Chapter 7 Interpersonal Psychotherapy
Interpersonal psychotherapy (IPT) is a brief, structured psychotherapeutic approach based on the operating principle that psychiatric disorders occur within an interpersonal, social context. Symptoms of psychiatric disorders in four specific areas of social functioning create problems in which IPT therapists are trained to intervene: interpersonal disputes, role transitions, grief, and interpersonal deficits.
Foundations of Interpersonal Psychotherapy
The work of three psychopathology theorists shaped some of the underlying approaches of IPT (Klerman et al., 1984; Weissman et al., 2000). Their theories emphasized the importance of the interpersonal environment and the relationships therein as the foundation of personality development. A brief background of the theorists and their theoretical frameworks are described in relation to the foundational concepts of IPT:
Harry Stack Sullivan is recognized as one of the major figures in American psychiatry. He became interested in the field in his early 30s and is widely recognized as a charismatic leader who became a pioneer in the treatment of schizophrenia. His views on the development of mental illness were influenced by many other fields, including cultural anthropology and political science (Ozarin, 1998). Sullivan’s central theory is that interpersonal relationships and the communications therein form the basis for psychiatric disorders. He believed that effective communications are interfered with by anxiety. Sullivan also suggested that “each person in a two-person relationship is involved as a portion of an interpersonal field, rather than as a separate entity, in processes which affect and are affected by the field” (Sullivan, 1953, p. xii). Sullivan and nurse theorist Hildegard Peplau, who is discussed later in this chapter, are both recognized as pioneer thinkers in the treatment of schizophrenia (Peplau, 1952; Sullivan, 1953). Although IPT is not recognized as a treatment model in the treatment of schizophrenia, the humanistic approaches of Sullivan and Peplau are respected as universally applicable in the mental health treatment of individuals in emotional pain.
Adolf Meyer was a Swiss psychoanalyst who was strongly influenced by the psychobiology and psychopathology theories of Darwin, Freud, and Jung. He became the primary architect in professionalizing the field of psychiatry when he became the first professor of psychiatry at Johns Hopkins University in Baltimore, Maryland. Meyer used the findings and recommendations for the field of clinical psychiatry that appeared in the Flexner Report, published early in the 20th century. He followed the Flexner Report when he implemented the use of research, professional scholarship, and full-time faculty to improve clinical knowledge in the field of psychiatry. The diligence that Klerman and Weissman later brought to their development of IPT is based on the recognition of the need for research to demonstrate the efficacy of innovative therapeutic interventions. Meyer “viewed mental illness as an attempt by the individual to adapt to the changing environment” (Klerman et al., 1984, p. 42). Adolf Meyer is recognized as one of the founding fathers of the field of social epidemiology (Klerman et al., 1984), the field that researches the causes and effective treatment of social and mental ills.
John Bowlby is an English psychoanalyst who developed the concept of attachment theory. He is recognized as one of the century’s most influential theorists on personality development and social relationships (Holmes, 1993). When Bowlby worked with infants and children as the head of the Children’s Department at the Tavistock Clinic after World War II, he recognized the powerful effects of mother-child separation. Bowlby believed that the attachment of the child to the mother had an evolutionary basis, rather than the oral gratification theoretical approach held by the Freudians. Bowlby is well known as the author of three important texts describing how the mother-child bond affects the humans’ responses to attachment, separation, loss, and depression over the life continuum (Bowlby, 1980; Holmes, 1993; Klerman et al., 1984).
Nursing Theory and Interpersonal Psychotherapy
Many psychotherapy models are studied in the course of becoming a proficient psychotherapist. Graduate students in any of the mental health discipline learn a set of core theoretical concepts about the evolution of psychopathology and its treatment. These concepts are derived from the theories of leaders in the field of mental health. Often, these theories are colored by and tailored to the primary clinical interests of the graduate student’s professional field. Among the professional groups that address psychiatric disorders, nursing consistently prioritizes and values the interaction of biopsychosocial processes and environmental factors that support adaptation, as well as those that contribute to maladaptation, one of the roots of psychiatric disorder (Barry, 1989).
Jacqueline Fawcett (1984) and Margaret Newman (1982) identified four themes that are the foundation of nursing theories that describe the clinical relationship and interactions of nurses with their patients. They are patient, nursing, environment, and health. An overview of these themes from the perspective of Hildegard Peplau, a nurse theorist whose work is related to the IPT model, appears below. While reading Peplau’s framework, observe the similar themes of its perspectives compared with those of Sullivan, Meyer, and Bowlby, which were described previously.
Peplau is considered to be the founder of the field of mental health nursing (Fawcett, 1986). Hildegard Peplau’s model and the fundamental values of psychosocial nursing are congruent with the foundational concepts of IPT. A core concept is the importance of interpersonal relations in nursing. Her clinical model of nursing interaction is outlined in her view of the major themes of nursing:
Martha Rogers’ theoretical framework, the Science of Unitary Human Beings, is similar to Sullivan’s field theories. Her theories, based on foundations in physics and systems and psychosocial theories, emphasized the power of fields in the maintenance of health and the development of and treatment of disease (Rogers, 1970). Watson’s transpersonal caring theory emphasizes the importance of the therapeutic and healing presence of the nurse who focuses his/her attention on caring, healing, and wholeness, rather than on disease, illness, and pathology. A meaningful nurse-patient relationship is based on caring and the demand for authentic person-to-person exchange (Watson, 1998).
The holistic nursing model outlined in Chapter 1 evolved from these theoretical roots and is consistent with the major themes of nursing identified previously. The individual is embedded in relationships with others that affect and influence all dimensions of the person. Interpersonal interactions reveal the perceptions, feelings, and thoughts unique for a person and give expression to implicit memory networks. IPT focuses on relationships, targeting current social and interpersonal interactions. By understanding the effects of the person’s problem on significant relationships and how past and present relationships affect the problem, new relational patterns and roles can be discussed and implemented. Changing the social context and relationships with others reverberates to all dimensions of the person, because all components are interrelated. Through interpersonal change, right relationship with others and self occurs.
History of Interpersonal Psychotherapy
Within the different psychiatric disorders they studied, including depression, bulimia nervosa, and others mentioned previously, these four types of interpersonal difficulties produced symptom clusters that were uniquely different from each other (Klerman et al., 1984; Weissman et al., 2000). As the psychiatric disorders were studied, it was found that the assessment and treatment of each disorder required modifications in the original model for depression (Elkin et al., 1989; Fairburn et al., 1993; Kupfer et al., 1992; Weissman et al., 1979). These IPT clinical approaches to a variety of psychiatric disorders and treatment settings are described later in the chapter.
Underlying Assumptions of the Interpersonal Psychotherapy Model
The work of John Bowlby (1980) in describing disruptions in the maternal-child relationship as the source of psychosocial difficulties in adolescence and adulthood is foundational to IPT. Bowlby’s research and teaching emphasized the impact of early life issues, with separation and loss as the underlying basis for depression. The developmental research efforts of Klerman and Weissman, the founders of IPT, were based on the theoretical perspectives of Bowlby and on the social interaction theories of Sullivan and Meyer. The original IPT research rationales focused on the development of a therapy model that would be an effective treatment for depression (Klerman et al., 1984; Weissman et al., 2000).
IPT recognizes that psychopathology arises from underlying personality issues that will not become the focus of treatment. Instead, IPT emphasizes that the problems created by the psychiatric disorder occur interdependently within the conscious social and interpersonal realms. These problems and conscious awareness of the context are the focus of IPT treatment (ISIP, 2006).
In developing the IPT approach, it was thought that earlier depression treatment programs paid too little attention to techniques aimed at reduction of symptoms and easing the patient’s current social functioning and interpersonal relations (Klerman et al., 1984). IPT emphasizes the patient’s disputes, frustrations, anxieties, and goals in their current social and interpersonal environments. The purpose of IPT is to intervene with symptoms and to reduce the risk of additional symptom formation by relieving current problems in interpersonal relations and social adjustment.
Symptoms are described as the development of depressive affect and its accompanying indications that may be the result of psychobiologic or psychodynamic mechanisms. Although the IPT founders recognize the presence of unconscious (implicit) personality and character dynamics in the development of depression, the IPT approach, which is a time-limited treatment model, does not intervene directly with these underlying dynamics. Social and interpersonal relations are described as interactions in social roles with others. These interactive social problems are addressed with “reassurance, clarification of emotional states, improvement of interpersonal communication, and testing of perceptions and performance through interpersonal contact” (Klerman et al., 1984, p. 7). Related aspects of IPT are addressed in subsequent sections of this chapter.
Contrasts between Underlying Assumptions of Interpersonal Psychotherapy and Psychodynamic Psychotherapy
Weissman and Klerman, the original developers of IPT, were well schooled in the underlying theory of psychodynamically oriented psychotherapy. They recognized the importance of understanding the original foundations of personality difficulties whose origins were based in early and later childhood. They acknowledged that these foundations were primarily housed in the unconscious (implicit memory) realms of depressed persons. Because of the many years of treatment usually required for dynamic psychotherapy or psychoanalysis, a new psychotherapy model was created, motivated by the changing worlds of the mental health treatment setting and by health care economics, both of which were oriented to a shorter length of mental health treatment than was generally available in the 1970s (Barry, 2002; Klerman et al., 1984; Weissman et al., 2000).
During the formative and developmental studies of depression, research models were created to demonstrate the most explicit operational approach to effective depression treatment. The original premises of the research recognized the seminal psychoanalytic and psychodynamic contributions of Freud and his followers. However, new ground was covered by integrating an updated approach to the theory of the causes of depression and empirical evidence about the treatment of depression based on the findings of depression researchers through the 1970s (Barry, 2002; Klerman et al., 1984; Weissman et al., 2000).
In addition to the emerging knowledge of the dynamics of depression, Weissman and Klerman worked with the premise that since World War II, there had been a significant change in the social face of psychiatry because of increased awareness of gender and race issues, concern about human potential, and increased interest in and striving for personal well-being. During the post–World War II era, there also was an important scientific and professional shift in recognition of the importance of personal development and interpersonal relations over the life span (Barry, 2002; Klerman et al., 1984; Weissman et al., 2000).
The result of these important changes in society and the field of psychiatry was that IPT theorists and practitioners recognized that psychodynamic psychotherapy was not a realistic clinical approach to use with the masses of people who were suffering from depression and who required a time-limited and affordable approach to treating psychiatric disorders. A model was developed that switched the traditional psychodynamic focus on unconscious mental processes and implicit memories to what they called a “purely interpersonal approach,” which focuses on social roles and interpersonal interactions in the patient’s current and past experiences. The IPT model addresses interpersonal relations, essentially addressing the interactions between self and other, whereas the psychodynamic therapist focuses on object relations, which is an intrapsychic formulation of self with others (Barry, 2002; Klerman et al., 1984; Weissman et al., 2000).
Principles and Guidelines of Interpersonal Psychotherapy
The development of IPT was driven by the belief that progress in creating new clinical interventions should be guided by clinical experience and research evidence. Research evidence is acquired by “carefully designed, well-controlled investigative trials” (Weissman et al., 2000, p. 4). Weissman laments that despite the prevalence of dozens of different psychotherapy models, only two clinical psychotherapeutic practices have been substantiated by such research: IPT and cognitive behavioral therapy (CBT) (Weissman et al., 2000).
The social roots of depression are the primary focus of IPT, which was developed to study effective treatments for depression. The IPT model allowed diagnosis and treatment of depression in a timely manner that expedited the recovery time of depressed individuals and met the requirements of the up-and-coming managed care insurance world during the late 1970s and subsequent decades. Mental health research during the 20th century pointed strongly to social factors being critical in the development of depression (Weissman et al., 2000).
1. Symptom function: how depressive affect and neurovegetative signs and symptoms are affecting the patient personally and with others
2. Social and interpersonal relations: how a person interacts with others, based on early childhood experiences, current social reinforcement, and the sense of mastery
3. Personality and character problems: characterologic traits, such as pessimism, poor self-esteem, resentment, and poor communication with others
IPT actively addresses the first two sources of depression described. Personality and character problems, the third source, are generally viewed as being deep seated and having their origins in unconscious (implicit) memory (Weissman et al., 2000). Although IPT does not actively address this aspect of personality and character issues, Weissman suggests that the active work on the first and second points, the symptom characteristics and interpersonal functioning, supports the development of new social skills that may reduce some of the characteristic personality difficulties (2000).
Weissman and colleagues (2000) describe IPT as follows:
Weissman and her colleagues (2000) explain that it is important for the IPT therapist to recognize clinical depression as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and to be aware of its social, biologic, and medical precipitants. The IPT therapist is then urged to recognize the interpersonal context of the depression and the importance of its underlying roots of difficulties with attachment, bonding, stress, and interpersonal disputes. The prominence and persistence of the depression is also associated with neurovegetative signs of sleep disruption, such as appetite disturbance, changes in weight, and energy level, as well as thought and memory processes, including worthlessness, guilt, helplessness, and thoughts of death and suicide.
IPT was used in research studies that investigated methods to support the early improvement in functioning observed 2 to 4 weeks after inception of antidepressant therapies. Research on depression treatments in the mid-20th century found a consistent and gradual decline in the original clinical improvement of patients. Treatment approaches were identified that built on the theoretical underpinnings of the origins of depression and that would sustain the early improvement related to psychopharmacologic interventions. Hundreds of clinical studies have demonstrated success in developing a clinical intervention based on a manual with very specific assessment and treatment criteria. Many of those studies (described later) demonstrated the efficacy of modifications to the original IPT protocol for use with other types of psychiatric populations.
The following features provide a summary of the IPT approach (Weissman et al., 2000) compared with other psychotherapy models:
1. Time limited, not long term
3. Based on current, not past, relationships
4. Interpersonal in nature, not intrapsychic
5. Interpersonal, not cognitive or behavioral
The Role of the Therapist in Interpersonal Psychotherapy
The IPT model is one in which the therapist is able to be interpersonally open with the patient when the therapist’s experience can be used to illustrate a point in the discussion. Activities between the therapist and patient that do not relate directly to the therapy should not be engaged in. The therapist is active and pro-active in the relationship, while at the same time recognizing that change is the responsibility of the patient. The therapist usually does not make active suggestions for change. Rather, change is viewed as the desired outcome of the interactions of the patient and therapist in the IPT therapy. Homework is not assigned in IPT. It is expected, however, that the results of clinical sessions will bring about gradual change that is reported in subsequent sessions (Weissman et al., 2000).
Establishing the Therapeutic Alliance in Interpersonal Psychotherapy
An important aspect of the therapeutic alliance is that therapists can be well trained in therapeutic skills and treatment models, but there are essential factors that cannot be gained through training. These factors include the personality and emotional styles of the therapist. These factors usually have been operative in therapists long before they became therapists. As the result of their studies on the effects of training in therapists, Strupp and Anderson (1997) concluded that the effects of the training were filtered through the therapists’ preexisting personality dispositions. They found that although therapists might have been trained to use a therapy using a specific manual that directed all aspects of patient-therapist interactions, the therapy results were strongly colored by the underlying personality characteristics of the therapists.
There were additional findings related to the use of training manuals by therapists. Although therapists demonstrated compliance with the recommended approaches of the manual, there were unanticipated consequences of manual-based therapies. In general, Henry and colleagues (1993) found that many therapists delivered the therapy in a “fairly forced mechanical fashion” (Safran & Muran, 2000, p. 4). Therapists with a style that was identified as self-controlling and self-blaming were more inclined to astutely follow the treatment manual and showed more hostility and a lack of warmth and friendliness with their patients. One of the questions in the conclusions of this study was how to avoid the possibility of the manual approach becoming an external standard that had to be conformed to, rather than a personally integrated way of being present with patients (Safran & Muran, 2000). A challenge for therapists who are using a manual approach to IPT therapy is to remain open and aware of their interpersonal style with patients and to create a social environment for the therapy that is human to human in its interpersonal style.
Application of evidence-based Interpersonal Psychotherapy practice for Selected Psychiatric Disorders
IPT was originally developed as a clinical intervention with a specific orientation to adult depression and the unique clinical syndromes that contribute to it. The use of IPT in adult depression has been studied meticulously by one of its founders, Myrna Weissman, a psychiatric epidemiologist at Columbia University. She and other researchers were able to demonstrate that IPT was effective in reducing symptoms of depression during IPT therapy and after the completion of IPT therapy (Dowrick et al., 2000; Frank, 1991; Hollon et al., 2002; Klein & Ross, 1993; Klerman, 1988; Shea et al., 1992; Ward et al., 2000). IPT has also demonstrated efficacy in conjunction with pharmacotherapy (Frank et al., 1990). In addition to depression, IPT is effective when used for several other types of disorders and in a variety of mental and physical health settings, including perinatal depression, eating disorders, adolescent depression, somatization, substance abuse, and bipolar disorder. IPT counseling, which is an abbreviated form of IPT, is used primarily in medical illness settings.
Treating Depression with Interpersonal Psychotherapy
The seminal study demonstrating the efficacy of IPT was completed in the early 1980s using sites at Harvard and Yale University—affiliated mental health centers that serviced patients from a wide range of social backgrounds. The initial IPT study was considered advanced for its time because the mental health clinicians who participated in the study adhered to a treatment manual (Weissman et al., 2000). The treatment manual eventually became the basis for IPT therapy training (Weissman et al., 2000). There were four groups of depressed individuals in the study: persons who received IPT intervention; persons who had IPT and antidepressant therapy; persons treated with antidepressant therapy with no psychotherapy; and persons who had unscheduled treatment, which involved each participant being assigned to a psychiatrist and being told to call the psychiatrist and talk whenever s/he needed to do so. The patients could also schedule an appointment with a psychiatrist for a 50-minute session no more than once per month if their symptoms were of a certain level of intensity. All study participants were assessed on a regular basis by a clinician who did not know the group to which the patient had been assigned.
At the end of the study, the participants who were in the groups that consisted of IPT alone or IPT with antidepressant medication were significantly improved compared with the individuals who were in the nonscheduled treatment group. Those who were treated with antidepressant medication alone were also improved compared with the nonscheduled treatment group. There were important differences, however, in the outcomes of the IPT groups and the group that received only the antidepressant medication. IPT recipients had improvements in mood, improved work performance and interest, and decreased suicidal ideation and guilt. These improvements were statistically significant after the initial 4 to 8 weeks of treatment. In contrast, those who received medication alone showed improvement only in decreased neurovegetative signs of depression: sleep, appetite disturbance, and somatic complaints (DiMascio et al., 1979).
There have been numerous studies demonstrating the beneficial outcomes of IPT treatment of depressed individuals since the original studies that brought optimism to the treatment of depression (Blanco et al., 2001; Dowrick et al., 2000; Klerman, 1988; Klein & Ross, 1993; Reay et al., 2003; Shea et al., 1992; Ward et al., 2000). The primary method used in these studies to demonstrate improvement in depressive symptoms was a statistical difference in the mean scores on depression scales of IPT recipients at the beginning of IPT and the mean scores on completion of the therapy (Blanco et al., 2001; Dowrick et al., 2000; Klerman, 1988; Klerman et al., 1984; Klein & Ross, 1993; Reay et al., 2003; Shea et al., 1992; Ward et al., 2000; Weissman et al., 2000).
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