11. Interpersonal Therapy – Flashcards

- 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

- 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

- 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

- 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

- 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

- 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

- Active - Client advocate, supportive, directive - To gather information - Educative - Modelling a secure attachment - Modelling of communication patterns - Safe background for change - No transference analysis

- Active - Client takes ultimate responsibility for the topics to be discussed - To discuss relationships with others openly - To explore feelings about those relationships

- Not insight but change, eg: - Improvement in interpersonal relationships or - Change in expectations about them - Symptom relief - Improvement in social networks

- 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)

- Intermediate sessions: Addressing key problem areas

- Termination: Consolidation; Relapse prevention; Termination

- 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

- 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

- 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

- Identificationof problem - Exploreclient's perceptions and expectations - Brainstormingand analysis of consequences - Implementation - Monitoring of attempted solution

- 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

- Use of the therapeutic relationship - Originally no homework tasks (cfCBT condition in research) but now, inter-session activities are used

- 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

- 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

- 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

- 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

- Reinforcement of client's gains - Acknowledgement of client's sense of loss/grief/transition - Normalisation of feelings about termination - Management of post-therapy contacts

- 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"

- 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)