Psychotherapy Applications by slp21736


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									Interpersonal Psychotherapy:
  Evidence and Application

     Joy E. Moel, Roberta Casko,
    Kimberly Nylen, & Tracy Moran

            University of Iowa
Iowa Depression and Clinical Research Center
    History and Development

 Developed in the 1970s by Gerald
 Klerman, Myrna Weissman and
 Era   of tricyclic antidepressants
 IPT was not initially developed as an
 active treatment for depression
       History and Development
   Served as the psychotherapy component
    in a drug treatment trial comparing the
    relative efficacy of antidepressants alone
    and in combination with psychotherapy

   Originally called “high contact,” indicating
    that benefit to patients would be due to
    nonspecific effects rather than specific
       History and Development
   Maintenance studies showed the efficacy of
    “high contact”
   Klerman and Weissman began to more fully
    describe the treatment, termed IPT, and
    published a manual (Klerman, Weissman,
    Rounsaville, 1984)
   Designed an acute treatment trial of
    medication, IPT, and combination.
           What is Interpersonal

   Interpersonally based psychotherapy
    – Focuses on modifying disrupted relationships
      or expectations about those relationships
   Time-limited
    – Focus on here-and-now
   Non-transferential
    – Psychodynamically informed vs.
      psychodynamically oriented
          What is Interpersonal

 Manual based
 Empirically based
 Goals of treatment
    – Symptom relief
    – Improved interpersonal functioning
    – Resolve acute interpersonal crisis
    – Increase social support
           Therapeutic Stance
 Understand the client
 Active
 Client advocate
 Supportive
 Directive
 Non-transferential

   Client responsible for direction and change
  IPT: Theoretical Framework
 Biopsychosocial
 Attachment Theory (Bowlby)
  – Relationships are primary
  – Attachment is a biological drive
  – Attachment is a cybernetic system
  – Capacity to form flexible attachment is
    principal feature of mental health
       Attachment Styles

 Secure
 Anxious Ambivalent
 Anxious Avoidant
        Attachment Theory

 Patterns of attachment develop early and
  tend to persist, but are not fixed
 Patterns of attachment persist within
 Patterns of attachment persist across
           Attachment Theory

 Those with less secure attachment are
  more prone to psychiatric symptoms
 Disruption of attachment increases
  vulnerability to psychiatric symptoms
 Psychiatric symptoms result from
  Biopsychosocial factors
 Dysfunction results from
    – An acute crisis, attachment disruption,
      inadequate social support
    Attachment Theory: Implications
            for Treatment

 Focus on attachment – i.e. interpersonal
 Resolution of here-and-now problems
  should result in symptom relief
 Fundamental personality change is
  unlikely in short-term treatment
                       Social Factors
Biological Factors     Intimate Relationships     Psychological Factors
Genetics               Social Support             Attachment Style
Substance Use                                     Temperament
Medical Illnesses                                 Cognitive Style
Medical Treatments                                Coping Mechanisms

                         Unique Individual

                      Interpersonal Crises
                      Grief and Loss
                      Interpersonal Disputes
                      Role Transitions
                      Interpersonal Sensitivity

                     Interpersonal Distress
          Problem Areas

 Grief& Loss
 Interpersonal Disputes
 Role Transitions
 Interpersonal Sensitivity
            IPT Techniques
 Clarification
 Communication Analysis
 Interpersonal Incidents
 Use of Affect
 Role Playing
 Problem Solving
 Homework
 Use of the Therapeutic Relationship
 Direct questioning
 Empathic listening
 Reflective listening
 Encouragement of spontaneous discourse
     Communication Analysis
 Importance of clearly communicating
  needs and expectations to others.
 Client’s understanding of her contribution
  to communication problems.
 Motivate client to communicate more
 Analyze quality of patient’s narrative.
 Analyze communications within sessions.
      Interpersonal Incidents
 Augment communication analysis
 Provide discrete examples of generalized
 Provide specific incidents for the therapist
  and client to problem-solve
               Use of Affect
   Help client to
       - recognize her own affect
       - communicate affect to others
       - recognize suppressed or painful affect
        Role Playing
 Allows the therapist to model new modes of
  interpersonal behavior and communication.
 Allows the client to:
      - develop new insights into her
            interpersonal behaviors
      - practice new communication skills
      - gain new perspectives on the reaction of
            others to her communications
           Problem Solving
 Carefully examine the problem.
 “Brainstorm” potential solutions with client
 Select a course of action.
 Monitor outcomes and refine solution.
 Assignments are interpersonal in nature
  and not paradoxical.
 Assignments involve:
     - direct communications with others
     - self-appraisal of her interactions
     - activities and behaviors with others
Use of the Therapeutic Relationship
   The ideal relationship includes:
       - mutual liking, caring, respect
       - importance to both parties
       - a degree of expertise on the part of
            the therapist
       Overall Structure of IPT
   Treatment Phases
    – Evaluation
    – Initial Sessions (1-2)
    – Intermediate Sessions (3-12)
    – Conclusions of Acute (13-14)
    – Maintenance treatment (15+)
New Haven – Boston Collaborative Study

   First controlled study of IPT for acute
   16 week treatment study of 81 depressed
     – IPT alone
     – Amitriptyline alone
     – Combination
     – Control: Nonscheduled psychotherapy
New Haven – Boston Collaborative Study

   IPT superior to nonscheduled psychotherapy

   Medication superior to nonscheduled

   Combination was more effective then either
    active treatment alone

   IPT equivalent to Amitriptyline
    – Differential effects on symptoms
           One-year follow-up
   Patients who received IPT (alone or in
    combination with medication) showed
    higher functioning than patients who
    received nonscheduled psychotherapy or
    medication alone
   No effect of IPT on symptom relapse or
NIMH Treatment of Depression Study

                    Acute Depression

 Imipramine   IPT                      CBT   Clinical Management
NIMH Treatment of Depression Study

   IPT superior to “placebo”
   IPT equal to Imipramine for mild to
    moderate depression
   IPT slightly better than CBT for severe
   No long-term preventive effects were
    noted for IPT, CBT, or Imipramine at 6,
    12, or 18 months
    NIMH Treatment of Depression Study
   43% of patients entering IPT achieved remission
    of depression (HRSD<7)
   55% of patients who completed IPT achieved
    remission of depression
   23% of patients terminated prematurely from
    – Premature terminators were more severely depressed
      at intake
   33% of patients achieving remission of
    depression relapsed within 18 months
 NIMH Treatment of Depression Study

 Treatment    response to IPT predicted
  – low social dysfunction
  – high interpersonal sensitivity
  – higher satisfaction with social
  – acute onset of depression
  – endogenous depression
          Maintenance Therapy
   Many patients have relapses and recurrences
   Weissman and colleagues established that 8
    months of antidepressant treatment could
    prevent relapse, and that maintenance IPT
    could enhance social functioning, but effects
    weren’t seen for 6-7 months
   Pittsburgh Maintenance Therapy with IPT -
    Frank, Kupfer and colleagues studied the
    efficacy of IPT as a maintenance treatment for
  Pittsburgh Maintenance Therapy

                            Recurrent Depression
                                  (3 + episodes)

                                Acute Treatment
                                Imipramine + IPT
                                Recovered Patients

Imipramine   Imipramine + IPT          IPT           IPT + placebo   placebo
Pittsburgh Maintenance Therapy - Results

   3-year survival analysis indicates that
    Imipramine reduced relapse of depression
   Combination of Imipramine and IPT did
    not further reduce relapse
   Maintenance IPT not as effective as
   Maintenance IPT superior to placebo
Pittsburgh Maintenance Therapy



100                                  IMI + IPT-M
 80                                  IMI alone
                                     IPT-M alone
 60                                  IPT-M + placebo
 40                                  placebo


      Mean 3 Year Survival (weeks)
Clinical Importance of Empirical Research

 Selection   of good candidates for IPT
 Prediction   of response
 Conviction   of treatment presentation
 Conviction   in treatment delivery
     Additional Applications
Research at the University of Iowa

   Social Phobia (Stuart et al.)

   Somatization Disorders (Stuart & Noyes,

   IPT for Couples (Stuart, Temple et al)

   Post-MI Depression (Stuart & Cole, 1996)
          Additional Applications
   Interpersonal Counseling in Primary Care (IPC; Klerman
    & Weissman, 1993)
   Eating Disorders (Fairburn et al., 1998)
   Adolescents (IPT-A; Mufson et al., 1999, 2004)
   Bipolar Disorder (Swartz et al., 2002)
   Drug Abuse (Rounsaville & Carroll, 1993)
   Dysthmia (Browne, Steiner et al., 2002)
   HIV Patients (Markowitz et al., 1992, 1997)
   Groups (IPT-G; Wifley et al., 2000)

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