Interpersonal psychotherapy is a form of therapy focused on resolving interpersonal-based issues, which are deemed as being the precipitant of the mental health concern(s) the individual is experiencing.
Interpersonal psychotherapy (IPT) was originally developed as a form of psychological treatment for those suffering depression (Hinrichsen 2008). As the name suggests, the focus of IPT is primarily on the interpersonal context within which the individual exists and therefore assumes that the cause of the depression, for example, is some form of social or interpersonal event (e.g., death of a loved one, change in job situation, difficulties connecting socially with others, etc.). As such, there are four key interpersonal problem areas upon which therapy might focus: (1) grief and loss; (2) interpersonal disputes; (3) interpersonal role transitions; and/or (4) interpersonal deficits. Fundamentally then, the primary goals of IPT are to reduce the symptoms of depression being experienced (by in effect problem-solving the interpersonal problem being experienced) and to also educate the individual in better managing their life situation with regards to their interpersonal circumstance. In doing so, the individual will be better able to cope into the future and reduce their risk of suffering depression should another interpersonal issue arise.
IPT was initially developed for use in a randomized controlled trial investigating maintenance effects of tricyclic antidepressants (Klerman et al. 1974; Weissman et al. 1976). In order to maintain research rigor, IPT was specifically created as a manualized approach with specific procedures so that across participants, the administration of the therapy was strictly controlled and easily replicable (Weissman 2006). While there were other forms of therapy being used and investigated at the time, Weissman (2006) cites that the development of IPT came from Klerman’s own clinical point of focus. Namely, his interest in the role of social and interpersonal stress in exacerbating the symptoms of depression (both in terms of the onset of an episode and relapse). Having initially explored the utility of IPT in the maintenance phase, Weisman et al. (1979) expanded their research to explore the efficacy of the treatment within the acute phase. Comparing amitriptyline and IPT (both in combination and separately), they found that the combination of the two treatments was more effective.
In the earliest iterations of IPT, the mental health condition was characterized in the same way an individual might be told they have any other medical diagnosis. Therefore, the individual was told that they were “suffering from depression.” The diagnosis was then discussed in a medicalized format such that the condition was named as an illness that could be treated and that it was therefore not the individual’s fault that they have the condition (Weissman et al. 2007). As such, IPT relied on giving the individual the “sick role” and aimed to remove fault. This allowed for the individual to disentangle themselves from the diagnosis and see it as something external to them, something that is to be treated; with an emphasis also on the individual needing to work at treating the diagnosis (i.e., it will not cure itself). However, the work of Stuart and Robertson (2012) expands on IPT by focusing more on the therapy being a treatment for interpersonal issues and less on the “sick role” purported in the original manual. Rather than a biological disease model then as a means of formulation, Stuart and Robertson (2012) highlighted the need for a biopsychosocial/cultural/spiritual model instead. In this way, IPT became more focused on what underpins the psychological distress being experienced, as well as building on protective factors into the future. In many ways, Stuart and Robertson’s (2012) work brought the focus of IPT back to its core feature, which is the interpersonal element (and as a result of treating the interpersonal element, reprieve is gained from the symptoms of psychological distress being experienced).
As a treatment approach, IPT focuses on (or is touted as more suited to situations where) grief and loss, interpersonal disputes, interpersonal role transitions, and/or interpersonal deficits that exist. In other words, an interpersonal crisis of some form. The problem area of grief and loss is fairly self-explanatory in that an interpersonal crisis in this area has occurred due to the loss of a loved one. It is important to note, however, that loss could be defined as other forms of loss. For example, a partner in the mid- to late-stages of dementia who no longer represents the same person they were in earlier phases of the relationship could cause a sense of loss in the other partner. Loss may also be the result of the diagnosis of a terminal illness, divorce, or the loss of a pet who has been the client’s core source of well-being since the loss of their partner. Fundamentally, the clinician should conceptualize the grief and loss problem area as one in which any form of loss has occurred, that has subsequently resulted in the expression and experience of grief. Interpersonal disputes are where a conflict has occurred within the client’s interpersonal network. There is often an associated difficulty with communication, which could be an inability to express the issue that has resulted in the conflict or an inability to express the issue in ways other than anger and aggression, for example. Interpersonal disputes can also arise when there is a change in the relationship (or a perceived change), requiring adaptation, understanding, and often also with the requirement of managing uncertainty. Interpersonal role transitions result when there is a change in the social role of the individual. Such changes are often in response to other occurrences such as the move from high school to university, getting married, having children, etc. Role transitions may also occur after the diagnosis of a medical condition that forces a change in the role(s) the individual sees themselves as playing within their social network(s). The problem area of interpersonal deficits has traditionally focused on issues that have prevented an individual from forming positive attachments with others. Therefore, the individual may lack social skills (e.g., someone diagnosed with autism spectrum disorder) and as a result experience social isolation. Weissman et al. (2007) characterize interpersonal deficits as being the category of problem area you focus on if none of the other problem areas apply. It is therefore not surprising that in more recent works, the element of interpersonal deficits has been de-emphasized as a specific interpersonal problem area. Authors such as Stuart and Robertson (2012) propose instead that interpersonal deficits might be better characterized as the attachment style the individual relies on to connect with others rather than a type of interpersonal problem area. With this viewpoint in mind, it could be argued that interpersonal deficits are a potential cause of interpersonal problems, rather than being an interpersonal problem in and of themselves. Of course, the client could be experiencing loneliness and social isolation for reasons other than interpersonal deficits. Alternatively, a change in medical status may leave them with interpersonal deficits (e.g., someone who has experienced a traumatic brain injury resulting in a change in social awareness). In such instances, it may be more applicable to consider another form of psychotherapy or the interpersonal problem area may be better defined as grief and loss, interpersonal dispute, and/or interpersonal role transition.
IPT typically includes 16 sessions and is made up of three stages: the initial stage (first phase), the intermediate stage (middle phase), and the final stage (end phase). Each stage or phase focuses on different aspects within the therapeutic process. The initial or first stage commonly occurs across between one and three sessions and incorporates the initial assessment (or intake), the completion of the Interpersonal Inventory, and the development of an Interpersonal Formulation. The intermediate or middle phase is where one might say the “work” is done as it is during this period (which encompasses four to 12 sessions) that resolution of the interpersonal problem area is the goal. In the final or end stage (encompassing one or two sessions), a review is conducted of the previous sessions and a plan developed to ensure remission is maintained. There is also the option of a maintenance phase, which as in other forms of therapy aims to assist the client in maintaining the gains achieved during therapy. The maintenance sessions are often spread out so that appointments are less frequent and if clinically useful, later sessions within the original three stages might also be spread out to enable the client to gain a greater sense of self-efficacy in their own ability to implement the strategies learnt during therapy.
Particular tools of relevance in IPT include the Interpersonal Inventory, the Interpersonal Formulation, and the Treatment Agreement. The Interpersonal Inventory is of course the only tool that is specific to IPT, with the use of formulation and treatment agreements common across other types of psychotherapy. The Interpersonal Inventory aims to collect data on the interpersonal relationships that currently exist within the client’s life, including the client’s most intimate supports, their close supports, and their extended supports. It also offers the opportunity to identify means of social support. From there, discussion can continue regarding which are the problematic relationships, those that are creating interpersonal problem areas, any communication difficulties, and thereby facilitate the setting of goals and the planning of treatment interventions. In addition, the Interpersonal Inventory should be seen as a dynamic tool that is fluid across therapy. This ensures that new and changing relationships can be accounted for within the therapeutic process. The Interpersonal Formulation aims to synthesize information gathered during the intake with the client. It incorporates the areas of biological factors, social factors, psychological factors, cultural factors, and spiritual factors. The interpersonal problem area is also identified, as is the type and level of distress being experienced by the client (often the triggering factor for the client to seek out therapy). As with the Interpersonal Inventory, the Interpersonal Formulation is a dynamic tool that will likely change and need to be adapted across sessions, particularly where the client may not have felt comfortable sharing particular information about themselves until rapport is firmly established. It is important to complete the Interpersonal Formulation with the client, engaging them in the process to further enhance their own understanding and insight into themselves. The Treatment Agreement sets the guidelines around the therapeutic process and ensures that all parties understand, and are agreeable to, the way forward. Essentially the Treatment Agreement is a tool used to set expectations and obligations, goals, session timing and termination, treatment boundaries, etc. While it might seem like the Treatment Agreement is not dynamic, in actual fact therapeutic alliance builds from the idea that the Agreement can be reconfigured based on the changing needs and goals of the client.
Particular techniques of relevance to IPT include clarification, communication analysis, problem solving, use of affect, role playing, and homework. To the clinician, most (if not all) of these techniques will be familiar and so focus here will be on what way these techniques might be used differently in IPT. Clarification essentially means ensuring that the clinician understands and appreciates what the client is sharing by seeking clarification when necessary. This might include such things as checking in that they have understood who the source of the interpersonal stress was, having the client repeat or rephrase what they have said, or by the therapist rephrasing what the client has said. The therapist can also use the technique to explore discrepancies in what the client reports, such as identifying a problematic relationship but focusing only on the positive qualities of the person. Communication analysis identifies problematic communication. An important conversation is often discussed in detail during the session in order to allow the therapist to gain as complete an understanding as possible of the interaction. This allows the therapist to point out poor communication strategies and guide the client in better strategies. The therapist must be sure to hold the values of the client in mind to avoid analyzing communication from their own frame of reference; however, the therapist can also take on the role of the other person in the interaction and assist the client in appreciating that how they themselves interpreted the conversation might not be the only way in which to interpret what the other person said. Problem solving often follows the technique of communication analysis. It is a technique that is quite practical in nature, looking at where communication deficits exist, for example, and looking at ways to problem solve and establish more effective ways of communicating. It can be quite a directive technique and so the therapist should be careful to ensure that the solutions are those of the client. Brainstorming can be helpful where a client is struggling to come up with their own solutions and the client then tries out the solutions between sessions, after which evaluation can occur during the next therapy session. The use of affect is a technique that ensures that the emotional reactions of the client are incorporated into the therapeutic process. Interpersonal relationships are often caught up in various emotions and so the use of affect as a technique ensures that the client can identify and describe their emotional state, which may be one of the sources of interpersonal problem areas. The therapist is encouraged to give feedback to the client as to the emotions they are seeing the client display, which helps the client themselves develop insight into their own emotional state. Role playing offers the opportunity for the client to practice strategies and solutions within the scaffolded and safe environment of the therapy room prior to testing them out in the “real world.” The following therapy session is then used to evaluate the success of the strategy and if the strategy was not attempted, problem-solve why that was the case. Role playing also has the advantage of not only allowing the client to “play” themselves, but to also take on the role of their significant other, thereby actively exploring different perspectives and allowing the therapist to become coach or guide in terms of improving on or changing ineffective strategies. Homework is another technique not unique to IPT. It ensures that the work done during therapy is practiced outside of the therapy room, which then encourages generalization to the client’s own life (rather than being only something done during the traditional 50-min therapy session). Within the context of IPT, homework consists of tasks designed to enhance interpersonal relationships, improve communication strategies, and engage in discussions regarding feelings, etc. depending on the interpersonal problem area being experienced.
Theoretical Underpinnings of IPT
The core theoretical underpinnings of IPT are attachment theory and interpersonal theory. While attachment theory underpins interpersonal difficulties in general and poor ability to “attach” to others, interpersonal theory focuses primarily on poor communication strategies, and relatedly, the way in which the individual engages in relationships. Social theory has also been linked to IPT given that IPT focuses also on the role of social support and life circumstances in well-being.
Attachment theory was first introduced by Bowlby (1969), who purported that childhood development relies on the child’s ability to connect and have a strong relationship with at least one of their primary caregivers. In essence, the ability to form strong relationships (and therefore attachments) offers the child a sense of security, making them feel safe in their world and having their needs met. In the absence of effective attachment, the child does not develop that same sense of security and as a result, feels unsafe and does not learn the necessary skills to build connections with others. This results in maladaptive strategies in their attempts to form relationships. Further developing the theory, Ainsworth (1969) explored the behaviors in which children with poor attachment engaged in an attempt to form attachments. In the absence of being able to form satisfying relationships, to be able to maintain them, and to be able to end them should that need arise, interpersonal distress can occur and lead to the development of symptoms associated with mental health issues such as depression and anxiety. IPT therefore looks to consider attachment and whether that might be the cause of the interpersonal crisis the client is experiencing. At the very least, attachment is considered by the therapist as a potential area of exploration in terms of the current issues being experienced by the client.
Interpersonal theory, as conceptualized by Sullivan (1953), affirms that the way in which we interact with others underpins our ability to feel secure in relationships with others and to also develop a good sense of self. Following on from this, the interpersonal relationships one holds have scope to influence both personality (i.e., who the individual becomes and/or is) and psychopathology (i.e., the psychological manifestations of both poor and good interpersonal relationships). Sullivan also asserts that the way in which the individual interprets their relationships and experiences plays a role. This helps to explain why in some quite traumatic circumstances some people can develop significant mental health problems, while others will seemingly move on with their lives. With respect to IPT, it helps to conceptualize why some clients will struggle more with, for example, the grief and loss process than others. And so fundamentally, interpersonal theory asks that consideration be given to the influence of interpersonal relationships in the construct of the individual.
With regards social theory, Weissman (2006) reflects that it was the work of Adolf Meyer that particularly influenced the development of IPT. Meyer’s (1957) work emphasized the need to focus on the experience of the individual and asserted that the life situation of the patient needed to be understood in order to fully appreciate their experience of mental illness. As such, it was Meyer who emphasized the importance of conducting a detailed interview in order to more fully appreciate the situation of the patient. IPT relies on understanding the habits of the client with regards, in particular, to their relationships. Meyer would suggest that the habits in which the client is engaging within their relationships need to be explored in order to be able to identify the goals of therapy. A client relying on the habit of angry retorts when they find a situation difficult to cope with or walking away from the situation would necessarily mean the use of different techniques within therapy.
Key Research Findings
Research focusing on the efficacy of IPT when working with older adults is limited and does not always rely on randomized controlled trials. In 1989, Elkin et al. (as part of a National Institute of Mental Health review of treatments of depression) identified that there was no significant difference in the effectiveness of either IPT or cognitive behavior therapy (CBT) in the treatment of depression. Further, they identified that psychotherapy was almost as effective as the use of medication (imipramine hydrochloride) combined with clinical management. In this particular study, however, the mean age was 35 years. In a later meta-analysis conducted by Cuijpers et al. (2008) comparing various forms of treatment for depression in adults, IPT was identified as somewhat more efficacious when compared to other forms of therapy such as CBT, psychodynamic therapy, and problem-solving therapy.
In studies using only older adult participants, the focus has primarily been on mood-related disorders, including bereavement-related depression (e.g., Heisel et al. 2015; Miller et al. 1994; Stewart et al. 2014; van Schaik et al. 2006) and bereavement (e.g., Reynolds et al. 1999).
With regards mood-related disorders and in particular reference to studies focused on older adult participants, IPT has been found to be effective in reducing symptoms. Reynolds et al. (1999) looked at bereavement-related depression in participants over the age of 50 years. As well as finding positive effects of the treatment, they also identified that treatment completion rates were high, indicating that IPT was palatable to participants. Miller et al. (1994) also explored bereavement-related depression and similarly found a positive effect using a protocol that included 17 sessions of IPT.
In relation to depression specifically, Stewart et al. (2014) used IPT in the treatment of depression in veterans. While the age of participants was slightly younger than the more traditional definition of older adults (mean age of 52 years), symptom reduction was achieved. In 2015, Heisel et al. used a 16-session protocol of IPT including adaptations made to include treatment of participants at risk of suicide. Similar to other studies, they also found a significant reduction in the severity of depression (as did van Schaik et al. 2006 when compared to general care), as well as in suicidal and death ideation. Further to this research, a single case study conducted by Van Orden et al. (2012) established a reduction in suicide risk in a 68-year-old male. The authors hypothesized that in using IPT, they would develop a sense of belonging and reduced sense of burden, thereby reducing suicidality. The patient themselves also reported an increase in hopefulness posttreatment. Hinrichsen (2008) also described a single case study: a 75-year-old female experiencing depression as a result of becoming a carer for her husband (diagnosed with Parkinson’s disease). The result was a reduction in symptoms of depression after 16 sessions of IPT. The work of van Schaik et al. (2006) identified in a randomized controlled trial that IPT significantly decreased symptoms of depression, but not in establishing remission. They also identified that compared to care as usual, IPT was superior as a form of treatment in those experiencing moderate to severe depression.
There has also been a tendency for some studies to explore the combination of medication and psychotherapy in the treatment of depression in older adults (mimicking the research origins of IPT). Lenze et al. (2002) compared nortriptyline and IPT with nortriptyline and clinic visits, placebo and IPT, or placebo and clinic visits. In this particular study, participants were aged over 60 years. They found greater effects in terms of maintaining social adjustment in those who received the combination of medication and IPT when compared to either treatment alone. In an earlier study, Reynolds et al. (1999) similarly found greater effects in terms of recurrence rates when a combination of medication (again nortriptyline) and IPT were used. Conversely, Dombrovski et al. (2007) found that maintenance antidepressant pharmacotherapy (paroxetine) was superior to placebo with regard to quality of life. IPT offered no such significant benefit. Changes in suicidality in the context of short-term treatment for late-life depression were investigated by Szanto et al. (2003). They compared IPT with or without the use of either paroxetine hydrochloride or nortriptyline hydrochloride. The authors found that there was a rapid decrease in suicidal ideation initially, and that those participants reporting high-risk suicidality responded less well over the longer term compared to those reporting low to moderate risk. As such, they concluded that those participants experiencing moderate to high risk required longer treatment periods.
In consideration of older adults with cognitive impairment, Carreira et al. (2008) explored maintenance IPT with clinic management. The results identified that participants with lower levels of cognitive ability maintained longer periods symptom free from depression when engaging in maintenance IPT compared with participants with average cognitive ability. This emphasizes the utility of IPT when working with older adults with cognitive impairment.
Some studies have also considered the utility of IPT within a group format, rather than a one-on-one format. Referred to as IPT-G, Scocco et al. (2002) adapted IPT in order to treat a group of older adults experiencing depression. Their offering to the literature did not measure efficacy, but instead was a practitioner’s report documenting the alternate methodology. The group format included individual sessions as well in order to both orient the patient to group work, but also to assess symptom severity and identify the interpersonal problem area being experienced by the individual. The group sessions focus on describing the symptoms being experienced, along with the ability to treat the symptoms. A final individual session was held posttreatment during which a personalized maintenance plan is developed.
Examples of Application
The United States Department of Veteran’s Affairs has the specific aim of providing health services to veterans and members of the military who have left ongoing service. In order to facilitate the effective treatment of depression in veterans, IPT was disseminated nationally. Stewart et al. (2014) evaluated therapist and patient outcomes. As would be expected, therapist competency increased with exposure to further patients (after an initial 3-day training workshop). In patients, significant reductions in depression were found, along with improved quality of life. Participants in this particular study had a mean age of 52 years and so did not specifically cater to those falling within older adulthood; however, it nonetheless provides compelling evidence for the utility of IPT in the treatment of depression in veterans.
Future Directions of Research
To date, research looking at the utility of IPT in working with older adults is sparse. Future research would therefore benefit from further studies exploring IPT in working with older adults and incorporating a randomized controlled trial format. In addition, it would be beneficial for future research to continue exploring the utility of IPT as a form of treatment for other mental health issue(s) in older adults, including PTSD, various forms of anxiety, carer stress and burden, and possibly more complex conditions such as schizophrenia.
As a form of therapy, IPT focuses on resolving interpersonal problems in order to relieve the mental health issue(s) being experienced by the client. The focus is therefore not on the symptoms of the mental health issue(s), but on the interpersonal problem itself. In resolving the interpersonal problem, IPT proposes that relief will be gained from the experience of mental health issue(s). Therefore, IPT is a form of therapy best suited to those clients who are in fact experiencing some form of interpersonal crisis, whether that be grief and loss, interpersonal dispute, role transition, and/or interpersonal deficits. In specific reference to older adults, who are more likely to experience grief and loss and role transitions in particular, IPT has been shown to be an effective means of therapy with good outcomes noted.
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