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Interpersonal Psychotherapy for Depression
Interpersonal Psychotherapy for Depression
Interpersonal Psychotherapy (IPT), according to Robertson, Rushton, and Wurm (2008) interpersonally focused, is a time-limited, psychodynamically informed psychotherapy whose goals include symptom relief and the improvement of interpersonal functioning. It is a treatment of ambulatory depressed, non-bipolar, non-psychotic patients that was developed by Gerald Klerman and Myrna Weissman and their colleagues. This development happened within the Haven-Boston Collaborative Depression Research Project. IPT has subsequently been studied in numerous research protocols over the last 20 years. This approach has been proven to treat patients successfully with depression. It has also been modified for the treatment of other psychiatric disorders such as dysthymia, bulimia, and substance abuse for various patient populations (primary medical care, late-life, and adolescents). IPT has been used as a short-term therapy but may also be modified for use among patients with recurrent depression. IPT is founded on theories that emerged from the interpersonal school of psychiatry (Sullivan, 1953) and empirical data linked to attachment bonds and social roles. IPT was designed for use without medication or combinations of anti-depressants. The techniques employed in IPT are largely familiar to practitioners of supportive and dynamic forms of psychotherapy. However, it involves specific strategies like assessing the symptoms of depression that relate the onset of the depressive inventory and select a focus for the treatment of several problem areas. These problem areas include delayed or incomplete grief, role disputes, role transitions or interpersonal deficits. These tasks are usually conducted completely after only three sessions. IPT has been applied in many geographical locations such as western countries, Asia, Sub-Saharan Africa, and Latin America. IPT conceptualizes depression as made up of three components: symptom development, social functioning and factors of personality. IPT also recognizes genetics, early childhood factors, personality, and clarifies the relationship between the beginning of depressive symptoms and interpersonal difficulties. This paper provides an exploratory look at IPT and relies on illustrative examples to illustrate the concepts and theoretical approaches.
The story of IPT began in 1969 at Yale University, when Dr. Eugene Paykel of London joined Dr. Gerald Klerman. Their mission was to design a study to test how relatively efficient a tricyclic antidepressant alone and with psychotherapy maintenance treatment could be for the treatment of the ambulatory nonbipolar depression (Robertson, Rushton & Wurm, 2008). There was strong evidence obtained from the study to indicate efficacy of tricyclic antidepressants in reducing the acute symptoms of depression. However, subsequent studies underlined the important role played by psychotherapy maintenance treatment. Dr. Klerman convinced his colleagues that psychotherapy could be subjected to empirical studies and clinical trials. These series of tests became the foundation for IPT (Robertson, Rushton & Wurm, 2008). Initially, it was found to have comparable efficacy to medication. As a result, it earned its position next to Aaron Beck’s Cognitive Behavior Theory for analysis as an active treatment. IPT remained largely unknown outside academic circles in Europe and USA. However, towards the 2000s, there was increased interest in IPT in clinical circles. This interest resulted in the inception of the International Society for IPT in the year 2000.
One of the most important aspects of IPT involves understanding the four problem areas for patients. Within these four areas, interpersonal processes become more understandable for the patient. These areas include grief, role transitions, interpersonal sensitivity and interpersonal disputes. Interpersonal disputes or role disputes become problem areas when they contribute to the patient’s illness or problems. Disputes may sometimes be covert because patients fail to mention them if they are too painful (Robertson, 2003). Such disputes include violence, verbal abuse, betrayal, disappointment and inhibited conflicts such as anger due to a partner’s disability or illness. According to the attachment theory, disruptions in the intimate attachments of an individual may result in psychological stress (Stuart & Robertson, 2003). Role transitions also cause psychological distress. Role Transitions involve changes and transitions. Changes may be as a result of job changes, loss, promotion, changes in a relationship, illness-related role transitions or post-event role transitions such as post-traumatic stress. Grief and loss can also cause considerable psychological distress. Grief-oriented therapy may be required to navigate a path towards alleviation of suffering for the patient.
Attachment is an enduring and deep emotional bond that connects one person to another across the boundaries of time and space (Ainsworth, 1973). In psychology, attachment theory emerges from the work of James Bowlby (1958). It holds that people have a basic need to form strong emotional bond with other people. The attachment theory is employed in psychology to target interpersonal relationship that may affect the attachment experiences of a patient. The theory holds that individuals who are secure are relatively more protected from psychological distress than people who are insecurely attached. Insecurely attached individuals have low self-esteem, emotional problems, and poorer regulation strategies.
This theory holds that the manner in which the patient communicates their attachment needs has significance in building a social support network. This theory focuses on aspects of interpersonal relationships that are below the conscious awareness level and thus difficult to identify (Stuart, 2006). Some IPT patients often unintentionally exhibit unsupportive or negative responses from others. This occurrence may be attributed to the fact that patients with maladaptive attachment styles participate in specific communications which lead to responses that fail to meet their attachment needs effectively (Kiesler, 1979).
Theory of Depression
The depression theory holds that depression happens on a biological basis. This basis is triggered by interpersonal distress. Interventions that are based on the depression theory focus on interpersonal problems and processes of building interpersonal skills
Process of Psychotherapy
IPT is a time-limited (12-16 weeks) treatment has five distinct phases, namely assessment, initial, middle, termination/ conclusion, and maintenance sessions (Robertson, Rushton & Wurm, 2008). The “assessment phase” of IPT is conducted to determine how suitable of a candidate the patient is for IPT. In this stage, non-specific issues are considered such as the suitability of any psychological intervention, ego strength, motivation for change, etc. The likelihood that patients will gain from IPT include:
A comparatively secure attachment styles;
A particular interpersonal focus for distress;
Ability to relate a rational narrative of their specific interpersonal interactions and interpersonal network;
The assessment step ends when a treatment contract to proceed with the treatment is made with the patient.
The second stage comprises of the initial sessions. It begins with the primary goal of developing an interpersonal formulation. This is a detailed hypothesis of the reason the patient is experiencing interpersonal difficulties. This process involves the creation of an interpersonal Inventory (IPI). The IPI focuses on:
Patient history of current problems,
Information on how to resolve the problem and
The setting-appropriate treatment objectives (see figure 1).
Figure 1: Example of an interpersonal inventory (Source: Robertson, Rushton & Wurm, 2008)
Figure one is an example of an interpersonal Inventory (IPI). This inventory lists the four items mentioned above. The current relationship is listed as that between the patient and her husband whom she has been with for nine years and married to for six years. There is no history of problems similar to the ones that the patient is currently experiencing. The patient states that the husband wanted a baby, and the two of them had talked about it before she eventually became pregnant. The current problems are listed in the IPI. The patient also lists her expectations from the IPT.
After the IPI is completed, the therapist formulates an interpersonal focus based on the four IPT problem areas. The middle sessions involve addressing of one or more of the IPT problem areas using the main IPT techniques. The therapist should be mindful of the patient’s communication style and attachment style. After identifying particular problems during the assessment and initial sessions, the therapy narrows down to specific problem areas. The patient and therapist work together to develop solutions to the given problem. For example, a solution to a problem may include improving the communication skills of the patient or modifying their expectations with regards to a dispute. The patient employs the solution in between sessions. The therapist collaborates with the patient in between sessions to refine the solutions. The concluding sessions end the acute treatment as stipulated by the therapeutic contract. This stage does not have toe signify the end of the therapeutic relationship. The therapist and patient continue to interact and may formulate other contracts in the future. The therapist tries to foster the independent functioning of the patient at this stage. This stage also involves feedback. The therapist collaborates with the patient to develop the best course of action based on the noted changes from the strategies proposed in earlier sessions. From this point, the psychotherapist lets the patient continue to administer the various courses of action proposed within the IPT.
Mechanisms of Change
IPT has been practiced all over the world. The main reason IPT is successful is because it is based on the evidence-supported idea that the quality of interpersonal relationships may contribute to, maintain of prevent depression. When an individual is depressed, it affects their interpersonal relationships. Similarly, the quality and stability of the individual’s relationships can influence their mood. As a result of these connections, depression interventions, such as IPT, which target interpersonal relationships have significant efficacy. This idea is consistent with other interpersonal theories related to depression such as Bowlby’s attachment theory and its focus on the significance of relational bonds in mental health. In addition, Weissman et al. (1979) have shown through empirical means that IPT is an effective treatment for adult and adolescent depression. Crowe and Luty (2005) indicate that the process of IPT is effective because once the relationships that influence and are influenced by the patient’s mood are identified, the problem of depression can be solved.
Example of an IPT intervention
Crowe and Luty (2005) provide a good example of an IPT intervention featuring patient X. Patient X was a 42-Year-old divorced female and a mother to a son 25 years old. She was diagnosed with major depressive disorder by an experienced psychiatrist. Her depression emerged from the context of her mother’s death as a result of cancer three years before, followed by the demise of her father one year later. Major conflict then ensued because the will of her father was contested by her three biological siblings as well as her three half-siblings from her father’s first marriage. X had an active sporting life and also enjoyed working with elderly people. She considered these activities as low stress. She lacked a supportive partner and intimate relationship and found it difficult to cope with these problems alone. She did not have a previous diagnosis of depression and had only previously experienced tough times during the course of her violent marriage which had ended 15 years before. X described herself as one who was never good at choosing men. She was raised in a blended family where there was always constant conflict between the two sets of half-siblings. X’s father was also a heavy drinker, and she had only begun to have a good relationship with him in her adulthood. X became pregnant at age 16 and left her family to marry the father of her child. She was close to her mother. In terms of symptoms, X highlighted low mood, insomnia, loss of employment, loss of appetite and did not see the need of going on. The psychotherapist identified the main problem as role disputes. Together with the patient, the therapist decided to focus relating X’s symptoms to dispute and working to determine how the dispute was perpetuated. The psychotherapist could also explore trying to understand how nonreciprocal role expectations were related to the dispute and other parallels.
The psychotherapist began by looking at the interpersonal disputes in X’s life. This process involves:
Seeking information at different levels,
exploring relationship patterns
Exploring parallels in relationships,
Exploring communication patterns of the patient.
Some of the questions that the therapists asked patient X regarding her husband include:
What is he like?
What activities do you do together?
Do you ever clash with him at all?
Would you wish the relationship to change? How?
The information sought in this section enables the psychotherapist to develop an interpersonal Inventory (IPI). The IPI identified the people that are significant to the patient and the problems that the patient identified with this relationship. In terms of exploring parallels with previous relationships, the psychotherapists helped patient X identify similarities between current problems and those that she had experienced in previous relationships. Some questions were:
Have you undergone this situation in the past?
Have you done this before?
How have you dealt with this situation in the past?
In this regard, the therapist explored lessons that the patient had gained from previous relationships. He suggested that she identifies successful aspects and apply them to her current situation.
The therapist then shifted to exploring relationship patterns. If the patient seems to have assumed certain roles, the therapist explores the possibility that the patient should shift from this assumed role so that conflict can be reduced. The psychotherapist shifts from exploring to naming emerging patterns and focusing on how the patient could make changes. The next step in the IPT intervention involves exploring the evident communication patterns. The therapist clarified how patient X communicated her wishes and feelings. The activity also involved identifying deficiencies in the patient’s communication style. Sample questions for this phase were:
How do you talk to him?
Is she (wife) aware that you don’t like her behavior?
What makes you not be an assertive individual?
Analysis of patient X’s IPT using attachment theory
The attachment theory of psychotherapy may be used to examine the therapeutic interventions that were undertaken by X’s psychotherapist. Patient X is not protected from psychological stress distress because she has very weak attachment bonds with her friends and family members. She also does not have a partner who she is involved with emotionally and intimately. This situation is reflected in her emotional problems and poor regulation strategies. Attachment is the basis for life-long interpersonal behavior patterns that make an individual to seek reassurance and care in a given way. Attachments contribute to reciprocal, social and personal bonds with significant others. Patient X lacked the feeling of being loved and the reassurance that someone would be there for her in times of trouble. X’s attachment bonds have been disrupted on several occasions. First, her father’s heavy drinking disrupted any meaningful emotional bond that X could experience in her childhood. The poor relationship and conflict between her and her half-siblings also disrupted the formation of emotional bonds. She also loses her mother and father through death, leading to further distress. Because of X’s divorce, there has been role transition and reduced security and trust amongst other men. These factors combined have posed serious challenges to patient X’s ability to initiate and maintain relationships. Interpersonal conflict between X and various people has contributed to her depression. Her depression also affects her interpersonal relationships negatively.
Strengths and weaknesses of the IPT intervention
In my opinion, the IPT intervention explores patient X’s depression considerably well. Perhaps the greatest merit of this approach is that it does not only explore the current problems faced by the patient, but also explores the past for patterns and recurring issues. The advantage of this approach is that it allows the psychotherapist to examine aspects of previous interventions that worked and those that did not. In addition, patterns in the patient’s communication tendencies emerge. The therapist may be able to effect change. The IPT approach does not have many weaknesses. However, one major weakness is that it is difficult to determine whether the intervention has worked.
The interpersonal therapy (IPT) approach, developed by Gerald Klerman and Myrna Weissman, aims at symptom relief as well as improvement of interpersonal functioning. It has been proven to treat patients from multiple age-groups who suffer from depression. IPT focuses on the four problem areas of grief, role transitions, interpersonal sensitivity and interpersonal disputes. These areas are viewed as the major causes of depression. There are several theories that underpin the IPT approach to depression. In the context of this study, however, the attachment theory is the most important. Developed by James Bowlby (1958), this theory holds that all people have a basic need to build strong emotional bonds with other people. The attachment theory is crucial to IPT because it explains the importance of interpersonal relationships on the mental health of individuals. When an individual is depressed, it affects their interpersonal relationships. Similarly, the quality and stability of the individual’s relationships can influence their mood. Overall, IPT provides a theory- and evidence-based approach to solving depression problems that is highly effective.
Ainsworth, M. D. S. (1973). The development of infant-mother attachment. In B. Cardwell & H. Ricciuti (Eds.), Review of child development research (Vol. 3, pp. 1-94) Chicago: University of Chicago Press.
Bowlby, J. (1958). The nature of the child’s tie to his mother. International Journal of Psychoanalysis, 39, 350-371.
Crowe, M., & Luty, S. (2005). The Process of Change in Interpersonal Psychotherapy (IPT) for Depression: A Case Study for the New IPT Therapist. Psychiatry: Interpersonal and Biological Processes, 68(1), 43-54. Doi:10.1521/psyc.126.96.36.199184
Kiesler, D. J. (1979). An interpersonal communication analysis of the relationship in psychotherapy. Psychiatry, 42, 299-311.
Robertson, M., Rushton, P., & Wurm, C. (2008). Interpersonal Psychotherapy: An overview. Psychotherapy in Australia, 14(3), 46-54.
Stuart, S. (2006). Interpersonal psychotherapy: A guide to the basics. Psychiatric Annals; August, 2006, 36(8): 542-550.
Stuart, S., & Robertson, M. (2003). Interpersonal Psychotherapy: A Clinician’s Guide. London: Edward Arnold.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W.W. Norton.
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