The Clinical Conduct of Interpersonal Psychotherapy

One of the best-researched psychotherapies (1), interpersonal therapy (IPT) has only recently permeated clinical practice. Developed in the early 1970s by the late Gerald L. Klerman, M.D., Myrna M. Weissman, Ph.D., and colleagues at Yale and Harvard, IPT for many years was practiced almost exclusively in research trials. In the last decade that has changed. Increasing numbers of psychiatric residency programs teach IPT, albeit not as a requirement of the Accreditation Council for Graduate Medical Education. Growing numbers of clinicians attend IPT workshops and supervision. An International Society for Interpersonal Psychotherapy (www.interpersonaltherapy.org) has formed and begun to hold scientific meetings (the next will be in Toronto in November 2006).

Sparking this interest are the success of IPT in randomized controlled trials demonstrating its efficacy, particularly for mood disorders and bulimia (1), and its inclusion in treatment guidelines. Ongoing research is exploring the application of IPT to anxiety and other psychiatric syndromes (1), including bipolar disorder (2). Studies of substance abuse (1) and dysthymic disorder (3) have not demonstrated efficacy. Other research has studied neuroimaging (4, 5) and process/outcome factors (6, 7). IPT has been adapted for couples, group (8), and telephone therapy formats.

This article focuses on clinical aspects of IPT rather than its validating research. Its clinical principles are straightforward. IPT is not intended for all patients—no psychiatric treatment should be considered universal. More practical than theoretical, IPT is not the first psychotherapy clinicians learn, but a targeted approach for clinicians experienced in working with patients who have one of its researched diagnoses, for example, major depressive disorder or bulimia. Thus most psychiatrists have the prerequisites to learn IPT.

Do you dare to use a manual?

Some clinicians assume that a psychotherapy based on a manual must be superficial. IPT, a manualized, relatively straightforward treatment for major depressive disorder and other disorders, might appear to fit that perception. No one would deny that the best manual cannot salvage a terrible therapist: even if the therapist can follow the manual’s directives, adherence to a manual does not denote therapeutic competence. No manual can impart intangible inborn qualities such as empathic understanding. Yet IPT provides a helpful, organized format in which good psychotherapy—in the hands of good psychotherapists—can take place. Several factors contribute to this:

Conducting IPT

The description that follows describes the use of IPT for patients with major depressive disorder, its original and most widely applied use. With some variation, the same general approach applies to adaptations of IPT for other diagnoses.

The first phase is as brief as possible: the minimum interval required to gather necessary information and set the frame for the remainder of treatment. It should not last more than three sessions.

Opening phase

The first phase has three goals: to diagnose, to frame the treatment to follow, to alleviate symptoms.

Diagnosis of the target syndrome (e.g., major depressive disorder) follows standard psychiatric practice. The IPT therapist explains that the patient has a recognizable, treatable medical illness, defined by DSM-IV-TR and by severity scales such as the Hamilton Depression Rating Scale (9). Naming the illness shifts blame for the patient’s suffering from the patient to that illness. Repeating the depression scale regularly during treatment contributes psychoeducation about depressive symptoms and updates patient and therapist on the patient’s progress.

The therapist also diagnoses the interpersonal context in which the depressive episode has arisen. Because the focus is on linkage, not etiology, it does not matter whether social difficulties precipitated the depressive episode or result from it: the goal is that the patient see the connection, that depression has an interpersonal context. The therapist gathers the “interpersonal inventory,” a history of the patient’s relationships since childhood, but focusing on the present. How does the patient typically get along with others? How capable has she been of self-assertion, confrontation, effective expression of anger, and social risk taking? These are difficult maneuvers for most people, but particularly so for the depressed. How close does the patient get to other people? What maladaptive patterns in the patient’s relationships risk repetition in the present? Who are potential social supports on whom the patient can rely? Who is contributing to friction and stress?

The last question may determine a treatment focus. If someone has died, the therapist considers the focus of complicated bereavement. If the patient is struggling with a significant other, a role dispute might apply. Upsetting life events, such as a geographic or occupational move, the start or end of a relationship, or a physical illness, could be cast as role transitions. If the patient presents without life events, describing an isolated, uneventful existence, the patient receives the focus confusingly named interpersonal deficits. This really means an absence of life events that would allow IPT to focus on one of the first three categories. Each of these four categories has an empirical basis in psychosocial research on depression.

Having gathered sufficient information to determine a focus, the therapist presents this to the patient in a formulation (16). The formulation should be brief, organized, and direct. It links the patient’s treatable psychiatric diagnosis (major depressive disorder) to a current interpersonal crisis. For example:

It usually does. The focus is a useful fiction: a coherent, simplified distillation of the patient’s history into a narrative that links the patient’s illness to a recent life crisis. The focal crisis has in fact evoked strong emotions that overwhelm the patient. Solving the crisis gives the patient a sense of mastery of his or her interpersonal environment while improving that environment; research has shown this to be associated with symptom relief. Although the patient’s history may offer more than one potential problem area, the therapist’s chooses only one focus (or no more than two) in order to simplify matters for a patient whose concentration is likely impaired by depression. For patients with multiple life events, such as those we treated who had depressive symptoms associated with HIV infection (17), the category of role transition covers swaths of ground.

The formulation provides a focus for the treatment. The therapist asks for the patient’s agreement on this focus. Once the patient agrees, IPT enters its middle phase. Thereafter, the therapist can use this contract to bring the therapy back to that focal theme in each session, keeping the patient and the therapy from wandering. The time pressure of acute IPT also tends to keep things focused.

Other aspects of the IPT framework include giving the patient the sick role, emphasizing the time limit, and thus planning when acute treatment will end. Symptoms often diminish in the early sessions: simply providing an empathic listener, a structure and rationale for treatment, and optimism—that is, the familiar common factors of psychotherapy—tends to bring relief. The IPT therapist uses these gains as momentum to get the patient moving in the second phase of treatment.

Middle phase

IPT differs from other treatments not through unique interventions but rather the coherence of its interpersonally focused strategies. Many therapists learning IPT say, “I already did a lot of this, but not in so organized a way.” Each of the four IPT problem areas has a specific set of strategies, delineated in the treatment manual (1). The overall goal is always to relate the illness episode to the patient’s current life situation and to help the patient resolve the current life crisis he or she faces, which will yield symptomatic improvement. Patients learn to engage social supports that protect against symptoms and to negotiate relationships more effectively.

Complicated bereavement (grief) denotes that depressive symptoms arose following the death of a loved one and that the patient has struggled to adjust to that terrible, often conflicted loss. The therapist normalizes the powerful feelings connected with the death and facilitates the patient’s grieving process, exploring positive and negative feelings about the deceased and the loss of the relationship. In addition to this catharsis, the therapist encourages the patient to find new directions, activities, and relationships to fill the rift death has torn in the patient’s life.

Role disputes may precipitate or result from depressive episodes. The therapist links the episode to the struggle with a significant other, examining nonreciprocal expectations that the patient and other person have about their relationship (hence the “role dispute”). Therapist and patient explore whether the dispute has reached an impasse and what the patient can do to try to improve the relationship. This renegotiation either solves the dispute or leads to the conclusion that the patient has made an honest reparative effort and that the problem cannot be all the patient’s fault. The patient then can decide to live with the relationship or to leave it, precipitating a role transition in which the patient mourns the lost relationship but hopefully moves on to something better.

Complicated bereavement is a special case of a role transition: a life change that disrupts the patient’s sense of equilibrium. Patients presenting after role transitions bemoan a life decision such as a marriage, divorce, job change, and the like, seeing the past as relatively blissful and the present as awful. The therapist helps the patient to link the depressive episode to the role transition, then helps the patient to mourn what has been lost in the transition, to appreciate the discomfort of the transition itself, but also to explore positive aspects of the new role—which are often considerable. As the patient recognizes that change is not necessarily chaos and that the new role can be mastered, symptoms subside.

Interpersonal deficits denotes an absence of life events. Some patients who fit this category have dysthymic disorder and often avoid the relationships and life events on which IPT typically focuses (6). As these patients are frequently isolated and lonely, strategies for this focus involve linking the depression to the patient’s isolation and facilitating development of new relationships. These are harder patients to treat, perhaps particularly in IPT (18): patients so isolated and socially impaired, who present without the life events on which IPT focuses, may fare better in other psychotherapies, such as cognitive behavior therapy. Conversely, IPT may be preferable to cognitive behavior therapy for depressed patients who have pressing life events (18).

Regardless of the treatment focus, each weekly session after the first follows the same logical structure. The therapist begins by asking: “How have things been since we last met?” This simple question elicits an interval history: the patient reports either a mood (“I’ve been feeling awful”) or an event (“I argued with my spouse”). The therapist offers sympathy when appropriate, then links mood to event or event to mood. If the patient reports a change in mood, the therapist seeks recent events in the week that might account for it. If the patient reports an event, the therapist asks how it affected mood. Having defined an affectively charged recent life event, therapist and patient then explore it. Where did things go right or wrong? With what words, what tone of voice? What did the patient want to happen?

If the patient coped well, the therapist offers congratulations, underscores the interpersonal behaviors that the patient successfully employed, and notes the link between mood shift and event. If things have gone badly, the therapist offers sympathy, blames the depression where appropriate, but then explores with the patient what went wrong. What other interpersonal options could the patient explore in a similar future situation? When the patient suggests feasible options, therapist and patient role play them to build the patient’s skills in using this therapy in real life. The IPT emphasis on interpersonal function outside the office understandably helps patients to develop new social skills.

To summarize, the general sequence of the psychotherapy is to:

If this doesn’t sound easy, it isn’t. Your prior experience as a psychotherapist may provide guidance, but different therapies have different paces and structures, so adjusting to IPT may take practice. Similarly, it helps to know your patients’ illness. Patients often confuse depression with who they are; an important aspect of IPT is distinguishing the illness from the person, and to do so you have to understand them both. Taping sessions and reviewing them with a supervisor, and using the manual, can help in assessing whether you are doing IPT or not.

General psychotherapeutic principles

Throughout IPT you will need to:

Termination phase

The last few sessions are used to tie up the treatment. If the patient has improved, as is usual, the therapist reinforces the patient’s sense of independence. Because most gains resulted from the patient’s encounters outside the office, the therapist can emphasize that the patient deserves the credit for the improvement: if the therapist has been a helpful coach, it’s the patient who played and won the game. The therapist underscores the patient’s new interpersonal tactics (e.g., self-assertion) that have helped to resolve the interpersonal crisis and relieve the symptoms and that may be useful in future situations. Therapist and patient note that ending therapy is an interpersonal separation that evokes sadness—which is not the same as depression. Most patients tolerate ending the brief therapy well.

Patients who have not improved in IPT should not blame themselves; the IPT therapist blames the therapy (analogously to a failed pharmacotherapy trial) and reminds the patient that the prognosis remains good with other antidepressant options. For patients who respond to IPT but have significant residual symptoms or who have had multiple prior episodes and hence remain at high risk, maintenance IPT has demonstrated protection against relapse (19, 20).

Limitations

It is no more reasonable to expect that one psychotherapy should benefit all patients than that one medication should. IPT has always been a targeted treatment, tested for each potential indication. As noted earlier, it has not shown specific benefit relative to control conditions in treating patients with substance abuse and dysthymic disorder. As a treatment that focuses on external relations, one might imagine that IPT would not be particularly helpful for internally focused illnesses such as schizophrenia and obsessive-compulsive disorder—although the studies to test this have never been attempted. Therapist style and temperament may also make this intervention more comfortable for some clinicians than for others: IPT requires a tolerance of affect and activity.

There is little evidence that axis I, axis II, or axis III comorbidity contraindicates the use of IPT. A nascent science of differential therapeutics, based on the results of comparative trials of IPT with other treatments, suggests that, for example, IPT may be preferable to cognitive behavior therapy for depressed patients who have endured upsetting life events, whereas cognitive behavior therapy may have advantages for the “interpersonal deficits” patients who lack life events and a modicum of social skills (19). Other factors, like a willingness to do homework, might make a practical difference in choosing between the two validated treatments. Ideally, the clinician might offer the depressed patient a range of treatment options—IPT, cognitive behavior therapy, pharmacotherapy, and combined psychotherapy/pharmacotherapy—explaining the advantages and limitations of each and offering the patient a choice. Patient preference is also an important predictor of treatment outcome.