This post aims to summarise a paper on Interpersonal Psychotherapy:
Lipsitz, J. D., & Markowitz, J. C. (2013). Mechanisms of change in interpersonal therapy (IPT). Clinical Psychology Review, 33, 1134-1147.
Psychiatrists Klerman and Paykel, in 1969 at Yale University began to investigate the clinical efficacy of tricyclic antidepressants accompanied by and separate from, what they described at the time as ‘supportive psychotherapy’. The expectations for success for the psychotherapy component of the treatment for depression were not high – randomised control trials were just beginning to be used with Beck’s Cognitive Therapy, with Beck’s own-designed manual for the same, as yet otherwise, pscyhotherapy remained largely untested. Successful outcomes in time-limited treatment beyond the original research group which provided support mostly for middle aged American women in extended family environments (Weissman, 2006), have included bipolar disorder (Frank et al., 2005), social phobia (Lipsitz, Markowitz, Cherry & Fyer, 1999), posttraumatic stress disorder (Bleiberg & Markowitz, 2005) and others.
The driving assumption in developing IPT was the sense that there would be an accompanying interpersonal disturbance connected to the mental health concern – something rarely recognised with psychopharmacologic or Cognitive-Behavioural Therapy (CBT) approaches. The early development was influenced by:
– writings from Harry Stack Sullivan (1940), on the interpersonal nature of psychiatric illnesses, and the way that interpersonal behaviours form significant emotional events for people, Sullivan includes interpersonal relationships as a basic need and an understanding of the structure of the self as articulated by ‘reflected appraisals’ from others, with the therapist role illuminated as participatory rather than expert;
– ideas of Adolf Meyer (1919) and his analysis of the person’s relationship to their environment by using life charts to track the course of illness in a person’s life which later evolved into recognition of enduring social conditions and chronic stressful life circumstances;
– and the work of John Bowlby (1969) on attachment, with individuals making strong affection bonds as a function of complex biologically informed systems, with separation or threat of separation giving rise to emotional distress and depression, for people.
In common, all theorists place human relationships as central to emotional health and illness. Until the emergence of IPT, there was a strong focus from interpersonal psychoanalysis and attachment theory on the internalised effects of early childhood experiences, even in later life. This meant the therapist had to access these early life experiences to effect change. Epidemiological research at the time on stress, social support and illness had revealed that the current interpersonal context was highly informative for the onset and repeat course for psychiatric disorders. An increasing focus on ongoing dynamic interpersonal interplay was emerging at the same time in relational theory, setting groundwork and structure-form for the possibility, of interpersonal psychotherapy.
IPT focuses on four interpersonal change processes –
1) Enhanced social support including awareness of social circles of support, emotional regulation within the social context and identification and recognition of roles inhabited and relationships so nurtured. Therapy functions transitionally as a safe space within which to explore a motivation to change, different possibilities within self expression during change, and identity shifts on the other side of change. The person may come to be able to appreciate the importance of social support in their own life and to be able to more easily ask for help when it is needed, from others, and also to understand that the present concern is not the individual’s fault, so enabling a needed shift from the presently inhabited role. There is evidence for example, that establishing daily social routine has a positive effect on diminishing the disruptive aspects of bipolar disorder and bipolar episodes (Frank et al., 2005);
2) Decreased interpersonal stress includes a focus on the effects of negative interpersonal experiences that extend beyond the impact of a lack of social support. Noting that although not all stressors are interpersonal but many are, the type of approach taken to enable diminished interpersonal stress will vary according to the type of interpersonal situation chosen as focus by the person, but may for example include perspective taking for family situations of high expressed emotion (EE), and psychoeducation regarding the impact of the expectations of others with regards to role transitions, role disputes and perhaps too, grief;
3) Facilitated emotional processing – IPT distinguished itself from Beck’s Cognitive Therapy by it’s focus on affective states and the way that these are interpersonal in character, rather than placing an evaluative framework around them. Intensive work on recognition of emotional responses, acceptance and validation of the same and finding constructive means for an ongoing appreciation of emotional responsivity can yield long term broad benefits, for people, including greater attunement to own feelings and other’s responses;
4) Improved interpersonal skills, acknowledging that improved interpersonal functioning is a general universal and often unstated goal within all psychotherapies, IPT seeks to adapt interpersonal skills already possessed by the person, to assist in diminishing the discomfort associated with the presenting concern. This may secondarily yield symptom relief via improved social support and decreased stress, and requires no particular methods or didactic approach, rather employing communication analysis and role play where appropriate;
IPT is thus activated within a ‘pragmatic, coherent, and affectively charged’ focus on a central interpersonal issue in the person’s life.
The interpersonal issue has intersubjectivity and absence as defining features, mapped in four possible ways:
– grief – bereavement following the death of a loved one, which remains unresolved in a personally satisfying way in present interpersonal contexts;
– role transition – where major life change, loss or absence of some previous role disturbs ongoing intersubjective interaction in a discomforting way;
– role dispute – overt or covert conflict in an important relationship, an absence of accepted roles, between subjects;
– interpersonal deficits/role insecurity – where interpersonal interaction is impoverished or uncertain in some way not identified and handled within the first three roles – there is an absence of recognised role, socially among and with others.
IPT has three phases – firstly, evaluating the conditions for the issue and looking at an interpersonal inventory for present life circumstances and past relationships; secondly, providing a case formulation which includes as well as the grounds for interpersonal psychotherapy itself a transitional sick role which is intended to alleviate responsibility for current difficulties so that a different perspective might become available for them and a linking might be made to the information in an interpersonal inventory, and then treatment planning which includes planning for the end of therapy from quite early in the process, reviewing progress made in the interpersonal context and anticipating future possible setbacks, developing strategies to handle them, together.
IPT explicitly works to instill hope and create positive conditions for change. It employs the medical model, specifically to work with the client’s interpretation of the current issues as faced, identified as the present sick role, emphatically validating the person’s current distress, and then working with them to enquire as to the healthy role they might like to inhabit. It thus is described as trans-diagnostic – looking to interpersonal considerations rather than particular symptoms, thought and behaviour that the psychotherapy community might otherwise expect to be associated with a particular disorder. An internal flexibility in adaptation thus enables the integration of IPT approaches regardless of the presenting problem – the structure of the therapy remains the same, regardless.
Although research on stress and social support indicates a causal role for the interpersonal context, IPT retains a reciprocal relation between the psychiatric concern and the interpersonal connections in question, seeing both the ‘sick role’ and other people as contributory to the current interpersonal container. In a diathesis-stress (vulnerability) analysis, this entails a focus on what maintains the stress in a person’s life in biological, psychological or behavioural registers.
Recognising distinctions between therapy change process, interpersonal change process and the change mechanisms themselves illuminated by Doss (2004), IPT is distinct from most individual therapies insofar as it does not locate a problem within an individual, but rather works to keep focus on relationships to other people and the indiviudual’s relationship to the current concern, to enhance the life situation of the person and alleviate what it is that the concern might address. Whereas practices outside of the therapeutic context for individual therapies involve solo homework, for example, identifying unhelpful cognitions and affects that might have occurred throughout a day, IPT keeps attentive to the interpersonal situation and the occurence of emotional responses within the interpersonal situation, working so as to reduce discomfort and increase capacity in psychoeducation, rehearsal and personal awareness. Therapists and clients can explore out-moded role-concepts, interpersonal approaches, emotional expression, with greatest efficacy where the therapist maintains focus on the interpersonal context (Frank et al., 2007).
Core assumptions for IPT include that the focal interpersonal problem has sufficient salience so that resolution includes improved social support and diminished interpersonal stress in a meaningful and everyday way, via improved emotional processing, which is interpersonal in essence, and better social skills. Clinically, people often present with more than one identified concern, and further work is needed to establish the extent to which other factors such as self-esteem or self-mastery may play more of a role than the interpersonal re-orientation, persay. There are difficulties associated with attempts to identify the extent of interpersonal change, for example, it is non-linear, and it may be the case that there is a heightening of distress related to factors outside of the chosen area that meaningfully influence therapeutic outcomes.
References
Bleiberg, K. L., & Markowitz, J. C. (2005). A pilot study of interpersonal psychotherapy for posttraumatic stress disorder. American Journal of Psychiatry, 162, 181-183.
Bowlby, J. (1969). Attachment and loss v. 3 (Vol. 1). New York: Random House.
Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., … & Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62(9), 996.
Lipsitz, J. D., Markowitz, J. C., Cherry, S., & Fyer, A. J. (1999). Open trial of interpersonal psychotherapy for the treatment of social phobia. American Journal of Psychiatry, 156, 1814-1816.
Lipsitz, J. D., & Markowitz, J. C. (2013). Mechanisms of change in interpersonal therapy (IPT). Clinical Psychology Review, 33, 1134-1147.
Meyer, A. (1919) The Life Chart, in: A. Lief (Ed.) (1948) The Commonsense Psychiatry of Dr. Adolf Meyer. New York: McGraw-Hill.
Stack, S. H. (1940). Conceptions of Modern Psychiatry. New York: McGraw-Hill.
Weissman, M. M. (2006). A brief history of interpersonal psychotherapy. Psychiatric Annals, 36, 553-557.