Interpersonal therapy



Interpersonal Therapy 864
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Definition

Interpersonal therapy (IPT) is a short-term supportive psychotherapy that focuses on the connection between interactions between people and the development of a person's psychiatric symptoms.

Purpose

Interpersonal therapy was initially developed to treat adult depression. It has since been applied to the treatment of depression in adolescents, the elderly, and people with Human Immunodeficiency Virus (HIV) infection. There is an IPT conjoint (couple) therapy for people whose marital disputes contribute to depressive episodes. IPT has also been modified for the treatment of a number of disorders, including substance abuse; bulimia and anorexia nervosa ; bipolar disorder ; and dysthymia. Research is underway to determine the efficacy of IPT in the treatment of patients with panic disorder or borderline personality disorder ; depressed caregivers of patients with traumatic brain injuries; depressed pregnant women; and people suffering from protracted bereavement.

Interpersonal therapy is a descendant of psychodynamic therapy, itself derived from psychoanalysis , with its emphasis on the unconscious and childhood experiences. Symptoms and personal difficulties are regarded as arising from deep, unresolved personality or character problems. Psychodynamic psychotherapy is a long-term method of treatment, with in-depth exploration of past family relationships as they were perceived during the client's infancy, childhood, and adolescence.

There are seven types of interventions that are commonly used in IPT, many of which reflect the influence of psychodynamic psychotherapy: a focus on clients' emotions; an exploration of clients' resistance to treatment; discussion of patterns in clients' relationships and experiences; taking a detailed past history; an emphasis on clients' current interpersonal experiences; exploration of the therapist/client relationship; and the identification of clients' wishes and fantasies. IPT is, however, distinctive for its brevity and its treatment focus. IPT emphasizes the ways in which a person's current relationships and social context cause or maintain symptoms rather than exploring the deep-seated sources of the symptoms. Its goals are rapid symptom reduction and improved social adjustment. A frequent byproduct of IPT treatment is more satisfying relationships in the present.

IPT has the following goals in the treatment of depression: to diagnose depression explicitly; to educate the client about depression, its causes, and the various treatments available for it; to identify the interpersonal context of depression as it relates to symptom development; and to develop strategies for the client to follow in coping with the depression. Because interpersonal therapy is a short-term approach, the therapist addresses only one or two problem areas in the client's current functioning. In the early sessions, the therapist and client determine which areas would be most helpful in reducing the client's symptoms. The remaining sessions are then organized toward resolving these agreed-upon problem areas. This time-limited framework distinguishes IPT from therapies that are open-ended in their exploration. The targeted approach of IPT has demonstrated rapid improvement for patients with problems ranging from mild situational depression to severe depression with a recent history of suicide attempts.

Interpersonal therapy has been outlined in a manual by Klerman and Weissman, which ensures some standardization in the training of interpersonal therapists and their practice. Because of this standardized training format, IPT is not usually combined with other talk therapies. Treatment with IPT, however, is often combined with drug therapy, particularly when the client suffers from such mood disorders as depression, dysthymia, or bipolar disorder.

Precautions

Training programs in interpersonal therapy are still not widely available, so that many practicing therapists base their work on the manual alone without additional supervision. It is unclear whether reading the manual alone is sufficient to provide an acceptable standard of care.

While interpersonal therapy has been adapted for use with substance abusers, it has not demonstrated its effectiveness with this group of patients. Researchers studying patients addicted to opiates or cocaine found little benefit to incorporating IPT into the standard recovery programs. These findings suggest that another treatment method that offers greater structure and direction would be more successful with these patients.

Description

Since the interpersonal therapy model was developed for the treatment of depression and then modified for use with other populations and mental disorders, an understanding of IPT's approach to depression is crucial. Interpersonal therapists focus on the functional role of depression rather than on its etiology or cause, and they look at the ways in which problematic interactions develop when a person becomes depressed. The IPT framework considers clinical depression as having three components: the development of symptoms, which arise from biological, genetic and/or psychodynamic processes; social interactions with other people, which are learned over the course of one's life; and personality, made up of the more enduring traits and behaviors that may predispose a person to depressive symptoms. IPT intervenes at the levels of symptom formation and social functioning, and does not attempt to alter aspects of the client's personality.

Subtypes of IPT

Interpersonal therapy offers two possible treatment plans for persons with depressive disorders. The first plan treats the acute episode of depression by eliminating the current depressive symptoms. This approach requires intervening while the person is in the midst of a depression. The acute phase of treatment typically lasts two to four months with weekly sessions. Many clients terminate treatment at that point, after their symptoms have subsided. Maintenance treatment (IPT-M) is the second treatment plan and is much less commonly utilized than acute treatment. IPT-M is a longer-term therapy based on the principles of interpersonal therapy but with the aim of preventing or reducing the frequency of further depressive episodes. Some clients choose IPT-M after the acute treatment phase. IPT-M can extend over a period of two to three years, with therapy sessions once a month.

Psychoeducation in IPT

Treatment with IPT is based on the premise that depression occurs in a social and interpersonal context that must be understood for improvement to occur. In the first session, the psychiatric history includes a review of the client's current social functioning and current close relationships, their patterns and their mutual expectations. Changes in relationships prior to the onset of symptoms are clarified, such as the death of a loved one, a child leaving home, or worsening marital conflict.

IPT is psychoeducational in nature to some degree. It involves teaching the client about the nature of depression and the ways that it manifests in his or her life and relationships. In the initial sessions, depressive symptoms are reviewed in detail, and the accurate naming of the problem is essential. The therapist then explains depression and its treatment and may explain to the client that he or she has adopted the "sick role." The concept of the "sick role" is derived from the work of a sociologist named Talcott Parsons, and is based on the notion that illness is not merely a condition but a social role that affects the attitudes and behaviors of the client and those around him or her. Over time, the client comes to see that the sick role has increasingly come to govern his or her social interactions.

Identification of problem areas

The techniques of IPT were developed to manage four basic interpersonal problem areas: unresolved grief ; role transitions; interpersonal role disputes (often marital disputes); and interpersonal deficits (deficiencies). In the early sessions, the interpersonal therapist and the client attempt to determine which of these four problems is most closely associated with the onset of the current depressive episode. Therapy is then organized to help the client deal with the interpersonal difficulties in the primary problem area. The coping strategies that the client is encouraged to discover and employ in daily life are tailored to his or her individual situation.

UNRESOLVED GRIEF. In normal bereavement, a person experiences symptoms such as sadness, disturbed sleep, and difficulty functioning but these usually resolve in two to four months. Unresolved grief in depressed people is usually either delayed grief, which has been postponed and then experienced long after the loss; or distorted grief, in which there is no felt emotion of sadness but there may be nonemotional symptoms, often physical. If unresolved grief is identified as the primary issue, the goals of treatment are to facilitate the mourning process. Successful therapy will help the client re-establish interests and relationships that can begin to fill the void of what has been lost.

ROLE DISPUTES. Interpersonal role disputes occur when the client and at least one other significant person have differing expectations of their relationship. The IPT therapist focuses on these disputes if they seem stalled or repetitious, or offer little hope of improvement. The treatment goals include helping the client identify the nature of the dispute; decide on a plan of action; and begin to modify unsatisfying patterns, reassess expectations of the relationship, or both. The therapist does not direct the client to one particular resolution of difficulties and should not attempt to preserve unworkable relationships.

ROLE TRANSITIONS. Depression associated with role transitions occurs when a person has difficulty coping with life changes that require new roles. These may be such transitions as retirement, a career change, moving, or leaving home. People who are clinically depressed are most likely to experience role changes as losses rather than opportunities. The loss may be obvious, as when a marriage ends, or more subtle, as the loss of freedom people experience after the birth of a child. Therapy is terminated when a client has given up the old role; expressed the accompanying feelings of guilt, anger, and loss; acquired new skills; and developed a new social network around the new role.

INTERPERSONAL DEFICITS. Interpersonal deficits are the focus of treatment when the client has a history of inadequate or unsupportive interpersonal relationships. The client may never have established lasting or intimate relationships as an adult, and may experience a sense of inadequacy, lack of self-assertion, and guilt about expressing anger. Generally, clients with a history of extreme social isolation come to therapy with more severe emotional disturbances. The goal of treatment is to reduce the client's social isolation. Instead of focusing on current relationships, IPT therapy in this area focuses on the client's past relationships; the present relationship with the therapist; and ways to form new relationships.

IPT in special populations

ELDERLY CLIENTS. In translating the IPT model of depression to work with different populations, the core principles and problem areas remain essentially the same, with some modifications. In working with the elderly, IPT sessions may be shorter to allow for decreased energy levels, and dependency issues may be more prominent. In addition, the therapist may work with an elderly client toward tolerating rather than eliminating long-standing role disputes.

CLIENTS WITH HIV INFECTION. In IPT with HIV-positive clients, particular attention is paid to the clients' unique set of psychosocial stressors: the stigma of the disease; the effects of being gay (if applicable); dealing with family members who may isolate themselves; and coping with the medical consequences of the disease.

ADOLESCENTS. In IPT with adolescents, the therapist addresses such common developmental issues as separation from parents; the client's authority in relationship to parents; the development of new interpersonal relationships; first experiences of the death of a relative or friend; peer pressure; and single-parent families. Adolescents are seen weekly for 12 weeks with once-weekly additional phone contact between therapist and client for the first four weeks of treatment. The parents are interviewed in the initial session to get a comprehensive history of the adolescent's symptoms, and to educate the parents as well as the young person about depression and possible treatments, including a discussion of the need for medication. The therapist refrains from giving advice when working with adolescents, and will primarily use supportive listening, while assessing the client for evidence of suicidal thoughts or problems with school attendance. So far, research does not support the efficacy of antidepressant medication in treating adolescents, though most clinicians will give some younger clients a trial of medication if it appears to offer relief.

CLIENTS WITH SUBSTANCE ABUSE DISORDERS. While IPT has not yet demonstrated its efficacy in the field of substance abuse recovery, a version of IPT has been developed for use with substance abusers. The two goals are to help the client stop or cut down on drug use; and to help the client develop better strategies for dealing with the social and interpersonal consequences of drug use. To meet these goals, the client must accept the need to stop; take steps to manage impulsiveness; and recognize the social contexts of drug purchase and use. Relapse is viewed as the rule rather than the exception in treating substance abuse disorders, and the therapist avoids treating the client in a punitive or disapproving manner when it occurs. Instead, the therapist reminds the client of the fact that staying away from drugs is the client's decision.

CLIENTS WITH EATING DISORDERS. IPT has been extended to the treatment of eating disorders. The IPT therapist does not focus directly on the symptoms of the disorder, but rather, allows for identification of problem areas that have contributed to the emergence of the disorder over time. IPT appears to be useful in treating clients with bulimia whose symptoms are maintained by interpersonal issues, including social anxiety; sensitivity to conflict and rejection; and difficulty managing negative emotions. IPT is helpful in bringing the problems underlying the bingeing and purging to the surface, such as conflict avoidance; difficulties with role expectations; confusion regarding needs for closeness and distance; and deficiencies in solving social problems. IPT also helps people with bulimia to regulate the emotional states that maintain the bulimic behavior.

Anorexia nervosa also appears to be responsive to treatment with IPT. Research indicates that there is a connection between interpersonal and family dysfunction and the development of anorexia nervosa. Therapists disagree as to whether interpersonal dysfunction causes or is caused by anorexia. IPT has been helpful because it is not concerned with the origin but rather seeks to improve the client's interpersonal functioning and thereby decreasing symptoms. IPT's four categories of grief, interpersonal disputes, interpersonal deficits, and role transitions correspond to the core issues of clients with anorexia. Social phobia is another disorder that responds well to IPT therapy.

Aftercare

Interpersonal therapy as a maintenance approach (IPT-M) could be viewed as aftercare for clients suffering from depression. It is designed as a preventive measure by focusing on the period after the acute depression has passed. Typically, once the client is in remission and is symptom-free, he or she takes on more responsibilities and has increased social contact. These changes can lead to increased stress and greater vulnerability to another episode of depression. IPT-M enables clients to reduce the stresses associated with remission and thereby lower the risk of recurrence. The goal of maintenance therapy is to keep the client at his or her current level of functioning. Research has shown that for clients with a history of recurrent depression, total prevention is unlikely, but that maintenance therapy may delay a recurrence.

In general, long-term maintenance psychotherapy by itself is not recommended unless there are such reasons as pregnancy or severe side effects that prevent the client from being treated with medication. IPT-M does, however, seem to be particularly helpful with certain groups of patients, either alone or in combination with medication. Women appear to benefit, due to the importance of social environment and social relations in female gender roles; the effects of the menstrual cycle on symptoms; and complications related to victimization by rape, incest, or battering. IPT is also useful for elderly clients who can't take antidepressants due to intolerable side effects or such medical conditions as autoimmune disorders, cardiovascular disorders, diabetes, or other general medical conditions.

Normal results

The expected outcomes of interpersonal therapy are a reduction or the elimination of symptoms and improved interpersonal functioning. There will also be a greater understanding of the presenting symptoms and ways to prevent their recurrence. For example, in the case of depression, a person will have been educated about the nature of depression; what it looks like for him or her; and the interpersonal triggers of a depressive episode. A person will also leave therapy with strategies for minimizing triggers and for resolving future depressive episodes more effectively. While interpersonal therapy focuses on the present, it can also improve the client's future through increased awareness of preventive measures and strengthened coping skills.

Abnormal results

Research has shown that IPT requires clients' commitment to therapy prior to starting the treatment. If clients are resistant to an educational approach, the results of IPT are generally poor. It has been found that when people do not accept IPT's methods and approach at the outset, they are unlikely to be convinced over the course of therapy and they receive little benefit from treatment. IPT clients appear to do better in therapy if they have confidence in their therapist; therefore, if the initial fit between therapist and client is not good, therapy will often be unsuccessful. A client should listen to his or her instincts early in treatment, and either seek out another interpersonal therapist or find a therapist who uses a different approach— such as cognitive-behavioral therapy , which was also developed specifically for the treatment of depression.

See also Bulimia nervosa ; Gender issues in mental health ; Grief ; Major depressive disorder

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Klerman, Gerald L., and others. Interpersonal Psychotherapy of Depression. New York: Basic Books, Inc., 1984.

Klerman, Gerald L., M.D., and Myrna M. Weissman, Ph.D., eds. New Applications of Interpersonal Psychotherapy. Washington, DC: American Psychiatric Press, Inc., 1993.

Mufson, Laura, Ph.D. Interpersonal Psychotherapy for Depressed Adolescents. New York: Guilford Press, 1993.

PERIODICALS

Apple, Robin F. "Interpersonal Therapy for Bulimia Nervosa." JCLP/In Session: Psychotherapy in Practice 55, no. 6 (1999): 715-725.

Barkham, Michael, and Gillian E. Hardy. "Counselling and interpersonal therapies for depression: towards securing an evidence-base." British Medical Bulletin 57 (2001): 115-132.

Frank, Ellen, Ph.D., and Michael E. Thase, M.D. "Natural History and Preventative Treatment of Recurrent Mood Disorders." Annual Reviews Medicine 50 (1999): 453-468.

House, Allan, D. M. "Brief psychodynamic interpersonal therapy after deliberate self-poisoning reduced suicidal ideation and deliberate self-harm." ACP Journal Club 136 (January/February 2002): 27.

McIntosh, Virginia V. "Interpersonal Psychotherapy for Anorexia Nervosa." International Journal of Eating Disorders 27 (March 2000): 125-139.

Mufson, Laura, Ph.D., and others. "Efficacy of Interpersonal Psychotherapy for Depressed Adolescents." Archives of General Psychiatry 56, no. 6 (June 1999): 573-579.

Weissman, Myrna M., Ph.D., and John C. Markowitz, M.D. "Interpersonal Psychotherapy: Current Status." Archives of General Psychiatry 51, no. 8 (August 1994): 599-606.

ORGANIZATIONS

International Society for Interpersonal Psychotherapy. c/o Myrna M. Weissman, Columbia University, 1051 Riverside Drive, Unit 24, New York, NY 10032. <http://interpersonalpsychotherapy.org> .

Holly Scherstuhl, M.Ed.



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