Interpersonal psychotherapy (IPT) was initially developed by the late Gerald Klerman, MD, Myrna Weissman, PhD and colleagues as a time-limited therapy for major depression. Over the last few years, IPT has become increasingly popular among mental health professionals. There are a number of reasons that may partially account for this growing interest in IPT. First, it is easy to teach and to learn. Second, it has been successfully adapted to a number of disorders and to different age and ethnic groups. There is a growing body of literature documenting its efficacy not only in depression, but also in most (although not all) of the disorders for which it has been adapted. Finally, the recent emphasis on evidenced-based medicine has increased the interest in time-limited psychotherapies with proven efficacy.
The idea underlying IPT is simple: psychiatric disorders, although multidetermined in their causes, always take place in a social and interpersonal context: one of the patient's significant relationships is strained, the patient moves to a new location or social role, a loved one dies. The goal of IPT is to achieve symptomatic relief for mental disorders by addressing current interpersonal problems associated with the onset of the disorder. It does not seek to attribute interpersonal problems to personality characteristics or unconscious motivations. Rather, IPT works with the assumption that little can really be said about the patient's personality until the disorder is alleviated.
IPT is continuously evolving, as researchers and clinicians refine its techniques and adapt them to the needs of their patients. In this chapter we present some basic concepts of IPT (see Klerman et al., 1984, for a detailed account of how to conduct IPT, and Weissman et al., 2000, for a comprehensive review of the state of IPT and its adaptations), summarize the data on the efficacy for the disorders for which it has been adapted, describe some of the techniques used in this therapeutic modality and briefly describe some of the potential problems that may arise while conducting IPT.
IPT was initially developed for the treatment of major depressive disorder. While it has since been adapted for treatment of other psychiatric disorders, we are focusing the presentation of its theoretical and empirical basis on the case of depression, consistent with the ideas that led to its creation. However, most of those ideas are readily generalizable to other disorders. IPT is based on three related premises: (1) depression is a medical disorder; (2) depression does not occur in isolation, but in the context of interpersonal relationships and social factors; and (3) the treatment of depression has to be based on empirical data available from any relevant discipline, i.e., epidemiology, phenomenology, neurobiology, and results from clinical trials in diverse populations.
Although the creators of IPT were influenced by a variety of theoretical perspectives, the interpersonal school of thought, founded by Adolf Meyer and Harry Stack Sullivan, was probably the most influential as the theoretical basis for IPT. Meyer's psychobiological approach to understanding psychiatric disorders placed great emphasis on the patient's current psychosocial and interpersonal experiences, in contrast to a psychoanalytic focus on the intrapsychic and the past (Meyer, 1957). Sullivan, who linked clinical psychiatry to other disciplines such as anthropology and social psychology, viewed psychiatry as the scientific study of people and their relationships, rather than the study of the individual in isolation. In Sullivan's interpersonal approach, the unit of observation and therapeutic intervention is the primary social group, the immediate involvement of the patient with the patient's significant others (Sullivan, 1953). IPT's emphasis on interpersonal and social factors in the understanding and treatment of depression also draws on the work of many others clinicians, especially Cohen et al. (1954), Fromm-Reichmann (1960), Frank (1973), and Arieti and Bemporad (1978).
The interpersonal approach applied to understanding clinical depression considers three interrelated processes.
Symptoms, which are presumed to have biological and psychosocial precipitants.
Social and interpersonal relations, such as interaction in social roles with other persons derived from childhood experiences, social reinforcement and personal mastery and competence.
Personality problems, which include enduring traits such as low self-esteem or inhibited expression of anger and guilt. Personality patterns can predispose the person to episodes of depression.
IPT attempts to intervene in the first two processes, symptom function and social and interpersonal relations. It does not attempt to modify personality patterns directly. On the other hand, as symptoms lift, it is expected that patients will gain some control over those patterns. Furthermore, mood disorders may mimic personality disorder and resolution of the mood symptoms may result in improvement or resolution of the ‘personality disorder’.
IPT intervenes with symptom formation, social adjustment, and interpersonal relations focusing on current problems at conscious and preconscious levels. Typically, those problems include disputes with significant others or relatives, frustrations, anxieties, and wishes as experienced in the interpersonal context. Although the IPT therapist may recognize unconscious factors, they are not directly addressed. The emphasis of IPT is to help the patient change, rather than to understand simply and accept their current unsatisfactory life situation. The influence of past experiences, particularly early childhood experiences, is recognized but the work focuses on the ‘here and now’, instead of focusing on an attempt to link the past with the present. This focus on the present is very much related to IPT's understanding of depression as a clinical disorder. Following the medical model, etiological factors are taken into account, but the emphasis is on treatment of the current symptoms and improvement of the psychosocial situation. The adoption of the medical model legitimizes the assumption of the ‘sick role’ on the part of the patient and helps explain the patient's symptoms and decrease the feelings of guilt that are characteristically experienced in depression.
IPT is based not on only on theory, but also on empirical research on the psychosocial aspects of depression. There is evidence to support each of the three key interpersonal problem areas: that people become depressed in the context of complicated bereavement (Maddison and Walker, 1967; Walker et al., 1977), interpersonal disputes (Paykel et al., 1969; Pearlin and Lieberman, 1977) and that interpersonal transitions in the context of life changes can lead to mood symptoms (Overholser and Adams, 1997), particularly in the absence of social supports. Social supports (having close relationships or feeling supported by someone) protect against depression (Brown et al., 1977; Henderson, 1977; Prigerson et al., 1993). Early life events such as the death of a parent (Brown and Harris, 1978) or poor parenting (Parker, 1979) can predispose to depression later in life, particularly when followed by later life stressors. The reverse is also true: once depressed, people have difficulty communicating effectively (Coyne, 1976; Merikangas et al., 1979), as well as generally functioning in their social roles. All this can lead to strained relationships and adverse life events (Weissman et al., 1974; Kendler et al., 1999).
The procedures of IPT share many characteristics with other psychotherapeutic approaches. This is not surprising, as most treatment approaches share the goals of helping patients gain a sense of mastery, decrease social isolation and improve satisfaction with their lives. However, IPT differs from other approaches in its overall strategies, some of the techniques used and the aspects it chooses to address (Markowitz et al., 1998):
IPT is time-limited, not long term. There is substantial evidence that short-term psychotherapy can be efficacious in treating depression in a variety of patients with different demographic characteristics and cultural backgrounds. It is true that short-term therapy might not be efficacious in treating personality disorders. However, that is not the goal of IPT. Furthermore, long-term treatment has the potential for promoting dependence and reinforcing avoidant behavior. Time-limited therapies, on the other hand, are more likely to avoid those adverse effects.
Focused, not open-ended. Because it is time limited, IPT does not attempt to solve all the problems of the patient's life. Rather, it addresses one or two problem areas of the patient's current functioning. The therapist and the patient agree on the specific focus of the therapy after the initial evaluation sessions. An implicit expectation of IPT is that as patients gain mastery of the problem areas discussed in the sessions, they will be able to address other problems on their own in the future.
Current, not past interpersonal relationships. Past depressive episodes, significant relationships, friendship patterns, and life experiences are assessed in order to improve the understanding of the patient's world. However, the focus of the treatment is on the patient's symptoms in the present social context, not on the identification of recurrent relationship patterns and their links to childhood experiences.
Interpersonal, not intrapsychic. In exploring current interpersonal problems with the patient, the IPT therapist may recognize intrapsychic conflicts and mechanisms of defense used by the patient. However, the therapist does not attempt to provide interpretations. Instead, the patient's behavior is explored in terms of interpersonal relations.
Interpersonal, not cognitive-behavioral. Like cognitive-behavioral therapy (CBT), IPT attempts to change distorted thought patterns that the patient might have. However, unlike CBT, IPT does not attempt to uncover distorted thoughts systematically, nor does it attempt to help the patient to develop alternative thoughts. Rather, the therapist calls attention to those thoughts as they interfere with the interpersonal relationships of the patient. The goal is to change the relationship pattern rather than the associated depressive cognitions, which are recognized as symptoms of depression.
Consistent with the technique of most time-limited psychotherapies, the IPT therapist is rather active during the sessions, particularly in the initial phase of the therapy. The therapist helps the patient connect feelings with interpersonal behaviors and alerts the patient when the session focuses exclusively on either of these two elements. The therapist also helps the patient discuss progress in the interpersonal problem area, identify potential barriers to improvement and discuss strategies to overcome those barriers. As the therapy progresses, the goal of the therapy becomes not only to solve the current interpersonal problem, but also to help patients learn to solve future problems and pursue their own goals. Thus, the therapist tends to be less active in the later phases of the therapy. For example, the therapist will generally not allow long silences during the session or free associations. If the patient does not talk about the problem area (e.g., role dispute), the therapist will actively ask the patient about episodes of disputes since the last session and help the patient relate the disputes (or their absence) to the mood of the patient.
In IPT the therapist is an explicit ally of the patient. The therapist is nonjudgmental, expresses warmth and positive regard for the patient and congratulates the patient as progress in the problem areas is made. Naturally, this does not imply that the therapist accepts all aspects of the patient, as that would preclude any stimulus for change. Rather, it implies that the therapist works with the patient and for the patient and believes that the patient's problems can be solved. The therapist always tries to have the patient find the solution for the problems discussed in the session. However, the therapist is not afraid to make suggestions or provide direct advice when they seem useful.
This is a consequence of the medical model of depression adopted by IPT. As the therapist is not neutral but offers an alliance, the patients’ expectations of understanding and help are accepted as realistic. Similarly, the relationship between patient and therapist is seen as realistic, and as such not seen as transferential. Naturally, this attitude does not imply that the therapist is not sensitive to the pattern of relationship of the patient, but this pattern is generally not interpreted. Feelings (positive or negative) towards the therapist are left untouched unless they interfere with the progress of the therapy. In that case, the feelings are discussed, as they would be in any other medical or even professional collaboration. However, the focus should remain on the task at hand, namely the resolution of the patient's disorder in the context of the patient's interpersonal relationships outside the therapy and not the exploration of the relationship between the patient and the therapist.
Although the number of sessions may vary for different patients (or in different research protocols), IPT is generally conducted in 12–20 sessions, grouped in three phases: evaluation, intermediate, and termination.
The initial sessions, generally three or four, constitute the evaluation phase. They are devoted to defining the disorder in its interpersonal context and the formulation of the interpersonal problem areas. During the initial phase the therapist should accomplish four goals: (1) diagnose the disorder; (2) complete an interpersonal inventory and relate the disorder to the interpersonal context; (3) identify the major interpersonal problem areas; and (4) explain the IPT approach and make a treatment contract that includes the structure and length of the treatment.
During these sessions the patient describes the symptoms and interpersonal situation that led to treatment seeking. The therapist also evaluates the patient's current and past interpersonal relationships, looking for patterns relevant to current relationships. Examining the interactions of these relationships may elucidate the patient's current behavior, expectations, and obstacles to change in the patient's relationship.
In the final phase of the evaluation, the therapist gives the depression a name and provides the patient with the sick role—alleviating the responsibility and sense of guilt for being depressed. The interpersonal problem is then formulated into one of four categories in relation to the onset of symptoms: (1) grief (e.g., death of a loved one); (2) role transition (e.g., marriage, graduation, loss of status); (3) role dispute; and (4) interpersonal deficits (additional problem areas have been suggested for particular age groups or disorders other than depression, see below). If the patient accepts the formulation, an explicit contract is then made with the patient to work on that problem area, with the expectation that improvement in that area will lead to improvement in the depression.
A common difficulty, even for experienced therapists who are treating their first cases with IPT, is to select the focus of treatment. Patients often come with multiple problems, all of which may influence their mood. In those situations it is tempting to suggest that a time-limited treatment is not advisable, or even possible. IPT proposes that it is possible to treat the depression by narrowing the focus to one or two problems. Our experience suggests that patients generally manage the other problems better once their mood improves. Similarly, many ‘personality traits’ substantially improve or disappear as the depression lifts.
The intermediate phase starts immediately after the treatment contract is set and lasts until the beginning of the termination phase, which typically comprises the last two to three sessions. It is during the intermediate phase that the majority of the therapeutic work is done on the selected interpersonal problem area. During this phase, the problem areas, which were defined in the initial phase, are highlighted and therapist and patient collaborate to find potential solutions for the interpersonal problems. These may require a change in the expectations of the patient or attempts at asserting the patient's wishes in an acceptable way for all the parties involved in the interpersonal situation. There is a continuous emphasis on the connection between the symptoms of the disorder and the interpersonal context.
In our experience, most therapists are skilled at helping the patient establish the connection between the symptoms and the interpersonal context of the patient in the initial phase of therapy. In contrast, when the patient improves therapists appear to forget to point out this connection to the patient. However, it is important to continue to remind the patient of this link. This helps the patient not only understand but also experience the rationale for the therapy. A reminder of the link also rewards patient progress in the problem area, increases patient sensitivity to changes in his or her mood and interpersonal relationships and teaches the patient how to monitor that link to prevent future episodes of the disorder.
Depending on the problem area, the goals and strategies of the intermediate phase may vary:
From the point of view of IPT, the term grief is reserved for the loss of a loved one. Other losses, such as loss of a job, or the break up of a relationship are categorized as ‘role transitions’ (see below). Appropriate goals for grief include facilitation of the mourning process and helping the patient reestablish interests and relationships that could substitute for the lost one. The main strategy in the treatment of cases of grief is the reconstruction of the patient's relationship with the deceased, with a particular focus on the events surrounding the death. In those cases, patients have frequently expressed positive feelings about the loved one to their relatives and friends. However, more often than not they have felt guilty about discussing their negative feelings towards the deceased, or feelings of guilt regarding interactions they had soon before the death. As patients discuss those feelings, it becomes easier for them to consider possible ways of becoming involved with others.
The goals of treatment in role disputes are: (1) to help identify the dispute, and (2) to make choices about how to address the dispute. The direct approach to the role dispute relies on careful tracking of the sequence of interactions. In this way the patient can make changes in his or her own behavior and expectations that may lead to decreased conflict. Alternatively, after careful consideration the patient may decide that it is preferable to terminate that relationship, in which case part of the therapy will be devoted to assisting the patient in readjusting his or her life after such termination.
Issues that are characteristic of role transitions include the mourning of the old role and the restoration of self-esteem by developing a sense of mastery regarding the demands of the new role. As in the previous categories, expression of affect and relating positive and negative feelings to the depressive symptoms are key strategies. Realistic evaluation of what has been lost and what are the opportunities offered by the new role and encouragement for the development of the social support system and new skills necessary to perform the new role are also important in these cases.
IPT therapists have often used this category when the depressive symptoms could not be easily included under one of the three previous categories. However, some of the new adaptations of IPT for other disorders such as dysthymia and social phobia (or social anxiety disorder) appear to overlap with this category. Patients with interpersonal deficits are encouraged to decrease their social isolation and form new relationships. Exploration of past significant relationships are useful, but, consistent with the focus of IPT on the here and now, it is important to organize work mainly around current relationships or opportunities for new relationships.
The last two to four sessions constitute the termination phase. The tasks of the termination phase are: (1) explicit discussion of the end of treatment; (2) acknowledgement that the end of treatment is a time of potential grieving and anxiety; and (3) discussion with the patient regarding his or her independent competence. As the goal of IPT is to help the patient cope well without therapy, termination provides an opportunity to internalize strategies.
A certain amount of activity on the part of the therapist is needed here both in terms of helping the patient move from the intermediate to the termination phase and, related to that, helping the patient accept the time-limited nature of the treatment. Although it is openly acknowledged that termination is a time of grieving, the focus of the termination sessions is not the discussion of the feelings towards the therapist. The majority of the work is devoted towards reviewing the gains achieved in the therapy, helping the patient plan how to address other problems that might not have been discussed in the therapy, and helping the patient apply newly learned strategies to possible future situations to minimize the risk of relapse. At the same time, the patient is informed that should a new episode occur, the door is always open to return to therapy, very much the same way that a patient with a new episode of pneumonia would return for a new course of antibiotics.
Most of the techniques used in IPT are common to other psychotherapies, particularly psychodynamic and cognitive therapies. We list them here in order of increasing intrusiveness on the part of the therapist. However, it should be clear that each patient needs a different combination of techniques and that often any of several techniques could be appropriate at particular times of the therapy:
Exploratory techniques are geared towards gathering systematic information about the patient's symptoms and presenting problems. In general, the therapist starts with open-ended questions to allow for nondirective exploration. The therapist may start asking a very general question such as ‘where should we start today?’ or, in a case of role dispute, say something like ‘tell me about your husband’. More direct questioning includes obtaining the interpersonal inventory of the patient, a detailed exploration of the patient's important relationships with significant others.
Encouragement of affect encompasses a series of techniques that allow the patient to verbalize painful affects about events or issues that cannot be changed, help the development and constructive expression of new or unacknowledged affects and use the newly gained access to emotional experiences to facilitate growth and change. In a case of grief, the therapist may ask the patient to talk about aspects of the relationship with the dead person that were unpleasant, and how the patient felt on those occasions. The therapist may make supportive remarks such as ‘Of course most people would feel angry in that situation’, which may allow the patient discuss negative feelings towards the deceased. In a case of role transition, the therapist may encourage the patient to talk about the anxiety generated by the new situation or the demoralization that may follow the failure to meet the demands and expectations of the new role.
Clarification is used to make the patient more aware of what has actually been communicated as well as to facilitate the discussion of previously suppressed material. Strategies frequently used for clarification include asking patients to rephrase what they have said, calling attention to the logical extension of a statement by the patient or pointing out the contradiction between statements made by the patient. In a case of role dispute, the patient may say ‘I felt there was no point in talking to her any more’. The therapist may then ask ‘Did you feel hopeless?’ or ‘Did you feel angry?’, depending on the affect that the therapist suspects predominated in that interaction.
Communication analysis is used to examine and identify communication failures in order to help the patient learn to communicate more efficiently and effectively. Communication analysis is most effectively done through a detailed account of important interactions of the patient with a significant other, down to the specific statements made in the interaction. In a case of role dispute with her husband, the patient may feel that she has clearly conveyed why she is angry. Detailed discussion with the therapist may reveal that the reasons for that anger may not have been communicated so clearly, limiting the ability of the husband to cooperate towards a solution. In a case of role transition, the patient may fear criticism from others and be afraid to ask if what was perceived as a criticism was indeed intended as that. Here again, discussion with the therapist may help provide a more realistic view of the interaction.
Behavior change techniques are often used in conjunction with communication analysis and their goal is to help the patient consider a wide range of alternative options, and a systematic way of making decisions. Role-playing and modeling can be used to facilitate internalization of these techniques by the patient. In a case of skills deficit, a patient who wants to ask out for lunch a coworker may role-play different possible scenarios with the therapist, and plan how to react to the possible outcomes. An adolescent negotiating a new relationship with her parents may role-play how to ask for more autonomy with assertiveness but without being disrespectful.
Use of the therapeutic relationship. In IPT, the patient–therapist relationship is not the primary focus of treatment. Therefore, the use of this technique should be generally limited to instances where the therapist can provide feedback about interpersonal style and behaviors observed in the session and its relation to other interpersonal relationships. In this way, the patient–therapist relationship can be another experimental setting in which to practice new interpersonal skills. In a case of skills deficit, the therapist may encourage the patient to voice any dissatisfaction with the treatment. In a case of role dispute, disagreements between the patient and the therapist can be used to model how to negotiate divergent point of views without damaging the relationship.
As with any treatment, there are an almost infinite number of problems that can present at different phases of the therapy. We present some common examples here in order to illustrate how an IPT therapist would typically address them, although as always, each case has its own nuances.
Patients with poor social support may be tempted to use the therapist as a substitute for these resources. This situation may be chronic or may arise as a result of tendency of patients (especially those with depression) to underestimate their own capabilities to establish interpersonal relationships. To allow the therapeutic relationship to be viewed as a substitute for friends or family is a disservice to the patient. First, because the structure and expectations of friendship is very different than those of therapeutic relationships, topics are likely to be discussed in the sessions that will distract from the focus of the therapy. Equally important, the therapeutic relationship may interfere with the patient's attempts at improving the interpersonal relationships outside the treatment. Finally, it would raise important technical problems for termination, as by design IPT is time limited, while friendships are generally expected to last.
Confronted with this type of problem, the therapist should praise the patient for demonstrating the ability to engage in a close relationship. However, the therapist should also point out how this situation would in reality interfere with the achievement of the patient's goals in the therapy.
In most other therapies, this would be considered a problem in the therapy and probably become a focus of the treatment until it was resolved. In IPT it may be considered a problem related to the disorder itself. The initial approach is to make sure that trivial misunderstandings are clarified or that realistic problems are not responsible, such as difficulty to obtain childcare during the session time. The patient can also be reminded that missed sessions or lateness means less time to work on problems. This uses the pressure of the time limit to motivate the patient and move the therapy forward.
It is also possible that lateness or missed appointments are due to other reasons. The therapist should then try to treat the behavior as an indirect and inefficient communication whether or not the patient is aware of the potentially irritating effects of such behavior. The therapist should ask the patient directly what is getting in the way of arriving on time and, once the reason for lateness is stated, offer to work with the patient to solve that problem. Whenever possible, it is important to point out that the depression may be responsible or at least compound these maladaptive interpersonal behaviors. At the same time, the therapist should try to help the patient discover alternative, more direct methods to get the point across.
Some silence occurs in any treatment and in general does not require any intervention. Because the style of the sessions is generally conversational and the therapist is active, silence is rarely a problem. At times it might even be welcome as an expression of the internal work of the patient. If silences become frequent or prolonged, the therapist should assume that the patient is either avoiding recognition of conflicted thoughts or feelings about an issue or would like to bring up something but is concerned about the therapist's reaction.
After reassuring the patient that anything can be discussed during the session, the therapist may begin by asking silent patients what is on their minds or whether there is something they are refraining from discussing. This inquiry usually leads to the discovery of irrational interpersonal fears connected with revealing thoughts and feelings to others. The patient may be afraid of saying something shameful or describing feelings or interactions that may be disapproved by the therapist. In general those concerns should be addressed. However, due to the time limit, it is also important to decide how much time should be reserved for discussion of those topics, as they may distract from the main focus of the therapy.
As a result of their hopelessness, patients often believe that nothing can help them and that their depression will go on forever. Those feelings may make the patients uncooperative or complain about trivial issues. It is important to instill hope in the patients that the prognosis is good and explain that research suggest that the vast majority of patients improve with treatment. At the same time patients should be made aware of the effects of their behavior on their interpersonal relationships and be provided with alternative ways of handling displeasure. The patients may be encouraged to discuss with others ways of changing the situation or to try to change the relationship that is displeasing them.
In rare cases, patients may completely refuse to discuss the focus of the therapy or decline to participate in the solution of their problems. In those cases, the therapist needs to address the issues directly before the therapy can continue. If the patient refuses to discuss the focus of the therapy, the patient and the therapist need to reconsider whether the selected problem area is the correct one or whether other issues such as hopelessness or shame prevent the patient from discussing the topic. If the patient declines to participate in the solution of the problems, the patient can be asked whether continuing with the current situation (including depression or any other disorder being treated) is a more acceptable alternative, and the impact of that option on the patient's interpersonal relationships.
Although IPT is conceived as an individual treatment (except in the group adaptations discussed below), the patient and the therapist may choose to include significant others in some therapy sessions either to provide information or to obtain information from the relative. In general it is useful to realize that the significant other may feel guilty about the patient's condition and the therapist should initially suspend judgment about the significant others’ role in the situation. Naturally, this attitude needs to be balanced with a careful exploration of whether some family members may in fact be contributing the patient's distress. If this is the case, the role of the family member in the patient's difficulty should be acknowledged.
Exploring alternatives and options in treatment are important themes in IPT. The therapist should maintain an open, nonjudgmental attitude about these activities and they should be discussed in the therapy sessions. It is important to clarify the reasons for the additional treatment and the phase in the therapy where they take place. Additional treatments that are agreed upon during the evaluation phase (e.g., treatment with medication) or that are aimed at addressing very different problems (e.g., smoking cessation) are of less concern. However, treatments that are started during the intermediate or termination phase should immediately alert the therapist to potential dissatisfactions of the patient with the therapy. In those cases, the therapist should help the patient explore the reasons for the need of additional treatment: are there any symptoms left? Is there a lack of hope that the therapy will be able to treat the depression? Does the patient lack the confidence of being able to function autonomously, in the absence of a therapist?
In many cases, early termination cannot be prevented because the assumption of psychotherapy that talking things out should precede action runs counter to the coping styles of many individuals. Patients who express a wish to terminate prematurely should first be asked if they are satisfied with the results of the treatment. This is seldom the case, but provides the patient with an opportunity to express what has been accomplished and what remains for possible future work. In fact, from the interpersonal point of view the wish to terminate treatment can be understood as a role dispute with the therapist and the patient holding different views of how to resolve it. This view should be made explicit to the patient and attempt to engage the patient in that discussion.
As any dispute, there should be no a priori assumption that one of the parties is right while the other is wrong. Rather, an attempt should be made to clarify the source of the discrepancies and, if possible, to find a solution that is mutually satisfactory. The therapist may ask when the patient started to think about premature termination and what events and interactions led the patient to consider that possibility. This discussion may lead to clarification of the different expectations of the patient and the therapist regarding treatment. It may also expose inefficient modes of communication between patient and therapist. At the end of this discussion there can be an agreement that no further work remains to be done at that time, or the patient may be referred to another psychotherapist or to another form of treatment. If the patient is determined to terminate prematurely, the therapist should communicate, as strongly as possible, that return to therapy is open and would not imply defeat or humiliation.
Continuation of treatment is generally discouraged. IPT is time-limited therapy and part of its therapeutic strength may stem from the fact that, by design, it does not allow for unlimited discussion of issues but rather encourages the patient to try to change the situation. On occasion, a change in the circumstances of the patient during the therapy may justify a brief extension of the therapy (Blanco et al., 2001). Another possible exception is when IPT is used for maintenance, where a short-time treatment period would not be sufficient. It is also possible that after finishing IPT, the patient and the therapist agree that other type of treatment are indicated. However, in our experience that is rare. Finally, as previously mentioned, the patient should be reminded that should a relapse of the disorder happen, the patient should seek treatment again, as would be expected in any other medical condition.
IPT was initially developed for the acute treatment of major depressive disorder. Similarly to what happens with other medical treatments, over time clinicians and researchers have tried to extend the applicability of IPT for other disorders and for a variety of populations. In this section we present a brief overview of the efficacy data of IPT.
The first test of efficacy of IPT as an acute antidepressant treatment was a four-cell, 16-week randomized trial of IPT, amitriptyline (100–200 mg/day), their combination and a nonscheduled control treatment for 81 outpatients with major depression (DiMascio et al., 1979; Weissman et al., 1979). Patients assigned to the control group did not have regular treatment sessions, but could telephone to arrange a session if they experienced sufficient distress. Analyses of the results found all active treatments to be superior to the control condition and the combined treatment to be superior to either active monotherapy. There were no significant differences in efficacy between IPT and amitriptyline, although the therapeutic effects of amitriptyline appeared earlier. On the other hand, IPT and amitriptyline seemed to work preferentially on different symptom clusters: medication appeared to be more effective on the neurovegetative symptoms of depression, while IPT worked mainly on mood, interest, apathy, work, and suicidal ideation (DiMascio et al., 1979).
The efficacy of IPT as an acute treatment for depression was confirmed in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). This study randomly assigned 250 depressed outpatients to 16 weeks of imipramine, IPT, CBT, or placebo. IPT had the lowest attrition rate among the treatments. Because all treatments worked equally well for mildly depressed patients, no overall difference was found among treatments. However, with only severely depressed patients, differences did appear. IPT was similar to imipramine and was superior to placebo. CBT produced an intermediate level of response and was not superior to placebo. A reanalysis of the TDCRP indicated that medication was superior to the psychotherapies, while the psychotherapies were superior to placebo, particularly among the most severe patients (Klein and Ross, 1993).
Follow-up of both the Boston-New Haven and the TDCRP patients suggested that 16 weeks of treatment could induce remission of the acute episode but did not protect against relapse. Based on those results, Frank et al. (1989), 1990) compared pharmacotherapy and IPT as prophylaxis for 128 adult outpatients at high risk of relapse. In this study IPT for maintenance (IPT-M) was administered monthly, in contrast with the weekly schedule generally used in the acute treatment. IPT was adapted to focus on the prevention of relapse. The focus of IPT-M was to watch for signs and symptoms of emergent episodes and to develop interpersonal strategies to prevent future episodes. Because the goal of IPT-M was to prevent relapse, it was administered over 3 years as opposed to the usual 12–20 weeks of acute IPT. Owing the longer time frame, therapists and patients were allowed to shift among the four IPT problem areas. The results of the study showed that IPT serves to lengthen the time between episodes in patients not receiving antidepressants. The Frank et al. (1989) study is particularly important because it included subjects with multiple episodes of depression and at high risk of relapse, as the placebo cell demonstrated. Reynolds and colleagues (1999) conducted a study with a similar design in 187 geriatric patients, using nortriptyline instead of imipramine. The results of this study showed that all monotherapies were superior to placebo and that combined treatment was superior to IPT-M alone.
The rationale for modifying IPT for depressed adolescents (IPT-A) is based on the high prevalence and initial onset of depressive disorders in this population, the recognition of the morbidity and precipitating stressors of depression in adolescents and on the limited data regarding the efficacy of pharmacotherapy in young individuals. Mufson et al. (1999) adapted IPT for adolescents with nonpsychotic depression without comorbid substance abuse disorders or conduct disorder. Modifications for adolescents include (1) telephone contact, particularly during the first month, to support engagement in the therapeutic process, and (2) development of an alliance of the therapist with the parents and the school system. This alliance can help the therapist gather information on the patient's behavior and academic performance and to monitor progress. At the same time, the therapist may act as an advocate for the patient, educating parents and teachers on the effects of depression on school performance. To date, there have been two controlled trials of IPT in adolescents (Roselló and Bernal, 1999; Mufson et al., 1999), both of them showing the superiority of IPT-A over controlled waiting-list.
There are also three published trials of IPT in patients with late-life depression. The first two, relatively small studies (Rothblum et al., 1982; Sloane et al., 1985) used the standard IPT approach based on the original manual (Klerman et al., 1984). The latest, a large trial that included a discontinuation treatment design, used a manual developed for maintenance IPT for late-life depression, IPT-LLM (discussed below). The study by Rothblum did not include an IPT-alone cell and, although it suggested that IPT was well tolerated, it could not test its efficacy as a stand-alone treatment. In contrast, the study by Sloane failed to find differences between patients treated with IPT, nortriptyline, and pill-placebo over a treatment period of 6 weeks. In the study by Reynolds all patients received IPT plus nortriptyline in the acute phase, precluding an assessment of IPT as treatment of acute depression in the elderly.
IPT has also been adapted for use with HIV-positive patients and with pregnant and postpartum women. The rationale in both cases is based on the substantial changes that accompany those conditions (although those changes are much less pronounced now for the HIV group than they were when the therapy was adapted in the late eighties), and the convenience of minimizing the number of medications taken by those individuals. A controlled trial of IPT for HIV-positive individuals, modeled after the TDRCP, indicated that IPT and imipramine plus supportive therapy were both superior to CBT, with supportive therapy a distant but not statistically different third (Markowitz et al., 1999). Regarding postpartum women, O'Hara et al. (2000) compared IPT with a waiting-list control group in 120 women with postpartum depression treated for 12 weeks. A significantly greater proportion of women who received IPT recovered from their depressive episode based on Hamilton Depression Rating Scale (HRSD) scores of 6 or lower (37. 5%) and BDI scores of 9 or lower (43.8%) compared with women in the waiting-list group (13.7% and 13.7%, respectively). Women receiving IPT also had significant improvement on the Postpartum Adjustment Questionnaire and the Social Adjustment Scale-Self-Report relative to women in the waiting-list group. In another study (Spinelli and Endicott, 2003) randomized 50 outpatient antepartum women who met DSM-IV criteria for major depressive disorder to IPT or a didactic parenting education program for 16 weeks bilingual. The IPT group showed significant improvement compared with the parenting education control program at termination on the Edinburgh Postnatal Depression Scale, the Beck Depression Inventory, and the Hamilton Depression Rating Scale.
Most recently, Bolton et al. (2003) compared group IPT versus usual care for major depressive disorder in rural Uganda. The authors selected 30 villages in two districts of rural Uganda using a random procedure; 15 were then randomly assigned for studying men and 15 for women. In each village, adult men or women believed by themselves and other villagers to have depression-like illness were interviewed using a locally adapted Hopkins Symptom Checklist (SCL-90) and an instrument assessing function. Eight of the 15 male villages and seven of the 15 female villages were randomly assigned to the intervention arm and the remainder to the control arm. The intervention villages received group IPT for depression as weekly 90-minute sessions for 16 weeks, whereas individuals in the other villages received usual care. The authors found a mean reduction in depression severity was 17.47 points in the modified SLC-90 depression score for intervention groups and 3.55 points for controls, a highly significant result.
Following the success of IPT in the treatment of major depression, researchers have tested the efficacy of IPT in other mood disorders, namely, dysthymia and bipolar disorder. The motivation to study dysthymia was the general paucity of treatment research in this area and the relatively low (less than 50%) response rate of this disorder to medication treatment. The potential interest in IPT as a treatment for bipolar disorder stems from the manicogenic effects of antidepressant medication.
Although the IPT format for dysthymia (IPT-D) is very similar to the format for major depression, there are some important differences. For instance, IPT-D is usually conducted in 16 weeks, but is not unusual to continue to see the patient monthly for maintenance sessions, a practice that is much less frequent in the treatment of major depression. The problem areas are also often different, with interpersonal deficits being more common in individuals with dysthymia than in patients with major depressive disorder. Consistent with this fact, in most treatments of major depression an acute change in the pattern of the patient's interpersonal relationships can readily be identified. In contrast, the pattern of relationships of the dysthymic patient are generally chronic. As a result, the focus of the therapy is frequently formulated as a ‘role transition to health’.
Following promising results from pilot studies at Cornell University Medical College, two large randomized studies are nearing completion. In one of them, Browne et al. (2002) at McMaster University in Hamilton, Ontario, randomized 700 overtly dysthymic patients to 12 sessions of IPT, sertraline, or a combination of both over 4 months. Defining response as 40% decrease in the score of the Montgomery-Asberg Depression Rating Scales (MADRS), preliminary results of this study indicate that at 1-year follow-up, 51% of IPT alone subjects responded, compared with 63% in the sertraline and 62% in the combined group. A second study, in Toronto, Canada, is comparing IPT with the short-term psychodynamic psychotherapy of Luborsky (1984) in the treatment of 72 patients with dysthymia or double depression. Results are not available to date.
Frank et al. (2000) have modified IPT for bipolar disorder. This adaptation, called interpersonal and social rhythm therapy (IPSRT) retains the focus on psychosocial factors and the four problem areas characteristic of the original IPT. Moreover, a new component has been added to manage symptoms by regulating social rhythms. The rationale for this new component is that disruption of social rhythms can induce disruptions of biological rhythms, which in turn can trigger the onset of a bipolar episode. Techniques, such as self-monitoring, guided task assignments, and cognitive restructuring, are utilized to regulate the patient's life-style and stabilize social rhythms.
To date, there has been only one study (Frank et al., 1997) of IPSRT as adjunctive treatment to conventional medication clinical treatment of bipolar disorder. Preliminary analysis of this study failed to find differences between the two treatment groups, i.e., in the sample treated to date there was no advantage in treatment outcome for the IPSRT sample. However, the authors found that the IPSRT group showed significantly greater stability in daily routines as treatment proceeded, possibly providing some additional protection against future episodes.
One area that has not been systematically studied to date is the treatment of mood disorders with associated comorbidity, a common presentation in patients seeking treatment. There are three possible reasons for this lack of information. First, although the efficacy of IPT for major depressive disorder has well established, its adaptation for the treatment of other disorders, which should precede its use in comorbid cases, is more recent. Second, from the technical point of view, the focus of IPT in one or two problem areas would, in most cases, force the patient and the therapist select one of the disorders as the focus of treatment, and expect that the comorbid disorder would improve as the result of progress made in the problem area of the main disorder. Third, the emphasis on effectiveness studies is relatively recent. As interest in this type of studies continue, it is likely that IPT researchers will move to include patients with comorbid disorders, who are often excluded from efficacy studies.
Another area where systematic data are lacking is the use of IPT for patients who have failed other treatments for depression. Because IPT tends to be more efficacious in moderate than in severe depression, it will probably not be the treatment of choice in most of those cases as monotherapy. However, studies of a combination of medication plus IPT may help provide empirical evidence for the efficacy of an alternative approach for treatment-resistant cases.
Because not only depression, but all psychiatric disorders occur in the context of interpersonal relationships, it is natural to think that IPT may be efficacious in nonmood disorders. Anxiety disorders are generally considered nosologically close to mood disorders and several researchers are currently investigating the efficacy of IPT to treat social phobia (also known as social anxiety disorder), posttraumatic stress disorder (PTSD), and panic disorder.
Both individual and group IPT for social phobia are being developed and tested. One particularity of IPT for social phobia (IPT-SP) is that the disorder itself subsumes some aspect of role dysfunction. Because social phobia often has an early onset and a chronic course, the approach of IPT-SP is in many ways similar to that of IPT-D. Lipsitz et al. (1999) have added an additional category of ‘role insecurity’ to the classical four problem areas. This category captures difficulties that are generally milder than those defined by interpersonal deficit. Role insecurity encompasses common symptoms of social phobia such as lack of assertiveness, avoidance of conflict and rejection sensitivity (called ‘interpersonal sensitivity’ by Stuart and O'Hara). Weissman and Jacobson have adapted IPT in a group format for patients with social phobia, using a 10-session time-limited group. Consistent with the work of Lipsitz, the focus of the treatment is on a therapeutic role transition to a less impaired state. An open trial by Lipsitz et al. (1999) has provided preliminary positive results for IPT-SP and controlled trials are currently under way.
Like social phobia, PTSD is defined by a connection between symptoms and life situation, although in the case of PTSD, by definition, the triggering life events are clearly identified. Krupnick at Georgetown University recently completed a comparison between IPT-PTSD and a waiting-list control group in low-income women attending gynecology clinics (personal communication). IPT was superior to the waiting-list control at the end of the treatment on several measures. A smaller trial, but with a more diverse population in terms of age, ethnicity, and gender distribution, using individual format also showed the superiority of IPT over supportive psychotherapy in measures of PTSD, depression and social functioning (Markowitz, personal communication). Several groups, both in the US and abroad, are currently adapting IPT for panic disorder. However, no manuals or efficacy data have been published to date.
IPT has also been adapted for bulimia nervosa. Although the basic principles of IPT remain unchanged in this adaptation, the four interpersonal problem areas associated with depression may not be as relevant for eating disorders. The maintenance of those areas or the creation of new ones better suited for the treatment of bulimia nervosa requires further exploration. In contrast with IPT for depression, where talk about depression is encouraged, in IPT for bulimia the focus is on the interpersonal relationships and discussion of eating patterns is expressly forbidden in the therapy sessions. Two randomized trials, one using an individual format (Fairburn et al., 1993) and the other a group format (Wilfley et al., 2002) have shown that IPT and CBT have similar efficacy in the treatment of bulimia nervosa. Preliminary results from a multicenter study using an individual format suggests that CBT may be superior to IPT at the end of the acute treatment, but similar at 1-year follow-up.
Currently, other applications of IPT are being studied. These include use of IPT for the treatment of body dysmorphic disorder, somatization disorder, depression following myocardial infarction and in patients with physical disabilities, primary insomnia, and borderline personality disorder. There has also been an increased interest in adapting IPT for administration in other formats. Among these the most popular has been the adaptation to group format for a variety of disorders. Administration of IPT over the phone (Miller and Weissman, 2002) has also become increasingly interesting due to the difficulties of certain patient groups in attending regular therapy sessions (e.g., low income women with young children). IPT is also being adapted to be more consonant with other cultures (Roselló and Bernal, 1999).
Finally, it is important to realize that IPT is not efficacious for all disorders. First, many of the applications described in this section have very limited data on efficacy and still require confirmation by other groups. Second, there have been two negative trials of IPT for the treatment of substance abuse disorders suggesting that certain conditions might require a different treatment approach (Rounsaville et al., 1983; Carroll et al., 1991). Third, it is possible that, similar to the case of clinical trials with medication, some negative studies with IPT may have not been published. If publication bias exists in IPT, this bias may overstate the efficacy of IPT for the treatment of psychiatric disorders. Meta-analytic techniques might be able to assess the existence of such bias, and assess whether IPT has similar efficacy for different disorders or appears to be more efficacious in selected disorders.
Over the last two decades the interest of clinicians and researchers in IPT has grown exponentially and its applications have multiplied. IPT is now a well-established treatment for major depression and it is likely to continue to grow as an alternative to medication and to other psychotherapies. There is growing evidence that IPT can be successfully adapted for other psychiatric disorders and for individuals with very different cultural backgrounds. The International Society for Interpersonal Psychotherapy (ISIPT) has been formed whose mission is to provide information on the application of IPT for a range of mental health disorders and to publicize recent research and clinical findings related to IPT (http://www.interpersonalpsychotherapy.org). Initially the homogeneity of treatment delivery was assured due to the relatively small number of practitioners and applications. A major challenge for IPT will now be to conserve its essence as it is practiced by an increasing number of clinicians, for an increased number of disorders and adapted to an increasing number of cultures.