IPT is a time-limited psychotherapy that was developed in the 1970s and 80s as an outpatient treatment for adults who were diagnosed with moderate or severe non-psychotic, unipolar depression. Over the last 30 years, a number of empirical studies have demonstrated the efficacy of IPT in the treatment of depression. Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults, dysthymia, bipolar disorder, bulimia, anxiety disorders and couples counseling. IPT has its roots in psychodynamic theory, but differs from the latter in that it focuses on improving interpersonal functioning in the present. It is similar to CBT in its time-limited approach, structured interviews and assessment tools, but also differs from CBT in that it focuses on the client's affect, rather than cognitions, and the development of a more supportive social network. And whereas nearly all CBTs use homework as a standard part of treatment, although Brief ITP (ITP-B) uses homework, regular IPT may not.
Download MP3 [39:15]Transcript
Jonathan Singer: Today, we're going to be talking about Interpersonal Psychotherapy, also referred to as IPT. IPT is a time-limited psychotherapy that was developed in the 1970s and 1980s as an outpatient treatment for adults who were diagnosed with moderate or severe non-delusional depression. Over the last 30 years a number of empirical studies have demonstrated the efficacy of IPT in the treatment of depression.
Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults, bipolar disorder, bulimia, postpartum depression and couples counseling. IPT has its roots in psychodynamic theory, but it really takes its cues from contemporary cognitive behavioral approaches in that it is time-limited and also in its use of technique such as homework, its use of structured interviews as well as assessment tools.
In today’s lecture, I'll discuss the key concepts that underlie IPT, the role of the therapist, the role of the client, the structure and goals of treatment and some of the techniques used in IPT. I'll end with a review of the strengths and limitation of the model. One of the strengths of IPT is that it was developed with an empirical basis. Epidemiological research in the 1970s and 1980s supported the notion that people with depression reported higher rates of interpersonal discord and that the presence of depression eroded interpersonal bonds, so interpersonal issues were then understood to be linked to depressed mood and that depression impairs interpersonal functioning.
IPT relies on the work of John Bowlby and the other attachment theorists to provide theoretical support for its model. They also looked at the work Meyer and Sullivan for interpersonal theory and briefly attachment theory itself has its basis in non-human primate research and Bowlby in the 1950s really sought out to explain how attachments form and what the purpose of attachments was in human development.
A basic assumption of Bowlby’s attachment theory is that attachment is a biologically-based system that is sensitive to environmental conditions and what that looks like in real life is that an infant has biologically-based impulses, hunger, need for sleep, shelter, those sorts of things and that they look to the environment to fill those needs. Now, some of Bowlby’s early studies predicted that infants in distressing situations would actively seek the comfort of their primary attachment figure.
The response of that attachment figure would have implications not only for the infant’s physical safety but also over time would determine the infant’s inner sense of security because attachment behavior was assumed to develop over time rather than response to a single event or experience. Attachment theory predicted that attachment behavior would be a fairly stable trait over time. For this reason and contrary to wildly held beliefs of the day, Bowlby and his colleagues argued that establishing and maintaining close emotional bonds between parent and child was both desirable and predictive of future adjustment.
One of the most important advances in attachment theory was the identification of distinct organized attachment systems. Ainsworth and colleagues in 1978 published a paper that identified the first three distinct organized attachment systems and they were the secure, the anxious or resistant and the avoidant attachment styles.
A fourth attachment style called disorganized or disoriented was added in the mid-1980s by Main and Solomon (1986) to describe infants who displayed no organized attachment system. Attachment theory provides not only a framework for understanding emotional reactions in infants but also a framework for understanding love, loneliness, and grief in adults. Attachment styles in adults are thought to stem directly from the working models also known as mental models of one’s self and others that were developed during infancy in childhood.
In a 1987 article, Hazan and Shaver discussed how Ainsworth’s three attachment styles could be translated into terms of adult romantic relationships and these translations were based on some of the first longitudinal studies that were conducted that provided evidence about the stability of these attachment styles over time.
Another theoretical basis for IPT is interpersonal theory. One of the ideas in interpersonal theory is that people lie along dimensions of hostility or friendliness, and dominance and submission. And so any one person can be more dominant and friendly or more dominant and hostile or more submissive and hostile or more submissive and friendly. The theory also holds that people can be either more flexible or more rigid in any of these quadrants, so somebody can be dominant in some situations, but submissive in others, friendly or hostile depending on the situation. However, there are some people for whom hostility or submissiveness are the primary modes of interpersonal relations almost regardless of the situation. Those folks will be considered rigid.
So you have attachment theory and interpersonal theory. Both suggesting that we have interpersonal relationship patterns that were developed early in our life and that continue throughout time. And this is really the psychodynamic basis for interpersonal therapy.
The epidemiological and empirical data as well as the theoretical justifications led the developers of IPT to identify four interpersonal relationship patterns that are most important to treat when working with people who are depressed.
Four Interpersonal Relationship Patterns
The first is “grief,” which also is talked about as complicated bereavement. And in this problem area there is the death of an important person in the client’s life.
The second interpersonal relationship pattern is what they call “interpersonal role disputes” and this is any relationship where there is a non-reciprocal expectation in the relationship. And this could be between partners, ot could be between an employee and a boss, it could be between a parent and a child.
The third type of interpersonal relationship pattern is called “role transitions” and this focuses on any major life event in your client’s life.
The final concept is “interpersonal deficits.” And this is really a default category. It reflects long term interpersonal problems and is described as having the worst prognosis. In the brief version of IPT, interpersonal deficits are not addressed simply because it's not possible to satisfactorily resolve any long standing interpersonal problems in four to eight sessions. It's also considered the category that is picked when none of the other three actually fits what's going on with the client.
Key Concepts
Some other key concepts of IPT are that the medical model is “good” and I say this because in social work there are some folks and some models that suggest that the medical model, the model that identifies clients as patients, that identify problems as pathology is in fact in itself problematic, but IPT really sees the medical model as good and we'll talk a little bit more about why that is in a minute.
Mood is seen as related to life events. Depression is seen as a medical illness with interpersonal triggers and consequences. Symptom reduction is understood to occur by focusing on current interpersonal functioning. So, again, this is the contemporary nature of IPT that although there is an understanding of the importance of interpersonal patterns that developed in the past, the focus is on the present.
And finally, IPT is a time-limited treatment and that being time-limited is valuable. So as a time-limited treatment, goals different from long term therapy. There's an explicit focus and that’s one of those four treatment areas. The treatment targets specific symptoms. What it does not do is it does not address character change. Also, time can be used as a leverage. And by this, what I mean is that your client should hear the ticking of the clock which can be used as a motivator for the client to make changes in a short period of time. This is in contrast to a long term treatment where there might not be that external motivation to get things moving.
Assessment
So, assessment is really important in IPT. Assessment is structured. It's systematic and is directly related to the intervention. In IPT, you start out with understanding the timeline of events leading up to the depression. You use an interpersonal inventory that helps to identify which interpersonal pattern would be most important to address over the 12 to 16 sessions.
The Hamilton Depression Rating Scale although not used to diagnose depression is recommended for use in treatment in the initial phase of the assessment as well as standardized measures such as the Beck Depression Inventory. The therapist’s role in IPT is to be active. The therapist is an active participant in this process. This is different than Freudian psychoanalysis where the therapist really was a blank slate and was there to interpret and to be the expert, but not really to be actively involved in the relationship.
The therapist is not a neutral figure. Again, this is different than traditional Freudian psychoanalysis. The therapist really has a bias towards the client and this is different than some cognitive therapy such as Ellis’ rational-emotive behavior therapy and it’s certainly different than traditional alcohol and drug treatment where there's a sense of breaking through the denial and confrontation that is typically necessary when working with clients who have used misrepresentation, deception and lying in order to continue their addictions. The therapist is responsible for assessing the client and making the DSM diagnosis.
And finally, the therapist defines the treatment and what I mean by this is that the therapist tells the client what type of interpersonal relationship issue they will focus on. Now, if the client disagrees, the therapist will modify this conclusion, but this is really different than Rogers’ person-centered approach or an existentialist approach that might say, you know, it's not my job to tell the client what they're going to work on. My job is to be here and to sort of understand the process of treatment, but not to understand what my client is going to do.
In IPT however, it is short term. There are specific things that can be worked on and so the therapist really has a responsibility to define that for the client and part of that definition is letting the client know what their role is in treatment. Their role most importantly is as the sick role. Sometimes this is analogized as similar to a person with diabetes. That is, they're in need of professional support and intervention.
In the Quick Guide to Interpersonal Psychotherapy (Weissman, Markowitz, & Klerman, 2007), Weissman and her colleagues suggest that a therapist might tell the client “if there are things you can't do because you're feeling depressed, that’s not our fault, you're ill.” This is a very very different approach than Rogers’, but it really underlies the medical model approach of IPT and perhaps one of the things that’s made it most successful.
What they do is in IPT, the therapist differentiates between being able to do work as somebody who’s sick and somebody who’s just unable to do anything at all. So, the client is understood to be responsible for working towards improved mood, but they do it within the context of being somebody who’s sick who’s looking to get better.
Three Phases of Treatment
IPT has three phases. The first is the initial phase and this is where you do your assessment and identify the problem area for treatment. In the middle phase, you have the treatment focus based on different problem areas, so even though are four problem areas in traditional IPT the middle phase would be an in-depth focus on one of them. In the termination phase, you identify treatment gains and unaddressed problems. You elicit thoughts and feelings about the end of treatment and you make referrals and follow ups.
Goals of Treatment
Now, the goals for treatment in general are symptom relief from depression and improved interpersonal functioning. Each problem area has its own set of specific treatment goals and objectives. Now, some of the treatment techniques that are most commonly utilized in interpersonal therapy regardless of the problem area include psychoeducation and this includes providing accurate information about depression, modeling of behaviors, problem solving, for example, helping the clients explore options and also limit setting and this is both in the session and also understanding – helping clients set limits in their own lives outside of the therapy session.
Two other techniques that I find really useful are communication analysis and role play. In communication analysis, what you do is you get the client to provide a detailed account of a conversation, an argument with the significant other and you really focus on the feelings and intentions. So, you're looking for what is said, felt, intended wished for or understood.
In Laura Mufson’s 2004 book Interpersonal Psychotherapy for Depressed Adolescents, the authors provide an outline for a communication analysis. It starts out by having the client describe the problem and specific feelings with regards to the specific conversation or argument and some questions that you can ask to help analyze the communication include “so what did you say” and then “what did she or he say,” “then what happened,” “ how did you feel,” “could you tell him or her how you felt,” “was that the message you wanted to convey,” “how do you think that made her feel,” “how could you have said it differently,” “how do you think she would have felt had you said it differently” and finally, “how would you have felt had you said it differently”.
Another technique that’s often used in IPT is role play. In role play, what you do is you ask your client to describe a problematic situation and then you ask your client to play him or herself and you play the significant other. In this role play, you want to make sure that your client is correcting you if your responses do not approximate the responses of the significant other.
So, for example, if I'm pretending to be my client’s father and I say something that her father wouldn’t say, you want to encourage the client to actually come up with what the father would say and there are a number of benefits to this. One it makes the role play more realistic. Two, you as the therapist get some insight into what's actually said and what's going on at home, but perhaps the most important thing is that by having your client correct you, it means that she’s really taking ownership of how the conversation is going and how the interaction occurs in the real world even though the real world isn't inside the therapy room.
So once you do that, the – you as the therapist work really hard to minimize anxiety associated with the role play. You can switch the roles so that you as the therapist play your client and your client gets to play the significant other and at any time you as the therapist can what they call break character to comment on the process or to provide some guidance for your client.
So, again, in the initial sessions, what you're doing is you're focusing on the mood by establishing rapport, providing a diagnosis of depression, you're providing psychoeducation and you're educating your client on the sick role. You also address – you also do the interpersonal inventory. You establish what the problem area is. You develop the interpersonal formulation and ultimately you try to instill hope.
In the initial sessions, you also want to make sure that you're blaming the depression and not the patient for what's going on in the patient’s life. One of the things that you can do to help distinguish the patient from the depression is to provide psychoeducation about depression as a medical illness. This can remove blame from the patient. It can also convey hope because the problem is well understood and also treatable. It can normalize the problem and by normalizing I mean that it makes the client not feel so different because what's true is that one out of five women will experience an episode of depression during her lifetime.
It also identifies the problem as time-limited and finally psychoeducation clarifies the expectation that your client will actively work to change. So once you provide the psychoeducation, you do the case formulation and all the other components of the initial phase, you're ready to set the stage for the middle phase. And so, one of the ways that you can do that because again in the middle phase you're focusing on a specific problem area is that you really want to provide your client with your case formulation.
Again, Weissman and colleagues in the Quick Guide to Interpersonal Psychotherapy suggest – is saying something like this. You're suffering from depression and that seems to have something to do with what's going on in your life. We call what you're experiencing, and this is where you come in with the area based on the interpersonal inventory, grief interpersonal role dispute, role transition or interpersonal deficits. I suggest that we spend the next however many weeks working on solving that difficult life crisis. Now if you can solve that problem, your depression is likely to lift as well. Does that make sense to you?
So after you provide your client with the case formulation, you want to make sure that your client is in agreement with this formulation. After there’s agreement, you want to formalize the treatment contract and this looks like identifying the number of sessions and addressing practical issues such as how to deal with being late, missed appointments, things like that. And also you want to anticipate your client’s need for homework and one of the things about homework that they found in the literature is that homework is not often done when clients don’t understand the relationship of the homework to their ultimate goals, so if you can be very clear with your clients about how completing this homework will help them achieve their goals faster and better, they're much more likely to do it.
In the middle sessions, you really want to focus your discussions on the problem area and specifically you want to link the mood to the current interpersonal situation or events and then link how your interpersonal situations or events are affecting your mood. This sort of circularity is a core concept that underlies interpersonal psychotherapy’s approach, understanding that there is a connection between the biological and the environmental and that interpersonal relationships affect mood and that mood affects interpersonal relationships.
Also, in the middle sessions, you want to attend to the client’s affect in the sessions and attend to the therapeutic relationship. This provides that modeling that we mentioned earlier when you can address issues in the interpersonal relationship that you are developing in your therapy session so that you can model positive and appropriate interpersonal relationships that they can then take out into the real world. You want to address resistance if it's interfering with treatment and resistance in this sense is understood as things that the client is doing that work against the goals.
And finally, you want to use weekly systematic assessment of the symptoms. As IPT is based in the medical model and treatment is based on symptoms, by doing a weekly systematic assessment of symptoms, you're staying true to the diagnosis, which inform the treatment plan and you're also getting data that support the improvement or a lack of improvement over time.
Now, the four problem areas as we mentioned are grief, interpersonal role dispute, role transition and interpersonal deficits. If you're interested in learning more about the four problem areas, I suggest reading Holly Schwartz’ chapter that’s in the Handbook of Comparative Interventions for Adult Disorders by Hersen and Bellack in 1999. Dr. Schwartz’ chapter is called “Interpersonal Therapy” and it's an excellent summary of the model.
The other resource and I've been mentioning this on and off throughout today’s podcast is the Quick Guide to Interpersonal Psychotherapy by Weissman and her colleagues that was just published this year in 2007.
Examples of the Four Problem Areas and Goals
Briefly, I want to talk about the four areas and talk about their problem goals and a couple of strategies when appropriate. So, the first one is grief and that’s also referred to as complicated bereavement and the goals for grief are to facilitate the mourning process and to help the client reestablish interest in relationships to substitute what has been lost. Really in grief you want to help your client more and then move on with his or her life by finding new relationships or interests and the ways that you do this are – and the first are similar for all of them.
You want to review the depressive symptoms, for example, through the HAM-D and then you relate the symptoms to the problem area and so for this one, you want to relate the symptoms to the onset of the death of the significant other then you reconstruct your client’s relationship with the deceased and you can use photos or mementos. And finally, you want to have your client in very behavioral and sequential terms describe the sequence and consequences of the events just prior to, during and after the death.
In the second area, interpersonal role disputes, it's important to make sure that your client understands that you're really talking about non-reciprocal role expectations between the client and another important person in his or her life. Now, these disputes can be overt or covert. Covert disputes can be particularly toxic and it's important to look for these covert issues when you're doing the interpersonal inventory.
The goals in the interpersonal dispute section are to identify what the dispute is, choose a plan of action and then modify the expectations or faulty communication patterns to bring about a satisfactory resolution. So, disputes can be in one of three stages. The first is renegotiation and in this stage this is when a dispute is oftentimes fairly fresh and you can calm the client down in order to facilitate the resolution.
The second stage of dispute is called impasse and this is a situation in which the client might be avoiding addressing the issues related to the interpersonal dispute. In the impasse, as the therapist, you sometimes want to increase the amount of awareness that your client has about the fears and concerns with this relationship and although that can be anxiety-provoking it can sometimes be the necessary motivator to pass the impasse.
The final stage is called dissolution and this is an interpersonal dispute that really can't be resolved and so at this point what the therapist does is to help the client to mourn the loss of that relationship.
Some of the strategies used in interpersonal role dispute are to understand how the non-reciprocal role expectations are related to the dispute and some of the questions that you can ask are what are the issues in the dispute, what are the differences and expectations and values, what are the options here, what is the likelihood of finding alternatives and what resources are available to bring about changes in the relationships.
One of the ways that the past is particularly helpful in interpersonal role dispute by identifying past patterns that mirror the present conflict and by identifying the past you can identify solutions that the client came up with in previous relationships that might be applied to the current situation. The third area is called role transition and some examples of role transitions include life cycle transitions such as transitions from childhood to adolescence, adolescence to adulthood, childbirth, menopause, decline of physical capacity.
There are also social transitions and these can be marriage, divorce, moving, employment, promotion, demotion, retirement, going to college and the thing about these role transitions is that these are all normal. However, those with a biological predisposition to depression may develop a depressive episode in the context of change, so some examples of role transition could include grief at the loss of an old role such as job loss or retirement or moving.
Poor adaptation to a new role: For example, moving to a different school, becoming a parent or finally the rejection of a new role such as unemployment, parenting or even leaving home. The goals for role transition include mourning and acceptance of the loss of the old role and the old role is oftentimes idealized. Another goal is to help the client to regard the new role as more positive than the old goal.
And finally, to restore self esteem by developing a sense of mastery of the new role. The final area is called interpersonal deficits and this area is only chosen if none of the other interpersonal areas exist and really interpersonal deficits suggest chronic but not acute problems and the goals for this area include reducing the patient’s social isolation, help the client to understand their problems in relationships and finally to encourage the formation of new relationships and rather than thinking about this as character change, it's important to understand that the goal is to focus on changes that the client can make today to improve their current life circumstances rather than making deep seated personality changes such as you might do with a traditional Freudian psychoanalysis.
So once you’ve gone through the interpersonal area in the middle phase and you’ve reached the end of your contracted sessions, you're in the final stages and that’s called the termination phase and this can be one to three sessions. This is the conclusion of the acute treatment and interestingly in IPT the developers have recognized that the termination stage is actually a form of role transition because the client has been in the sick role and now they're transitioning out of the sick role into the not sick role.
You can bolster the patient’s sense of independence and competence in the termination stage. It can be really beneficial in the termination stage to use the data gathered from all those Beck depression inventories or HAM-Ds that you’ve gathered over the weeks to provide the client with an indicator of symptom remission and to say you know what, you’ve really gotten better and here are some proof that we have not just my observations and not just your reports, but here are some grasp that we have that suggest how your symptoms have been reduced over the course of treatment.
If however treatment has not been successful, it's important the therapist relieve guilt and blame and to explore alternative treatments. With people who are suffering from depression, it's common to internalize negative self-beliefs and to take responsibility for a situation and say “oh, this is all my fault.” If treatment is not successful, it's important to help the client to avoid internalizing that and seeing this treatment as yet another failure in a life that’s full of failures.
So, one of the things you can do is to contract for continuation or booster sessions and you finally want to repeat your formal assessments. Now, some of the contraindications for IPT include psychosis, active substance abuse. In fact, there were two studies that reported that IPT when used with substance abusers actually was in one study no better than the treatment as usual and then the other study fared worse than treatment as usual. So, it's contraindicated for active substance abuse treatment.
It's also contraindicated for individuals who are actively suicidal or at risk for homicidality, for folks with severe cognitive deficits, or for those folks with severe interpersonal deficits such as borderline personality disorder, anti-social personality disorder, things like that.
One thing that I wanted to mention here as we start to wrap up is that there are a couple of variants of IPT that have added a fifth problem area, one of those is the adolescent-specific IPT and that adds the problem area of single parent family which can be understood as a type of role transition. The other is couples IPT and this has the problem area of marital satisfaction.
Some of the strengths of IPT are that it is an established structured time-limited treatment that is effective in the treatment of moderate to severe depression and it is as effective as other psychotherapies and pharmacotherapies. It's been adapted for use with adolescents, geriatric populations and couples, other depressed populations including people with HIV, people in primary care settings and antepartum and postpartum depression.
Other diagnoses that have been used with modified versions include bulimia, anxiety disorders including social phobia and panic disorder. Some of the limitations of IPT are that it doesn’t address chronic issues such as character pathology, distant familial conflict or other psychiatric disorders. The research suggests that IPT is not indicated for use with substance treatment. Its use has been limited in clinical trials until recently and there's limited information that’s available regarding its value in the community.
And finally, as with most manualized treatments, treatment fidelity that is the degree to which the therapist adhere to the protocols specifically about focusing on interpersonal themes in the session is significantly correlated with treatment outcome. In other words, if you stray from the program, the treatment is less effective.
As we wrap up this podcast on interpersonal psychotherapy, I want to send out a big thanks to Nancy Grote whose research on IPT focuses on women who are experiencing postpartum depression. Dr. Grote provided me a number of excellent resources including her PowerPoints that she uses in community presentations as well as a DVD of clinical vignettes of interpersonal therapy in action, so Nancy thanks a lot.
References and Resources
Hazan, C. & Shaver, P. (1987) Romantic Love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52(3), 511-524.
Joiner, T. E., Brown, J. S., & Kistner, J. (2006). The interpersonal, cognitive, and social nature of depression. Mahwah, N.J.: Lawrence Erlbaum Associates.
Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/ disoriented attachment pattern: Procedures, findings and implications for the classification of behavior. In T. B. Brazelton & M. Yogman (eds), Affective Development in Infancy, 95-124. Norwood, NJ: Ablex.
Swartz, H. (1999).Interpersonal therapy. In M. Hersen and A. S. Bellack (Eds). Handbook of Comparative Interventions for Adult Disorders, 2nd ed. (pp. 139 – 159). New York: John Wiley & Sons, Inc.
Weissman, M., Markowitz, J., & Klerman, G. L. (2007). Clinician's quick guide to interpersonal psychotherapy. New York: Oxford University Press.
Weissman, M. M. & Markowitz, J. C. (1998). An Overview of Interpersonal Psychotherapy. In J. Markowitz, Interpersonal Psychotherapy (pp. 1 – 33). Washington D.C.: American Psychiatric Press.
June 1, 2007. Dr. David Van Nuys, host of one of the most popular psychology podcast Shrink Rap Radio, has posted an interview with Myrna Weissman Ph.D. on Interpersonal Psychotherapy. You can read about the podcast on the MentalHelp.net website, or click here to listen to the audio interview.
APA (6th ed) citation for this podcast:
Singer, J. B. (Host). (2007, February 26). Interpersonal psychotherapy (IPT) [Episode 10]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/02/interpersonal-psychotherapy-ipt.html
No comments:
Post a Comment