Interpersonal Psychotherapy Research Paper

1. Development

Adolf Meyer’s (1957) theory that psychopathology is a result of maladaptive adjustment to the social environment lay the groundwork for IPT. Harry Stack Sullivan (1953) stands as the theorist who most clearly articulated the interpersonal paradigm and popularized the term ‘interpersonal’ as a balance to the thendominant intrapsychic approach. Sullivan believed that psychiatry involves the scientific study of people and the processes that go on among them, rather than the exclusive study of the mind or of society. According to Sullivan, the unit of clinical study is the patient’s interpersonal relationships and people cannot be understood in isolation from them. In his theory, Sullivan (1953, p. 13) posited that people have ‘relatively enduring patterns of recurrent interpersonal situations’ which can either foster self-esteem or result in hopelessness, anxiety, and psychopathology.

Sullivan developed a comprehensive theory of the connections between psychiatric disorders and interpersonal relations for the developing child in the family and for the adult in the multiple transactions of life. The roles of major interest to interpersonal psychotherapy occur within the nuclear family (as parent, child, sibling, partner); the extended family; the friendship group; the work situation (as supervisor, supervisee, or peer); and the neighborhood or community. The interpersonal approach views the relationship between social roles and psychopathology as occurring in two ways: disturbances in social roles can serve as antecedents for psychopathology; and mental illness can produce impairments in the individual’s capacity to perform social roles. IPT is also associated with the work of John Bowlby (1982), originator of attachment theory, who acknowledged the importance of early attachment to subsequent interpersonal relationships and psychopathology. In sum, IPT is derived from theories in which interpersonal function is recognized as a critical component of psychological adjustment and well-being.

IPT is based not only on theory but on empirical research linking change in the social environment to the onset and maintenance of depression. Considerable research exists that documents support for the key interpersonal problem areas. For instance, scientists have demonstrated that people become depressed in the circumstances of complicated bereavement, marital disputes, and the life changes associated with interpersonal role transitions, particularly in the absence of social ties. Moreover, several longitudinal studies have focused on the interpersonal consequences of depression (e.g., separation and divorce, withdrawal from social activities), showing that not only can life events trigger depression, but indeed depression can trigger adverse life events (for a review see Frank and Spanier 1995, Weissman et al. 2000). In combination, these data provide strong support for use of an interpersonal approach for the understanding and treatment of depression.

Depression is conceptualized as having three component processes: symptom function, social and interpersonal relations, and personality and character problems. Symptom function entails the development of depressive affect and the neurovegetative signs and symptoms (low energy, sleep and appetite disturbance, etc.). These are believed to have both biological and psychological precipitants. Social and interpersonal relations entail interactions in social roles with other persons derived from learning based on childhood experiences, concurrent social reinforcement, and personal mastery and competence. Personality and character problems refer to enduring traits such as inhibited expression of anger or guilt, poor psychological communication with significant others, and difficulty with self-esteem. These traits determine a person’s reactions to interpersonal experience. IPT intervenes in symptom formation and social dysfunction associated with depression, rather than enduring aspects of personality, because of its relatively short duration and low level of psychotherapeutic intensity. There is little expectation that IPT will have a pronounced effect upon personality structure; however, many IPT patients do acquire new social abilities that may help offset personality difficulties. An important component of IPT for depression is the deliberate avoidance, during the treatment of the acute symptomatic episode, of issues related to personality functioning (Weismann et al. 2000).

The methods and techniques of many schools of psychotherapy share common ground (Frank 1973), including attempts to help patients gain a sense of mastery and reduce social isolation. A major difference among the therapies lies in their conceptualization of the causes of the patient’s problems, and in the typical length and focus of treatment. For instance, IPT differs from traditional psychodynamic approaches in that it is time-limited, focused, examines current rather than past relationships, and recognizes but does not focus on intrapsychic defense mechanisms and internal conflicts. IPT also differs from cognitive and behavioral approaches in that maladaptive thoughts and behaviors are addressed only as they apply to problematic interpersonal relationships. The goal is to change the relationship pattern rather than associated depressive cognitions, which are acknowledged in IPT as depressive symptoms. Although the therapeutic style is less directive in IPT than in cognitive and behavioral approaches (i.e., less didactic prescriptive), the therapies are similar in terms of their active current focus on specified target areas. In contradistinction to other psychotherapies, IPT recognizes but does not directly focus on the patient’s personality characteristics.

2. Treatment Phases, Goals, And Strategies

The initial phase, ordinarily the first one to three sessions, includes diagnostic assessment and psychiatric history and establishes the context for the treatment. After a standardized diagnostic symptom review is conducted, the patient is diagnosed as depressed and assigned the ‘sick role.’ Patients are given the ‘sick role’ to exempt them from additional social pressures, increase their awareness of the need for help, and elicit their cooperation in the process of recovery. A detailed examination of the patient’s interpersonal history (the interpersonal inventory) is conducted, which includes a review of the patient’s current social functioning and current close relationships, their patterns and mutual expectations. During this review, changes in relationships are illuminated that were proximal to the onset of symptoms (e.g., the death of a significant other, changing to a new job, increasing marital discord, or disconnection from a friend). The interpersonal inventory provides a structure for elucidating the social and interpersonal context of the onset and maintenance of depressive symptoms and delineates the focus of treatment.

An evaluation of need for medication is based on the severity of symptoms, previous experience with medications, and patient preference. The therapist and patient then discusses the diagnosis and what the patient might expect from treatment. Symptom relief starts with helping the patient understand that the vague and uncomfortable symptoms are a part of a known syndrome, which responds to several treatments and has good prognosis. The therapist then links the depressive syndrome to one of four interpersonal problem areas: grief, role transitions, interpersonal role disputes, or interpersonal deficits. After the major interpersonal problem area associated with the onset of the depression is identified, the therapist makes a specific treatment plan with the patient to work on this problem area.

During the intermediate phase of treatment, typically the middle 7 to 11 sessions, the therapist implements treatment strategies that are specific to the identified problem area. Grief is identified as the problem area when the onset of the patient’s symptoms are associated with the death of a loved one, either recent or past. The goals for treating complicated bereavement include facilitating mourning and helping the patient to find new activities and relationships to substitute for the loss. Role transition includes any difficulties resulting from a change in life status (e.g., divorce, retirement or change in one’s work role, moving, leaving home, diagnosis of medical illness). The patient is helped to deal with the change by recognizing positive and negative aspects of the new role they are assuming, and pros and cons of the old role this replaces. Interpersonal role disputes are conflicts with a significant other (e.g., a partner, other family member, co-worker, or close friend) which emerge from differences in expectations about the relationship. The therapist assists the patient to identify the nature of the dispute and generate options to resolve it. If resolution is impossible, the therapist assists the patient in dissolving the relationship and in mourning its loss. Interpersonal deficits include patients who are socially isolated or who are in chronically unfulfilling relationships. The goal is to reduce the patient’s social isolation by helping to enhance the quality of existing relationships and encouraging the formation of new relationships. The problem area may change during the course of treatment. The patient may have several related problem areas and may work on more than one or may select the most prominent or changeable.

In the termination phase of treatment, usually the last few of the 12 to 16 sessions, the therapist assists the patient in evaluating and consolidating gains, acknowledging the feelings associated with termination, detailing plans for maintaining improvements in the identified interpersonal problem area(s), and outlining remaining work. Patients are also encouraged to identify early warning signs (e.g., low energy) and to identify plans of action.

Throughout IPT, focus stays on the interpersonal context of a patient’s life. For example if a patient is having depressive symptoms, the therapist will focus on relationship difficulties that exacerbate the symptoms rather than review cognitions or inner conflict associated with the depression. Interpersonal goals are derived from specified problem areas and are formulated within the first three sessions. Meetings should not pass without reference to these goals, as they are unique and require specific and directive interventions by the therapist. Indeed, research on IPT maintenance treatment for recurrent depression has demonstrated that the therapist’s ability to maintain focus on interpersonal themes is associated with better outcomes (Frank et al. 1991). In session, unfocused discussions are redirected to the key interpersonal issues, and abstract and general discussions are minimized in order to preserve focus. Therapists refrain from making inquiries that evoke vague or passive responses, such as general questions about the patient’s week. Rather, sessions begin with questions such as ‘What would you like to work on today?’ and ‘How have things been since we last met?’ These questions provide more direction for patients and focus them on recent interpersonal events and recent mood, which the therapist attempts to connect. Patients who describe problem areas will be asked about recent mood and other depressive symptoms; alternatively, if the patient focuses on symptoms, the therapist asks about recent life events and interactions (Weissman et al. 2000).

3. Therapeutic Stance And Techniques

Each model of psychotherapy can be characterized in part by the positioning of the therapist in terms of the nature of the relationship with the patient and the level of therapeutic activity. The IPT therapeutic stance is one of warmth, support, and empathy. The IPT therapist is active and advocates for the patient rather than remaining neutral. Moreover, the therapeutic relationship is not viewed as a manifestation of transference, nor is it to be treated as a friendship. Whereas IPT is distinct at the level of strategies, it is similar to many other therapies at the level of techniques. Some of the most frequently used techniques include exploratory techniques, encouragement of affect, clarification, and communication analysis; other techniques include use of therapeutic relationship, behavior change techniques, and adjunctive techniques.

4. Outcome Research

IPT has demonstrated efficacy for the treatment of several mood disorders including nonpsychotic major depression and recurrent depression (Weissman et al. 2000), as well as bipolar mood disorder (Frank et al. 1999). IPT has also shown efficacy for bulimia nervosa (Agras et al. 2000), and binge eating disorder (Wilfley et al. 1993). In addition, a number of new research applications are currently under investigation for various disorders including dysthymia, post-traumatic stress disorder, social phobia, body dysmorphic disorder, chronic somatization, borderline personality disorder, and anorexia nervosa. For a comprehensive review of empirical support and studies in progress see Weissman et al. (2000).

IPT has been adapted for various populations including the elderly, adolescents, and patients with comorbid medical conditions (e.g., human immunodeficiency virus) (Weissman et al. 2000). IPT also has been modified for groups (Wilfley et al. 2000), long-term treatment, couples, telephone intervention, primary care, and adjunctive self-help, and has been translated into several languages (Weissman et al. 2000). Together, these findings indicate that IPT is not only an effective and promising treatment for a range of psychiatric disorders, but it also has the potential for wide dissemination.

5. Future Directions

Four key areas are in need of further investigation. First, although a number of outcome studies in IPT clearly document its efficacy, little is known about the mechanisms by which IPT exerts its effects (Frank and Spanier 1995). A greater understanding of the mechanisms by which change occurs in IPT would assist in further refinements of the treatment and yield insights about the nature of the psychiatric syndrome under investigation. Second, increased efforts to improve the effectiveness of IPT are warranted. Frank and Spanier (1995) suggest that specific efforts to improve outcome in IPT could entail altering the structure of the treatment itself (e.g., timing, duration, frequency of the sessions) and identifying specific therapists’ behaviors and patient responses and features that are associated with better outcome. For instance, initial data suggest that high treatment specificity (i.e., consistent focus on the interpersonal problems and consistent use of IPT techniques) is associated with better outcome (Frank et al. 1991). However, it still remains unclear how treatment specificity translates into specific actions of the therapist and patient. Moreover, data from a comparative treatment trial in patients with bulimia nervosa (BN) suggests that IPT is slower acting than cognitive behavior therapy (Agras et al. 2000). Further research is needed to determine whether refinements can be made to increase the rapidity of BN patients’ response in IPT which may lead to improvements in ultimate outcome as well. Third, continued research is warranted to examine whether IPT is effective for other populations and disorders. For some conditions and formats the original form of IPT will be sufficient whereas for others unique adaptations may need to be employed to increase the overall effectiveness and applicability of IPT. It will be critical to determine the optimal length and dosing for particular disorders as well. Fourth, IPT was developed as a research intervention and still remains to be well disseminated among clinicians (Weissman et al. 2000). Thus, there exists a need to translate IPT efficacy data to effectiveness studies and routine clinical practice.

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