Interpersonal Psychotherapy for Depression

Interpersonal Psychotherapy for Depression

Bob Hill, Ph.D.Bob Hill, Ph.D.

Appalachian State UniversityAppalachian State University

Boone, NC 28608Boone, NC 28608

Email: [email protected]: [email protected]

Overview

DepressionDepression Theoretical Sources for IPTTheoretical Sources for IPT Prominent Features of IPTProminent Features of IPT Outline of IPTOutline of IPT Phases of IPT TreatmentPhases of IPT Treatment Clinical ExamplesClinical Examples Empirical SupportEmpirical Support

Depression IPT clearly effective for treating DepressionIPT clearly effective for treating Depression Diagnostic Criteria for Depression: Diagnostic Criteria for Depression:

A.Five (or more) of the following symptoms have been present during the same 2-week period; at least one of the symptoms is either

1.depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. Note in children, can be irritable mood.

2. anhedonia: markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

Depression Criteria continued (2+ needed):

3.significant weight loss when not dieting or weight gain or decrease or increase in appetite..

4.insomnia or hypersomnia nearly every day 5.psychomotor agitation or retardation observable by others 6.fatigue or loss of energy nearly every day 7.feelings of worthlessness or excessive or inappropriate guilt 8.diminished ability to think or concentrate, or indecisiveness 9.recurrent thoughts of death, recurrent suicidal ideation with

or without a specific plan, or suicidal intent.

Reasons to consider Medication

Client too depressed to participate in treatmentClient too depressed to participate in treatment Client not psychological, resistant to talking txClient not psychological, resistant to talking tx Client who is at risk for suicideClient who is at risk for suicide Client with recurrent Depressive episodes, with Client with recurrent Depressive episodes, with

symptoms of symptoms of Melancholic FeaturesMelancholic Features May respond more quickly with medication and May respond more quickly with medication and

IPT combinedIPT combined

Depression with Melancholic Features

1) anhedonia1) anhedonia 2) lack of reactivity to usually pleasant stimuli2) lack of reactivity to usually pleasant stimuli 3) Three or more of: 3) Three or more of:

Distinct quality of depressed moodDistinct quality of depressed mood Depression is worse in a.m.Depression is worse in a.m. Early morning awakening (at least 2 hrs)Early morning awakening (at least 2 hrs) Marked psychomotor agitation or retardationMarked psychomotor agitation or retardation Significant anorexia or weight lossSignificant anorexia or weight loss Excessive or inappropriate guiltExcessive or inappropriate guilt Psychotic symptomsPsychotic symptoms Suicide riskSuicide risk

Prevalence of Depression

DysthymiaDysthymia

DepressionDepression

DisorderDisorder TotalTotalMalesMalesFemalesFemales

6.4 %6.4 % 4.8 %4.8 % 8.0 %8.0 %

17.1 %17.1 %12.7 %12.7 %21.3 %21.3 %

National Comorbidity Survey (1994)

Historical Influences of IPT

PsychoanalysisPsychoanalysis Harry Stack SullivanHarry Stack Sullivan Object Relations TherapyObject Relations Therapy Interpersonal Theory (Leary, Kiesler)Interpersonal Theory (Leary, Kiesler)

IPT: Roots in Psychodynamic Theory

Primary instincts of sex and aggression involve relating to others

Relationships with others contribute to personality development

Psychological Problems due to deficits in early relations

Transference and counter-transference are interpersonal

Object Relations Influence

““Object” is human beingObject” is human being ““Relations” are internal, external, fantasied or real Relations” are internal, external, fantasied or real

interactions with othersinteractions with others Early parent-child relations are internalized as Early parent-child relations are internalized as

expectations for future relationshipsexpectations for future relationships Identity/personality derived from pattern of early Identity/personality derived from pattern of early

relationship experiencesrelationship experiences Expectations of others impacts quality of current Expectations of others impacts quality of current

interpersonal relationships and moodinterpersonal relationships and mood

Manualized Interpersonal Therapy

Klerman, G. (1984). Klerman, G. (1984). Interpersonal Interpersonal Psychotherapy for Depression.Psychotherapy for Depression.

Weissman, M. (2002). Weissman, M. (2002). Comprehensive Comprehensive Guide to Interpersonal PsychotherapyGuide to Interpersonal Psychotherapy..

Prominent Features of IPT

IPT designed for symptom reduction and IPT designed for symptom reduction and improved interpersonal relationshipsimproved interpersonal relationships

Focus on current disputes, frustrations, Focus on current disputes, frustrations, anxieties in the interpersonal context which anxieties in the interpersonal context which impact mood and self esteemimpact mood and self esteem

IPT Compared to Other Therapies

Time-limited- outcome studies document efficacy Time-limited- outcome studies document efficacy of short-term (12-16 weeks) txof short-term (12-16 weeks) tx Not designed for personality changeNot designed for personality change

Focused on current interpersonal disputes, Focused on current interpersonal disputes, anxieties, frustrations anxieties, frustrations Addresses 1-2 problem areas in interpersonal Addresses 1-2 problem areas in interpersonal

functioningfunctioning

IPT Compared to Other Therapies

Interpersonal, not intrapsychicInterpersonal, not intrapsychic Interpersonal, not Cognitive BehavioralInterpersonal, not Cognitive Behavioral

Goal is to change feelings, thoughts, actions in Goal is to change feelings, thoughts, actions in problematic relationshipsproblematic relationships

Negative/irrational cognitions are addressed Negative/irrational cognitions are addressed only in interpersonal functiononly in interpersonal function

IPT attends to distorted thinking in relation to IPT attends to distorted thinking in relation to significant otherssignificant others

Goal is to change relationship pattern rather Goal is to change relationship pattern rather than depressive cognitionsthan depressive cognitions

IPT Compared to CBT Focus on affect and expression of emotionsFocus on affect and expression of emotions Explores avoidance and resistance behaviorExplores avoidance and resistance behavior Identification of patterns in client’s behavior, Identification of patterns in client’s behavior,

thinking, feeling and relationshipsthinking, feeling and relationships Attention to past experiences Attention to past experiences Focus on interpersonal experienceFocus on interpersonal experience Emphasis on the therapeutic relationshipEmphasis on the therapeutic relationship Exploration of client’s wishes, dreams, Exploration of client’s wishes, dreams,

fantasiesfantasies

Blagys & Hilsenroth, 2000

IPT and Personality Change

IPT does not target alteration of personalityIPT does not target alteration of personality Personality pathology may limit IPT Personality pathology may limit IPT

outcomeoutcome IPT may help patient recognize maladaptive IPT may help patient recognize maladaptive

personality featurespersonality features IPT may improve social skills and thus IPT may improve social skills and thus

ameliorate maladaptive personality traitsameliorate maladaptive personality traits

Role of IPT Therapist

Therapist is patient advocate, not neutralTherapist is patient advocate, not neutral Expresses unconditional positive regardExpresses unconditional positive regard Intentionally cultivates positive Intentionally cultivates positive

expectations of treatmentexpectations of treatment Optimistic, positive, reassuringOptimistic, positive, reassuring

Therapist is active in keeping interpersonal Therapist is active in keeping interpersonal problem areas to focusproblem areas to focus

Outline of IPT Intervention

Initial Sessions (Overview)Initial Sessions (Overview) Assess Depressive symptomsAssess Depressive symptoms Complete Interpersonal AssessmentComplete Interpersonal Assessment Identify Major Interpersonal Problem Identify Major Interpersonal Problem

AreaArea Explain IPT and make treatment contractExplain IPT and make treatment contract

Initial Sessions (“Sick Role”)

Review Sxs, Dx of depression to communicate Review Sxs, Dx of depression to communicate “sick role”“sick role”

Functions of “Sick Role”Functions of “Sick Role” Sick person exempt from responsibilitiesSick person exempt from responsibilities Sick person in need of helpSick person in need of help Sick is undesirable and needs to be improvedSick is undesirable and needs to be improved Sick person obliged to cooperate with TxSick person obliged to cooperate with Tx Sick role shifts blame from client to illnessSick role shifts blame from client to illness

Mitigates self blameMitigates self blame

Relate Depression to Interpersonal Context

What interpersonal events related to depression?What interpersonal events related to depression?Review current & past interpersonal relationshipsReview current & past interpersonal relationships• Who does client interact with?Who does client interact with?• Frequency of contact, activities shared?Frequency of contact, activities shared?• Assess quality and themes of relationshipsAssess quality and themes of relationships• Assess expectations of client (and other) in Assess expectations of client (and other) in

relationshipsrelationships• Assess satisfying and unsatisfying aspects of Assess satisfying and unsatisfying aspects of

relationshipsrelationships• Discuss changes client wants in relationshipsDiscuss changes client wants in relationships

Inventory of Interpersonal Problems 64 items assess diverse interpersonal problems: 64 items assess diverse interpersonal problems:

• • Being too controlling or manipulativeBeing too controlling or manipulative

• • Being self-centered and resentfulBeing self-centered and resentful

• • Having minimal feelings of affection for, and Having minimal feelings of affection for, and little connection with, other peoplelittle connection with, other people

• • Being socially avoidantBeing socially avoidant

• • Being nonassertiveBeing nonassertive

• • Being gullible and easily taken advantage of Being gullible and easily taken advantage of

• • Being excessively selfless, generous, trusting, Being excessively selfless, generous, trusting,

• • Being too intrusiveBeing too intrusive

Interpersonal Problems Circumplex

IIP Circumplex Evan

IIP Scale Profile

Identification of Major Problem Area

Assess interpersonal experience and depression to Assess interpersonal experience and depression to identify of one of identify of one of FourFour Problem Areas: Problem Areas:

Interpersonal Role DisputeInterpersonal Role Dispute: with spouse, lover, : with spouse, lover, family member, friends, co-workerfamily member, friends, co-worker

Role TransitionRole Transition: e.g. new job, relocation, divorce: e.g. new job, relocation, divorce Interpersonal DeficitsInterpersonal Deficits: evidenced by social : evidenced by social

impoverishment, loneliness, isolationimpoverishment, loneliness, isolation GriefGrief: following death if abnormally severe, : following death if abnormally severe,

protracted or impairingprotracted or impairing

Problem Area Focus Four problems areas are:Four problems areas are:

Not exhaustive, nor mutually exclusiveNot exhaustive, nor mutually exclusive Not “deep” conceptual theoryNot “deep” conceptual theory

Communicate to client Problem area focusCommunicate to client Problem area focus Problem area ensures focus on Problem area ensures focus on

recognized problem rather than personal recognized problem rather than personal weaknessweakness

E.g. E.g. ‘try to discover what you want and need ‘try to discover what you want and need from others and help you learn how to get from others and help you learn how to get it’it’

Explain Interpersonal Focus Tx focus will be interpersonal satisfaction, not Tx focus will be interpersonal satisfaction, not

intrapsychic explorationintrapsychic exploration Educate about link between depressed mood Educate about link between depressed mood

and difficulty getting what we want/need from and difficulty getting what we want/need from othersothers

Therapist describes nature of clients Therapist describes nature of clients interpersonal difficultyinterpersonal difficulty

Agree on goal of improved interpersonal Agree on goal of improved interpersonal relationsrelations

Set expectation: make changes btwn sessionsSet expectation: make changes btwn sessions

Setting Treatment Contract

Set 2 –3 treatment goals with client related Set 2 –3 treatment goals with client related to problem area focusto problem area focus

Ask client what would be the: Ask client what would be the: Best possible outcomeBest possible outcome Most expectable outcomeMost expectable outcome Worst possible outcomeWorst possible outcome

Describe expected Duration and Frequency Describe expected Duration and Frequency of treatment (12-16 weeks)of treatment (12-16 weeks)

Teaching Client Their Role in IPT ““Talk about things that affect you Talk about things that affect you

emotionallyemotionally ““Your responsibility to select topics that are Your responsibility to select topics that are

most important to you”most important to you” ““No right or wrong thing to talk about”No right or wrong thing to talk about” ““When important feelings emerge, raise When important feelings emerge, raise

them”them” ““including feeling about me or the including feeling about me or the

therapy”therapy”

Starting Intermediate Sessions Initial Assessment and Development of Initial Assessment and Development of

Treatment Contract Typically 2-3 SessionsTreatment Contract Typically 2-3 Sessions Important tasks of Important tasks of Intermediate SessionsIntermediate Sessions: :

Help client discuss topics pertinent to Help client discuss topics pertinent to problem areaproblem area

Attend to clients affective stateAttend to clients affective state Assist client in discussing therapeutic Assist client in discussing therapeutic

relationshiprelationship Prevent client from sabotaging treatmentPrevent client from sabotaging treatment

Interpersonal Disputes: Diagnosis Current Overt or Covert disputes with a Current Overt or Covert disputes with a

significant othersignificant other Client and other have non-reciprocal Client and other have non-reciprocal

expectations expectations Dispute related to onset or perpetuation of Dispute related to onset or perpetuation of

depressiondepression Client demoralized about relationshipClient demoralized about relationship

Poor patterns of communicationPoor patterns of communication or irreconcilable differencesor irreconcilable differences

Interpersonal Disputes: Goals

Identify the disputeIdentify the dispute Make choices about a plan of actionMake choices about a plan of action Modify communication patterns or Modify communication patterns or Reassess ExpectationsReassess Expectations Consider satisfying needs outside Consider satisfying needs outside

relationshiprelationship

Interpersonal Disputes: Strategies Assess stage of Role Dispute:Assess stage of Role Dispute: ImpasseImpasse- discussion stopped, low-level resentment - discussion stopped, low-level resentment

existsexists Tx may initially increase disharmonyTx may initially increase disharmony

RenegotiationRenegotiation- aware of differences, actively - aware of differences, actively trying to changetrying to change Tx may require calming parties to facilitate Tx may require calming parties to facilitate

resolutionresolution DissolutionDissolution- implies the relationship is - implies the relationship is

irretrievably disruptedirretrievably disrupted Treatment may resemble grief therapyTreatment may resemble grief therapy

Interpersonal Disputes: Issues

Differences in expectations/values between Differences in expectations/values between client and other?client and other?

Clients wishes in relationship? Other wishes?Clients wishes in relationship? Other wishes? What are the client’s options?What are the client’s options? How have they resolved disagreements in past?How have they resolved disagreements in past? Strengths and weaknesses in relationship?Strengths and weaknesses in relationship? What changes are realistically possible?What changes are realistically possible?

Interpersonal Disputes: Strategies

Find Parallels in previous relationshipsFind Parallels in previous relationships What does client gain by the behavior?What does client gain by the behavior? What are unspoken assumptions that lie What are unspoken assumptions that lie

behind behavior?behind behavior? Optimistic tone: “lets figure out what went Optimistic tone: “lets figure out what went

wrong here so we can decide how to help wrong here so we can decide how to help you make it better”you make it better”

Often communication problems are Often communication problems are revealed- Tx involves improving skillsrevealed- Tx involves improving skills

Interpersonal Disputes: Strategies Help identify “mixed feelings” e.g. anger, fear, Help identify “mixed feelings” e.g. anger, fear,

sadnesssadness Devise strategies for managing feelings e.g. direct Devise strategies for managing feelings e.g. direct

communications, reducing irrational suspicionscommunications, reducing irrational suspicions Role PlayRole Play

Rehearse expressing feelings and wishesRehearse expressing feelings and wishes Anticipate communication problemsAnticipate communication problems

Consider Conjoint sessions with significant otherConsider Conjoint sessions with significant other

Problem Area: Role Transitions

Diagnosis: Depression and interpersonal Diagnosis: Depression and interpersonal problems related to problems related to role changesrole changes e. g. separation/divorce, children left e. g. separation/divorce, children left

home, start/end job or school, retired, home, start/end job or school, retired, promoted, financial or health problemspromoted, financial or health problems

Assess: How did life change? What people Assess: How did life change? What people in you life changed or left? in you life changed or left?

Role Transition: Tx Strategies

Facilitate evaluation of lost roleFacilitate evaluation of lost role ““Tell me about the old ___. What were Tell me about the old ___. What were

the good, and bad, things? What has the good, and bad, things? What has changed?changed?

Encourage expression of affectEncourage expression of affect How did it feel to give up ___? How did it feel to give up ___?

Identify positive aspects of new roleIdentify positive aspects of new role Are there potential benefits?Are there potential benefits?

Role Transition: Tx Strategies Develop Social Skills needed for new roleDevelop Social Skills needed for new role

What is required in new role?What is required in new role? Are assumptions of role demands accurate?Are assumptions of role demands accurate?

Role play or rehearse difficult situationsRole play or rehearse difficult situations Assist with managing performance anxietyAssist with managing performance anxiety

Establish new relationships and social supportEstablish new relationships and social support Facilitate discovery of new opportunities for Facilitate discovery of new opportunities for

social support social support

Interpersonal Deficits: Diagnosis

History of social impoverishment, chronic History of social impoverishment, chronic inadequate or unsustained relationshipsinadequate or unsustained relationships

Consider Dysthymia (or Double Depression)Consider Dysthymia (or Double Depression) IPT adaptation for dysthymia IPT adaptation for dysthymia

Long standing or temporary deficits in social Long standing or temporary deficits in social skills yields low self-esteem, withdrawalskills yields low self-esteem, withdrawal

Interpersonal Deficits: Goals

Reduce Client’s social isolationReduce Client’s social isolation Enable: Enable:

close relationships with intimates or close relationships with intimates or family membersfamily members

satisfying relationships with friendssatisfying relationships with friends adequate relationships in work roleadequate relationships in work role

Interpersonal Deficits: Strategies

Review past significant relationshipsReview past significant relationships including childhood relationships with family including childhood relationships with family

membersmembers depressed patients minimize or forget positive depressed patients minimize or forget positive

experiencesexperiences explore repetitive or parallel problems in past explore repetitive or parallel problems in past

relationshipsrelationships define interpersonal situations that lead to define interpersonal situations that lead to

difficultiesdifficulties

Interpersonal Deficits: Strategies

Use therapist-client relationshipUse therapist-client relationship explore client’s positive and negative explore client’s positive and negative

feelings toward therapistfeelings toward therapist discuss distorted or unrealistic thoughts discuss distorted or unrealistic thoughts

or feelings toward therapistor feelings toward therapist model resolution of relationship tension model resolution of relationship tension

by open and genuine communicationby open and genuine communication

Interpersonal Deficits: Strategies

Encourage patient to increase social Encourage patient to increase social interactionsinteractions review attempts in treatment to identify review attempts in treatment to identify

deficitsdeficits identify deficits in communication skillsidentify deficits in communication skills look for assumptions client makes about look for assumptions client makes about

others thoughts and feelingsothers thoughts and feelings

Use Communication Analysis Get detailed account of conversation or argumentGet detailed account of conversation or argument identify communication difficultiesidentify communication difficulties

ambiguous, indirect, & non-verbal as substitute for ambiguous, indirect, & non-verbal as substitute for open confrontationopen confrontation

incorrect assumptions re communicationincorrect assumptions re communicationassuming that others know their feelingsassuming that others know their feelingsaccompanied by anger, frustration, silenceaccompanied by anger, frustration, silencefailing to make sure they are heard, understoodfailing to make sure they are heard, understood

Use Communication Analysis Incorrect interpretation of others statementsIncorrect interpretation of others statements

perceive criticism where none intendedperceive criticism where none intended indirect verbal communicationindirect verbal communication

inhibited directly expressing expectations or inhibited directly expressing expectations or criticismcriticism

instead use hints and ambiguous messagesinstead use hints and ambiguous messages prone to build resentments toward others who prone to build resentments toward others who

are unaware of offenseare unaware of offense silence - unaware of destructive impactsilence - unaware of destructive impact

Use Communication Analysis Use role playingUse role playing

rehearse difficult interactions with clientrehearse difficult interactions with client explore style of communicating with explore style of communicating with

othersothers practice new skills practice new skills

e.g. expressing anger or being assertivee.g. expressing anger or being assertive rehearsal with therapist increases client’s rehearsal with therapist increases client’s

interpersonal confidenceinterpersonal confidence

Interpersonal Deficits: Prognosis

Treatment of interpersonal deficits difficultTreatment of interpersonal deficits difficult client often lacks relationships to practice client often lacks relationships to practice

and develop skillsand develop skills treatment goals limited to making early treatment goals limited to making early

gains interpersonally, not resolving gains interpersonally, not resolving interpersonal deficits interpersonal deficits

Grief Problem Area Focus

Normal Grief involves: Normal Grief involves: Symptoms including sadness, disturbed Symptoms including sadness, disturbed

sleep, agitation, impairment, etc. sleep, agitation, impairment, etc. Symptoms usually resolve in 2 –4 weeks Symptoms usually resolve in 2 –4 weeks

without treatmentwithout treatment

Abnormal Grief Evidence

Inadequate grief in bereavement periodInadequate grief in bereavement period Multiple lossesMultiple losses Avoidance behavior (re funeral, grave, talk)Avoidance behavior (re funeral, grave, talk) Symptoms around significant anniversarySymptoms around significant anniversary Preserving environment of deceasedPreserving environment of deceased Fear of illness that caused deathFear of illness that caused death Absence of social support during Absence of social support during

bereavementbereavement

Abnormal Grief Treatment Goals

Facilitate the mourning processFacilitate the mourning process Help client reestablish interests and Help client reestablish interests and

relationships to substitute for what has been relationships to substitute for what has been lost lost

Grief Treatment Strategies Explore Events and Elicitation of FeelingsExplore Events and Elicitation of Feelings

Discuss events prior to, during and after Discuss events prior to, during and after the deaththe death

Reconstruction of RelationshipReconstruction of Relationship Use photos and stories to discuss Use photos and stories to discuss

relationshiprelationship Use belongings and memories to evoke Use belongings and memories to evoke

painful feelings client has avoidedpainful feelings client has avoided What were the ups and downs in What were the ups and downs in

relationship? (normalize negative relationship? (normalize negative features) Facilitate Expression of Affectfeatures) Facilitate Expression of Affect

Grief Treatment Strategies (cont.)

Behavior change: Behavior change: Plan and discuss development of new Plan and discuss development of new

social relationships (e.g. organizations, social relationships (e.g. organizations, church, work, dating)church, work, dating)

Support client as they learn to fill “empty Support client as they learn to fill “empty space” space”

Termination of Treatment For time-limited treatment, important to keep For time-limited treatment, important to keep

initial contract for 12-16 weeksinitial contract for 12-16 weeks Termination Treatment issuesTermination Treatment issues

explicit discussion of termination during last 3-explicit discussion of termination during last 3-4 sessions4 sessions

acknowledge ending may involve loss and griefacknowledge ending may involve loss and griefnormalize fear, anger, sadnessnormalize fear, anger, sadnessmay need to distinguish sadness from may need to distinguish sadness from

depressiondepression

Termination Issues

Foster client’s self-confidence in coping Foster client’s self-confidence in coping independentlyindependently

deflect client’s attribution of success to therapistdeflect client’s attribution of success to therapist call attention to client’s accomplishmentscall attention to client’s accomplishments anticipate future difficulties with clientanticipate future difficulties with client

help plan for future problemshelp plan for future problems rehearse explicit scenarios if helpfulrehearse explicit scenarios if helpful discuss possibility of relapse of depressiondiscuss possibility of relapse of depression

Termination Difficulties Failure depression to resolveFailure depression to resolve

refer for other treatment, encourage hoperefer for other treatment, encourage hope client wants to continueclient wants to continue

schedule 8 week waiting period schedule 8 week waiting period impart to client self-confidence in ability to impart to client self-confidence in ability to

copecope maintenance IPT may be appropriate for:maintenance IPT may be appropriate for:

chronic or recurring depressionchronic or recurring depression clients with personality problems or clients with personality problems or

interpersonal deficitsinterpersonal deficits

Specific IPT Techniques

Essential IPT techniques include: Essential IPT techniques include: discuss feelings (both positive & discuss feelings (both positive &

negative) about interpersonal experiencenegative) about interpersonal experience take action to change interpersonal take action to change interpersonal

experienceexperience

Other IPT techniques common to other Other IPT techniques common to other psychotherapiespsychotherapies

Exploratory Techniques Non-directive explorationNon-directive exploration Begin sessions with: “How have things Begin sessions with: “How have things

been since we last met?”been since we last met?” use open-ended questionsuse open-ended questions encourage clients sense of responsibilityencourage clients sense of responsibility Direct questioningDirect questioning

necessary to review depressive symptomsnecessary to review depressive symptoms necessary to review interpersonal necessary to review interpersonal

relationshipsrelationships

Encourage Affect

Learning in psychotherapy is emotional Learning in psychotherapy is emotional learninglearning

eliciting affect informs client re meaningful eliciting affect informs client re meaningful goalsgoals

facilitate acceptance of painful affectfacilitate acceptance of painful affect encourage clear expression of painful, encourage clear expression of painful,

suppressed or unacknowledged feelingssuppressed or unacknowledged feelings inquire into sensitive areasinquire into sensitive areas

Use emotions in relationships Assist client to negotiate painful affect in Assist client to negotiate painful affect in

significant relationshipssignificant relationships client may change relationship behavior client may change relationship behavior

(self or other) to eliminate painful affect(self or other) to eliminate painful affect client may learn new ways to cope with client may learn new ways to cope with

anger or anxietyanger or anxiety client may eliminate irrational thinking and client may eliminate irrational thinking and

emotional sequelaeemotional sequelae

Help Client with suppressed emotions

For Clients who may be emotionally For Clients who may be emotionally constricted or unassertiveconstricted or unassertive

client may lack awareness or confidence to client may lack awareness or confidence to expressexpress

some clients distressed by strong emotions some clients distressed by strong emotions (e.g. trauma history) may need help (e.g. trauma history) may need help suppressing overwhelming emotionssuppressing overwhelming emotions may be counter-productive to encourage may be counter-productive to encourage

emotional displayemotional display

Clarification

Communication techniques to review Communication techniques to review content, clarify feelings, promote awarenesscontent, clarify feelings, promote awareness repeating, rephrasing statementsrepeating, rephrasing statements calling attention to logical implications of calling attention to logical implications of

statementsstatements raising contradictions or contrastsraising contradictions or contrasts

Alert client to false, irrational or pervasive Alert client to false, irrational or pervasive beliefs regarding interpersonal relationshipsbeliefs regarding interpersonal relationships

Communication Analysis

Identify communication failures to improve Identify communication failures to improve relationship satisfactionrelationship satisfaction

Frequently review important conversations Frequently review important conversations or arguments or arguments

Illuminate common communication Illuminate common communication difficultiesdifficulties

Use of Therapeutic Relationship

Client’s feelings toward therapist and therapy are Client’s feelings toward therapist and therapy are helpful focushelpful focus may reflect characteristic ways of feeling and may reflect characteristic ways of feeling and

behaving in other relationshipsbehaving in other relationships Therapist instructs client to express complaints, Therapist instructs client to express complaints,

fears, that arise about therapistfears, that arise about therapist model genuine negotiation with such feelingmodel genuine negotiation with such feeling therapist can correct distortions and therapist can correct distortions and

acknowledge genuine deficienciesacknowledge genuine deficiencies

Directive Techniques Include educating, advising, modelingInclude educating, advising, modeling initially open to practical help: depressed clients initially open to practical help: depressed clients

may need “case management”may need “case management” provide suggestions if client unable to make provide suggestions if client unable to make

successful decisions independentlysuccessful decisions independently modeling may involve informing client how modeling may involve informing client how

therapist might handle similar situationtherapist might handle similar situation use directive techniques sparinglyuse directive techniques sparingly

use early, w/o undermining clients autonomyuse early, w/o undermining clients autonomy

Decision Analysis

Depressed clients often have history of self-Depressed clients often have history of self-defeating decisionsdefeating decisions because they fail to consider consequencesbecause they fail to consider consequences and fail to see alternativesand fail to see alternatives

Therapist helps with decision analysis to help Therapist helps with decision analysis to help client recognize range of optionsclient recognize range of options insist on delaying action until each option is insist on delaying action until each option is

exploredexplored for interpersonal situationsfor interpersonal situations

Decision Analysis Involves

Set goal for interpersonal situation: “What Set goal for interpersonal situation: “What do you want to happen?”do you want to happen?”

Consider all useful alternativesConsider all useful alternatives observe alternatives that client omitsobserve alternatives that client omits

direct client to explore probable direct client to explore probable consequences of each line of behaviorconsequences of each line of behavior clients often restrict range of alternatives clients often restrict range of alternatives

or unrealistically assess consequencesor unrealistically assess consequences beware of premature decision analysisbeware of premature decision analysis

Role Playing

Useful to explore client’s feelings and style Useful to explore client’s feelings and style of communicating with othersof communicating with others

Rehearse new ways for client to Rehearse new ways for client to communicate in safe settingcommunicate in safe setting e.g. practice more assertiveness or e.g. practice more assertiveness or

expressing affectionexpressing affection Bolsters client’s self-confidence in Bolsters client’s self-confidence in

communicating genuinelycommunicating genuinely

Evidence for IPT Efficacy

Boston-New Haven Study (1979)Boston-New Haven Study (1979) 4 Tx Groups 4 Tx Groups (16 wks & 1yr follow-up):(16 wks & 1yr follow-up): IPT, amitriptyline, both combined, controlIPT, amitriptyline, both combined, control IPT and amitriptyline equally effectiveIPT and amitriptyline equally effective Combination IPT & amitrip. most effectiveCombination IPT & amitrip. most effective IPT grp. Sustained improved psychosocial IPT grp. Sustained improved psychosocial

functioning 1 yr later (not amitrip. Grp)functioning 1 yr later (not amitrip. Grp)

NIMH Tx Depression Research (1989)

4 Tx grps (16 wks, multi-site, N=250)4 Tx grps (16 wks, multi-site, N=250) IPT, CBT, Imipramine & clinical IPT, CBT, Imipramine & clinical

management (CM), placebo & CMmanagement (CM), placebo & CM IPT comparable to Imipramine & CMIPT comparable to Imipramine & CM CBT showed somewhat less improvementCBT showed somewhat less improvement IPT grp. had lowest attrition rateIPT grp. had lowest attrition rate Results for mod.-severe depression Results for mod.-severe depression

Brain Activity Changes with either IPT or Antidepressant Tx Pet scans showed higher prefrontal and less Pet scans showed higher prefrontal and less

temporal activity in depressed vs controlstemporal activity in depressed vs controls Both IPT and Paxil resulted in normalized Both IPT and Paxil resulted in normalized

Pet scan activity and improved Dep. SxsPet scan activity and improved Dep. Sxs Brody (2001); Martin (2001)Brody (2001); Martin (2001)

IPT Also Useful for Treating:

Dysthymia (see chapter in Weissman (2000) Dysthymia (see chapter in Weissman (2000) Comprehensive Guide to IPT)Comprehensive Guide to IPT)

Social Phobia (Lipsitz et al., 1999)Social Phobia (Lipsitz et al., 1999) Adolescent Depression (Muffson et al., 1999)Adolescent Depression (Muffson et al., 1999) Postpartum Depression (Postpartum Depression (O’Hara et al., 2000) Bulimia (Wilson et al., 2002)Bulimia (Wilson et al., 2002) Late-Life Depression (Late-Life Depression (Miller et al., 2001)

Bob Hill’s IPT Website:

Click on link at: Click on link at:

http://www.appstate.edu/~hillrw/http://www.appstate.edu/~hillrw/