Interpersonal Psychotherapy

IPT

Interpersonal Psychotherapy provides a pragmatic, time limited and focused approach to the treatment of major depression. It is modest in its use of psychotherapy jargon and promotes attention to the relationship based issues which are central to the experience of many depressed patients. The treatment does not become entangled in questions of causation, acknowledging the capacity for depression to both precipitate and reflect interpersonal change and difficulty. Instead it attends to difficulties arising in the daily experience of maintaining relationships and resolving difficulties while suffering an episode of major depression. The fundamental clinical task of IPT is to help patients to learn to link mood with interpersonal contacts, and to recognise that by appropriately addressing interpersonal situations they may simultaneously improve both their relationships and depressive state.

Goals of IPT

To reduce the symptoms of depression
To improve the quality of the patient' social and interpersonal functioning

Stages of IPT

IPT employs a flexible structure, moving through three main phases. In so doing it specifies particular goals for each stage and proposes a range of strategies by which the therapist may achieve these. The first phase constitutes assessment, giving particular attention to both the collaborative diagnosis of depression and developing an understanding of the interpersonal context. The overlap between symptomatic and interpersonal experience guides the decision on treatment focus, with four choices available - interpersonal dispute, interpersonal role transitions, grief and interpersonal deficits. The second stage takes on the negotiated focus as the guide, working to alleviate symptomatic experience through the resolution of the primary area of interpersonal difficulty. The final stage of IPT specifically addresses issues of termination.

Initial Sessions (1-4)

Diagnosis and sick role
Detailed assessment of the interpersonal environment
Relate depression to the interpersonal context: focus selection
Formulation and contract setting

The first four sessions of IPT constitute the assessment phase. The tasks for this phase include taking a thorough psychiatric history, making an explicit diagnostic evaluation with reference to recognised criteria i.e. DSM-IV or ICD-10, engaging the patient in the sick role, which brings with it responsibility to work towards recovery, conducting a detailed review of the patient's interpersonal context, and establishing an interpersonal focus for treatment, based on the interconnections apparent between the other factors. Particular attention is given to interpersonal changes occurring proximal to the onset of symptoms to establish this focus.

Middle Sessions (5-12)

Interpersonal Role Transition
Interpersonal Role Dispute
Grief
Interpersonal Sensitivity/Deficits

During the middle sessions the task is to help the patient discuss the weekly experiences which are related to the identified interpersonal area for work. The therapist helps the patient to link the weekly onset of symptoms to the interpersonal context or vice versa, clarify the issues and themes which emerge, and attend to the associated emotional experience. These sessions open with a general question about how the patient has been since the last meeting i.e. focusing the patient on here and now concerns and events, and strategies are selected and implemented as appropriate to the stage of therapy, and the experiences of the week. Patients are helped to understand their experiences within the focus framework and to consider and ultimately attempt alternative responses which may disentangle their relationships from their depressive symptoms. The IPT model sets out specific goals for each of the focus areas and strategies whereby these may be achieved. These provide a guide to therapist during the middle sessions.

With each problem area the sequence of movement in therapy is, first, general exploration of the problem, second, focusing on the patient's expectations and perceptions, third, analysis of possible alternative ways to handle the problem area, and, finally, attempt at new behaviour.

Final Sessions (13-16)

Termination

Explicit discussion of the end of therapy;
Discuss the patient's reaction to the end of therapy;
Acknowledgement that termination is a time of grieving;
Move the patient towards recognition of independent competence;
Review the course of treatment and progress with the patient;
Evaluate the treatment and assess future needs;

Assess early warning signs and discuss procedures for re-entry into treatment if necessary.

As the IPT sessions draw to a conclusion increasing attention is given to the end of the therapy relationship, and relapse prevention. Although this is identified as a distinct phase of therapy, the work of the termination sessions overlaps with the final work of the middle sessions. In additional the issue of termination is one that will have received attention throughout therapy, as the time limit on contact would have been specifically negotiated in the early sessions. The number of remaining session would also have been counted down each week, helping both the therapist and patient to maintain an awareness of the time remaining. Research has repeatedly indicated that the effects of IPT are increasingly demonstrated in the months after therapy has stopped, and so it is important that attention is given to helping the patient to independently continue the work which was initiated during the sessions. The maintenance model of IPT was developed to help those patients who had responded to the acute intervention, but were at risk of recurrence of depressive symptoms, to consolidate and maintain their therapy gains by continuing to attend monthly IPT sessions following the acute treatment phase.