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11. Interpersonal Therapy

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Development of IPT
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– Developed as a manualisedtreatment for depression in NIMH depression project: – CBT vs IPT vs Med+CMvs Placebo+CM – But it worked —> hypothesised that change in social circumstances and relationships was driving change
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What is IPT?
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– Adopts medical model of depression – Link between depressed mood and interpersonal relationships – Focuses on modifying disrupted interpersonal relationships or expectations about those relationships – Goal of treatment = symptom relief
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Characteristics of IPT
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– Time limited (eg12 – 16 weeks) – Focused rather than open-ended – Current interpersonal relationships – Interpersonal not intrapsychic(not transference based) – Interpersonal not cognitive – Personality is recognised but not a focus – Relationship is primary – Interpersonal school founded by Adolf Meyer and Harry Stack Sullivan – Meyer (1957) psychobiological theory emphasised patients’ current interpersonal experiences – Sullivan (1953) linked psychiatry with sociology, anthropology and social psychology
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Theoretical underpinnings of IPT: Attachment
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– Attachment theory: basis for formulating relationship difficulties – Attachment styles – Later theory added by Scott Stuart and colleagues, based on Bowlby’s attachment theory – Secure: trusting lasting relationships; tend to have good self esteem; seek social support when stressed. – Ambivalent: reluctant to become close to others; may worry that their partner doesn’t love them; become distraught when a relationship ends. – Avoidant: may have problems with intimacy; invests little emotion in social and romantic relationships; unable or unwilling to share thoughts and feelings with others. – Patterns of attachment are developed in childhood and tend to persist but are not fixed – Insecure attachment styles are vulnerable to depression
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Theoretical underpinnings of IPT: Communication Theory
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– Communication theory: describes how maladaptive communication patterns can lead to difficulties in interpersonal relationships – Attachment is template on which specific communication occurs – Ways of communicating attachment needs to significant others – Communication analysis and skills building is a central part of IPT
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Theoretical underpinnings of IPT: Social Theory
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– Social theory: basis for understanding social context and the effects of social networks – Isolation or dysfunction in social relationships is causal in psychological distress – Conversely, people with depression tend to decrease in social functioning – Spectrum of responses to interpersonal stressors – Intervening in interpersonal relationships will improve functioning
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Therapist’s role in IPT is…
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– Active – Client advocate, supportive, directive – To gather information – Educative – Modelling a secure attachment – Modelling of communication patterns – Safe background for change – No transference analysis
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Client’s role in IPT is:
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– Active – Client takes ultimate responsibility for the topics to be discussed – To discuss relationships with others openly – To explore feelings about those relationships
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Goals of IPT
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– Not insight but change, eg: – Improvement in interpersonal relationships or – Change in expectations about them – Symptom relief – Improvement in social networks
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Discuss the first phase of treatment
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– Initial sessions: Diagnostic evaluation and framework for treatment; Treatment contract – Diagnosis and feedback of symptoms and nature of diagnosis – Establish a therapy contract – Encourage client to assume a “sick role” – Removes blame from client – Conveys hope – Normalises the problem – Identifies problem as time-limited – Interpersonal inventory – All significant relationships – History of problematic relationships – Social support – Communication problems – Problems with expectations in relationships – Summary in terms of 4 interpersonal problem areas – Grief (complicated bereavement) – Role disputes (e.g. with significant others) – Role transitions (e.g. from single to married) – Interpersonal deficits (e.g. loneliness, social isolation) – These are not mutually exclusive, clients may present with combination of several or no one area with clearcutproblems (in which case focus is IP deficits)
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Discuss the second phase of treatment
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– Intermediate sessions: Addressing key problem areas
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Discuss the third phase of treatment
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– Termination: Consolidation; Relapse prevention; Termination
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Clarification and directives in IPT
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– Aim to: – Restructure and feedback client’s material – Make client more aware of what has actually been communicated – May use: – Open ended and closed questions – Clarification of all aspects of a situation – Paraphrasing and reflecting – Receptive and empathic listening – Receptive silence
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Encouragement of affect in IPT
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– Facilitate recognition and acceptance of painful affect – Awareness – Clear expression of affect – Using affect to bring about change – Negotiate behaviour change with others – Delay expression or acting on affect until calm – Revise thinking about affect-laden topics – Based on the notion that poor emotion regulation and communication within relationships may cause ip problems
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Communication analysis in IPT
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– Clients are encouraged to “put everything into words” – Communication discussed in an interpersonal context – Reconstruction of interpersonal events – Therapist as role model – Common communication difficulties – Ambiguous, indirect non-verbal communication as substitute for open confrontation – Incorrect assumption that one has: – Communicated clearly – Been understood – Silence, closing off communication
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Problem solving in IPT
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– Identificationof problem – Exploreclient’s perceptions and expectations – Brainstormingand analysis of consequences – Implementation – Monitoring of attempted solution
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Role playing in IPT
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– Assist client to develop different points of view – Assist in understanding communication patterns – Rehearsal: – Practising and reinforcing communication – Ask clients to play themselfand also the other person in the communication
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Other key techniques in IPT
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– Use of the therapeutic relationship – Originally no homework tasks (cfCBT condition in research) but now, inter-session activities are used
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Key problem area 1 in IPT
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– Grief – Loss through death – “Normal” grief includes a full awareness of the reality of death; symptoms usually resolve in 2 -4 months – Complicated bereavement – delayed; failure to mourn; or “over-grieving” – Many stages described in dealing with loss – Goals in working with grief: – Facilitate mourning – Help find new activities and relationships – Tasks in working with grief – Relate onset of symptoms to timing of loss – Exploration of circumstances of loss – Exploration of actual relationship with deceased – Generation of associated affect and promoting its acceptance as part of loss experience – Helping client make new attachments
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Key problem area 2 in IPT
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– Interpersonal disputes – Conflict with significant others – Differing expectations of roles – Stages of dispute: – Negotiation – active attempts to change things – Impasse – stalled negotiations – Dissolution – considering ending the relationship – Addressing interpersonal disputes – Identify stage of dispute – Modify communication patterns – Reassess expectations of relationship – Assist patient to communicate their needs – Could entail: – Examining parallels in other relationships – Encourage direct communication – Model direct communication – Role playing
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Key problem area 3 in IPT
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– Role transitions – Depression associated with role transitions occurs when person has difficulty coping with life change – Difficulties may involve: – Loss of social support or network – Management of emotions such as fear or anger – Demands for a new repertoire of social skills – Diminished self esteem – Goals in role transitions – Facilitate mourning of old role and acceptance of new role – Help client see new role as less negative – Help gain mastery over new role – Developing new attachments and supports – Techniques in role transitions – Relate symptoms to recent life change – Explore affective component of loss – Review old role in positive and negative light – Review new role in positive and negative light – Identify challenges of new role – Problem solve and implement solution to deal with challenges
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Key problem area 4 in IPT
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– Interpersonal deficits – Can occur in social phobia – Avoidance or anxiety in social relationships – Lacking in social skills – Problems in initiating or sustaining relationships – Describes consistent style of attachment or personality (cfacute social stressor) – Note: not common and if other problem areas present focus on those – Goals: – Reduce isolation – Assess strengths realistically – Begin extending social repertoire – Strategies: – Review past significant relationships – Problem solving with positive reinforcement – Communication analysis and role play
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Termination in IPT
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– Reinforcement of client’s gains – Acknowledgement of client’s sense of loss/grief/transition – Normalisation of feelings about termination – Management of post-therapy contacts
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Empirical support for ITP
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– NIMH Treatment of Depression Study: – Imipramine+CMvsCBT vsIPT vsplacebo+CM – All approaches effective – IPT > placebo – IPT = medication for mild to mod depression – IPT > CBT for severe depression – Current American Psychiatric Assoc guidelines for treatment of depression (Fochtmann& Gelenberg, 2005) – “women in particular may respond better to sequential treatment with IPT followed by antidepressant medication in the non responders”
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IPT applied to other disorders
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– Postpartum depression (O’Hara et al., 2000) – Women in IPT condition showed sig greater improvements in depression symptoms, remission from depression episode and social adjustment than women in control condition; Interpersonal psychotherapy reduced depressive symptoms and improved social adjustment, and represents an alternative to pharmacotherapy, particularly for women who are breastfeeding. – Dysthymia + alcohol (Markowitz et al, 2008) – Dysthymic disorder (Mason et al, 1993) – HIV patients (Markowitz et al., 1992) – Bipolar disorders (Frank et al., 1990) – Bulimia nervosa (Fairburn et al, 1998) – Social phobia (Lipsitzet al, 2008) – Comorbid anxiety and depression in adolescents (Young et al, 2006)