Introducing IPT into a Mental Health Service

Introduction

This paper outlines the processes involved in establishing Interpersonal Psychotherapy into a mental health service. One of the consistent findings of mental health services is the lack of consistency of approach, variable quality of treatments and time limitations on clinicians. The introduction of Interpersonal Psychotherapy into a service is a relatively straightforward process and can address some of these problems. IPT was designed to be delivered by a range of mental health professionals from the disciplines of Psychiatry, Psychology, Social Work, Occupational Therapy and Nursing. Following an intensive period of training and supervision, it can be reliably delivered in a variety of clinical and research settings.

The trainee

IPT is best delivered by health professionals who have at least two years postgraduate clinical experience in a dynamically oriented form of psychotherapy eg Rogerian psychotherapy. For these therapists, the therapeutic stance and techniques of IPT will be familiar. However, it will require a refocusing of interventions primarily on relationships within a time-limited framework. The Interpersonal Psychotherapist needs the ability to relate to patients with interest, warmth and empathy. The therapist also needs to have a positive attitude to the use of short-term treatments. An important assumption is that the trainee has an understanding of personality, transference and countertransference issues.

The training (current standards for research quality IPT)

Proficiency in IPT can generally be attained when the therapist:

1. attends a didactic seminar - 40 hours
2. adheres to the manual (2)
3. receives intensive supervision of 2 patients with depression

a) Didactic seminar

Didactic seminars can be provided for between 2 and 5 days, depending on the level of training and practical experience required. To achieve the standard required for research 40 hours didactic training is required, whereas 16-20 hours is sufficient for clinical applications. The seminars/ workshops consist of a review of the research evidence supporting IPT, followed by an interactive, multimedia presentation demonstrating the use of IPT with depressed patients. At then end of the seminar participants should be able to:

1. conduct Interpersonal Psychotherapy (IPT) and use IPT techniques
2. demonstrate knowledge of interpersonal theory and the research literature regarding IPT
3. deal effectively with difficult and resistant psychotherapy patients using IPT techniques

b) The Manual

The original manual, first published in 1984, provided an important guide for clinicians in the treatment process (1). However, the comprehensive update of the original manual currently provides the best available description of the theory and processes of IPT (2). Experience has shown that those therapists who adhere to the manual, whilst attending to the therapeutic relationship, are more likely to achieve good outcomes with their patients.

c) Supervision

Supervision can take a number of forms, depending on the level of expertise required. To attain a research level the trainee is required to videotape all 12-16 sessions with 2 patients. The tapes are reviewed by a qualified supervisor with supervision occurring on the telephone or in person. At a less intensive level, trainees can be supervised on 1-2 cases by a qualified trainer on a monthly basis in small groups of 4-6. Local expertise can be strengthened by the intensive training of key individuals who then go on to provide supervision to others. Experience with this approach has shown that less experienced clinicians require a lengthier period of supervision than their more experienced colleagues.

Problems encountered in implementing the treatment:

Some of the difficulties encountered by novitiates to this treatment have included:

• difficulties selecting appropriate clients
• difficulties clarifying the explicit contract and expectations of the client
• deviating from the interpersonal focus eg long exploration of early childhood issues without relating such issues to current interpersonal problems
• being unable to work within a biopsychosocial model. Eg reviewing depressive symptoms, diagnosing depression as medical illness, reviewing need for medication.
• the stance of the therapist, for example, the ability to be active in sessions to ensure progress in short time frame.

Recommendations

Attempts to integrate a new modality into an existing service are sometimes met with obstacles and poor uptake by health professionals. Ensuring that training in efficacious treatments results in such approaches being offered to consumers of mental health services can be improved by:

• involving clinical staff in the review, planning, implementation and evaluation of a new treatment modality
• ensuring quality supervision is provided in the crucial early stages of implementing the treatment
• staff being given support by management and teams for time away from clinical work to participate in training and follow-up supervision.
• developing adequate local expertise to continue training and supervision without reliance on external resources.

References

1. Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES (1984) Interpersonal Psychotherapy of Depression New York: Basic Books.
2. Weissman, M.M., Markowitz,J.C.,and Klerman, G.L. (2000) Comprehensive Guide to Interpersonal Psychotherapy. New York, New York: Basic Books.