Interpersonal therapy (IPT) is a type of treatment for patients with depression which focuses on past and present social roles and interpersonal interactions. During treatment, the therapist generally chooses one or two problem areas in the patient's current life to focus on. Examples of areas covered are disputes with friends, family or co-workers, grief and loss and role transitions, such as retirement or divorce.
IPT does not attempt to delve into inner conflicts resulting from past experiences. Rather it attempts to help the patient find better ways to deal with current problems.
Historical Background
- IPT has no specific theoretical origin although its theoretical basis can be seen as coming from the work of Sullivan, Meyer and Bowlby. Whilst Sullivan wrote of a type of "interpersonal therapy" in the 1930s, this was more in the form of a long term analytic but relational based therapy and would not be seen to resemble the current form of IPT. Attachment theorists view the experience of loss and to a lesser degree disordered attachment as underlying much of human psychopathology. IPT can be seen as indirectly addressing these issues within the therapeutic frame.
- The current form of the treatment was developed by the late Gerald Klerman and Myrna Weissman in the 1980s as a means of operationalizing the interpersonal approach to psychotherapy for a series of treatment studies in depression conducted in the
Subtypes of Interpersonal Therapy
There are two subtypes of IPT. The first type is used for the short-term treatment of a depressive episode. The patient and therapist typically meet weekly for two to four months and treatment ends once the symptoms subside. The second type is maintenance treatment (IPT-M), which is long-term treatment with the goal of preventing or reducing the number of future episodes of depression. IPT-M may consist of monthly sessions over a period of two to three years.
Structure and Duration of Sessions
- IPT usually runs from 12 to 16 one hour sessions that usually occur weekly. The initial sessions are devoted to information gathering and clarifying the nature of the patient's illness and interpersonal experience. The patient's illness is then formulated and explained in interpersonal terms and the nature and structure of the IPT sessions are explained. This phase of treatment concludes with the composition of the "interpersonal inventory" which is essentially a register of all the key relationships in the individual's life. Within the interpersonal inventory relationships are categorized according to the four areas mentioned above.
- Sessions 3 - 14 are devoted to addressing the problematic relationship areas and there is little focus upon the specific illness process apart from enquiries as to symptom severity and response to treatment modalities.
- The final sessions 15 - 16 focus upon termination, which is usually formulated as a loss experience from which the patient can learn a great deal about their own responses to loss and how well the modifications attempted in the therapeutic process have evolved.
Four Basic Problem Areas Identified by Interpersonal Therapy
IPT identifies four basic problem areas which contribute to depression. The therapist helps the patient determine which area is the most responsible for his depression and therapy is then directed at helping the patient deal with this problem area.
The four basic problem areas recognized by Interpersonal Therapy are:
- Interpersonal Disputes
These tend to occur in marital, family, social or work settings. They can be conceptualized as a situation in which the patient and other parties have diverging expectations of a situation and that this conflict is excessive enough to lead to significant distress. One example may be a marital dispute in which a wife's attempts to use initiative leads to conflict with her spouse. In these circumstances IPT would aim to define how intractable the dispute was, identify sources of misunderstanding via faulty communication and invalid or unreasonable expectations and the aim to intervene by communication training, problem solving or other techniques that aim to facilitate change in the situation.
- Role Transitions
Role transitions are situations in which the patient has to adapt to a change in life circumstances. These may be developmental crises, adjustments in work or social settings or adaptations following life events or relationship dissolutions. In those who develop depression, these transitions are experienced as losses and hence contribute to the development of psychopathology. IPT aims to help the patient with role transitions to reappraise the old and new roles, to identify sources of difficulty in the new role and fashion solutions for these. In many cases clarification of inconsistencies or clear errors in the patient's cognitions as well as problem solving and encouragement of affect within the therapeutic frame are suitable interventions.
- Grief
Grief is simply defined in IPT as "loss through death". Whilst many clinicians would formulate sequelae of severe medical e.g. loss of function illness as grief, in IPT the term is reserved specifically for bereavement. In IPT, if grief is formulated as an issue of relevance in the interpersonal inventory, the assumption of the patient and therapist is that the grieving process has been complicated by delay or in many cases excess. The IPT therapist will help to reconstruct the patient's relationship with the deceased and by encouraging affect as well as clarification and empathic listening help facilitate the mourning process with the aim of helping the patient to establish new relationships.
- Interpersonal Deficits
These would be diagnosed when a patient reports impoverished interpersonal relationships in terms of both number and quality of the relationships described. In many cases the interpersonal inventory will be sparse and the patient and therapist will need to focus upon both old relationships as well as the relationship with the therapist. In the former common themes should be identified and linked to current circumstances. In using the therapeutic relationship the therapist aims to identify problematic processes occurring such as excess dependency or hostility and aim to modify these within the therapeutic frame. In this way the therapeutic relationship can serve as a template for further relationships which the therapist will aim to help the patient create. This group of problems is common in the more chronic affective disorders such a dysthymia in which significant degrees of social impoverishment have occurred either before or after the illness.
Techniques used in IPT
- IPT utilizes several techniques within the therapeutic process. Many of these are modified interventions borrowed from other therapies such as cognitive-behavior therapy and brief crisis intervention.
- The use of various questioning styles such as "Clarification" which seeks to obviate the patient's biases in describing interpersonal issues as well as "Supportive Listening" are often therapeutic within themselves. "Role playing" and "Communication Analysis" are highly behavioral interventions and are invaluable tools in intervening in interpersonal disputes. The "Encouragement of Affect" allows the patient to experience unpleasant or unwanted affects (that have perhaps resulted in the deployment of pathogenic defense mechanisms) safely within the therapeutic frame. This process allows the patient to acknowledge the affective component of an interpersonal issue e.g. grief and helps the patient to accept it as a part of their experience. The "Use of the Therapeutic Relationship" has been described earlier.
- There is some degree of debate as to whether therapists should be more or less active in the conduct of the sessions other than keep the focus on interpersonal issues. There are clearly no distinct guidelines in this area although the goal of IPT is to facilitate the process of the patient generating their own interventions and thus progressively phasing the therapist out of the process. It is likely that the process of patient initiated changes is the likely mechanism to account for the observation that symptomatic improvement arising from IPT often peaks 3 - 6 months subsequent to the termination of treatment.
Conclusion
IPT is most useful for people who are in the midst of recent conflicts with significant others and/or have experienced difficulty adjusting to stressful life transitions. As with CBT, patients who are unable or unwilling to practice skills taught in therapy are not likely to gain significant symptom relief. Most therapists recommend that clients remain in ongoing, maintenance therapy if that is possible. Maintenance IPT (IPT-M) is often used following termination of the short-term phase of therapy. Recent research suggests that IPT-M may prevent future episodes of depression, particularly in women.
In clinical trials, both CBT and IPT have been found to be effective treatments for depression. There is no certain way to know up front (without actually trying them) whether one form of therapy will be a better fit for patients than the other. The available studies are too small and specific to recommend a specific type of person who would benefit best from one or another type of therapy. Just as patients may need to try different types of antidepressant medication, the may also need to try different types of therapy, or even different therapists within a particular therapeutic approach to gain maximum relief.
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