I NTER P ERSONAL T HERAPY for DEPRESSION An Overview Presented by: Eric L. Strang, Psy.D.

INTERPERSONAL THERAPY for

DEPRESSION

An OverviewPresented by:

Eric L. Strang, Psy.D.

IPT Is…

• Evidence based• Brief / Time-Limited• Manualized Treatment that:

– Targets improvement of interpersonal functioning

– Promotes enhancement of communication within relationships

– Focuses on current interpersonal conflicts

CONCEPTUAL MODEL

• Recognizes the role of Attachment in the development of depression

• Focuses on conflicts, transitions, and grief in key relationships.

• Improvement comes from changing the affective experience of key relationships.

Goals of ITP

• Reduce Symptoms of Depression– Improve

• Sleep• Appetite• Energy• Outlook

• Enhance Patient’s ability to cope with the people and situations associated with the onset

Treatment Focus

• IPT focuses on:– Current Problems– Key figures in Patient’s present life– Clarification of Patient’s perspective of

their life– Patient’s affect– Recognition of emotional response– Development of new experience

IPT includes

• Identifying / exploring options• Problem solving• Psychoeducation• Resource development

IPT Does Not…

• Delve into early childhood• Focus on cognitions• Interpret defenses• Seek the sources of guilt, shame, or

resentment (viewed as symptoms)

• Encourage free association• Allow indefinite treatment• Encourage dependence

COURSE OF TREATMENT

• Initial Sessions (Meetings 1-4)– Diagnosis– Explain treatment procedures– Provide initial symptom relief

• Intermediate Sessions (Meetings 5-8)– Implementation of Treatment Strategies– Monitoring symptoms– Enabling clarification– Maintain alliance

• Termination (Sessions 9-12)– Process role transition– Recognize Patient’s independent competence

PATIENT SELECTION

The following are characteristics of Patients appropriate for IPT:

• Ability to establish therapeutic relationship

• Willingness to work within a time limited framework

• Able to acknowledge contribution of interpersonal difficulties

INITIAL PHASE

During the First Three Sessions:• Review of Symptoms and Diagnosis• Explanation of Depression & Treatment

Options• Medication Evaluation (if indicated)• Interpersonal Inventory• Case Formulation• Treatment Contract• Sick Role

DIAGNOSIS

• Review depressive symptoms• Assess severity• Link to DSM• Use Scales to assess & track• Name the disorder• Evaluate need for medication

EXPLANATION

Explain:• The “medical” nature of their

disorder (blame free illness)• The treatable nature of Depression• The framework of treatment• Positive prognosis

INTERPERSONALINVENTORY

• Review of key people in Patient’s life to assess the relationship’s:– Comfort and closeness– Open expression of feelings & needs– Level of Support– Pros and Cons

IDENTIFICATION OF PROBLEM AREAS

• Grief (complicated bereavement)• Role Dispute• Role Transition• Interpersonal Deficits

GRIEF

• Focus of treatment when Pt’s symptoms are associated with the death of a significant other.

• Complicated bereavement– Postponed, avoided, or interrupted

mourning– Anniversary effects

INTERPERSONAL DISPUTES

• Focus of treatment when Pt is at odds with an important other regarding expectations of the relationship.

• Disagreements that are repetitive or at a stalemate.

• Most common

ROLE TRANSITIONS

• Focus of treatment when Pt’s symptoms are related to changes in relationships.– Divorce– Moves– Graduation– Birth of siblings

• Can be positive or negative change

INTERPERSONAL DEFICITS

• Usually the focus when the other problem areas don’t apply.– Problems with loneliness, social isolation,

limited attachments.

• Problems establishing or sustaining intimate relationships due to:– Low self-esteem– Dysthymia – Social anxiety

FORMULATION

• Bridge to treatment phase• Provides focus for treatment• Must be:

– Plausible– Understandable– Based on interpersonal history– Organizing and empathic

Sample Formulation

It seems that you have been having conflicts with your parents. It is possible that these problems may be related to your feelings of depression, since these feelings emerged at the same time. Sometimes depression can make a problem seem too large to handle. This is because you are depressed, not because you can’t change the situation. Over the next few weeks, we will meet once a week to talk about these problematic situations, and we will try to generate alternative ways to cope with them. At this time medication does not seem to be necessary to relieve your symptoms but may be considered in the future if they continue.

TREATMENT CONTRACT

• Linked to the formulation and presented immediately following

• Must include the time frame and number of sessions (weekly sessions for 3-4 months)

• Must include the proposed focus based on the formulation

• Includes an explanation of the prognosis and supporting research

SICK ROLE

• Remove Blame• Use Medical Analogies• Provide relief from the pressure of

performing at their normal (premorbid) level.

• Arrange for extra support for effort or quantity/quality.

IPT Techniques

• Nondirective Exploration• Direct Elicitation• Encouragement of Affect• Clarification• Communication Analysis• Decision Analysis• Role-Play

Nondirective Exploration

• Use of open-ended questions to facilitate gathering of information

• Use of supportive acknowledgement: – Go on– Tell me more– I understand

Direct Elicitation

• Specific questioning used to obtain information used for:– Developing the interpersonal inventory– Symptom identification– Clarification of key points

Encouragement of Affect

• Therapist is attuned to emotion laden statements

• Therapist encourages expansion of these topics by eliciting details.

• Therapist provides validation and normalization of emotional responses.

• Provides opportunities for Pt to:– Become aware of their emotions– Better understand their feelings – Make informed decisions– Practice managing affect

Clarification

• Requests for Pt to rephrase or repeat a statement in order to:– Call attention to an important point– Set up expansion by therapist– Create awareness of contradictions

Communication Analysis

• Identifies communication problems• Therapist elicits a detailed account of a

critical conversation/argument in order to:– Understand the meaning of the interaction– Assess the methods of communication– Call attention to distortions– Highlight possible assumptive errors– Offer alternative interpretations

• Must be done within cultural context

Decision Analysis

• Technique for assisting Pt in considering the pros and cons of alternatives.

• Identify desired goals• List possible methods• Generate likely outcomes

Role-Play

• Can provide opportunities for identifying problematic skills

• Opportunity for evaluating Pt’s emotional responses to interaction

• Allows for practice of skills• Pt can take the role of a person they

would like a relationship with.

Therapeutic Relationship

• Transference not Interpreted• Used to assess outside functioning• Here-and-now issues provide

teachable moments

Therapists Role

• Active Non-neutral Advocate– Advice / suggestions– Psychoeducation– Modeling– Problem solving

• Unconditional / Nonjudgmental• Present focused• Skills Trainer• Coach

INTERMEDIATE PHASE

• Maintenance of supportive alliance: active listening / empathy

• Avoid drift: focus on identified problem area• Normalize depressive symptoms• Pull for affect• Focus on interpersonal encounters:

– Highlight positive effort as well as problems• Role-play interpersonal options• Summarize sessions• Repeat depression measure every 3-4 weeks

Treating Grief

• Facilitate mourning (catharsis)• Reestablish interests• Establish substitute relationships• Process the details of the loss

– Sequence of events– Consequences of the loss

• Address feelings of guilt• Develop tolerance for affect

Treating Interpersonal Disputes

• Identify the disagreement and the stage:– Renegotiation– Impasse– Dissolution

• Chose plan of action• Modification of communication

and/or expectations

Treating Role Transitions

• Communicate understanding of Pt’s perspectives of:– The demands of the new situation– What was gained– What was lost– The new expectations and responsibilities

• Assist in: – Giving up old role– Mourning old role– Acquiring new skills– Developing new supports and attachments– Recognizing the positive aspects of the change

Treating Interpersonal Deficits

• Primary treatment goal is to increase social contacts

• Practice forming new relationships• Review past relationships• Clarify patterns of strengths and

problems in relationships• Clarify Pt’s feelings regarding

relationships

TERMINATION• Begins during final quarter of treatment

(sessions 9-12)• Must be explicitly discussed and planned

for• Review warning symptoms of depression• Review identified problem area• Review strategies for improving

relationships• Review changes in patient• Address potential relapse

TERMINATION(Continued)

• Acknowledge healthy sadness and role transition

• Call Patient’s attention to their independent competence

• Address Non-response– Minimize Pt’s self-blame– Emphasize alternative treatments

• Assess need for continued Treatment or Maintenance– Renegotiate contract

Differences Between IPT and Psychodynamic Psychotherapy

• IPT focuses more on the Here-and-Now

• IPT focuses more on Pt’s life outside the clinic

• No Transference Interpretation• IPT focuses on changing current

interpersonal patterns• IPT is more structured

Differences Between IPT and Cognitive Behavioral Therapy

• IPT focuses on interpersonal affect and behavior

• IPT Less Structured• IPT does not assign homework