Training |
* Western Psychiatric Institute and Clinic, Dept of Psychiatry, Pittsburgh, USA
° Clinica Psichiatrica, Dipartimento Interaziendale di Salute Mentale, Padova, Italy
While IPT has been shown to be a highly efficacious treatment in experimental studies, it is not yet widely used in clinical practice. There are many reasons for this paradox. Until recently, IPT had been considered a treatment to be used only in research settings or, (because of its focus on recent interpersonal problems), in the case of depressions that appear to be a reaction to an environmental event. No specific training procedures for community practitioners have yet been established and there had been no organizational structure to define such procedures. Finally, the expectation coming from the research training requirements for IPT clinicians has been that trainees already be trained as psychotherapists. Perhaps precisely because of this apparent requirement, IPT has not yet been integrated into most psychiatric residency or clinical psychology training programs.
From its inception, one of the main aims of the International Society of Interpersonal Psychotherapists (ISIPT) has been the dissemination of IPT as a therapeutic tool and the promotion of IPT training by means of formal training courses. During the ISIPT meeting held in 2002, both clinical and research standards for training and supervision of IPT therapists were discussed, and various levels of training proposed, taking into account the need enlarge the number of training programs and make them accessible to many more clinicians than has been possible so far (ISIPT bulletin, July 2002). These discussions continued at the 2003 meeting.
Probably the most serious challenge to the broad diffusion of IPT is the shortage of IPT supervisors, particularly non-English speaking supervisors. This problem must be resolved in order to facilitate the dissemination of the treatment. It represents a concern both in the U.S., where most of the potential supervisors are concentrated in a small number of university settings, and in other countries where IPT is not widely practiced and there may be only one or two individuals competent both in the language of the country and in IPT.
For adequate training in IPT, Klerman et al. (1986) suggested that the trainee must become familiar with the details of the IPT manual, participate in a didactic seminar of at least 12-20 hours duraction and treat at least two patients with IPT while receiving supervision, based on video-taped sessions. The candidates in training, according to Klerman et al., were to be experienced psychotherapists already trained in other techniques or approaches who would be required to modify their methods to comply with IPT strategies and techniques. The authors did not consider the possibility of creating a training course for clinicians who were not already qualified psychotherapists. This expectation of training only experienced candidates has very likely been one contributing factor to limiting the diffusion of IPT as a therapeutic tool in clinical settings. Undoubtedly, the background and experience of a candidate who takes on IPT training brings both advantages and disadvantages, and thus will influence the quality and the duration of the training itself.
From our perspective the most important part of IPT training is the supervised therapy experience. Because of the very limited diffusion of IPT, considerable distance often separates supervisors and therapists in training. This necessitates the use of alternative modalities of supervision to those usually adopted, involving other means of communication than the face-to-face supervision session. In an effort to train a group of IPT therapists in a non-English-speaking country where there was essentially only one person qualified as an IPT trainer, we evolved a training procedure that depends primarily on e-mail and telephone contacts with occasional face-to-face group meetings attended also by an English-speaking supervisor who is competent but not completely fluent in the second language. Because we have found this procedure to work extremely well, we bring it to the attention of the ISIPT.
This model of IPT training for clinicians who are not psychotherapists was developed for a multi-site research project entitled "Depression: The Search for Treatment-Relevant Phenotypes," involving the University of Pittsburgh, an established center for training and research in IPT, and the University of Pisa. The project is coordinated by Prof. E. Frank and Prof. G. B. Cassano at the respective research centers. The candidates in training are all psychiatrists with several years of clinical experience whose full training (from complete IPT novice to novice IPT supervisor) was programmed for a period of approximately two years of intensive activity. The italian language IPT trainer and supervisor was Dr. Paolo Scocco, a psychiatrist from the Mental Health Department and Univerty of Padua, who had been studying the use of IPT in the depressed elderly for several years and with whom Prof. Frank had collaborated previously.
We begin the training by asking the candidates to familiarize themselves with the IPT manual of which there is, fortunately, an excellent Italian translation. This first step is useful for learning the basic theory and the characteristics of the treatment. Subsequently the candidates participate in an intensive didactic seminar, conducted by Dr. Scocco, in which the manual s studied more closely and videotaped therapy sessions are watched and discussed, before simulating IPT interactions by means of role-play. After the intensive didactic seminar the candidates are asked to experiment with the interpersonal approach, (at least in terms of their approach to assessment) with all the patients they are treating, and in particular to use the interpersonal inventory, despite the fact that some patients will proceed with pharmacological treatment. This phase is of critical importance to modify their approach to clinical interviewing. Informal supervision is provided at this point, via e-mail or telephone, on specific questions that arise for the therapists in training.
Only after this phase, are the candidates encouraged to take on their first IPT patient. Treatment sessions are audio-taped and the tapes subsequently sent to the supervisor who has an undergraduate or graduate student transcribe the session. In the meantime, the trainee therapists are asked to send a brief summary of the session by e-mail while it is still "fresh" in their minds, including their impressions of the session and some references to key passages. Trainees then receive a reply of written comments from the supervisor, even before he has had the opportunity to listen to the audiotape.
After the first session and again after the session focused on selecting the problem area with the patient, the trainee therapist fills out and sends to the supervisor a revised version of the IPT Problem Area Rating Scale (Markowitz, 2000 -revised and translated by Andrade, Frank & Scocco). This instrument is very useful for encouraging the trainee to work right from the first session on gathering the information necessary to reach a decision, always in collaboration with the patient, about the problem area upon which the treatment will focus and ensuring that the initial phase of IPT does not continue beyond the third or fourth session.
After receiving the audiotapes and the transcription, the supervisor is able to both read and listen to the recorded session. In the next supervision meeting via telephone, he discusses "line-by-line" the trainee's technique throughout the entire session. On a technical level, we have found that it is important to maintain a constant and rapid flow of recordings to the supervisor in order to guarantee on time supervision of the treatment in a way that is truly useful to the trainee. The most common methodological and technical problems encountered in the sessions, which are then noted and underscored in supervision, are:
To enhance the training experience, we use other supports such as a weekly group meeting to discuss themes that are inherent to the management of the sessions, transference and counter-transference aspects of the treatment and any particular problems the trainees are encountering. Weekly conference calls are arranged for overall study management, during which time is specifically put aside to provide updates on the IPT training. Plenary meetings are organized with the whole research group three times a year for two or more days, during which all the cases being followed in IPT are discussed at a half-day session.
In this project we have experimented with a new approach to IPT training, adapted to a particular context that presented several unique challenges. We were training clinicians who had no previous psychotherapeutic experience and there was only one available supervisor fluent in the language of the trainees and he was not residing in the same city as the trainees. To accomplish our goals we have drawn upon various forms of supervision: informal and structured, individual and group, face-to-face, e-mail and telephone, with the intention of drawing maximum benefit from the peculiarities and strengths of each one and of being able to utilize the particular skills of the supervisors available.
A crucial aspect of training IPT therapists is the creation of a supportive training climate in which all trainees can identify problems and successes and compare and contrast their work. This can be achieved by creating a work-group orientated toward the objectives of growth and change. It seems that this can be accomplished even if that work-group must sometimes cross considerable geographical and linguistic distance.
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