Depression-Focused Psychotherapies: Interpersonal Psychotherapy
IPT evolved between the late 1960s and the early 1980s. The developers of IPT trace its origins to the work of Adolph Meyer (1957), which emphasizes the significance of psychosocial and interpersonal experiences within a more comprehensive psychobiological model of psychopathology. One of Meyer’s associates, Harry Stack, is similarly acknowledged for blending work from anthropology and sociology within a more interpersonally based approach to psychoanalysis. The interpersonal model of depression also draws on the writings of Bowlby, G. W. Brown , in which depression is viewed from relational and social perspectives.
IPT of depression was initially conceived as a brief psychological treatment for unipolar major depression. This outpatient therapy is typically provided over 12-16 weeks on an individual basis, although it has also been adapted for work with couples. It is readily used with or without concomitant antidepressant pharmacotherapy. A manual guiding individual therapy for patients with major depressive disorder is available, and various modifications of IPT for conditions such as dysthymia, depression in adolescents, and late-life depression have been described. When administered in research protocols, IPT is readily discriminated from CT and pharmacotherapy.
Shared Features of Depression-Focused Psychotherapies
At the most basic level, IPT aims to improve the quality of a depressed patient’s interpersonal world. Klerman and Weissman (1982) emphasized that the premise of IPT is that depression occurs within an interpersonal context regardless of its severity, phenomenology, or presumed etiology. The authors further proposed that helping patients to improve their understanding of and ability to modify the interpersonal context associated with depression facilitates the recovery process. Additional long-term benefits were predicated to include improved social function and prophylaxis against relapse. The original work using IPT also drew heavily on the methods and findings of social casework (e.g., Weissman and Paykel 1974). As a result, the therapy was always intended to be feasible for social workers and other master’s degree-prepared mental health workers, as well as psychologists and psychiatrists.
The social milieu of those with depression is central to the interpersonal therapist’s formulation of the treatment plan. Of particular importance are the high rates of life stressors temporally associated with the onset of unipolar depression, especially both acute and chronic marital difficulties. From this vantage point, a common theme in IPT centers on the relationship between the fragility of attachment bonds and vulnerability to depression. Conversely, the apparent protective or “neutralizing” role of social support provides a potent avenue for therapy through efforts to help the patient strengthen his or her intimate relationships. Another important aspect of the depressed person’s social milieu is his or her performance in social and interpersonal roles. Not only the depressed person’s role functioning within his or her nuclear family is germane to IPT, but also his or her social role performance at the workplace, with friends and peer groups, and in the broader sense of neighborhood or community. Attention to social role performance thus includes the individual’s current and long-term patterns of functioning in diverse situations, as well as more recent or still-evolving role transitions.
IPT also may be considered a psychoeducational intervention because, in addition to the strong social emphasis, therapists explicitly teach patients about depression and its treatment. This includes the therapist’s willingness to provide practical advice or recommendations to help patients better tolerate the symptoms of depression. Although less structured than CT or behavior therapy, IPT similarly aims to help patients improve management of the symptoms and impairments associated with the depressive state. These efforts also serve to help lessen the demoralization and hopelessness experienced by most depressed people. The therapy may be quite active in this regard, including providing assistance to patients through the use of problem-solving strategies.
Treatment with IPT thus begins with an explanation of the diagnosis and treatment plan. Concurrently, the therapist establishes a working alliance and performs an assessment of current interpersonal relationships. Many therapeutic strategies used in IPT are based directly on core psychotherapy skills and processes, such as creating an environment in which there is nonjudgmental exploration and elicitation of feelings. In fact, the ability to become a competent interpersonal therapist is highly correlated with the therapist’s ability to be empathic and genuine.
Next, the interpersonal therapist helps the patient to identify the common interpersonal theme areas that are associated with the depressive disorder. During the initial sessions of therapy, an interpersonal inventory is obtained to help guide treatment on one or two key problem areas. Four common theme areas generally serve as the focus for IPT: unresolved grief, role disputes, role transitions, and interpersonal deficits. The latter category incorporates areas such as the maladaptive interpersonal patterns associated with personality disorders, regression or deterioration in the patient’s social role performance (the “sick” role), social isolation, and/or decline of socioeconomic status.
Therapeutic interventions are guided by the manual of Klerman et al. (1984). In cases of unresolved grief, explicit attention is provided to help the patient to mourn the lost loved one. Encouragement to begin to develop new relationships is also emphasized. When IPT centers on social role disputes, the therapist helps the patient to determine if his or her relationship difficulties might benefit from renegotiation (as when the conflict appears to be at an impasse) or dissolution (as when options might include separation or divorce). In states of role transition, the therapeutic strategies center on recognition of how the transition has affected the person’s life, exploration of the likely consequences of these changes, and assistance in developing solutions to problems engendered by the transition. When interpersonal deficits are paramount, overcoming social isolation and lack of fulfillment is often emphasized. Regardless of the key theme area, the interpersonal therapist attends to the role of personality patterns in the genesis and maintenance of the problem. For example, the therapist may encourage the patient to “try out” a different way of interacting and to compare the outcome with his or her more habitual response. Patients who have difficulty engaging in such a productive relationship may have a harder time with IPT and, in turn, may elicit less effective interventions from otherwise well-trained therapists.
Some evidence suggests that IPT may be perceived as a more acceptable treatment for depression than either pharmacotherapy or cognitive-behavioral therapy (CBT), at least with respect to younger patients. Moreover, it has been suggested that it may be easier for traditionally trained therapists to master IPT than either behavioral therapy or cognitive therapy (CT).
Revision date: July 7, 2011
Last revised: by Jorge P. Ribeiro, MD