Interpersonal psychotherapy

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Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and achieving symptomatic recovery. IPT is an empirically supported treatment (EST) that follows a highly structured and time-limited approach. Interpersonal therapy is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and vice versa. [1] [2] The treatment was developed by Gerald Klerman and Myrna Weissman in order to treat major depression in the 1970s and has since been adapted for other mental disorders. [3] IPT is an empirically validated intervention for depressive disorders and is more effective when used in combination with psychiatric medications. [4]

Contents

History

Originally named "high contact" therapy, IPT was first developed in 1969 at Yale University as part of a study designed by Gerald Klerman, Myrna Weissman and colleagues to test the efficacy of an antidepressant with and without psychotherapy as maintenance treatment of depression. [5] [6] Gerald Klerman specialized in treating depression, anxiety disorders, and schizophrenia. He wanted to test whether interpersonal relationships influenced mental illness onset or duration. Studies were conducted using a primitive model of IPT. From these studies, Klerman concluded that one-on-one therapy that is designed to improve interpersonal relationships was correlated to symptom improvements. [7]

Foundations

IPT was influenced by CBT as well as psychodynamic approaches. It takes its structure from CBT in that it is time-limited, employs structured interviews and assessment tools. [8] In general, however, IPT focuses directly on affects, or feelings, whereas CBT focuses on cognitions with strong associated affects. Unlike CBT, IPT makes no attempt to uncover distorted thoughts systematically by giving homework or other assignments, nor does it help the patient develop alternative thought patterns through prescribed practice. Rather, as evidence arises during the course of therapy, the therapist calls attention to distorted thinking in relation to significant others. The goal is to change the relationship pattern rather than associated depressive cognitions, which are acknowledged as depressive symptoms. [9]

The content of IPT's therapy was inspired by Attachment theory and Harry Stack Sullivan's Interpersonal psychoanalysis. Social theory is also influenced in a lesser role to emphasis on qualitative impact of social support networks for recovery. [10] Unlike psychodynamic approaches, IPT does not include a personality theory or attempt to conceptualize or treat personality but focuses on humanistic applications of interpersonal sensitivity. [11] [12]

The aim of IPT is to help the patient to improve interpersonal and intrapersonal communication skills within relationships and to develop social support network with realistic expectations to deal with the crises precipitated in distress and to weather 'interpersonal storms'.

Methodology

Interpersonal therapy deals with current interpersonal relationships and focuses on the patient's immediate social context. The original model of interpersonal therapy consists of three distinct phases. The first phase lasts for three psychotherapy sessions maximum. In this phase, the clinician evaluates a patient's symptoms and assigns them a diagnosis. They review the patient’s current social functioning and close relationships. The clinician then evaluates how the patient’s current interpersonal influence has influenced the patient’s mood or contributed to the onset of their symptoms. Symptoms are linked to the patient’s situation, which could consist of grief, interpersonal role disputes, role transitions, or interpersonal deficits. In the second phase, the therapist selects therapeutic strategies that are specific for the patient's interpersonal relationship problems. The third phase takes from 12 to 16 weeks, and it is aimed at giving the patient support and acknowledging the progress they have made. [16]

Clinical applications

It has been demonstrated to be an effective treatment for depression and has been modified to treat other psychiatric disorders such as substance use disorders and eating disorders. It is incumbent upon the therapist in the treatment to quickly establish a therapeutic alliance with positive countertransference of warmth, empathy, affective attunement and positive regard for encouraging a positive transferential relationship, from which the patient is able to seek help from the therapist despite resistance. It is primarily used as a short-term therapy completed in 12–16 weeks, but it has also been used as a maintenance therapy for patients with recurrent depression. [17] A shorter, 6-week therapy suited to primary care settings called Interpersonal counselling (IPC) has been derived from IPT. [18]

Interpersonal psychotherapy has been found to be an effective treatment for the following: [19]

Bipolar Disorder

Bipolar disorder is correlated with a decline in the quality of interpersonal relationships and personal fulfillment with social or leisure activities. Research on treatments for bipolar disorder conclude that patients will most likely require a combination of medication and therapy. One study that used interpersonal therapy as treatment for bipolar found that a combination of IPT, social rhythm therapy and medication improved patient functioning. However, these patients did still experience both mania and depression. [22] A review that analyzed different therapeutic approaches and their benefits to bipolar patients concluded that IPT exhibited clinical effectiveness for subsyndromal symptoms. [23]

Bulimia Nervosa

There is a theoretical interpersonal framework that attempts to explain the onset of symptoms for bulimia nervosa. The framework proposes that interpersonal hardships cause low self-esteem and negative affect which then lead to behaviors seen in bulimic patients. In two different trials involving bulimic patients, interpersonal therapy was not concluded to be effective at treating bulimia nervosa compared to cognitive behavioral therapy. [24] [25] However, researchers discovered that one year after both of these trials, there was no clinically significant difference between patients who received IPT compared to CBT. [26]

Major Depressive Disorder

When an individual is depressed, they can experience the following symptoms: social isolation, excessive fatigue, lack of motivation, loss of joy, and more. IPT has been utilized as a therapeutic treatment for depression because of its ability to aid in restoring social relations. Typically, there are three phases of IPT for the treatment of depression. The first phase involves introductory therapy sessions with a counselor and patient in which the counselor begins to familiarize themselves with the patient’s symptoms and interpersonal conflicts. Goals are then curated in order to establish a path of healing for the patient. The second phase of IPT connects the patient’s presenting symptoms to their interpersonal conflicts. Specifically, this phase of treatment attempts to find potential causes for the patient’s low mood. The third and final phase of this treatment begins when the patient’s symptoms have stabilized. Plans are established for continuance of treatment in case the patient begins to develop depressive symptoms again. [27]

Post-Traumatic Stress Disorder

Post-traumatic stress disorder can stem from interpersonal conflict. Traumatic events such as rape or child neglect can cause lasting effects on the patient’s ability to engage in certain relationships. Interpersonal conflicts are one of the main diagnostic symptoms for PTSD. There are many different psychotherapies that have been utilized to treat PTSD symptoms, but a single effective treatment does not yet exist. Interpersonal therapy is one of the potential effective therapies to treat depressive symptoms in PTSD patients. In clinical studies, interpersonal therapy has led to a decrease in depressive PTSD symptomatology after 16 group sessions. Group sessions follow the same three stages as individual interpersonal therapy. Depressive symptoms were also decreased in women who have experienced sexual abuse trauma after 16 individualized IPT sessions. This decrease was significant compared to individualized psychotherapy. [28]

Postpartum Depression

Postpartum depression occurs after the delivery of an infant and mimics typical depressive symptoms, although some symptoms are different: ideas of infanticide, paranoia, and compulsive thoughts. Interpersonal therapy has been thought to be a good potential treatment for postpartum depression because it is short-term and focused on present life events and relationships. In one twelve week study using IPT, 100% of patients did not meet diagnostic criteria for postpartum depression by the end of the study. Results of a similar study also showed that 12 weekly sessions of interpersonal therapy ceased depressive episodes in postpartum mothers. A majority of other studies conducted found that the average amount of time it took for mothers to completely recover was 28.60 weeks. [29]

Adolescents

Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults. [19]

IPT for children is based on the premise that depression occurs in the context of an individual's relationships regardless of its origins in biology or genetics. More specifically, depression affects people's relationships and these relationships further affect our mood. The IPT model identifies four general areas in which a person may be having relationship difficulties:

  1. grief after the loss of a loved one;
  2. conflict in significant relationships, including a client's relationship with his or her own self; [30]
  3. difficulties adapting to changes in relationships or life circumstances; and
  4. difficulties stemming from social isolation. [19]

The IPT therapist helps identify areas in need of skill-building to improve the client's relationships and decrease the depressive symptoms. Over time, the client learns to link changes in mood to events occurring in his/her relationships, communicate feelings and expectations for the relationships, and problem-solve solutions to difficulties in the relationships. [31]

IPT has been adapted for the treatment of depressed adolescents (IPT-A) to address developmental issues most common to teenagers such as separation from parents, development of romantic relationships, and initial experience with death of a relative or friend. [31] IPT-A helps the adolescent identify and develop more adaptive methods for dealing with the interpersonal issues associated with the onset or maintenance of their depression. IPT-A is typically a 12- to 16-week treatment. Although the treatment involves primarily individual sessions with the teenager, parents are asked to participate in a few sessions to receive education about depression, to address any relationship difficulties that may be occurring between the adolescent and his/her parents, and to help support the adolescent's treatment. [32]

Elderly

IPT has been used as a psychotherapy for depressed elderly, with its emphasis on addressing interpersonally relevant problems. IPT appears especially well suited to the life changes that many people experience in their later years. [33]

Interpersonal therapy has been studied as a treatment for elderly people with depression. Older adults have been found to work effectively towards their goals in treatment due to the natural conversational style of IPT. In one particular study that assessed IPT’s efficacy in treating late-life depression, 78% of older adults experienced full remission of their depressive symptoms. However, 100% of participants who were focusing on role transitions experienced a resurgence of symptoms upon finishing IPT treatment. [34]

There has been research conducted on using IPT as treatment for older adults who are suicidal. In these studies, IPT was administered alongside medication and additional psychiatric assistance. The results showed that IPT diminished depressive symptoms and stopped engaging in verbal statements of suicidal ideation quicker than without IPT. [35]

Types

Dynamic Interpersonal Therapy

Dynamic interpersonal therapy was developed due to the lack of modern psychodynamic approaches used as forms of brief interventions for mental health conditions. DIT lasts for sixteen sessions and has three distinct phases. This therapeutic technique focuses on the patient's internal and external interpersonal relationships. DIT explores internal relationships, which is similar to Sigmund Freud's psychodynamic theory. Internalized relationships refer to unconscious patterns that an individual may be carrying from their previous relationships into their present ones. Dynamic interpersonal therapy differs from ordinary IPT because it dives into these unconscious internalized relationships. [36]

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Type of therapy to improve mental health

Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD and anxiety disorders. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

<span class="mw-page-title-main">Major depressive disorder</span> Mood disorder

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since. The disorder causes the second-most years lived with disability, after lower back pain.

<span class="mw-page-title-main">Bulimia nervosa</span> Type of eating disorder

Bulimia nervosa, also known simply as bulimia, is an eating disorder characterized by binge eating, followed by purging or fasting, as well as excessive concern with body shape and weight. This activity aims to expel the body of calories eaten from the binging phase of the process. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives.

Binge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is a common symptom of eating disorders such as binge eating disorder and bulimia nervosa. During such binges, a person rapidly consumes an excessive quantity of food. A diagnosis of binge eating is associated with feelings of loss of control. Binge eating disorder is also linked with being overweight and obesity.

Cognitive restructuring (CR) is a psychotherapeutic process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, overgeneralization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. CR employs many strategies, such as Socratic questioning, thought recording, and guided imagery, and is used in many types of therapies, including cognitive behavioral therapy (CBT) and rational emotive behaviour therapy (REBT). A number of studies demonstrate considerable efficacy in using CR-based therapies.

Dysthymia, also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with longer-lasting symptoms. The concept was used by Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s.

Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

John C. Markowitz is an American physician, a Professor of Clinical Psychiatry at the Columbia University College of Physicians & Surgeons and a Research Psychiatrist at the New York State Psychiatric Institute. For several decades he has conducted research on psychotherapies and medications as treatments for mood disorders, anxiety disorders, and personality disorders, and more recently posttraumatic stress disorder (PTSD). He is most widely published in the area of interpersonal psychotherapy or IPT, a manualized form of treatment, in which he was trained by the late Gerald L. Klerman, M.D. Dr. Markowitz is a graduate of Columbia University and Columbia University College of Physicians and Surgeons and received his psychiatric residency training at the Payne Whitney Psychiatric Clinic of Cornell University Medical School/New York-Presbyterian Hospital.

Interpersonal and social rhythm therapy (IPSRT) is an intervention for people with bipolar disorder (BD). Its primary focus is stabilizing the circadian rhythm disruptions that are common among people with bipolar disorder (BD). IPSRT draws upon principles from interpersonal psychotherapy, an evidence-based treatment for depression and emphasizes the importance of daily routine (rhythm).

A major depressive episode (MDE) is a period characterized by symptoms of major depressive disorder. Those affected primarily exhibit a depressive mood for at least two weeks or more, and a loss of interest or pleasure in everyday activities. Other symptoms can include feelings of emptiness, hopelessness, anxiety, worthlessness, guilt, irritability, changes in appetite, difficulties in concentration, difficulties remembering details, making decisions, and thoughts of suicide. Insomnia or hypersomnia and aches, pains, or digestive problems that are resistant to treatment may also be present.

<span class="mw-page-title-main">Psychological intervention</span>

In applied psychology, interventions are actions performed to bring about change in people. A wide range of intervention strategies exist and they are directed towards various types of issues. Most generally, it means any activities used to modify behavior, emotional state, or feelings. Psychological interventions have many different applications and the most common use is for the treatment of mental disorders, most commonly using psychotherapy. The ultimate goal behind these interventions is not only to alleviate symptoms but also to target the root cause of mental disorders.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Management of depression is the treatment of depression that may involve a number of different therapies: medications, behavior therapy, psychotherapy, and medical devices.

<span class="mw-page-title-main">Depression in childhood and adolescence</span> Pediatric depressive disorders

Major depressive disorder, often simply referred to as depression, is a mental disorder characterized by prolonged unhappiness or irritability. It is accompanied by a constellation of somatic and cognitive signs and symptoms such as fatigue, apathy, sleep problems, loss of appetite, loss of engagement, low self-regard/worthlessness, difficulty concentrating or indecisiveness, or recurrent thoughts of death or suicide.

Supportive psychotherapy is a psychotherapeutic approach that integrates various therapeutic schools such as psychodynamic and cognitive-behavioral, as well as interpersonal conceptual models and techniques.

Maudsley family therapy, also known as family-based treatment or Maudsley approach, is a family therapy for the treatment of anorexia nervosa devised by Christopher Dare and colleagues at the Maudsley Hospital in London. A comparison of family to individual therapy was conducted with eighty anorexia patients. The study showed family therapy to be the more effective approach in patients under 18 and within 3 years of the onset of their illness. Subsequent research confirmed the efficacy of family-based treatment for teens with anorexia nervosa. Family-based treatment has been adapted for bulimia nervosa and showed promising results in a randomized controlled trial comparing it to supportive individual therapy.

Gerald L. Klerman was an American psychiatrist and researcher whose work included the development of interpersonal psychotherapy, a short-term treatment for depression. He was chief of the US national mental health agency from 1977 to 1980.

Cognitive behavioral therapy (CBT) is derived from both the cognitive and behavioral schools of psychology and focuses on the alteration of thoughts and actions with the goal of treating various disorders. The cognitive behavioral treatment of eating disorders emphasizes on the minimization of negative thoughts about body image and the act of eating, and attempts to alter negative and harmful behaviors that are involved in and perpetuate eating disorders. It also encourages the ability to tolerate negative thoughts and feelings as well as the ability to think about food and body perception in a multi-dimensional way. The emphasis is not only placed on altering cognition, but also on tangible practices like making goals and being rewarded for meeting those goals. CBT is a "time-limited and focused approach" which means that it is important for the patients of this type of therapy to have particular issues that they want to address when they begin treatment. CBT has also proven to be one of the most effective treatments for eating disorders.

Ellen Frank is a psychologist and Distinguished Professor Emeritus of Psychiatry and Distinguished Professor of Psychology at the University of Pittsburgh. She is known in the field of Psychotherapy as one of the developers of Interpersonal and Social Rhythm Therapy, which aims to treat bipolar disorder by correcting disruptions in the circadian rhythm while promoting increased regularity of daily social routines. Frank is the co-founder and Chief Scientific Officer of HealthRhythms, a company that uses mobile technology to monitor the health and mental health of clients, facilitate the detection of changes in their status, and better manage mental health conditions.

<span class="mw-page-title-main">Myrna Weissman</span>

Myrna Milgram Weissman is Diane Goldman Kemper Family Professor of Epidemiology in Psychiatry at the Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, and Chief of the Division of Translational Epidemiology at the New York State Psychiatric Institute. She is an epidemiologist known for her research on the prevalence of psychiatric disorders and psychiatric epidemiology, as it pertains to rates and risks of anxiety and mood disorders across generations. Among her many influential works are longitudinal studies of the impact of parental depression on their children.

References

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