' in other models), in which the individual puts their feelings into words and links them up with other aspects of their experience, self-concept and history. In so doing, they become more able to understand and master painful feelings, allowing them to develop a more complete and coherent sense of self as they accept previously disowned mental contents.

Core practical concepts

Although the theory behind PIT is complex, the therapy itself is comprised of a small set of clearly defined interventions that are easy to learn. These include:

- closely listening to and noticing what is being 'said' during the therapy, including what is implicit in the client and therapist's utterances and behaviour; Hobson calls this a focus on the 'minute particulars';

- using statements (e.g., "I wonder how you're feeling about that"), which are seen as less anxiety-provoking and interrogative than questions (e.g., "How do you feel about that?"), providing a starting point for a process of exploration, whilst leaving things open to correction;

- using a tentative, negotiating style of speaking (e.g., "I'm not sure if I've got this right, but I wonder if...") that conveys a wish to understand and be corrected when misunderstandings have occurred;

- a language of mutuality where the therapist explictly refers to the relationship in terms of first-person words like "I" and "We" (e.g. "I wonder if it feels like an effort to come and see me"); N.B., this may be too threatening for some people, where a different approach may be required (see Russell Meares' development of the model for use with patients with severe borderline personality disorder);

- focusing on what is happening in the immediate 'here and now' of the therapy relationship, to facilate the expression of feelings as they arise (as opposed to 'talking about' feelings in an abstract sense);

- looking out for and picking up cues in what the patient is saying and doing, ensuring that interventions are related to what is actually happening at that moment;

- developing a mutual feeling language that puts the client's experience into words in an emotionally vivid way, often using metaphors and other figurative language to amplify feelings and expand the client's understanding of them;

- use of understanding hypotheses, that is, tentative empathic statements of what the therapist feels the client is experiencing at that moment in the relationship (e.g. "I wonder if you're feeling a bit stuck right now"), with a view to bringing feelings on the edge of awareness into focus;

- use of linking hypotheses, that is, tentative statements drawing a parallel between what is happening at that moment in therapy with previous experiences in relationships (e.g., “I wonder if it feels as though I’m being mean to you, a bit like when your Mum used to criticise you”), with a view to linking up previously unrelated aspects of experience;

- use of explanatory hypotheses, that is, tentative statements introducing possible reasons for disturbances in relationships within and outside therapy, which provide an opening whereby conflicts and avoidance actions can be acknowledged, owned and explored;

Although straightforward to apply, the skill of PIT is in the combination and timing of these interventions.

Hobson and Meares also emphasised the need to avoid certain common ways of relating that are counter-therapeutic and potentially damaging to clients. These include responding in an intrusive, derogatory, invalidating or opaque manner, as well as creating situations in therapy that are untenable for clients. These concepts are articulated in a now classic paper on the concept of the persecutory therapist by Hobson and Meares, which describes how even well-meaning, reflective and informed therapists can find themselves relating in unhelpful ways. The ability to spot when one's behaviour is becoming counter-therapeutic and potentially persecutory and to address this are regarded as important therapist skills.

 

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