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
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Depression
IPT clearly effective for treating Depression
 Diagnostic Criteria for Depression:
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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
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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
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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)
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IPT: Roots in Psychodynamic Theory
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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
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Transference and counter-transference are interpersonal
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Object Relations Influence
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“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.
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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
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IPT Compared to Other Therapies
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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
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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
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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
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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
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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”)
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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
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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’
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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
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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)
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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”
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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
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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
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Interpersonal Disputes: Goals
Identify the dispute
 Make choices about a plan of action
 Modify communication patterns or
 Reassess Expectations
 Consider satisfying needs outside
relationship
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Interpersonal Disputes: Strategies
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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?
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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
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Interpersonal Disputes: Strategies
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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?
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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?
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Role Transition: Tx Strategies
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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
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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
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Interpersonal Deficits: Strategies
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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
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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
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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
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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
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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
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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
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Grief Problem Area Focus
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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
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Abnormal Grief Treatment Goals
Facilitate the mourning process
 Help client reestablish interests and
relationships to substitute for what has been
lost
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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
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Grief Treatment Strategies (cont.)
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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
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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
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Termination Difficulties
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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
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Essential IPT techniques include:
 discuss feelings (both positive &
negative) about interpersonal experience
 take action to change interpersonal
experience
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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
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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
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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
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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
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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
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Communication Analysis
Identify communication failures to improve
relationship satisfaction
 Frequently review important conversations
or arguments
 Illuminate common communication
difficulties
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Use of Therapeutic Relationship
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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
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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
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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
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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
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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)
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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
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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)
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IPT Also Useful for Treating:
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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/