Introduction

• Interpersonal Psychotherapy (IPT) is a brief and highly structured manual based psychotherapy that addresses interpersonal issues in depression, to the exclusion of all other foci of clinical attention. This approach has allowed ready modification of the original treatment manual for depression to a variety of illnesses.



• IPT has no specific theoretical origin although its theoretical basis can be seen as coming from the work of Sullivan, Meyer and Bowlby. Whilst Sullivan wrote of a type of "interpersonal therapy" in the 1930s, this was more in the form of a long term analytic but relational based therapy and would not be seen to resemble the current form of IPT. Attachment theorists view the experience of loss and to a lesser degree disordered attachment as underlying much of human psychopathology. IPT can be seen as indirectly addressing these issues within the therapeutic frame.



• The current form of the treatment was developed by the late Gerald Klerman and Myrna Weissman in the 1980s as a means of operationalising the interpersonal approach to psychotherapy for a series of treatment studies in depression conducted in the United States. Since that time it has been modified for a variety of other indications including Dysthymia, Bulimia Nervosa, Substance Misuse ,Somatization and depression in a variety of clinical settings. Preliminary studies in Anorexia Nervosa, Bipolar Disorder, PTSD and some anxiety disorders are underway. In each adaptation the fundamentals of the treatment manual are adhered to, however different components are emphasized.

Theoretical Assumptions of IPT

• IPT does not presume that psychopathology arises exclusively from problems within an interpersonal realm. It does emphasize however, that these problems occur within an interpersonal context that is often interdependent with the illness process. Depression is conceptualized by IPT as having three components



1. Symptom Formation
2. Social Functioning
3. Personality contributants



• IPT would aim to intervene specifically in social functioning with consequent benefits in symptom experience. Personality is not a focus in IPT given the brevity of the treatment course. Patient's social functioning problems are conceptualized as one or more of four areas:-



1. Interpersonal Disputes
2. Role Transitions
3. Grief
4. Interpersonal Deficits



• The therapist remains warm and positions themselves in a collaborative framework with strict adherence to the manual. There is constant focus upon termination from the outset, so regression and other more analytic processes are avoided as far as possible. Whilst problematic transference or countertransference are not interpreted, they are utilized as a tool for identifying problematic processes within the IPT process.

Structure and Duration of Sessions

• IPT usually runs from 12 to 16 one hour sessions that usually occur weekly. The initial sessions are devoted to information gathering and clarifying the nature of the patient's illness and interpersonal experience. The patient's illness is then formulated and explained in interpersonal terms and the nature and structure of the IPT sessions are explained. This phase of treatment concludes with the composition of the "interpersonal inventory" which is essentially a register of all the key relationships in the individual's life. Within the interpersonal inventory relationships are categorized according to the four areas mentioned above.



• Sessions 3 - 14 are devoted to addressing the problematic relationship areas and there is little focus upon the specific illness process apart from enquiries as to symptom severity and response to treatment modalities.



• The final sessions 15 - 16 focus upon termination, which is usually formulated as a loss experience from which the patient can learn a great deal about their own responses to loss and how well the modifications attempted in the therapeutic process have evolved.

Specific Interpersonal Problems as conceptualized in IPT

Interpersonal Disputes

These tend to occur in marital, family, social or work settings. They can be conceptualized as a situation in which the patient and other parties have diverging expectations of a situation and that this conflict is excessive enough to lead to significant distress. One example may be a marital dispute in which a wife's attempts to use initiative leads to conflict with her spouse. In these circumstances IPT would aim to define how intractable the dispute was, identify sources of misunderstanding via faulty communication and invalid or unreasonable expectations and the aim to intervene by communication training, problem solving or other techniques that aim to facilitate change in the situation.

Role Transitions

Role transitions are situations in which the patient has to adapt to a change in life circumstances. These may be developmental crises, adjustments in work or social settings or adaptations following life events or relationship dissolutions. In those who develop depression, these transitions are experienced as losses and hence contribute to the development of psychopathology. IPT aims to help the patient with role transitions to reappraise the old and new roles, to identify sources of difficulty in the new role and fashion solutions for these. In many cases clarification of inconsistencies or clear errors in the patient's cognitions as well as problem solving and encouragement of affect within the therapeutic frame are suitable interventions.

Grief

Grief is simply defined in IPT as "loss through death". Whilst many clinicians would formulate sequelae of severe medical eg loss of function illness as grief, in IPT the term is reserved specifically for bereavement. In IPT, if grief is formulated as an issue of relevance in the interpersonal inventory, the assumption of the patient and therapist is that the grieving process has been complicated by delay or in many cases excess. The IPT therapist will help to reconstruct the patient's relationship with the deceased and by encouraging affect as well as clarification and empathic listening help facilitate the mourning process with the aim of helping the patient to establish new relationships.

Interpersonal Deficits

These would be diagnosed when a patient reports impoverished interpersonal relationships in terms of both number and quality of the relationships described. In many cases the interpersonal inventory will be sparse and the patient and therapist will need to focus upon both old relationships as well as the relationship with the therapist. In the former common themes should be identified and linked to current circumstances. In using the therapeutic relationship the therapist aims to identify problematic processes occurring such as excess dependency or hostility and aim to modify these within the therapeutic frame. In this way the therapeutic relationship can serve as a template for further relationships which the therapist will aim to help the patient create. This group of problems is common in the more chronic affective disorders such a dysthymia in which significant degrees of social impoverishment have occurred either before or after the illness.

Techniques used in IPT

• IPT utilizes several techniques within the therapeutic process. Many of these are modified interventions borrowed from other therapies such as cognitive-behaviour therapy and brief crisis intervention.



• The use of various questioning styles such as "Clarification" which seeks to obviate the patient's biases in describing interpersonal issues as well as "Supportive Listening" are often therapeutic within themselves. "Role playing" and "Communication Analysis" are highly behavioural interventions and are invaluable tools in intervening in interpersonal disputes. The "Encouragement of Affect" allows the patient to experience unpleasant or unwanted affects (that have perhaps resulted in the deployment of pathogenic defence mechaninsms) safely within the therapeutic frame. This process allows the patient to acknowledge the affective component of an interpersonal issue eg grief and helps the patient to accept it as a part of their experience. The "Use of the Therapeutic Relationship" has been described earlier.



• There is some degree of debate as to whether therapists should be more or less active in the conduct of the sessions other than keep the focus on interpersonal issues. There are clearly no distinct guidelines in this area although the goal of IPT is to facilitate the process of the patient generating their own interventions and thus progressively phasing the therapist out of the process. It is likely that the process of patient initiated changes is the likely mechanism to account for the observation that symptomatic improvement arising from IPT often peaks 3 - 6 months subsequent to the termination of treatment.

Efficacy of IPT

• Several large scale randomised control trials support IPT's efficacy in treating depression. The New Haven - Boston Collaborative study in 1973 found IPT of comparable efficacy to amitriptyline in treating major depression and both in combination had an additive effect¹. The larger National Institute of Mental Health(NIMH) study 13 years later studied 250 outpatients randomized to Cognitive Behaviour Therapy (CBT), IPT, Imipramine or Clinical management. CBT, IPT and Imipramine were equal in antidepressant efficacy at 12 weeks². Curiously, the patients studied who scored greater than 20 (defined as "severe depression" )on the Hamilton Rating Scale for Depression responded as well to IPT as Imipramine. Those patients receiving CBT with severe depression did not do as well. The University of Pittsburgh Group led by David Kupfer and Ellen Frank studied maintenance treatments of depression and found that low dose IPT (monthly) and high dose Imipramine (greater than 200mg daily) seemed to be effective in preventing relapse compared with placebo^3,4.



• The data indicating IPTs efficacy in treating Bulimia Nervosa is modest but promising⁵. Christopher Fairburn's group in Oxford found IPT and CBT equal in efficacy, with IPT continuing to show benefits subsequent to termination. What was striking was the benefit of IPT in improving dysfunctional cognitions in terms of weight and body image, given that these were not addressed in IPT.



• Preliminary findings support IPT in the acute treatment of Adolescent Depression, Dysthymic Disorder, Bipolar Disorder and Post Natal Depression



• Preliminary studies are underway in a variety of disorders and new data is expected in the next 3 - 5 years

References

1. Weissman MM, Prusoff BA, DiMascio A. The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Am J Psychiatry .1979; 136: 555-558.
2. Elkin I, Shea MT, Watkins JT, et al: National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Archives of General Psychiatry. 1989; 46:971-982.
3. Frank E, Kupfer DJ, Perel JM, et al: Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 1990;47:1093-1099.
4. Kupfer DJ, Frank E, Perel JM, et al: Five-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 1992; 49:769-773.
5. Fairburn CG, Jones R, Peveler RC, Hope RA, O'Connor M. Psychotherapy and bulimia nervosa: the longer term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Archives of General Psychiatry 50: 419-428, 1993.