8 Psychotherapy8.1 Psychodynamic psychotherapy
8.1.4 Psychodynamic therapy in stepped care
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
Choosing the intervention
Stepped care matches how intensive a treatment is to the person's clinical need, their previous response and their preference. Progress is reviewed, and the person moves between levels when that is indicated.
Exploratory psychodynamic work looks at emotional and relational patterns that keep repeating. It suits a patient who can reflect on them within a reliable therapeutic relationship.
Short-term psychodynamic psychotherapy is an option for depression. It need not wait until every other therapy has failed.
Supportive work may come before exploration or run alongside it, when immediate distress, practical insecurity or impaired coping makes reflection hard.
Complex trauma
Clinical need | Therapeutic response |
|---|---|
Current danger or overwhelming instability | Deal with safety, housing, crisis care and coordination |
Difficulty trusting clinicians | Give time to establish reliability, and agree boundaries |
Repeated relational patterns | Explore how the patterns protect the person and what they cost now |
Post-traumatic stress symptoms | Offer an indicated trauma-focused treatment, with adaptations |
Problems that persist after treatment | Review the formulation, the goals and the need for specialist care |
Trauma-informed care means recognising the effects of trauma throughout treatment. Trauma-focused therapy works directly on trauma memories and what they mean to the person.
A psychodynamic understanding can inform care for complex trauma. It does not make exploratory therapy equivalent to trauma-focused cognitive behavioural therapy or eye movement desensitisation and reprocessing.
Review readiness together with the patient. Open-ended preparatory work does not suit every patient, and neither does moving straight into intensive exploration.
Reviewing the step
What to review: functioning, symptoms, safety, the therapeutic alliance and the patient's goals. Attendance alone is not enough.
If there is no response: reassess the diagnosis, treatment fit, practical barriers and the therapeutic relationship before you increase intensity.
At transitions: make clear who holds responsibility, what the next treatment is and what support is in place in the gap. Fragmented care can repeat experiences of abandonment.