Interpersonal Psychotherapy for Depression��Heather A. Flynn, PhD�Professor and Chair�Florida State University College of Medicine�Department of Behavioral and Social Sciences�Past President, International Society of Interpersonal Psychotherapy (ISIPT: interpersonalpsychotherapy.org)

Case example – Ms. R

• 28 year old woman, at least 1 prior episode of depression (age 16)
• Gave birth to second child 6 months ago
• Moved; partner recently changed job
• depressed, losing interest in work, increased conflicts with partner / irritability, feeling guilty and badly about parenting
• Thoughts of something terrible happening to her baby; wants to “run away”

IPT Defined

• IPT is a pluralistic approach;

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a “focused, time limited psychotherapy that emphasizes the link between mood and the current interpersonal relations of the depressed patient while recognizing the roles of genetic, biochemical, developmental, and personality factors in the causation of and vulnerability to depression”

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(Weissman, Markowitz, Klerman, 2000, p.4)

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Basic Characteristics of IPT

• Helps patients to “change rather than to simply understand and accept current life situation” – a focus on what is not working in a persons life and how to make it work for him/her.

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• IPT intervenes with symptom formation, social adjustment and interpersonal relationships…works predominately on current problems on a conscious and pre-conscious level.

Goals of IPT

• Remission of current depression
• Improved interpersonal capacity
• Tools to cope with future problems
• Insight into needs (of self/others) & choices
• Plan to detect & seek tx for future MDE

IPT Overview

1. Initial Phase

Assessment and identification of Focus Area

• Middle Phase

Maintain focus on problem area; elicitation of affect and behavior change

• Termination Phase

Consolidate Gains; Relapse Prevention

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4 Interpersonal Problem Areas

1. Complicated Grief
2. Interpersonal Role Conflict / Dispute
3. Interpersonal Role Transition
4. “Interpersonal sensitivity” / “Interpersonal Deficits”

IPT for Perinatal Depression: Rationale

• 10-20% of perinatal women experience mood and anxiety disorders
• Perinatal period characterized by role transitions, conflicts, and unresolved grief
• Women show a strong preference for non-pharmacological treatments in the perinatal period
• Perinatal women report distressing disruptions in social support and partner dissatisfaction

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Sokol (2018); Flynn et al. (2010)

Meta-analyses and Clinical Guidelines Recommend IPT for Perinatal Depression

• IPT is efficacious for the prevention and treatment of Perinatal Depression
• Some review studies have found IPT to be superior to CBT
• IPT shows improvement in anxiety and improved relationship quality, social adjustment and social support
• IPT may also be an effective preventive intervention for perinatal anxiety, but more research is needed

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Sokol 2018; van Ravestayne 2017; Bledsoe and Grote 2006; Sokol 2011

Primary Theoretical Underpinnings of IPT

1. Attachment Theory – Bowlby

Biologically based, instinctual drive to form relationships with others; describes the ways in which people form, maintain, end relationships and ways in which they develop problems with them

Difficulty results from disrupted attachments with others: specific loss or inadequacy of social support network due to a conflict, loss or transition

Attachment and IPT

• Attachment - a person’s “working model” / expectations of relationships and individual interactions
• Set’s the stage (“background music”) for day-to-day as well as global relationship perceptions and behaviors
• Perturbations in relationship, either real or perceived contribute to mood and anxiety

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Selective Pt Variables for IPT for Depression

• Life Events: Recent, focused dispute with significant other, social or communication problems, recent role transition or life change, abnormal grief reaction
• Relatively secure attachment style – Low attachment avoidance (McBride et al., 2006)
• The ability to relate a coherent narrative with the ability to relate specific dialogue between parties
• A specific interpersonal focus for distress
• Modest to moderate need for direction and guidance
• Available support network (responsiveness to environmental manipulation)

Interpersonal Psychotherapy

Two major goals:

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• Depression / distress symptom remission
• Improve interpersonal functioning
• Resolving acute interpersonal crisis
• Increasing social support

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The Initial Phase

• 4 main tasks:

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1) Diagnose the depression

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2) Complete the Interpersonal Inventory and relate the depression to the interpersonal context

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3) Identify major interpersonal problem areas

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4) Explain IPT approach and make a treatment contract

The Initial Phase

• Key Issues:

Education of the patient about depression, including reassurance and guidance, creates a sense the problems are being “worked on” right away

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• Review of symptoms – reassures the patient that they fit a pattern that is anticipated and understood (by therapist); helps pt understand that they are part of a patterned, time-limited, treatable illness.

The Initial Phase

• Key Issues:

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• Patient’s perceptions of symptoms should be elicited without challenge or disagreement

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• Need for medication – severity and recurrent pattern; the medical model of IPT makes it easily compatible with med tx; present treatment options and pertinent information about options

Tasks of Intermediate IPT Sessions

• Focus discussion to topics relevant to problem area - link mood to IP events, clarify wishes (expectations) and options, communication analysis, decision analysis, behavioral activation
• Stay ‘on focus’
• Attend to affect and therapeutic relationship
• Address resistance IF interfering with tx

Interpersonal Strategies and Techniques for Facilitating Change

• Use discrepancies between effective & ineffective IP responses to identify maladaptive elements
• Communication analysis to guide more effective communication
• Decision analysis to reveal alternatives and consider consequences of potential choices
• Modify role relationship models
• Role playing (Beitman 1999; Weissman 2000)

Communication Analysis

• Detailed account of conversation or argument with significant other with feelings and intentions
• Help pts recognize unpleasant feelings
• Assist with direct expression & strategize ways to cope when overwhelmed
• Encourage assertion with appropriate expression of anger (Weissman 2000)

Decision Analysis

• ? What has pt already tried
• Help pt recognize broadening range of options and insist action held off until each option explored
• “what would you want to happen in this IP situation? What solution to this would make you happiest? What alternatives do you feel you have now? Why don’t we try to consider all the choices you have?”
• Explore consequences, advantages & disadvantages of each line of behavior

• What are best Interpersonal focus areas and why
• What are possible interpersonal / communication patterns that would be targets of intervernion

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• Spokesperson – summarize issues and challenges

IPT - Grief

• Goals: Facilitate mourning process & help patient to reestablish interest & relationships to substitute for what has been lost
• Strategies: Review depressive symptoms & relate onset to death;reconstruct relationship with deceased; describe sequence & consequences of events prior, during & after death; explore associated feelings; consider ways to become involved with others. (Weissman 2000)

IPT Strategies - Grief

• Recall sequence of events before, during and after the death
• Reconstruct the lost one
• Reconstruct the lost relationship
• Explore associated feelings/regrets
• Help pt to bring into focus memories of the loast person and emotions related the experiences with the lost person

(Weissman 2000)

Interpersonal Role Disputes

• Defined within IPT as “a situation in which that patient and at least one significant other have non—reciprocal expectations about a relationship”; These become the focus of therapy if they appear to be important in the onset and perpetuation of the depression

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• Identification of a role dispute often involves careful assessment of current important relationships; listen as much for what is omitted as what is said about relationships: insufficient or over-idealized descriptions provide clues

Interpersonal Role Disputes

• General goals in working on role disputes:
• 1 – identify the dispute
• 2 – make choices about a plan of action
• 3 – modify non-adaptive communication patterns and / or re-assess expectations for a satisfactory resolution

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• * Therapist has no investment in a particular outcome – must be driven by the patient
• Helping patients to understand the nature of the dispute (expectations etc) may take the entire course of therapy

IPT Goals - Role Disputes

• Outcome:
• changed expectations and behavior of pt +/or other;

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• OR accept that which cannot change;

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• OR dissolution (Weissman 2000)

Interpersonal Role Transitions

• Depression often occurs as a result of difficulty dealing with a life change; persons with depression are more likely to experience a role change as a loss – again, the goal is to bring about a more complex, well rounded, realistic perception of the change

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Examples: marriage, divorce, job change, moving, leaving home, new responsibilities, retirement, changing roles in important relationships, graduation etc. Most are associated with progression to another part of the life cycle

Interpersonal Role Transitions

• Difficulty coping with the change is associated with:

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1 – loss of familiar social supports

2 – management of accompanying emotions (sadness, fear, anger)

3 – demands for new social skills / attachments

4 – diminished self-esteem

Interpersonal Role Transitions

• 4 tasks associated with managing Role Transitions:

1 - Giving up the old role – this resembles facilitation of grief

2 - Encouraging expression of affect – elicit feelings

3 - Developing new social skills:

Help the patient realistically assess assets and skills needed to manage the transition, looking for over and underestimation of skills; helpful to have the person imagine the worst thing that can happen around the new transition

Difficulty developing new social skills may involve incorrect, or stereotyped assumptions about the role; i.e. marriage

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4 – Establishing Social Supports – carefully review opportunities available in the new role for getting involved with others

Termination of Treatment in IPT

• Specifically discuss termination at least 2-3 sessions before ending
• Termination Tasks:
• Giving up a relationship
• Establishing sense of competence to deal with future problem autonomously

Termination Phase - IPT

• Feelings of sadness are inevitable and should be expected as important part of the process of termination that provides therapeutic opportunity to work through
• Need to differentiate normal sadness with endings from clinical major depression
• Loss begets loss: Other ending/separation might emerge in the material
• Opportunity for a ‘good bye’

(Weissman 2000; Luborsky 1984)

IPT Certification

• International Society for Interpersonal Psychotherapy (ISIPT)

www.interpersonalpsychotherapy.org

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