Interpersonal Psychotherapy

:
Evidence and Application
Joy E. Moel, Roberta Casko,
Kimberly Nylen, & Tracy Moran

University of Iowa
Iowa Depression and Clinical Research Center
History and Development

Developed in the 1970s by Gerald
Klerman, Myrna Weissman and
colleagues
Era of tricyclic antidepressants
IPT was not initially developed as an
active treatment for depression
History and Development
 Served as the psychotherapy component
in a drug treatment trial comparing the
relative efficacy of antidepressants alone
and in combination with psychotherapy

 Originally called “high contact,” indicating
that benefit to patients would be due to
nonspecific effects rather than specific
techniques
History and Development
 Maintenance studies showed the efficacy of
“high contact”
 Klerman and Weissman began to more fully
describe the treatment, termed IPT, and
published a manual (Klerman, Weissman,
Rounsaville, 1984)
 Designed an acute treatment trial of
medication, IPT, and combination.
What is Interpersonal
Psychotherapy?

 Interpersonally based psychotherapy
– Focuses on modifying disrupted relationships
or expectations about those relationships
 Time-limited
– Focus on here-and-now
 Non-transferential
– Psychodynamically informed vs.
psychodynamically oriented
What is Interpersonal
Psychotherapy?

 Manual based
 Empirically based
 Goals of treatment
– Symptom relief
– Improved interpersonal functioning
– Resolve acute interpersonal crisis
– Increase social support
Therapeutic Stance
 Understand the client
 Active
 Client advocate
 Supportive
 Directive
 Non-transferential

 Client responsible for direction and change
IPT: Theoretical Framework
Biopsychosocial model
Attachment Theory (Bowlby)
–Relationships are primary
–Attachment is a biological drive
–Attachment is a cybernetic system
–Capacity to form flexible attachment is
principal feature of mental health
Attachment Styles

Secure
Anxious Ambivalent
Anxious Avoidant
Attachment Theory

 Patterns of attachment develop early and
tend to persist, but are not fixed
 Patterns of attachment persist within
relationships
 Patterns of attachment persist across
relationships
Attachment Theory

 Those with less secure attachment are
more prone to psychiatric symptoms
 Disruption of attachment increases
vulnerability to psychiatric symptoms
 Psychiatric symptoms result from
Biopsychosocial factors
 Dysfunction results from
– An acute crisis, attachment disruption,
inadequate social support
Attachment Theory: Implications
for Treatment

 Focus on attachment – i.e. interpersonal
relationships
 Resolution of here-and-now problems
should result in symptom relief
 Fundamental personality change is
unlikely in short-term treatment

Psychological Factors
Attachment Style
Temperament
Cognitive Style
Coping Mechanisms

Interpersonal Distress
Social Factors
Intimate Relationships
Social Support
Unique Individual
Interpersonal Crises
Grief and Loss
Interpersonal Disputes
Role Transitions
Interpersonal Sensitivity
Biological Factors
Genetics
Substance Use
Medical Illnesses
Medical Treatments
Problem Areas

Grief & Loss
Interpersonal Disputes
Role Transitions
Interpersonal Sensitivity
IPT Techniques
 Clarification
 Communication Analysis
 Interpersonal Incidents
 Use of Affect
 Role Playing
 Problem Solving
 Homework
 Use of the Therapeutic Relationship
Clarification
 Direct questioning
 Empathic listening
 Reflective listening
 Encouragement of spontaneous discourse

Communication Analysis
 Importance of clearly communicating
needs and expectations to others.
 Client’s understanding of her contribution
to communication problems.
 Motivate client to communicate more
clearly.
 Analyze quality of patient’s narrative.
 Analyze communications within sessions.
Interpersonal Incidents
 Augment communication analysis
 Provide discrete examples of generalized
beliefs/complaints
 Provide specific incidents for the therapist
and client to problem-solve

Use of Affect
 Help client to
- recognize her own affect
- communicate affect to others
- recognize suppressed or painful affect

Role Playing
 Allows the therapist to model new modes of
interpersonal behavior and communication.
 Allows the client to:
- develop new insights into her
interpersonal behaviors
- practice new communication skills
- gain new perspectives on the reaction of
others to her communications
Problem Solving
 Carefully examine the problem.
 “Brainstorm” potential solutions with client
 Select a course of action.
 Monitor outcomes and refine solution.
Homework
 Assignments are interpersonal in nature
and not paradoxical.
 Assignments involve:
- direct communications with others
- self-appraisal of her interactions
- activities and behaviors with others

Use of the Therapeutic Relationship
 The ideal relationship includes:
- mutual liking, caring, respect
- importance to both parties
- a degree of expertise on the part of
the therapist

Overall Structure of IPT
 Treatment Phases
– Evaluation
– Initial Sessions (1-2)
– Intermediate Sessions (3-12)
– Conclusions of Acute (13-14)
– Maintenance treatment (15+)
New Haven – Boston Collaborative Study
 First controlled study of IPT for acute
depression
 16 week treatment study of 81 depressed
patients
–IPT alone
–Amitriptyline alone
–Combination
–Control: Nonscheduled psychotherapy
New Haven – Boston Collaborative Study

 IPT superior to nonscheduled psychotherapy

 Medication superior to nonscheduled
psychotherapy

 Combination was more effective then either
active treatment alone

 IPT equivalent to Amitriptyline
– Differential effects on symptoms

One-year follow-up
 Patients who received IPT (alone or in
combination with medication) showed
higher functioning than patients who
received nonscheduled psychotherapy or
medication alone
 No effect of IPT on symptom relapse or
recurrence
NIMH Treatment of Depression Study
Imipramine IPT CBT Clinical Management
Acute Depression
NIMH Treatment of Depression Study
 IPT superior to “placebo”
 IPT equal to Imipramine for mild to
moderate depression
 IPT slightly better than CBT for severe
depression
 No long-term preventive effects were
noted for IPT, CBT, or Imipramine at 6,
12, or 18 months
NIMH Treatment of Depression Study
 43% of patients entering IPT achieved remission
of depression (HRSD<7)
 55% of patients who completed IPT achieved
remission of depression
 23% of patients terminated prematurely from
IPT
– Premature terminators were more severely depressed
at intake
 33% of patients achieving remission of
depression relapsed within 18 months
NIMH Treatment of Depression Study
Treatment response to IPT predicted
by:
– low social dysfunction
– high interpersonal sensitivity
– higher satisfaction with social
relationships
– acute onset of depression
– endogenous depression

Maintenance Therapy
 Many patients have relapses and recurrences
 Weissman and colleagues established that 8
months of antidepressant treatment could
prevent relapse, and that maintenance IPT
could enhance social functioning, but effects
weren’t seen for 6-7 months
 Pittsburgh Maintenance Therapy with IPT -
Frank, Kupfer and colleagues studied the
efficacy of IPT as a maintenance treatment for
depression
Pittsburgh Maintenance Therapy
Imipramine Imipramine + IPT IPT IPT + placebo placebo
Acute Treatment
Imipramine + IPT
Recovered Patients
Recurrent Depression
(3 + episodes)
Pittsburgh Maintenance Therapy - Results
 3-year survival analysis indicates that
Imipramine reduced relapse of depression
 Combination of Imipramine and IPT did
not further reduce relapse
 Maintenance IPT not as effective as
Imipramine
 Maintenance IPT superior to placebo
Pittsburgh Maintenance Therapy
0
20
40
60
80
100
120
140
IMI + IPT-M
IMI alone
IPT-M alone
IPT-M + placebo
placebo

Mean 3 Year Survival (weeks)
Clinical Importance of Empirical Research

Selection of good candidates for IPT
Prediction of response
Conviction of treatment presentation
Conviction in treatment delivery


Additional Applications
Research at the University of Iowa

 Social Phobia (Stuart et al.)

 Somatization Disorders (Stuart & Noyes,
1999)

 IPT for Couples (Stuart, Temple et al)

 Post-MI Depression (Stuart & Cole, 1996)
Additional Applications
 Interpersonal Counseling in Primary Care (IPC; Klerman
& Weissman, 1993)
 Eating Disorders (Fairburn et al., 1998)
 Adolescents (IPT-A; Mufson et al., 1999, 2004)
 Bipolar Disorder (Swartz et al., 2002)
 Drug Abuse (Rounsaville & Carroll, 1993)

 Dysthmia (Browne, Steiner et al., 2002)

 HIV Patients (Markowitz et al., 1992, 1997)

 Groups (IPT-G; Wifley et al., 2000)