Interpersonal Psychotherapy for Depression
Download
Report
Transcript Interpersonal Psychotherapy for Depression
Interpersonal Psychotherapy
for Depression
Bob Hill, Ph.D.
Appalachian State University
Boone, NC 28608
Email: [email protected]
Overview
Depression
Theoretical Sources for IPT
Prominent Features of IPT
Outline of IPT
Phases of IPT Treatment
Clinical Examples
Empirical Support
Depression
IPT clearly effective for treating Depression
Diagnostic Criteria for Depression:
A.Five (or more) of the following symptoms have been
present during the same 2-week period; at least one of
the symptoms is either
1.depressed mood most of the day, nearly every day, as
indicated by either subjective report or observation
made by others. Note in children, can be irritable mood.
2. anhedonia: markedly diminished interest or pleasure in
all, or almost all, activities most of the day, nearly every
day
Depression Criteria continued (2+ needed):
3.significant weight loss when not dieting or weight gain or
decrease or increase in appetite..
4.insomnia or hypersomnia nearly every day
5.psychomotor agitation or retardation observable by others
6.fatigue or loss of energy nearly every day
7.feelings of worthlessness or excessive or inappropriate guilt
8.diminished ability to think or concentrate, or indecisiveness
9.recurrent thoughts of death, recurrent suicidal ideation with
or without a specific plan, or suicidal intent.
Reasons to consider Medication
Client too depressed to participate in treatment
Client not psychological, resistant to talking tx
Client who is at risk for suicide
Client with recurrent Depressive episodes, with
symptoms of Melancholic Features
May respond more quickly with medication and
IPT combined
Depression with Melancholic Features
1) anhedonia
2) lack of reactivity to usually pleasant stimuli
3) Three or more of:
Distinct quality of depressed mood
Depression is worse in a.m.
Early morning awakening (at least 2 hrs)
Marked psychomotor agitation or retardation
Significant anorexia or weight loss
Excessive or inappropriate guilt
Psychotic symptoms
Suicide risk
Prevalence of Depression
Disorder
Females
Males
Depression
21.3 %
12.7 % 17.1 %
Dysthymia
8.0 %
4.8 %
National Comorbidity Survey (1994)
Total
6.4 %
Historical Influences of IPT
Psychoanalysis
Harry Stack Sullivan
Object Relations Therapy
Interpersonal Theory (Leary, Kiesler)
IPT: Roots in Psychodynamic Theory
Primary instincts of sex and aggression involve relating to
others
Relationships with others contribute to personality
development
Psychological Problems due to deficits in early relations
Transference and counter-transference are interpersonal
Object Relations Influence
“Object” is human being
“Relations” are internal, external, fantasied or real
interactions with others
Early parent-child relations are internalized as
expectations for future relationships
Identity/personality derived from pattern of early
relationship experiences
Expectations of others impacts quality of current
interpersonal relationships and mood
Manualized Interpersonal Therapy
Klerman, G. (1984). Interpersonal
Psychotherapy for Depression.
Weissman, M. (2002). Comprehensive
Guide to Interpersonal Psychotherapy.
Prominent Features of IPT
IPT designed for symptom reduction and
improved interpersonal relationships
Focus on current disputes, frustrations,
anxieties in the interpersonal context which
impact mood and self esteem
IPT Compared to Other Therapies
Time-limited- outcome studies document efficacy
of short-term (12-16 weeks) tx
Not designed for personality change
Focused on current interpersonal disputes,
anxieties, frustrations
Addresses 1-2 problem areas in interpersonal
functioning
IPT Compared to Other Therapies
Interpersonal, not intrapsychic
Interpersonal, not Cognitive Behavioral
Goal is to change feelings, thoughts, actions in
problematic relationships
Negative/irrational cognitions are addressed
only in interpersonal function
IPT attends to distorted thinking in relation to
significant others
Goal is to change relationship pattern rather
than depressive cognitions
IPT Compared to CBT
Focus on affect and expression of emotions
Explores avoidance and resistance behavior
Identification of patterns in client’s behavior,
thinking, feeling and relationships
Attention to past experiences
Focus on interpersonal experience
Emphasis on the therapeutic relationship
Exploration of client’s wishes, dreams,
fantasies
Blagys & Hilsenroth, 2000
IPT and Personality Change
IPT does not target alteration of personality
Personality pathology may limit IPT
outcome
IPT may help patient recognize maladaptive
personality features
IPT may improve social skills and thus
ameliorate maladaptive personality traits
Role of IPT Therapist
Therapist is patient advocate, not neutral
Expresses unconditional positive regard
Intentionally cultivates positive
expectations of treatment
Optimistic, positive, reassuring
Therapist is active in keeping interpersonal
problem areas to focus
Outline of IPT Intervention
Initial Sessions (Overview)
Assess Depressive symptoms
Complete Interpersonal Assessment
Identify Major Interpersonal Problem Area
Explain IPT and make treatment contract
Initial Sessions (“Sick Role”)
Review Sxs, Dx of depression to communicate
“sick role”
Functions of “Sick Role”
Sick person exempt from responsibilities
Sick person in need of help
Sick is undesirable and needs to be improved
Sick person obliged to cooperate with Tx
Sick role shifts blame from client to illness
Mitigates self blame
Relate Depression to Interpersonal Context
What interpersonal events related to depression?
Review current & past interpersonal relationships
• Who does client interact with?
• Frequency of contact, activities shared?
• Assess quality and themes of relationships
• Assess expectations of client (and other) in
relationships
• Assess satisfying and unsatisfying aspects of
relationships
• Discuss changes client wants in relationships
Inventory of Interpersonal Problems
64 items assess diverse interpersonal problems:
• Being too controlling or manipulative
• Being self-centered and resentful
• Having minimal feelings of affection for, and
little connection with, other people
• Being socially avoidant
• Being nonassertive
• Being gullible and easily taken advantage of
• Being excessively selfless, generous, trusting,
• Being too intrusive
Interpersonal Problems Circumplex
IIP Circumplex Evan
IIP Scale Profile
Identification of Major Problem Area
Assess interpersonal experience and depression to
identify of one of Four Problem Areas:
Interpersonal Role Dispute: with spouse, lover,
family member, friends, co-worker
Role Transition: e.g. new job, relocation, divorce
Interpersonal Deficits: evidenced by social
impoverishment, loneliness, isolation
Grief: following death if abnormally severe,
protracted or impairing
Problem Area Focus
Four problems areas are:
Not exhaustive, nor mutually exclusive
Not “deep” conceptual theory
Communicate to client Problem area focus
Problem area ensures focus on
recognized problem rather than personal
weakness
E.g. ‘try to discover what you want and need
from others and help you learn how to get
it’
Explain Interpersonal Focus
Tx focus will be interpersonal satisfaction, not
intrapsychic exploration
Educate about link between depressed mood
and difficulty getting what we want/need from
others
Therapist describes nature of clients
interpersonal difficulty
Agree on goal of improved interpersonal
relations
Set expectation: make changes btwn sessions
Setting Treatment Contract
Set 2 –3 treatment goals with client related
to problem area focus
Ask client what would be the:
Best possible outcome
Most expectable outcome
Worst possible outcome
Describe expected Duration and Frequency
of treatment (12-16 weeks)
Teaching Client Their Role in IPT
“Talk about things that affect you
emotionally
“Your responsibility to select topics that are
most important to you”
“No right or wrong thing to talk about”
“When important feelings emerge, raise
them”
“including feeling about me or the
therapy”
Starting Intermediate Sessions
Initial Assessment and Development of
Treatment Contract Typically 2-3 Sessions
Important tasks of Intermediate Sessions:
Help client discuss topics pertinent to
problem area
Attend to clients affective state
Assist client in discussing therapeutic
relationship
Prevent client from sabotaging treatment
Interpersonal Disputes: Diagnosis
Current Overt or Covert disputes with a
significant other
Client and other have non-reciprocal
expectations
Dispute related to onset or perpetuation of
depression
Client demoralized about relationship
Poor patterns of communication
or irreconcilable differences
Interpersonal Disputes: Goals
Identify the dispute
Make choices about a plan of action
Modify communication patterns or
Reassess Expectations
Consider satisfying needs outside
relationship
Interpersonal Disputes: Strategies
Assess stage of Role Dispute:
Impasse- discussion stopped, low-level resentment
exists
Tx may initially increase disharmony
Renegotiation- aware of differences, actively
trying to change
Tx may require calming parties to facilitate
resolution
Dissolution- implies the relationship is
irretrievably disrupted
Treatment may resemble grief therapy
Interpersonal Disputes: Issues
Differences in expectations/values between
client and other?
Clients wishes in relationship? Other wishes?
What are the client’s options?
How have they resolved disagreements in past?
Strengths and weaknesses in relationship?
What changes are realistically possible?
Interpersonal Disputes: Strategies
Find Parallels in previous relationships
What does client gain by the behavior?
What are unspoken assumptions that lie
behind behavior?
Optimistic tone: “lets figure out what went
wrong here so we can decide how to help
you make it better”
Often communication problems are
revealed- Tx involves improving skills
Interpersonal Disputes: Strategies
Help identify “mixed feelings” e.g. anger, fear,
sadness
Devise strategies for managing feelings e.g. direct
communications, reducing irrational suspicions
Role Play
Rehearse expressing feelings and wishes
Anticipate communication problems
Consider Conjoint sessions with significant other
Problem Area: Role Transitions
Diagnosis: Depression and interpersonal
problems related to role changes
e. g. separation/divorce, children left
home, start/end job or school, retired,
promoted, financial or health problems
Assess: How did life change? What people
in you life changed or left?
Role Transition: Tx Strategies
Facilitate evaluation of lost role
“Tell me about the old ___. What were
the good, and bad, things? What has
changed?
Encourage expression of affect
How did it feel to give up ___?
Identify positive aspects of new role
Are there potential benefits?
Role Transition: Tx Strategies
Develop Social Skills needed for new role
What is required in new role?
Are assumptions of role demands accurate?
Role play or rehearse difficult situations
Assist with managing performance anxiety
Establish new relationships and social support
Facilitate discovery of new opportunities for
social support
Interpersonal Deficits: Diagnosis
History of social impoverishment, chronic
inadequate or unsustained relationships
Consider Dysthymia (or Double Depression)
IPT adaptation for dysthymia
Long standing or temporary deficits in social
skills yields low self-esteem, withdrawal
Interpersonal Deficits: Goals
Reduce Client’s social isolation
Enable:
close relationships with intimates or
family members
satisfying relationships with friends
adequate relationships in work role
Interpersonal Deficits: Strategies
Review past significant relationships
including childhood relationships with family
members
depressed patients minimize or forget positive
experiences
explore repetitive or parallel problems in past
relationships
define interpersonal situations that lead to
difficulties
Interpersonal Deficits: Strategies
Use therapist-client relationship
explore client’s positive and negative
feelings toward therapist
discuss distorted or unrealistic thoughts
or feelings toward therapist
model resolution of relationship tension
by open and genuine communication
Interpersonal Deficits: Strategies
Encourage patient to increase social
interactions
review attempts in treatment to identify
deficits
identify deficits in communication skills
look for assumptions client makes about
others thoughts and feelings
Use Communication Analysis
Get detailed account of conversation or argument
identify communication difficulties
ambiguous, indirect, & non-verbal as substitute for
open confrontation
incorrect assumptions re communication
assuming that others know their feelings
accompanied by anger, frustration, silence
failing to make sure they are heard, understood
Use Communication Analysis
Incorrect interpretation of others statements
perceive criticism where none intended
indirect verbal communication
inhibited directly expressing expectations or
criticism
instead use hints and ambiguous messages
prone to build resentments toward others who
are unaware of offense
silence - unaware of destructive impact
Use Communication Analysis
Use role playing
rehearse difficult interactions with client
explore style of communicating with
others
practice new skills
e.g. expressing anger or being assertive
rehearsal with therapist increases client’s
interpersonal confidence
Interpersonal Deficits: Prognosis
Treatment of interpersonal deficits difficult
client often lacks relationships to practice
and develop skills
treatment goals limited to making early
gains interpersonally, not resolving
interpersonal deficits
Grief Problem Area Focus
Normal Grief involves:
Symptoms including sadness, disturbed
sleep, agitation, impairment, etc.
Symptoms usually resolve in 2 –4 weeks
without treatment
Abnormal Grief Evidence
Inadequate grief in bereavement period
Multiple losses
Avoidance behavior (re funeral, grave, talk)
Symptoms around significant anniversary
Preserving environment of deceased
Fear of illness that caused death
Absence of social support during
bereavement
Abnormal Grief Treatment Goals
Facilitate the mourning process
Help client reestablish interests and
relationships to substitute for what has been
lost
Grief Treatment Strategies
Explore Events and Elicitation of Feelings
Discuss events prior to, during and after
the death
Reconstruction of Relationship
Use photos and stories to discuss
relationship
Use belongings and memories to evoke
painful feelings client has avoided
What were the ups and downs in
relationship? (normalize negative
features) Facilitate Expression of Affect
Grief Treatment Strategies (cont.)
Behavior change:
Plan and discuss development of new
social relationships (e.g. organizations,
church, work, dating)
Support client as they learn to fill “empty
space”
Termination of Treatment
For time-limited treatment, important to keep
initial contract for 12-16 weeks
Termination Treatment issues
explicit discussion of termination during last 34 sessions
acknowledge ending may involve loss and grief
normalize fear, anger, sadness
may need to distinguish sadness from
depression
Termination Issues
Foster client’s self-confidence in coping
independently
deflect client’s attribution of success to therapist
call attention to client’s accomplishments
anticipate future difficulties with client
help plan for future problems
rehearse explicit scenarios if helpful
discuss possibility of relapse of depression
Termination Difficulties
Failure depression to resolve
refer for other treatment, encourage hope
client wants to continue
schedule 8 week waiting period
impart to client self-confidence in ability to
cope
maintenance IPT may be appropriate for:
chronic or recurring depression
clients with personality problems or
interpersonal deficits
Specific IPT Techniques
Essential IPT techniques include:
discuss feelings (both positive &
negative) about interpersonal experience
take action to change interpersonal
experience
Other IPT techniques common to other
psychotherapies
Exploratory Techniques
Non-directive exploration
Begin sessions with: “How have things
been since we last met?”
use open-ended questions
encourage clients sense of responsibility
Direct questioning
necessary to review depressive symptoms
necessary to review interpersonal
relationships
Encourage Affect
Learning in psychotherapy is emotional
learning
eliciting affect informs client re meaningful
goals
facilitate acceptance of painful affect
encourage clear expression of painful,
suppressed or unacknowledged feelings
inquire into sensitive areas
Use emotions in relationships
Assist client to negotiate painful affect in
significant relationships
client may change relationship behavior
(self or other) to eliminate painful affect
client may learn new ways to cope with
anger or anxiety
client may eliminate irrational thinking and
emotional sequelae
Help Client with suppressed emotions
For Clients who may be emotionally
constricted or unassertive
client may lack awareness or confidence to
express
some clients distressed by strong emotions
(e.g. trauma history) may need help
suppressing overwhelming emotions
may be counter-productive to encourage
emotional display
Clarification
Communication techniques to review
content, clarify feelings, promote awareness
repeating, rephrasing statements
calling attention to logical implications of
statements
raising contradictions or contrasts
Alert client to false, irrational or pervasive
beliefs regarding interpersonal relationships
Communication Analysis
Identify communication failures to improve
relationship satisfaction
Frequently review important conversations
or arguments
Illuminate common communication
difficulties
Use of Therapeutic Relationship
Client’s feelings toward therapist and therapy are
helpful focus
may reflect characteristic ways of feeling and
behaving in other relationships
Therapist instructs client to express complaints,
fears, that arise about therapist
model genuine negotiation with such feeling
therapist can correct distortions and
acknowledge genuine deficiencies
Directive Techniques
Include educating, advising, modeling
initially open to practical help: depressed clients
may need “case management”
provide suggestions if client unable to make
successful decisions independently
modeling may involve informing client how
therapist might handle similar situation
use directive techniques sparingly
use early, w/o undermining clients autonomy
Decision Analysis
Depressed clients often have history of selfdefeating decisions
because they fail to consider consequences
and fail to see alternatives
Therapist helps with decision analysis to help
client recognize range of options
insist on delaying action until each option is
explored
for interpersonal situations
Decision Analysis Involves
Set goal for interpersonal situation: “What
do you want to happen?”
Consider all useful alternatives
observe alternatives that client omits
direct client to explore probable
consequences of each line of behavior
clients often restrict range of alternatives
or unrealistically assess consequences
beware of premature decision analysis
Role Playing
Useful to explore client’s feelings and style
of communicating with others
Rehearse new ways for client to
communicate in safe setting
e.g. practice more assertiveness or
expressing affection
Bolsters client’s self-confidence in
communicating genuinely
Evidence for IPT Efficacy
Boston-New Haven Study (1979)
4 Tx Groups (16 wks & 1yr follow-up):
IPT, amitriptyline, both combined, control
IPT and amitriptyline equally effective
Combination IPT & amitrip. most effective
IPT grp. Sustained improved psychosocial
functioning 1 yr later (not amitrip. Grp)
NIMH Tx Depression Research (1989)
4 Tx grps (16 wks, multi-site, N=250)
IPT, CBT, Imipramine & clinical
management (CM), placebo & CM
IPT comparable to Imipramine & CM
CBT showed somewhat less improvement
IPT grp. had lowest attrition rate
Results for mod.-severe depression
Brain Activity Changes with
either IPT or Antidepressant Tx
Pet scans showed higher prefrontal and less
temporal activity in depressed vs controls
Both IPT and Paxil resulted in normalized
Pet scan activity and improved Dep. Sxs
Brody (2001); Martin (2001)
IPT Also Useful for Treating:
Dysthymia (see chapter in Weissman (2000)
Comprehensive Guide to IPT)
Social Phobia (Lipsitz et al., 1999)
Adolescent Depression (Muffson et al., 1999)
Postpartum Depression (O’Hara et al., 2000)
Bulimia (Wilson et al., 2002)
Late-Life Depression (Miller et al., 2001)
Bob Hill’s IPT Website:
Click on link at:
http://www.appstate.edu/~hillrw/