INTERPERSONAL PSYCHOTHERAPY

Interpersonal Psychotherapy (IPT) is a structured, individual, time limited (12-16 sessions) psychotherapy which has been shown to be effective in clinical trials of major depressive disorder, bulimia nervosa, dysthymia and generalised anxiety disorder.

IPT has two aims: to reduce depressive symptoms and to improve the social and interpersonal functioning associated with the onset of the symptoms. The initial sessions are devoted to establishing the treatment contract, dealing with the depressive symptoms, and identifying the problem areas. During the initial sessions, both the depression and the interpersonal problems are diagnosed and assessed. In these sessions, the therapist should accomplish six tasks:

1. Begin dealing with the depression;
2. Complete an interpersonal inventory and relate the depression to the interpersonal context;
3. Identify the principal problem areas;
4. Explain the rationale and intent of interpersonal psychotherapy;
5. Set a treatment contract with the patient; and
6. Explain the patient's expected role in the treatment.

Relating Depression to the Interpersonal Context in the Initial Sessions

The Interpersonal Inventory, Problem Areas, Diagnosis of Interpersonal Disputes, RoleTransitions.

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The Interpersonal Inventory

Once the review of the depression has been completed, the therapist should direct the patient's attention to the onset of symptoms and to the reason for seeking treatment: What has been going on in the patient's social and interpersonal life that is associated with the onset of symptoms? The review of key persons and issues often follows easily. If not, it is useful to begin an inventory of current and past relationships, to get a full picture of what the important current social interactions are in the patient's life.

The systematic review of current and past interpersonal relationships involves an exploration of the patient's important relationships with others, beginning with the present. This may all be done during the sessions or the psychotherapist may ask the patient to write an autobiographical statement containing interpersonal information.

In this inventory, the following should be gathered about each person who is important in the patient's life.

1. Interactions with the patient, including frequency of contact, activity shares, and so on;
2. The expectations of each party in the relationship, including some assessment of whether these expectations were or are fulfilled;
3. A review of the satisfactory and unsatisfactory aspects of the relationship, with specific, detailed examples of both kinds of interactions;
4. The ways the patient would like to change the relationship, whether through changing his or her own behaviour or bringing about changes in the other person.

Although the inventory is concentrated in the first two sessions, it may be added to less systematically as treatment progresses. Problem Areas

It is important to define the problem areas because they can help the psychotherapist formulate a treatment strategy with the patient. Since IPT is short-term, it is usually concentrated on one or two of the four problem areas that depressed patients commonly encounter.

The main problem areas are usually:

1. Grief;
2. Interpersonal disputes with spouse, lover, children, other family members, friends, co-workers;
3. Role transitions - eg a new job, leaving one's family, going away to school, relocation in a new home or area, divorce, economic or other family changes; and
4. Interpersonal deficits - loneliness and social isolation.

Diagnosis of Interpersonal Disputes

For the therapist to choose role disputes as the focus of IPT, the patient must give evidence of current overt or covert conflicts with a significant other. Such disputes are usually revealed in the patient's initial complaints or in the course of the interpersonal inventory. In some IPT research, role disputes with the spouse have been the most common problem area. In practice, however, recognition of important interpersonal disputes in the lives of depressed patients may be difficult.

In developing a treatment plan, the therapist first determines the stage of the role dispute:

1. Re-negotiation implies that the patient and the significant other are openly aware of differences and are actively trying, even if unsuccessfully, to bring about changes.
2. Impasse implies that discussion between the patient and the significant other has stopped and that the smouldering, low-level resentment typical of 'cold marriages' exists.
3. Dissolution implies that the relationship is irretrievably disrupted.

Role Transitions

Depression frequently results when a person recognises the need to make a normative role transition but has difficulty with the necessary changes required or when a person correctly recognises failure in a particular role but is unable to change the behaviour or to change roles. In depressions associated with role transitions, the patient feels helpless to cope with the change I role. The transition may be experienced as threatening to one's self-esteem and sense of identity, or as a challenge one is unable to meet.

In general, difficulties in coping with role transitions are associated with the following issues:

1. Loss of familiar social supports and attachments;
2. Management of accompanying emotions, such as anger or fear;
3. Demands for a new repertoire of social skills; and
4. Diminished self-esteem.

Training

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Didactic Seminar

In a two-to-five day seminar, we attempt to help the therapists identify what they are already doing that is like IPT, what they are doing that is not IPT, and the special skills needed for the IPT approach. This takes the form of an exegesis of the written material with extensive clinical illustration using videotaped case material, role play and discussion. Supervised Casework

After the Didactic Seminar, therapists are assigned two to four training cases each, on which they receive weekly supervision on a session-by-session basis. This is done on the telephone or in person and follows the supervisor's having reviewed the video or audiotape of the session. Both trainee and supervisor have video or audiotape equipment and tapes available, so that they can watch specific segments as the discuss the session. Written evaluations of whether specific IPT strategies are being used, and the quality of these interventions are also provided. The primary purpose of the supervision is boundary marking, or helping the therapists learn which techniques are included and which are excluded in IPT. It is also helpful if the supervisor reviews the ratings made by the patient during the session as well as the observer ratings.

References:

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This is the first published prospective controlled trial examining the outcome of the full-dose tricyclic maintenance-treatment strategy over 5 years.

This is a very important study that further clarifies the usefulness and limitations of psychotherapy as an alternative to maintenance pharmacotherapy. In the main study (10), patients randomly assigned to withdrawal of active antidepressant medication and continued monthly sessions of IPT had a significantly poorer outcome than those randomly assigned to active maintenance pharmacotherapy. However, when the psychotherapy - treated patients were stratified (median split) on the basis of whether the quality of therapy they received was above or below average on a measure of therapy fidelity, a highly significant advantage was found favouring the patients in the higher quality condition with respect to increased well-time and lower risk recurrence. In fact, lower quality dyads had outcomes similar to placebo-treated patients, whereas higher-quality dyads had outcomes that approached those of patients receiving active pharmacotherapy.