Background

Klerman, Weissman, and colleagues developed IPT as a treatment arm for a pharmacotherapy study of depression. They recognized that many outpatients in clinical practice received talking therapy as well as medication, and felt that their study would gain face validity by

* This chapter is based in part on a chapter previously published as Markowitz, J.C. (2003). Interpersonal Psychotherapy. In R.E. Hales and S.C. Yudofsky (Eds) The American Psychiatric Publishing Textbook of Clinical Psychiatry (4th edn) (pp. 12071223). Washington, DC: American Psychiatric Publishing. www.appi.org. Reproduced with permission.

Mood Disorders: A Handbook of Science and Practice. Edited by M. Power. © 2004 John Wiley & Sons, Ltd. ISBN 0-470-84390-X.

including both modalities. Yet, they had no idea what was actually practiced in the surrounding offices in New England—as, indeed, we have little grasp of what is presumably eclectic community practice today. Being researchers, they developed a psychotherapy based on research data, as well as to some degree on existing interpersonal theory.

IPT is based on principles derived from psychosocial and life events research on depression, which has demonstrated relationships between depression and complicated bereavement, role disputes (as in bad marriages), role transitions (and meaningful life changes), and interpersonal deficits. Life stressors can trigger depressive episodes in vulnerable individuals, and, conversely, depressive episodes compromise psychosocial functioning, leading to further negative life events. In contrast, social supports protect against depression. IPT theory borrows from the post-World War II work of Adolph Meyer and Harry Stack Sullivan (1953), as well as the attachment theory of John Bowlby and others. Sullivan, who popularized the term "interpersonal", emphasized that life events occurring after the early childhood years influence psychopathology. This idea, which seems commonplace enough today, was radical in an era dominated by psychoanalysis, when the focus was almost exclusively on early childhood experiences. IPT uses this principle for practical, not etiological purposes. Without presuming to know the cause of a depressive episode, whose etiology is presumably multifactorial, IPT therapists pragmatically use the connection between current life events and onset of depressive symptoms to help patients understand and combat their episode of illness.

TREATMENT WITH IPT

IPT therapists use a few simple principles to explain the patient's situation and illness. These are simple enough that dysphoric patients with poor concentration can grasp them. First, they define depression as a medical illness, a treatable condition that is not the patient's fault. This definition displaces the burdensome guilt from the depressed patients to their illness, making the symptoms ego-dystonic and discrete. It also provides hope for a response to treatment. The therapist uses ICD-10 or DSM-IV (American Psychiatric Association, 1994) criteria to make the mood diagnosis, and rating scales, such as the Hamilton Depression Rating Scale (HDRS) (Hamilton, 1960) or Beck Depression Inventory (BDI) (Beck, 1978), to assess symptoms.

Indeed, the therapist temporarily gives the patient the "sick role" (Parsons, 1951), which helps patients to recognize that they suffer from a common mood disorder with a predictable set of symptoms—not the personal failure, weakness, or character flaw that depressed patients often believe is the problem. The sick role excuses patients from what the illness prevents them from doing, but also obliges patients to work as patients in order ultimately to recover the lost healthy role. I am told that in the UK (unlike the USA), clinicians hear the term "sick role" as a tainted term associated with long-term psychiatric disability. This is not at all its IPT connotation. On the contrary, the sick role is intended as a temporary role, coincident with the term of a time-limited treatment, to relieve self-blame while focusing the patient on a medical diagnosis. The time limit and brief duration of IPT, and the IPT therapist's frequent encouragement of patients to take social risks and improve their situation, guard against regression and passivity.

A second principle of IPT is to focus the treatment on an interpersonal crisis in the patient's life, a problem area connected to the patient's episode of illness. By solving an interpersonal problem—complicated bereavement, or a role dispute or transition—IPT

patients can both improve their life situation and simultaneously relieve the symptoms of the depressive episode. Since randomized, controlled outcome studies have repeatedly validated this coupled formula, IPT can be offered with confidence and optimism similar to that accompanying an antidepressant prescription. This therapeutic optimism, while hardly specific to IPT, very likely provides part of its power in remoralizing the patient.

IPT is an eclectic therapy, using techniques seen in other treatment approaches. It makes use of the so-called common factors of psychotherapy (Frank, 1971). These include building a therapeutic alliance, helping the patient feel understood (through use of a medical disease model and relating mood to event), facilitation of affect, a rationale for improvement (if you fix your situation, your mood should improve), support and encouragement, a treatment ritual, and success experiences (that is, actual life changes). Beyond this, its medical model of depressive illness is consistent with pharmacotherapy (and makes IPT highly compatible with medication in combination treatment). IPT shares role-playing and a "here and now" focus with cognitive behavior therapy (CBT), and addresses interpersonal issues in a manner marital therapists would find familiar. It is not its particular techniques but its overall strategies that make IPT a unique and coherent approach. Although IPT overlaps to some degree with psychodynamic psychotherapies, and many of its early research therapists came from psychodynamic backgrounds, IPT meaningfully differs from them. It focuses on the present, not the past; it focuses on real life change rather than self-understanding; it employs a medical model; and it avoids exploration of the transference and genetic and dream interpretations (Markowitz et al., 1998). Like CBT, IPT is a time-limited treatment targeting a syndromal constellation (such as major depression); however, it is much less structured, assigns no explicit homework, and focuses on affect and interpersonal problem areas rather than automatic thoughts. Each of the four IPT interpersonal problem areas has discrete, if somewhat overlapping, goals for therapist and patient to pursue.

IPT techniques help the patient to pursue these interpersonal goals. The therapist repeatedly helps the patient relate life events to mood and other symptoms. These techniques include an opening question, which elicits an interval history of mood and events; communication analysis, the reconstruction and evaluation of recent, affectively charged life circumstances; exploration of patient wishes and options, in order to pursue these goals in particular interpersonal situations; decision analysis, to help the patient choose which options to employ; and role-playing, to help patients prepare interpersonal tactics for real life. The reformulation of cases using an IPT focal problem area often makes difficult cases more manageable both for patient and clinician.

IPT deals with current interpersonal relationships, focusing on the patient's immediate social context rather than on the past. The IPT therapist attempts to intervene in depressive symptom formation and social dysfunction rather than enduring aspects of personality. In any case, it is difficult to assess accurately personality traits when confounded by the state changes of an Axis I disorder such as a depressive episode (Hirschfeld et al., 1983). IPT builds new social skills (Weissman et al., 1981), which may be as valuable as changing personality traits.

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