Interpersonal Psychotherapy: Evidence and Application

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Interpersonal Psychotherapy Evidence and
Application

• Joy E. Moel, Roberta Casko,
• Kimberly Nylen, Tracy Moran
• University of Iowa
• Iowa Depression and Clinical Research Center

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History and Development

• Developed in the 1970s by Gerald Klerman, Myrna
  Weissman and colleagues
• Era of tricyclic antidepressants
• IPT was not initially developed as an active
  treatment for depression

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History and Development

• Served as the psychotherapy component in a drug
  treatment trial comparing the relative efficacy
  of antidepressants alone and in combination with
  psychotherapy
• Originally called high contact, indicating that
  benefit to patients would be due to nonspecific
  effects rather than specific techniques

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History and Development

• Maintenance studies showed the efficacy of high
  contact
• Klerman and Weissman began to more fully describe
  the treatment, termed IPT, and published a manual
  (Klerman, Weissman, Rounsaville, 1984)
• Designed an acute treatment trial of medication,
  IPT, and combination.

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What is Interpersonal Psychotherapy?

• Interpersonally based psychotherapy
• Focuses on modifying disrupted relationships or
  expectations about those relationships
• Time-limited
• Focus on here-and-now
• Non-transferential
• Psychodynamically informed vs. psychodynamically
  oriented

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What is Interpersonal Psychotherapy?

• Manual based
• Empirically based
• Goals of treatment
• Symptom relief
• Improved interpersonal functioning
• Resolve acute interpersonal crisis
• Increase social support

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Therapeutic Stance

• Understand the client
• Active
• Client advocate
• Supportive
• Directive
• Non-transferential
• Client responsible for direction and change

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IPT Theoretical Framework

• Biopsychosocial model
• Attachment Theory (Bowlby)
• Relationships are primary
• Attachment is a biological drive
• Attachment is a cybernetic system
• Capacity to form flexible attachment is principal
  feature of mental health

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Attachment Styles

• Secure
• Anxious Ambivalent
• Anxious Avoidant

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Attachment Theory

• Patterns of attachment develop early and tend to
  persist, but are not fixed
• Patterns of attachment persist within
  relationships
• Patterns of attachment persist across
  relationships

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Attachment Theory

• Those with less secure attachment are more prone
  to psychiatric symptoms
• Disruption of attachment increases vulnerability
  to psychiatric symptoms
• Psychiatric symptoms result from Biopsychosocial
  factors
• Dysfunction results from
• An acute crisis, attachment disruption,
  inadequate social support

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Attachment Theory Implications for Treatment

• Focus on attachment i.e. interpersonal
  relationships
• Resolution of here-and-now problems should result
  in symptom relief
• Fundamental personality change is unlikely in
  short-term treatment

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Problem Areas

• Grief Loss
• Interpersonal Disputes
• Role Transitions
• Interpersonal Sensitivity

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IPT Techniques

• Clarification
• Communication Analysis
• Interpersonal Incidents
• Use of Affect
• Role Playing
• Problem Solving
• Homework
• Use of the Therapeutic Relationship

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Clarification

• Direct questioning
• Empathic listening
• Reflective listening
• Encouragement of spontaneous discourse

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Communication Analysis

• Importance of clearly communicating needs and
  expectations to others.
• Clients understanding of her contribution to
  communication problems.
• Motivate client to communicate more clearly.
• Analyze quality of patients narrative.
• Analyze communications within sessions.

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Interpersonal Incidents

• Augment communication analysis
• Provide discrete examples of generalized
  beliefs/complaints
• Provide specific incidents for the therapist and
  client to problem-solve

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Use of Affect

• Help client to - recognize her own affect
  - communicate affect to others - recognize
  suppressed or painful affect

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Role Playing

• Allows the therapist to model new modes of
  interpersonal behavior and communication.
• Allows the client to - develop new insights
  into her interpersonal behaviors - practice
  new communication skills - gain new perspectives
  on the reaction of others to her communications
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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Problem Solving

• Carefully examine the problem.
• Brainstorm potential solutions with client
• Select a course of action.
• Monitor outcomes and refine solution.

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Homework

• Assignments are interpersonal in nature and not
  paradoxical.
• Assignments involve - direct communications
  with others - self-appraisal of her
  interactions - activities and behaviors with
  others

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Use of the Therapeutic Relationship

• The ideal relationship includes - mutual
  liking, caring, respect - importance to both
  parties - a degree of expertise on the part of
  the therapist

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Overall Structure of IPT

• Treatment Phases
• Evaluation
• Initial Sessions (1-2)
• Intermediate Sessions (3-12)
• Conclusions of Acute (13-14)
• Maintenance treatment (15)

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New Haven Boston Collaborative Study

• First controlled study of IPT for acute
  depression
• 16 week treatment study of 81 depressed patients
• IPT alone
• Amitriptyline alone
• Combination
• Control Nonscheduled psychotherapy

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New Haven Boston Collaborative Study

• IPT superior to nonscheduled psychotherapy
• Medication superior to nonscheduled psychotherapy
• Combination was more effective then either active
  treatment alone
• IPT equivalent to Amitriptyline
• Differential effects on symptoms

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One-year follow-up

• Patients who received IPT (alone or in
  combination with medication) showed higher
  functioning than patients who received
  nonscheduled psychotherapy or medication alone
• No effect of IPT on symptom relapse or recurrence

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NIMH Treatment of Depression Study
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NIMH Treatment of Depression Study

• IPT superior to placebo
• IPT equal to Imipramine for mild to moderate
  depression
• IPT slightly better than CBT for severe
  depression
• No long-term preventive effects were noted for
  IPT, CBT, or Imipramine at 6, 12, or 18 months

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NIMH Treatment of Depression Study

• 43 of patients entering IPT achieved remission
  of depression (HRSDlt7)
• 55 of patients who completed IPT achieved
  remission of depression
• 23 of patients terminated prematurely from IPT
• Premature terminators were more severely
  depressed at intake
• 33 of patients achieving remission of depression
  relapsed within 18 months

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NIMH Treatment of Depression Study

• Treatment response to IPT predicted by
• low social dysfunction
• high interpersonal sensitivity
• higher satisfaction with social relationships
• acute onset of depression
• endogenous depression

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Maintenance Therapy

• Many patients have relapses and recurrences
• Weissman and colleagues established that 8 months
  of antidepressant treatment could prevent
  relapse, and that maintenance IPT could enhance
  social functioning, but effects werent seen for
  6-7 months
• Pittsburgh Maintenance Therapy with IPT - Frank,
  Kupfer and colleagues studied the efficacy of IPT
  as a maintenance treatment for depression

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Pittsburgh Maintenance Therapy
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Pittsburgh Maintenance Therapy - Results

• 3-year survival analysis indicates that
  Imipramine reduced relapse of depression
• Combination of Imipramine and IPT did not further
  reduce relapse
• Maintenance IPT not as effective as Imipramine
• Maintenance IPT superior to placebo

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Pittsburgh Maintenance Therapy
Mean 3 Year Survival (weeks)
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Clinical Importance of Empirical Research

• Selection of good candidates for IPT
• Prediction of response
• Conviction of treatment presentation
• Conviction in treatment delivery

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Additional Applications Research at the
University of Iowa

• Social Phobia (Stuart et al.)
• Somatization Disorders (Stuart Noyes, 1999)
• IPT for Couples (Stuart, Temple et al)
• Post-MI Depression (Stuart Cole, 1996)

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Additional Applications

• Interpersonal Counseling in Primary Care (IPC
  Klerman Weissman, 1993)
• Eating Disorders (Fairburn et al., 1998)
• Adolescents (IPT-A Mufson et al., 1999, 2004)
• Bipolar Disorder (Swartz et al., 2002)
• Drug Abuse (Rounsaville Carroll, 1993)
• Dysthmia (Browne, Steiner et al., 2002)
• HIV Patients (Markowitz et al., 1992, 1997)
• Groups (IPT-G Wifley et al., 2000)