IPT West Midlands Dr Marie Wardle Programme Director ipt.westmidlands@nhs.net
Interpersonal Psychotherapy (IPT) A focused treatment plan for depression and other psychiatric disorders Maintains a focus on the interpersonal context of the symptoms
NICE stepped-care model of depression STEP 1: All known and suspected presentations of depression n Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions STEP 2: Persistent subthreshold depressive symptoms; mild to moderate depression n Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions STEP 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate and severe depression n Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions STEP 4: Severe and complex depression; risk to life; severe self-neglect n Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care 3
Efficacy and Research Adults, adolescence, elderly, veterans CAMHS Eating Disorders Service P.T.S.D. Depression with HIV, medical illness Depression with post/peri-natal and postpartum, parent/child, pre-adolescents, abuse Depression with P.D. or Bi-polar
What is IPT? Treatment specific processes Therapeutic alliance IPT
Depression associated with... Interpersonal Role Transition Role change, subjectively experienced as a loss Interpersonal Role Disputes Current overt or covert dispute with a significant other Grief - complicated Bereavement related depression associated with withdrawal from current relationships Interpersonal Sensitivity/Deficits Long standing difficulty establishing and/or maintaining relationships
Introducing the IPT model Evidence based treatment for depression IPT with and without medication Symptom and interpersonal focus combined 3 phases of treatment and associated goals Task of selecting an interpersonal focus and agreeing an interpersonal formulation Engaging others in the work Here and now timeframe Time limited delivery
The phases of IPT treatment Initial sessions 1-4 Middle sessions 5-12 Grief Interpersonal Disputes Role Transitions Interpersonal Sensitivity/Deficits Conclusions of acute treatment 13-16 Diagnosis Interpersonal Inventory Interpersonal formulation Contract Monitoring symptoms Interpersonal work Specific Techniques Separation responses Review of progress Contingency planning Maintenance Maintenance contract Prevention of relapse
Theoretical Influences Medical model Interpersonal School of Psychiatry Attachment Theory Communication Theory Social Theory
Medical Model The medical model is one in which illness is seen as the result of a physical condition, is intrinsic to the individual, may reduce the individual's quality of life, and causes clear disadvantages to the individual. As a result, curing or managing illness revolves around identifying the illness, understanding it and learning to control and alter its course. In IPT the patient is understood to have a disorder. The disorder is understandable. diagnosable and to some extent It is therapeutically beneficial to the patient to identify depression as means of understanding current experience. As a consequence he/she should be given the sick role (for a short time)
Attachment Theory Attachment theory hypothesizes that individuals have difficulties when they experience disruption in their attachments with others. This is because of the specific loss of the attachment relationship and/or because their social network is not able to sustain them during significant loss, conflict or transition. Insecurely attached individuals are much more vulnerable to difficulties with personal conflicts, such as divorce or separation, to role transitions such as moving or loss of a job, and to the loss of significant attachment figures through bereavement, both because of their tenuous primary relationships and because of their poor social support networks.
Communication Theory 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 & Roberston, 2003
Social Theory Having few social relationships contributes to psychological distress regardless of level of adversity. The current social environment is of crucial importance, independent of past experience. Interventions 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.
Interpersonal School Adolf Meyer Placed great emphasis on the patient s current psychosocial and interpersonal experience 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 Viewed psychiatry as the detailed study of people and the processes which go on among them. Focused on direct and verifiable observation. Attention to the interactional rather than the intrapsychic. First reference to the significant other and problems in living in psychological literature. The search for satisfaction via personal involvement with others led him to characterise loneliness as the most painful of human experiences. I-You behaviours what an individual does is meant to elicit a reaction from others. Rigid or limited patterns can create interpersonal problems and barriers in adult life.
Interpersonal Inventory Significant contemporary relationships recent changes, losses, and gains History of current problems and impact on relationships and vice versa i.e. expand on existing assessment Communication styles & patterns of interaction Level of social support Relationship expectations and satisfaction Facilitates planning of treatment interventions Evolves and changes during treatment and may re-orientate therapy Evaluative NOT simply descriptive
The hierarchy of relationship involvement Best friend Partner Colleague Most involved self self Least involved Intensity of emotional investment Daughter Teacher Mother
Framework for IPT formulation Biological Factors Genetics, Medical Illness Medical Treatments Social Factors Intimate Relationships, Social Support, Loss Psychological Factors Attachment Style, Temperament, Coping Mechanisms, Cognitive Style Unique Individual Sufficient Social Support Interpersonal Crisis Grief Interpersonal Disputes Role Transition Interpersonal Deficits/Sensitivity Resolution Interpersonal Distress Psychiatric/Psychological Symptoms
Driven by results PHQ-9 score improvement using IPT 30 25 PHQ9 scores 20 15 10 Session 1 Session 16 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Cases
Training p High Intensity for qualified mental health practitioners who must also have a qualification in psychological therapies p IPTUK Accredited Training p Training delivered locally by IPT West Midlands, hosted through SSSFT p 1 yr training for Practitioner Level p 18 months for Supervisory Level