Interpersonal Psychotherapy (IPT) for depression

Transcription

1 Interpersonal Psychotherapy (IPT) for depression Dr Marie Wardle Psychotherapist, PhD, MA, PGCE IPTUK Accredited Trainer, Supervisor & Practitioner, BACP Accredited Psychotherapist Programme Director for IPT West Midlands, South Staffordshire & Shropshire Healthcare NHS Foundation Trust Introduction Interpersonal Psychotherapy (IPT) is an evidence-based therapy, which was originally developed as a treatment for moderate to severe depression. It is now an empirically validated treatment that is offered for a variety of psychiatric disorders and for a wide range of patients from children, adolescents to the elderly. It is a time-limited psychotherapy that focuses on interpersonal issues, which are understood to be a factor in the genesis and maintenance of psychological distress and illness. The targets of IPT are symptom resolution, improved interpersonal functioning and increased social support. Typical courses of IPT range from 8-20 sessions, depending on the severity of the illness and provision for maintenance treatment as necessary. IPT is concerned with the interpersonal context and relational factors that predispose, precipitate and perpetuate the patient s distress. The theoretical rationale of IPT rests on the idea that psychiatric disorders occur in an interpersonal context and the therapy focuses specifically on interpersonal relationships as a means of bringing about change and improvement in their functioning. IPT maintains a here and now perspective on what might be recent or recurrent and is primarily concerned with current interpersonal relationships; it recognises that early interpersonal relationships and attachments will feature in current patterns of interpersonal relationships. IPT does not seek to modify early attachment patterns, due to the 1

2 thematic nature of the treatment, but does seek to help the patient to recognise and understand where these patterns and difficulties originate from. IPT has a dual model, it is a treatment specific process with clinical interventions that are specific to the agreed focal area of interpersonal difficulty, and a therapeutic alliance which requires the patient to be very involved in the therapy and involve others outside of the therapeutic room in the recovery of their depression. Interpersonal Therapy is what it says it is, that is it is interpersonal by name and nature and involves others in the journey from being unwell to well. It is very much concerned with what is going on outside of the therapy room that is contributing towards the patient s illness and also their journey into recovery and beyond therapy in remaining well for longer (Law, 2013). Patients who enter into a treatment of IPT should expect to get well, as they will learn to navigate around the formation of psychiatric symptoms. They will come to know what is holding their depression in place, and where there have been previous episodes of depression, will come to understand what has been tripping them up in the past. Whilst the patient may well already know that they are depressed when entering therapy, they will come to know the illness from every corner of their interpersonal world. Historical Development IPT is a well-researched and well-practised approach that has been used effectively for over forty years in lifting people out of depression (Law, 2013). It is true that it has been slow to develop, particularly in the UK, and whilst it was back in the 1970 s thought at that time to be the new therapy of that decade, it somehow managed to get left behind when the development of CBT took us by storm. Slowly, but gradually, we are seeing the development of IPT start to take residence in Psychological 2

3 Therapies with more IPT training courses now spreading across the UK in a steady but upwards turn. The origins of IPT sprang from the work of Gerry Klerman, Myrna Weissman, and their colleagues a group of psychiatrists, psychotherapists, social workers and researchers who were interested in how the social, biological and psychological parts of depression overlap and how they could be used together in treatment. This work began in the States in the 1960 s with the research project underway and out of which IPT was created (Klerman and Weissman, 1993). They could not have known then the profound impact that their work would have on the treatment of individuals with major depression, but also for those patients who had a depression alongside other disorders (Frank and Levenson, 2011). IPT was developed as an effective treatment for individuals who experience depression at many stages of the life span, and it has been successfully adapted over the years to use with clients experiencing a wide variety of disorders (Hollon et al., 2005, Lipsitz et al., 2006). In recent years the popularity of IPT has spread around the globe to communities in Europe, South America, Australia and Africa. Along with the global expansion of IPT, comes the ability to offer IPT to non-western clinicians in non-western cultures and treat people who have a depression alongside for example HIV, Eating Disorders, and other physical illnesses. The fact that IPT has reached and been found beneficial in so many communities speaks to Klerman and Weissman s ability to envision a treatment that appears to have near-universal applicability. When Klerman and Weissman commenced their development of IPT, it was not their intention to develop a new model, but to draw on some already established theories from the world of psychiatry, psychology and sociology (Klerman, Markowitz and Weissman, 2000). 3

4 The Five Theoretical Influences The body of theory is derived from five theoretical influences, namely the medical model, attachment theory, communication theory, social theory and the interpersonal school of psychiatry. These form the foundation on which the IPT model sits and all five of these are instrumental in shaping the strategies and interventions employed in the treatment. On the surface, it seems that they bear no relation to each other, as they appear to be coming from a different perspective, but the geniality of incorporating these into a time-limited treatment demonstrates the extent to which IPT can treat some fairly complex cases. The medical Theory - The patient is understood to have an illness, and that there are genetics involved in depression. Having a diagnosis of depression can be very demoralising and it is important that the patient is offered some psycho education to understand the illness, and what is expected of them during the acute treatment phase. IPT helps to alleviate some of the burden and guilt that the patient can carry in being depressed, whilst also helping them to accept that this is an illness which can be diagnosable, treatable, and to some extent understandable. The IPT therapist will offer the patient optimism and hope, and some reprieve from some of the daily demands placed on them, particularly during the first part of the treatment phase. Here we are aiming to reduce self blame, and this will subsequently help to get the patient started on their treatment and involve getting others to assist with the patient s treatment. Anti-depressant activity is commenced immediately, and this is often described as doubling the therapeutic dose. This will give the treatment a kick start and be instrumental in starting to see some of the depressive symptoms fluctuate in frequency, intensity and duration. There is extensive clinical trial evidence for the effectiveness of IPT as an independent treatment for depression (Cuijpers et al), but 4

5 where IPT is offered as a combined treatment there is a synergistic effect in the combination of IPT and pharmacological treatment. NICE review of effectiveness of pharmacological treatments states that the more severe the symptoms, the greater the benefit from antidepressant treatment, but 30% of patients will not respond to a firstline treatment. Attachment Theory - A lot of this theory in IPT comes from the work of Bowlby (1969, 1980). Where the early attachment of the patient has not been very solid or secure, in IPT it is understood that it will impact on the depression, and also the treatment. Attachment theory hypothesizes that individuals have difficulties when they experience disruption or injury in their early attachments with others. If there have been dysfunctional or deficits in the early childhood attachments, these disruptions may well be played out through a cycle of change in the patient s adult life as they experience change, loss or relationship disharmony in their adult life; this may well provoke the patient to deal with this current or recent difficulty in the manner of their earliest attachment patterns. As I have already mentioned, IPT does not attempt to modify the underlying attachment style, but does use attachment style to inform and help the patient to see where difficulties comes from now, why they arise, and the impact on their mental health. The early attachment between baby and primary caregiver is essential for the child s development and learning (Bowlby, 1980). The adult s attachment behaviour towards the baby is key to the child s attachment pattern because it stays with us in adult life and is repeated in later relationships. IPT looks at how current attachments are affected by early attachments. Communication Theory - Following on from attachment theory, we can see that inadequate interpersonal attachments lead to inadequate communication patterns and 5

6 styles, which may illicit conflict, disharmony and depression. IPT teaches the patient how to do things differently. We know that maladaptive attachment styles lead to inappropriate or inadequate interpersonal communication that prevents individuals attachment needs from being met. The continual and rigid verbal and non-verbal pattern of communication elicits a rigidly restricted range of responses from others, usually culminating in a rejecting response from others. Interpersonal problems occur because individuals unintentionally elicit negative reciprocal responses from others in a recurrent and consistent manner, e.g. consistently avoid asking for help, consistently demand help in a manner, which results in others avoiding. Maladaptive attachment styles and communication patterns are reinforced by the responses which they provoke (Stuart & Robertson, 2003). Interpersonal School of Psychiatry focuses on what is going on in the here and now that is making the patient ill and what is going on in the interpersonal world that contributes to the patient s mental health difficulties. By this I mean what feeds the illness, is it the environment, social, psychological and emotional that is in addition to the biological. In the here and now interpersonal context, we can still tell much about the past because the patterns run throughout the life stages. Two psychiatrists who were instrumental in the development of interpersonal school of psychiatry were looking at different ways to understand their patient s mental health back in the 1930 s. Adolf Meyer a Swiss psychiatrist placed great emphasis on the patient s current psychosocial and interpersonal experience. He insisted that patient s could be best understood by consideration of their life situations. Psychobiology focused detailed attention on the biological, psychological and social aspects of the individual s experience - protective and vulnerability factors. Harry Stack Sullivan was an American psychiatrist and a student of Meyer s. He viewed psychiatry as the 6

7 detailed study of people and the processes which go on among them. He focused on direct and verifiable observation and gave attention to the interactional rather than the intrapsychic aspect of people s mental health (Jacobson, 1955). The search for satisfaction via personal involvement with others led him to characterise loneliness as the most painful of human experiences. Sullivan was described by many of his colleagues as ahead of his time (Barton Evans, 1996). The majority of them first responded to his ideas by ignoring them and then criticising and attacking them. Sullivan totally dis-regarded the importance of the intrapsychic experience as he was more concerned with we can see out there in the interpersonal space. He believed that once a person discusses or even anticipates discussing an internal experience it is no longer private or internal, but becomes an interpersonal event affected by social forces. He became interested in the patient s interpersonal world and the dynamisms of energy exchanges between people. By a trained awareness of his own processes the psychiatrist was perhaps qualified to recognize distortions in the patient s behaviour, caused by his own unresolved past situations. During Sullivan s professional years he did much to revise outdated views of psychiatry, attending to the interpersonal element that was missing in understanding a patients disorder. The roots of Sullivan s interpersonal theory brought him success in treating patients with schizophrenia and other paranoid states. Sullivan s perspectives on the problem of mental disorder, has been defined variously as difficulties in interpersonal living or patterns of inadequate or inappropriate interpersonal relations. In approaching the subject of mental disorder, I must emphasize that, in my view, persons showing mental disorder do not manifest anything specifically different in kind from what is manifested by practically all human beings. 7

8 (Sullivan, 1940/1953:3) Social Theory - Is concerned with how a person get their needs met in a social world and what is going on in their social world now is of primary importance, is it a rich or poor social world. Having few social relationships contributes to psychological distress regardless of level of adversity and the interventions used in IPT, which affect current social relationships, will lead to improved functioning. Those individuals who do not have, or do not perceive that they have, confidants or a sufficient social network are much more likely to have mental health difficulty, especially when faced with a significant social stressor. Early/Assessment Phase - sessions 1-4 A typical treatment of IPT consists of a 16 session treatment with three distinct phases of treatment early/assessment, middle/intermediate and end phase. The assessment phase includes a diagnosis, identifies the cluster of depressive symptoms that form the patient s symptom signature, and provides the patient with psychoeducation on depressive disorder. The clinical importance of conducting a comprehensive interpersonal inventory cannot be overemphasized and accurate identification of the patient s primary problem areas is often complicated and crucial to successful treatment (Markowitz and Weissman, 2012). A full history is taken of the current onset of depression, previous depressive episodes, past treatments, narrative and an understanding of how this current interpersonal crisis has developed. The different strands of the assessment are drawn together to explicitly link the depressive symptoms to a central difficulty within the patient s interpersonal situation in a focused formulation. This will form the basis of the second stage of treatment. Many patients experience difficulties in more than one area simultaneously, and by being helped to prioritise one area to work on they 8

9 are assisted in evaluating the relative impact of interpersonal difficulties on the depression. This allows the prioritising of energy to resolve difficulties in a specified area rather than becoming overwhelmed by the enormity of the task they face. There are four identified focal areas used in IPT and one of these will be agreed to form the middle phase work with the patient. Formulation The IPT Formulation should explicitly reflect the patient s interpersonal story, the information gathered in the timeline, narrative, symptom review and the interpersonal inventory. It should also make some reference to the biological, social and psychological factors that the patient has told you about. The Formulation should help the patient to develop an understanding of how the difficulty began and how the patient might achieve constructive change. It is important that the formulation is meaningful and acceptable to the patient and is the basis for identifying specific goals to work with in middle phase treatment. Intermediate/Middle Phase: sessions 5-12 The intermediate or middle phase usually consists of 8 sessions and is considered the work of treatment (Denise, et. al), 20012). One of the following four focal areas is selected to treat the depression and will be employed throughout this phase and carry on into end phase work with the patient. Complicated Grief Grief associated with the death of a loved one can be normal or abnormal. IPT deals with depression associated with abnormal grief reactions that result from failure to go through the various phases of the normal mourning process. People who experience normal grief do not generally seek psychiatric treatment. The principal assumption 9

10 behind the therapist s strategy for dealing with abnormal grief is that inadequate grieving can lead to depression, either immediately following the loss or at some later time when the patient is somehow reminded of the loss, or it is triggered by another interpersonal event that involves change or loss. Abnormal grief processes of two general kinds are commonly noted in depressed persons. Delayed grief and distorted grief. In delayed grief reaction grief is postponed and experienced long after the loss. When this grieving occurs, it may not be recognized as a reaction to the original loss, but the symptoms are those of normal grieving. Delayed grief reaction taps into previous significant losses that are keeping someone stuck. In distorted grief reaction may occur immediately following the loss or years afterward. There may be no sadness or dysphoric mood, but instead non affective symptoms may be present. In IPT, due to the thematic time-limited nature that IPT will only start the grieving process and this will continue after treatment has ended. Goals Facilitate the mourning process Help the patient re-establish interest and relationships to substitute for what has been lost Strategies Review the depressive symptoms Relate symptoms onset to death of significant other Reconstruct the patients relationship wit the deceased Describe the sequence and consequences of events just prior to, during and after the death Explore associated feelings (negative as well as positive) Help patient to consider possible ways of becoming involved 10

11 ROLE DISPUTES For this focal area to be selected in treating the depression there must be evidence of current overt and covert conflicts with a significant other. Dispute work focuses on detailed reconstructions of unsatisfactory exchanges, reviewing not only what was said but how it was said, how it was received, what was left unsaid and to what extent the communication achieved the desired outcome. Here we look at how to help the patient to get people on their side, identify the client s communication patterns, how they link to the depression, help them to recognise their part in the dance and what keeps the difficulty going. The use of communication analysis forms a strong feature in the treatment of this focal area. This involves learning to do things differently, how to manage the anxiety and hopelessness of the situation and how to work on motivation to attempt change and work on repeating pattern and clarifying issues to discuss reciprocal roles. Key concepts to understand in formulation are: a) who is the primary dispute with, b) what are the interpersonal implications of this dispute happening and c) what resources can be called on or developed to manage or reduce the impact. Goals Identify dispute Choose a plan of action Modify expectations or faulty communication to bring about satisfactory resolution Strategies Review depressive symptoms Relate symptoms onset to overt or covert dispute with significant other with whom patient is currently involved Determine stage of dispute impasse renegotiation - dissolution Understand how nonreciprocal role expectations relate to dispute 11

12 Are there parallels in other relationships? ROLE TRANSITIONS For this patient group change is a problem and they have difficulty in coping with life changes that require a change of role. Adjustment is a real problem and is identified as feeding into the depression. Indicators of role transitions are varied and wide and include age, life stage, illness, relationships, change of status, employment, failing in a new role, situational change, migration to name but a few. Key concepts to understand in formulation when working with this focal area is which role has changed that is most closely linked to the depression, what are the interpersonal implications and symptom formation, and what resources can be called on or developed to manage or reduce the impact. Goals Facilitate mourning and acceptance of loss of old role Help the patient to regard the new role as more positive Help the patient to restore self esteem by developing a sense of mastery regarding Strategies demands of new roles Review depressive symptoms Relate depressive symptoms to difficulty on coping with some recent life change Review positive and negative aspects of old and new roles Explore feelings about what is lost Explore feelings about the change itself Explore opportunities in new role Realistically review what is lost Encourage appropriate release of affect 12

13 Encourage development of social support system and new skills called for in new role INTERPERSONAL DEFICITS The patients for whom Interpersonal Sensitivity is the primary focus often have a history of interpersonal difficulties or isolation extending far beyond the period of the most recent episode of depression. The long standing difficulty in interpersonal relationships is often accompanied by the patient having disorganized and chaotic attachment patterns; relationships are often unstable and difficult to sustain. Some indicators of identifying patients who may fall into this category are that they may well have a limited or exclusive contact with family, a lack of significant intimate relationships, a history of repeated relationship failures, isolative employment, a preference for solitary activities, and they are not aware of the implications on their behaviour and this may be a feature of the work in the therapeutic alliance. The timeline of the depression may not be as clear for the onset of depression. Goals Reduce the patient s social isolation Encourage formation of new relationships Strategies Review depressive symptoms Relate depressive symptoms to problems of social isolation or unfulfillment Review past significant relationships including their negative and positive aspects Explore repetitive patterns in relationships Discuss patient s positive and negative feelings about the therapist and seek parallels 13

14 Termination Phase sessions The four session termination phase is a time for reflection and evaluation on what has been achieved during treatment and what is to be accomplished in the future (Markowitz & Weissman, 2012). The work will consist of:- Explicitly discuss termination Acknowledge that termination is a time of grieving Separation responses Review of progress Contingency planning Maintenance contract and relapse prevention strategies Finally, No two people s depression is the same, but IPT finds out what characterizes the patient s depression and if we can treat the depression then we can ease some of the psychiatric symptoms. Through IPT the patient learns how to resolve the existing interpersonal challenges, how to anticipate future interpersonal concerns and how resolution will contribute to reducing the depression. In IPT the patient will learn how to tune into their symptoms so that they can learn what sets them off, whom and what can help to tone them down and how to stay well for longer. There is no doubt that IPT efficaciously treats depression, both as an independent treatment and in combination with pharmacotherapy. IPT deserves its place in treatment guidelines as one of the most empirically validated treatments for depression. References Barton Evans, F. III. (1996). Harry Stack Sullivan. Interpersonal Psychotherapy. Routledge: London. Bowlby, J. (1969). Attachment. Pelican: London. 14

15 Bowlby, J. (1980). Attachment and Loss. Volume 3 Loss: Sadness and Depression. Basic Books: London. Cuijpers, P., Geraedts, M.A., van Oppen, P., Andersson, G., Markowitz, J.C., van Straten, A. (2011). Interpersonal Psychotherapy for Depression: A Meta-Analysis. American Journal of Psychiatry, 168: Laten eraedts, M.A., van Oppen, P., Andersson, G., Markowitz, M.D., Annemieke van St Denise, E., Wilfley, Juliette, M., Iacovino, and Dorothy, J. Van Buren. (2012). Oxford University Press: New York.. Frank, E., & Levenson, J.C. (2011). Interpersonal Psychotherapy. American Psychological Association. Washington, D.C. Hollon, S.D., Jarrett, D.B., Nierenberg, A.A., Thase, M.E., Madhukar, T., & Rush, J. (2005). Psychotherapy and medication in the treatment of adult and geriatric depression: Which monotherapy or combined treatment? The Journal of Clinical Psychiatry, 66(4), Jacobson, E. (1955). Review of Sullivan s Interpersonal Theory of Psychiatry. Journal of the American Psychoanalytic Association, 3: Klerman, G.L., & Weissman, M. M. (1993). (Eds.). New applications of interpersonal psychotherapy. Washington, DC: American Psychiatric Press. Klerman, G.L. Markowitz, J..W., & Weissman, M.M. (2000). Comprehensive Guide to Interpersonal Psychotherapy. Basic Books: London. Law, R. (2013). Defeating Depression. Constable & Robinson: London. Lipsitz, J.D., Gur, M., Miller, N.L., Forand, N., Fyer, A. J., Vermes, D. (2006). An open pilot study of interpersonal psychotherapy for panic disorder (IPT-PD). The Journal of Nervous and Mental Disease, 194(6), Markowitz, J.C. & Weissman, M.M. (2012). Casebook of Interpersonal Psychotherapy. Oxford University Press: New York. Stuart, S.& Robertson, M. (2003). Interpersonal Psychotherapy: A Clinician s Guide. Arnold: London. Sullivan, H. S. (1940/1953). Conceptions of Modern Psychiatry, (2nd ed). W.W. Norton & Company: New York. 15

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