Transcript of "Interpersonal Psychotherapy. A Guide To The Basics. (Stuart, 2006)"
A Guide to the Basics
Scott Stuart, MD
nterpersonal psychotherapy (IPT) which the primary focus is the patient’s end relationships and is based on the
is a time-limited, dynamically in- internal cognitions, IPT focuses on the premise that humans have an intrinsic
formed psychotherapy that aims to patient’s interpersonal communications drive to form interpersonal relationships
alleviate patients’ suffering and improve with others. Although IPT may address with others.6-11 Simply put, attachment
their interpersonal functioning.1-4 IPT cognitions, they are not primary targets. forms the basis for an enduring pat-
focuses speciﬁcally on interpersonal Similarly, CBT and other approaches tern of interpersonal behavior that leads
relationships, with the goal of helping may deal with interpersonal issues, but an individual to seek care and reassur-
patients to either improve their interper- they are not the primary target. ance in a characteristic way. As Bowlby
sonal relationships or change their ex- In contrast to analytically oriented stated, “The desire to be loved and cared
pectations about them. In addition, IPT treatments, in which the focus is the con- for is an integral part of human nature
also aims to assist patients to improve tribution of early life experiences to psy- throughout adult life as well as earlier,
their social support so they can better chological functioning, IPT focuses on and the expression of such desires is to
manage their current interpersonal dis- helping the patient to improve his or her be expected in every grown-up, espe-
tress. communication and social support in the cially in times of sickness or calamity.”8
A number of elements characterize present. By virtue of its time limit and its Attachment theory hypothesizes that
IPT. These can be categorized as the the- focus on “here-and-now” relationships, people experience distress when disrup-
ories supporting IPT; the targets of IPT; IPT is designed to resolve psychiatric tions in their attachments with others
the tactics of IPT; and the techniques of symptoms and improve interpersonal occur. This is both because of the prob-
IPT. Although individual elements in functioning, rather than to change under- lems within the speciﬁc relationship and
each of these categories may be shared lying dynamic structures. The question because their social support network is
with other psychotherapeutic approach- that drives the IPT therapist’s interven- not able to sustain them during the loss,
es, it is their unique combination that de- tions is: “How can this patient be helped conﬂict, or transition. Insecurely at-
ﬁnes IPT (Table, see page xxx). to improve here-and-now interpersonal tached people are more prone to become
relationships and build a more effective distressed during interpersonal conﬂicts,
INTERPERSONAL ORIENTATION OF social support network?” after the loss of a relationship, or follow-
IPT ing role transitions, both because they
IPT is based on the premise that in- THE THEORY SUPPORTING IPT are less secure in their primary attach-
terpersonal distress is connected to psy- IPT rests on a triad of theories. The ments and because they have poor social
chological symptoms. Thus, the targets ﬁrst and most important is attachment support networks.12-14 These problem ar-
of treatment are threefold: the relief of theory. The second, communication eas — interpersonal disputes, role transi-
psychiatric symptoms; the conﬂicts, theory, describes the ways in which tions, and grief and loss — are addressed
transitions, and loss experiences in the patients’ maladaptive communication speciﬁcally in IPT.
patient’s relationships; and the help the patterns may lead to difﬁculty in their Rather than attempting to change the
patient needs to better use his or her ex- current interpersonal relationships. The patient’s fundamental attachment style,
tended social support network. IPT is third, social theory, is the basis for un- IPT focuses on the ways the patient
therefore clearly distinct from treatments derstanding the interpersonal context in communicates attachment needs and
such as cognitive-behavior therapy which patients interact with others. on how he or she can construct a more
(CBT)5 and psychoanalytically oriented Attachment theory describes the way supportive social network. Taking the
psychotherapies. In contrast to CBT, in in which individuals form, maintain, and patient’s attachment style as a constant,
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IPT works in real-time relationships fundamental basis of IPT is that current the context of poor social support will
to help the patient communicate needs interpersonal stressors lead to psychopa- be likely to experience psychological
more effectively. thology — there is no need to involve distress or psychiatric symptoms.
Communication theory can be un- either unconscious processes or psychic The biopsychosocial model is consis-
derstood in IPT as describing the way determinism as causal factors in psycho- tent with the theoretical basis for IPT, in
in which individuals communicate their logical dysfunction. which attachments in relationships and
attachment needs to speciﬁc signiﬁcant In sum, IPT rests on three theoretical a person’s ability to communicate ef-
others.15-20 Attachment theory is con- underpinnings: attachment theory, inter- fectively are linked with psychological
nected to the broad, or macro, social personal theory, and social theory. All functioning. In addition, the biopsycho-
context, while communication theory are used in the interpersonal conceptu- social model leads directly to the spe-
informs individual relationships on a mi- alization of the patient’s distress, as well ciﬁc techniques and interventions used
cro level. Attachment is the template on as to direct the interventions used in IPT. in IPT. This includes the use of IPT in
which speciﬁc communication occurs. An acute psychosocial stressor in a pa- combination with psychotropic medica-
According to Kiesler, interpersonal tient with attachment vulnerabilities, in tions when indicated. Treatment with
problems occur as a result of negative the context of insufﬁcient social sup- IPT therefore targets the biological, psy-
or nonsupportive responses from others port, forms the interpersonal triad which chological, and social determinants of
that are elicited unintentionally by the leads to the development of symptoms the patient’s distress.
patient.21 Maladaptive attachment styles and psychological distress (Figure 1, see
are manifested on a micro level as specif- page xxx). IPT is designed to address IPT TACTICS
ic communications that elicit responses this by helping patients to improve their The Interpersonal Inventory
that do not meet the patient’s attachment interpersonal communication and to use The Interpersonal Inventory2 is a reg-
needs effectively. In short, maladaptive their social support systems more fully. ister of the patient’s key current relation-
attachment styles lead to inappropriate ships. It is a unique feature of IPT that
or inadequate interpersonal communica- THE TARGETS OF IPT structures the process of history gath-
tion, which prevents a person’s attach- IPT is based on a biopsychosocial ering and formulation of interpersonal
ment needs from being met.22 model of psychological functioning,27 problem areas and provides a reference
Social theory emphasizes the role which asserts that biological, psycholog- point for conducting IPT. The Interper-
of interpersonal factors such as loss ical, and social factors coalesce within an sonal Inventory typically is compiled
and poor or disrupted social support in individual to produce a unique diathesis during the ﬁrst two to three sessions of
maladaptive responses to life events and and response to stress. When faced with IPT, but it is best considered a “work in
the genesis of depression and anxiety.23- a sufﬁcient interpersonal crisis, vulner- progress,” as most therapists and patients
The social milieu in which a patient able people are likely to have psycho- ﬁnd that their perspectives of relation-
develops interpersonal relationships logical difﬁculties. The biopsychosocial ships and the problems associated with
strongly inﬂuences his or her ability to model, therefore, frames psychological them change during the course of IPT.
cope with interpersonal stress. Further, difﬁculties as the response of a unique The Interpersonal Inventory focuses
it is the effect of the person’s current en- individual to a speciﬁc stressor, rather on the patient’s contemporary relation-
vironment that is crucial.23 In essence, than as categorical illnesses. Instead of ships, the history of the patient’s current
social theory posits that poor social sup- narrowly viewing psychological distress interpersonal problems, and the infor-
port is a causal factor in the genesis of or psychiatric symptoms as a manifesta- mation that is relevant to resolving the
psychological distress. tion of a medical illness, IPT conceptu- interpersonal problem (eg, the patient’s
The social theory that supports IPT alizes the patient’s functioning in broad attachment and communication styles).
stands in sharp contrast to psychoanalyt- terms as a product of his or her tempera- The Interpersonal Inventory is a critical
ic theory and clearly differentiates IPT. ment, personality, and attachment style, element of IPT that orients both patient
Psychoanalysis rests on two fundamen- based on a foundation of biological fac- and therapist to the interpersonal prob-
tal principles: psychic determinism, and tors such as genetics and physiological lems that are to be addressed in therapy.
the proposition that unconscious mental functioning, placed in the context of so- These problems are further character-
processes are a primary drive for con- cial relationships and broad social sup- ized within one of the four interpersonal
scious thoughts and behaviors.26 In con- port (Figure 2, see page xxx). A patient problem areas: interpersonal disputes,
trast, the social theory supporting IPT with a biopsychosocial diathesis coupled role transitions, grief and loss, and inter-
invokes neither of these principles. The with an acute interpersonal stressor in personal sensitivities (or deﬁcits). The
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use of the Interpersonal Inventory and TABLE 1.
the interpersonal problem areas are tac-
tical methods in IPT of addressing the The Deﬁning Elements of Interpersonal Therapy (IPT)
patient’s interpersonal distress. Theory Attachment, Interpersonal, and Social Theory
Targets Biopsychosocial: Psychiatric Symptoms, Interpersonal Relationships, Social
Interpersonal Problem Areas Support
Interpersonal Disputes. Interpersonal Tactics Interpersonal Inventory
disputes are simply conﬂicts between Interpersonal Problem Areas: Interpersonal Disputes, Role Transitions, Grief
individuals that are causing distress. and Loss, Interpersonal Sensitivity
Determining the stage of a dispute is
IPT Structure: Acute Time Limit; Maintenance Treatment
important in IPT in understanding the Nontransferential Focus of Interventions
patient’s perception of the problem and Present Focus
expectations for the relationship. Inter- Collaboration and Goal Consensus
personal disputes are conceptualized in Supportive and Directive Therapeutic Stance
IPT in one of three stages:2 Techniques Communication Analysis
● Negotiation — ongoing attempts by Interpersonal Incidents
Use of Content and Process Affect
both parties to bring about changes.
● Impasse — attempts at resolving the
dispute have stalled.
● Dissolution — the relationship is be-
yond repair. stage, or helps the patient recognize that The therapist’s task is to help the patient
The IPT strategy with interpersonal he or she is less invested in the relation- recognize these ambivalent reactions
disputes is to help patients move away ship, shifting the conﬂict to the dissolu- and deal with them effectively. The strat-
from the impasse stage, where by deﬁ- tion stage. This can be done by paying egy in dealing with role transitions is to
nition the conﬂict is unresolved. The particular attention to the patient’s style help the patient mourn the loss of the old
therapist either helps the patient become of communication and his or her expec- role and develop a more balanced view
more invested in the relationship, shift- tations about the relationship (both of of both the old and new roles. Encour-
ing the conﬂict back to the negotiation which are frequent contributors to the aging the patient to develop new social
problem), as well as factors that main- supports in his or her new environment
CM E EDUCATIONAL OBJECTIVES tain the dispute. also is crucial.
1. Deﬁne and describe interpersonal Role Transitions. All interpersonal re- Grief and Loss. Bowlby13 described
psychotherapy (IPT). lationships occur in complex psychoso- three stages of loss, which he labeled as
2. Review the theories supporting IPT. cial contexts. When the context changes, protest, despair, and detachment. In IPT,
as in a role transition, the relationship the goal is to help patients work through
3. Discuss the tactics and techniques
unique to IPT. changes. In IPT, the process of change these phases and continue on through a
within relationships that occurs as a con- resolution of their grief. The resolution
Dr. Stuart is professor of psychiatry sequence of contextual changes within involves helping patients to understand
and psychology, University of Iowa, and the patient’s life is conceptualized as a and articulate their grief and loss experi-
co-director, Iowa Depression and Clinical role transition. ence more fully, and then to share their
Research Center (IDCRC), Iowa City, IA. Although some transitions, such as experiences with others. The latter is ab-
Address reprint requests to: Scott Stu- loss of health, may be seen as wholly solutely crucial in IPT. This process of
art, MD, University of Iowa, Department negative by the patient, most change connecting with others will engage so-
of Psychiatry, 1-293 Medical Education involves some good and bad elements. cial support, diminish patients’ sense of
Building, Iowa City, Iowa 52242; or e-mail When working with a patient who is isolation, and help patients develop new
email@example.com. experiencing a role transition, the thera- attachments.
This work was supported by Na- pist focuses directly on the ambivalent While the working through of the
tional Institute of Mental Health grants feelings that the patient is experiencing loss intrapsychically is extremely help-
MH59668 and MH072757. Dr. Stuart dis- while undergoing the transition, bring- ful and is a necessary part of IPT, it is
closed no relevant ﬁnancial relationships. ing the patient’s attention to both posi- the communication of the experience
tive and negative reactions to the change. to others and the development of social
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support surrounding the loss that charac- perience also suggests
Acute Interpersonal Crisis
terizes IPT. In essence, once a grief issue that such patients may
is established as a focus of treatment, the respond well to IPT.
therapist’s tasks are simply to facilitate The primary therapeu- Attachment and
the patient’s mourning process and to as- tic goals when working DISTRESS Biopsychosocial
sist the patient to obtain increased social with interpersonal sen- Vulnerability
support. sitivities are to help the
In IPT, grief and loss can be con- patient improve his or
ceptualized broadly. The problem area her social skills and to Inadequate Social Support
includes reactions to an actual death, as develop a social support Figure 1. The interpersonal triad.
well as anticipatory grief of another’s, system that more fully
or of one’s own, death. Loss of physi- meets his or her attachment needs. duct of treatment.
cal health or of relationships also can be The Interpersonal Formulation should
considered grief and loss issues. As with The Interpersonal Formulation provide:
the other problem areas, the tactic in IPT The Interpersonal Formulation1 syn- ● A plausible hypothesis explaining the
is to use the area to maintain the inter- thesizes information from the Interper- patient’s problems and their onset,
personal focus of treatment. sonal Inventory and psychiatric history clinical manifestation, and course;
Interpersonal Sensitivity/Deﬁcit. In- regarding a patient’s biological and psy- ● A validation of the patient’s experi-
terpersonal sensitivity1 or deﬁcits2 may chological makeup, attachment style, ence and a way of understanding his
be used to describe a patient’s difﬁculty personality, and social context, creating or her problems;
in establishing and maintaining close a plausible hypothesis explaining his or ● A mutually determined focus for in-
interpersonal relationships. It is distinct her psychological symptoms (Figure 3, tervention based on the four problem
from the other problem areas in IPT be- see page xxx). In essence, the “formu- areas; and
cause it usually describes a consistent lation” is nothing more than a theoreti- ● A plausible rationale for treatment
style of attachment, rather than refer- cally grounded working understanding with IPT and for the use of speciﬁc
ring to an acute interpersonal stressor. of the unique person with whom the IPT techniques.
In many cases, interpersonal sensitivity clinician forms a relationship in therapy.
can be understood as the baseline attach- Because the theoretical orientation of Time Limit for Acute Treatment with
ment style on which an acute stressor is IPT is based on attachment, communica- IPT
imposed and can therefore be conceptu- tion, and social theory, the formulation IPT is characterized by a time-limit-
alized as a complicating factor in any of is an approximate understanding of the ed acute treatment phase, and a contract
the other three problem areas. In other patient’s experience from that perspec- should be established with the patient to
words, patients with sensitivities may tive. As such, it is a critical bridge be- complete acute treatment after a speciﬁed
present for treatment not because of tween a general theory of human behav- number of sessions. In general, a course
their longstanding relationship problems ior and the patient’s speciﬁc and unique of 10 to 20 sessions is used for the acute
but because they are in the midst of an problems. treatment of interpersonal problems, de-
acute interpersonal crisis, such as a tran- The Interpersonal Formulation is a pression, or other major psychiatric ill-
sition, a dispute, or a major loss. hypothesis that addresses several ques- nesses. Clinical experience suggests that
When interpersonal sensitivity is the tions: How did the patient come to be tapering sessions over time is generally
patient’s presenting problem, the pa- the way he or she is? What factors are a more effective way of using the treat-
tient’s longstanding sensitivities usually maintaining the problem? What can be ment. For example, weekly therapy may
have left him or her with a paucity of so- done about it? The formulation empha- be provided for 6 to 10 weeks, followed
cial relationships and a lack of interper- sizes both the interpersonal factors in- by a gradual increase in the time be-
sonal connectivity. Intuitively, this kind volved in the origin and context of the tween sessions as the patient improves,
of longstanding problem would seem to problem, as well as how IPT will help such that weekly sessions are followed
be less amenable to a time-limited treat- the patient overcome his or her symp- by biweekly and monthly meetings.
ment, but limited empirical research toms. It is therefore a pivotal part of IPT,
does suggest that IPT can be helpful for as the successful collaboration between Maintenance Treatment
patients with interpersonal sensitivities patient and therapist to construct a valid Although acute treatment should be
such as social phobia.28,29 Clinical ex- formulation “sets the scene” for the con- time-limited, both empirical research
PSYCHIATRIC ANNALS 36:8 | AUGUST 2006 545
Nontransferential Focus of IPT
Biopsychosocial Diatheses IPT is characterized by the absence
of interventions that address the thera-
peutic relationship directly. Although
Biological Factors Psychological Factors
sharing this characteristic with CBT and
Genetic Predisposition to Stress Early Life Experiences
several other solution-focused therapies,
Temperament Attachment Style
IPT clearly differs in this way from the
Social Factors dynamically oriented therapies.
Current Signiﬁant Relationships Attachment theory and clinical expe-
Current Social Support rience both support the fact that, given
enough time, a patient will display be-
havior towards his or her therapist that
Interpersonal Crisis is reﬂective of his or her attachment
style.9,32 This is in essence the basis for
transference. Thus, the therapist is in a
Interpersonal Dispute Role Transition Grief and Loss Interpersonal Sensitivity unique position to experience and exam-
ine the way in which a patient develops
and maintains relationships, because the
Subthreshold Intensity Suprathreshold Intensity therapist is in a relationship in which he
or she is the person on whom the attach-
Resolution ment behaviors are imposed.
Insufﬁcient Social Support Transference and the display of at-
tachment behavior in the therapeutic re-
Sufﬁcient Social Support Attachment Needs Unmet lationship are universal phenomena in all
psychotherapy, including IPT. However,
Resolution while in IPT the therapist’s experience of
Maladaptive Communication the patient–therapist relationship is used
of Attachment Needs to provide information about the patient
and his or her interpersonal world, the
Interpersonal Problems and transference elements of this relation-
Psychiatric Symptoms ship are not addressed directly by the
therapist as a part of the treatment. The
Figure 2. The biopsychosocial stress-diathesis model of IPT. use of the therapeutic relationship in IPT
to understand the patient’s interpersonal
and clinical experience with IPT have in IPT to “terminate” at the end of acute functioning and to assess the patient’s
demonstrated clearly that maintenance treatment, especially as it is not in the attachment style is crucial. The use of
treatment, particularly for those pa- interest of most patients to do so. the therapeutic relationship in IPT to
tients with recurrent disorders such as IPT follows a “family practice” mod- formulate questions about the patient’s
depression, should be provided for pa- el of care, in which short-term treatment interpersonal relationships outside of
tients in order to reduce relapse risk.30 for an acute problem or stressor is pro- therapy also is extraordinarily impor-
A speciﬁc contract for the maintenance vided. Once the interpersonal problem is tant. The use of transference to inform
phase should be negotiated with the pa- resolved, the therapeutic relationship is the therapist about potential points of
tient.31 IPT should be conceptualized as not terminated; the therapist makes him resistance and potential problems in
a two-phase treatment, in which a more or herself available to the patient should therapy is paramount.
intense acute phase of treatment focuses another crisis occur, at which time an- However, the direct examination of
on resolution of immediate symptoms, other time-limited course of acute treat- the patient–therapist relationship is not
and a subsequent maintenance phase ment can be undertaken. In the interim, encouraged in IPT because it changes the
follows with the intent of preventing re- the therapist can provide “health mainte- focus of treatment from more immediate
lapse and maintaining productive inter- nance” sessions periodically. work on the patient’s current social rela-
personal functioning. There is no need tionships to an intense experience with,
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and analysis of, the relationship with the
therapist. Addressing the patient–thera- Biological Factors Psychological Factors
pist relationship directly as a primary Genetics Attachment Style
technique shifts the therapy from one Substance Use Temperament
that is oriented toward improvement in Medical Illnesses Cognitive Style
symptoms and immediate interpersonal Medical Treatments Coping Mechanisms
functioning to a therapy that is oriented
towards intrapsychic insight.
IPT therefore is structured in such a Unique Individual
way that transference problems are less
likely to develop. First and foremost,
the patient is not explicitly encouraged Interpersonal Crises
to discuss the patient–therapist relation- Grief and Loss
ship. In addition, the IPT therapist gen- Interpersonal Disputes
erally takes a supportive stance, rather Role Transitions
than being neutral. The acute phase of Interpersonal Sensitivity
therapy is time-limited, and the treat-
ment is focused speciﬁcally on interper-
sonal issues in the patient’s social rela- Psychological Distress
In sum, the patient–therapist relation- Figure 3. The Interpersonal Foundation.
ship, and particularly the information
provided by the transference relation- This is of particular importance in Communication Analysis
ship, are extremely important in IPT but IPT because the therapy is time limited. Communication analysis is simply a
are not addressed directly in therapy. To It is incumbent on the therapist to quick- structured method of investigating the
do so detracts from the focus on symp- ly establish a therapeutic alliance. Thus hypothesis that the patient’s difﬁculties
tom reduction and rapid improvement in in IPT, particular attention must be paid are being caused, perpetuated, or exac-
interpersonal functioning that is the ba- to all of the “nonspeciﬁc elements” of erbated by poor communication. The
sis of IPT, and also typically leads to a therapy — warmth, empathy, affective goals for communication analysis are to
much longer course of treatment than is attunement, positive regard — that were help the patient identify his or her com-
required for IPT. The goal in IPT is liter- described by Rogers33 as necessary to munication patterns and recognize his or
ally to work with the patient to resolve bring about psychotherapeutic change. her contribution to the communication
his or her interpersonal distress quickly, It is crucial that IPT therapists be more problem, and to motivate the patient to
before problematic transference devel- than technicians; without establishing a communicate more effectively.
ops and becomes the focus of treatment. productive therapeutic alliance, none of To do this, the therapist works se-
the IPT techniques and strategies will be quentially with the patient through the
IPT TECHNIQUES effective. following steps:
Common Techniques Clariﬁcation is one of the most fre- ● Collecting information about the pa-
Warmth, empathy, genuineness, and quently used techniques in IPT to devel- tient’s interpersonal relationships and
unconditional positive regard, although op such a positive alliance. Clariﬁcation the communication that occurs within
not sufﬁcient for change in IPT, are all in IPT is in essence nothing more than them.
necessary for change in IPT. Sophisti- listening, asking good questions so that ● Developing hypotheses about the
cated techniques have no effect if the pa- the therapist can better understand the cause of the communication problem.
tient is not engaged in the therapy. With- patient’s experience, asking very good ● Presenting the hypotheses to the pa-
out a productive alliance, the patient will questions so that the patient can better tient as feedback about his or her com-
simply discontinue therapy, an obstacle understand his or her own experience, munication.
that no amount of technical expertise and asking extraordinarily good ques- ● Soliciting responses from the patient
can overcome. The primary goal of the tions so that the patient is motivated to about the therapist’s critiques.
IPT therapist is therefore to understand change his or her behavior. ● Revising the hypotheses if needed.
the patient. ● Problem solving to develop new ways
PSYCHIATRIC ANNALS 36:8 | AUGUST 2006 547
of communicating. Use of Content and Process Affect tient and therapist understand the ways
● Practicing new ways of communicat- Recognition and discussion of the in which the patient is communicating,
ing. patient’s affective state is crucial in IPT. and will also draw the patient more into
The more affectively engaged the pa- the therapeutic process.
Interpersonal Incidents tient is in therapy, the more likely it is
Interpersonal incidents1 frequently that change will occur. In IPT, the goals Role Playing
are used as a form of communication regarding affect are to help the patient Role playing is a technique in which
analysis. In essence, an interpersonal in- recognize his or her immediate affect; the patient and therapist create an in vi-
cident is a single episode in which com- facilitate the patient’s recognition of tro interaction in therapy to reinforce
munication occurs between the patient affect that may have been suppressed, behavioral change outside of therapy.
and a signiﬁcant other. An interpersonal or that the patient may ﬁnd painful to While role playing, the patient’s com-
incident is a description by the patient of acknowledge; and assist the patient to munication style and his or her mode of
a speciﬁc interaction with his or her at- communicate his or her affect more ef- affective interaction can be examined in
tachment ﬁgures or social contacts — it fectively to others. detail. In addition, the patient often can
is not a description of a general pattern The most obvious technique that the gain a better understanding of the expe-
of interaction. For example, if an identi- therapist can use to reach these goals rience of others involved in the patient’s
ﬁed dispute is a conﬂict between spous- is to give direct feedback to the patient social relationships. Role playing also
es, the therapist might ask the patient regarding the therapist’s perception of allows more effective communications
to “describe the last time you and your the patient’s affective state. A variation to be discussed, modeled, and practiced.
spouse got into a ﬁght,” or to “describe of this technique with particular rel- Role playing is not a mandatory in-
one of the more recent big ﬁghts you had evance to IPT is based on the therapist’s tervention in IPT; it is best used with
with your spouse.” The therapist then di- observation of “process” and “content” selected patients and with selected prob-
rects the patient to describe in detail the affect.1 Process affect is the affect that lems. It tends to be most effective when
communication that occurred in the spe- the patient displays during the conduct the therapeutic relationship is such that
ciﬁc incident, taking care to recreate the of therapy; that is, the affect that the pa- the patient is feeling supported and can
dialogue as accurately as possible. The tient displays in session with the thera- tolerate a degree of confrontation by the
patient should be directed to describe pist while discussing important issues. therapist.
his or her affective responses, as well Content affect, on the other hand, is the
as both verbal and nonverbal responses, affect that the patient reports having ex- SUMMARY
and to describe observations of his or her perienced in the past, in interactions out- It is a Herculean task to condense the
spouse’s nonverbal behavior. side of the therapeutic relationship. hours of clinical experience, volumes of
In contrast to an approach that ques- When working with content and pro- theoretical writings, and collections of
tions the accuracy of the patient’s cog- cess affect, it is extremely important for treatment manuals into a coherent yet
nitions, the IPT therapist is interested in the therapist to be aware of incongrui- brief description of IPT. The issue is not
the way in which the patient communi- ties in the patient’s presentation. In other complexity; in many ways, IPT is quite
cates his or her attachment needs. IPT words, when process and content affect simple to understand, learn, and deliver.
is directed at the patient’s communica- are dissimilar, it signals the therapist IPT speaks to the universal human con-
tions and is concerned with the ways in that the topic under discussion should be dition: interpersonal relationships and
which the communication between the explored further. It also signals that the the changes, conﬂicts, and losses that
patient and his or her signiﬁcant other is therapist, when the patient is able to tol- occur within them. It also speaks to our
maladaptive. In other words, rather than erate the feedback, should point out the need to connect to and to be understood
addressing internal processes, the IPT incongruity to the patient. This will as- by others. The concepts are intuitive.
therapist is concerned with examining sist the patient to become aware of emo- Instead, the difﬁculties in describing
the interpersonal communication that is tions that he or she may be suppressing, IPT fully are a function of the unique na-
occurring in the relationship. The prem- or that he or she may be aware of but is ture of every patient and therapist. The
ise under which an interpersonal inci- ﬁnding difﬁcult to acknowledge. power of the IPT rests on two nearly
dent is analyzed is that the “problem” The recognition of incongruity be- paradoxical factors. First, the clear theo-
presented by the patient is the result of tween content and process affect is ex- retical base, well-deﬁned targets, and the
poor communication. tremely important in IPT. Recognizing tactical approach that ﬂows from them
these discrepancies will help both pa- in IPT lead to a solid structure on which
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Addtional Resources on Interpersonal Therapy 22. Stuart S, Noyes R Jr. Attachment and inter-
personal communication in somatization dis-
Additional details regarding IPT can be found in Interpersonal Psychotherapy: A order. Psychosomatics. 1999;40(1):34-43.
Clinician’s Guide by Scott Stuart and Michael Robertson (Oxford Press US). The text in- 23. Henderson S, Byrne DG, Duncan-Jones P.
Neurosis and the Social Environment. Sydney,
cludes information about the practical conduct of IPT, case examples, and a review
Australia: Academic Pressl 1982.
of the empirical data supporting IPT. A CD-ROM–based IPT training program includ- 24. Brown GW. Genetic and population perspec-
ing didactic materials and standardized training videotapes is slated for publication in tives on life events and depression. Soc Psy-
2007. This program will serve as a template that users can modify for the needs of their chiatry Psychiatr Epidemiol. 1998;33(8):363-
own training curricula. 25. Weissman MM, Paykel ES. The Depressed
More information on IPT training can be found on the website of the International Woman: A Study of Social Relationships. Chi-
Society for Interpersonal Psychotherapy, http://www.interpersonalpsychotherapy.org. cago, IL: University of Chicago Press; 1974.
26. Brenner C. An Elementary Textbook of Psy-
choanalysis. New York, NY: Anchor Press;
Psychiatry. 1977 Mar;130:201-210.
both therapist and patient can rely. On 1973.
8. Bowlby J. The making and breaking of affec-
the other hand, IPT is also ﬂexible, so tional bonds. II. Some principles of psycho-
27. Engel GL. The clinical application of the bio-
psychosocial model. Am J Psychiatry. 1980;
that it can be adapted to the unique indi- therapy. The ﬁftieth Maudsley Lecture. Br J
viduals that seek help, and to the human Psychiatry. 1977 May;130:421-431.
28. Lipsitz JD, Markowitz JC, Cherry S, Fyer AJ.
9. Bowlby J. Developmental psychiatry comes
therapists that attempt to provide it. Both of age. Am J Psychiatry. 1988;145(1):1-10.
Open trial of interpersonal psychotherapy for
of these aspects of IPT are critical in un- the treatment of social phobia. Am J Psychia-
10. Ainsworth MD. Object relations, depen-
derstanding the individuals with whom dency, and attachment: a theoretical review
29. Stuart S. Use of interpersonal psychotherapy
of the infant-mother relationship. Child Dev.
we work and facilitating change. 1969;40(4):969-1025.
for other disorders. In: Directions in Mental
Consider IPT as a work of ﬁne cu- Health Counseling. New York, NY: Hather-
11. Ainsworth MDS, Blehar MC, Waters E, Wall
leigh Press; 1997:4-16.
linary art. Our patients’ fundamental S. Patterns of Attachment: A Psychological
30. Frank E, Kupfer DJ, Perel JM, et al. Three-
Study of the Strange Situation. Hillsdale, N J:
needs to be nourished and cared for must year outcomes for maintenance therapies in
Lawrence Erlbaum Associates; 1978.
be met. The basic recipe is clear, but it 12. Parkes CM. Psycho-social transitions: a ﬁeld
recurrent depression. Arch Gen Psychiatry.
is the nuanced and peculiar skill of each for study. Soc Sci Med. 1971;5(2):101-115.
31. Stuart S, Robertson M. Interpersonal psycho-
chef that brings out the right ﬂavors for 13. Bowlby J. Attachment and Loss: Separation.
therapy. In: Hersen M, Sledge WH, eds. En-
New York, NY: Basic Books; 1973. Anxiety
the unique patient who needs help that and Anger, vol. 2.
cyclopedia of Psychotherapy. New York, NY:
truly satisﬁes. Academic Press; 2002:37-47.
14. Parkes CM. Bereavement and mental illness.
32. Sullivan HS. The Interpersonal Theory of
Br J Med Psychol. 1965 Mar;38:1-26.
Psychiatry. New York, NY: Norton; 1953.
15. Kiesler DJ, Watkins LM. Interpersonal com-
REFERENCES plimentarity and the therapeutic alliance: a
33. Rogers CR. The necessary and sufﬁcient con-
1. Stuart S, Robertson M. Interpersonal Psycho- ditions of therapeutic personality change. J
study of the relationship in psychotherapy.
therapy: A Clinician’s Guide. London, Eng- Consult Psychol. 1957;21(2):95-103.
land: Edward Arnold; 2003.
16. Kiesler DJ. Contemporary Interpersonal The-
2. Klerman GL, Weissman MM, Rounsaville
ory and Research: Personality, Psychopathol-
B, Chevron E. Interpersonal Psychotherapy
ogy, and Psychotherapy. New York, NY: John
of Depression. New York, NY: Basic Books;
Wiley & Sons; 1996.
17. Kiesler DJ. Interpersonal circle inventories:
3. Klerman GL, Weissman MM. New Applica-
pantheoretical applications to psychotherapy
tions of Interpersonal Psychotherapy. Wash-
research and practice. J Psychotherapy Inte-
ington, DC: American Psychiatric Publishing;
18. Kiesler DJ. Interpersonal methods of assess-
4. Weissman MM, Markowitz JC, Klerman GL.
ment and diagnosis. In: Snyder CR, Forsyth
Comprehensive Guide to Interpersonal Psy-
DR, eds. Handbook of Social and Clinical
chotherapy. New York, NY: Basic Books;
Psychology: The Health Perspective. Elms-
ford, NY: Pergamon Press; 1991:[PAGE
5. Beck AT, Rush AJ, Shaw BF, Emery G. Cog-
nitive Therapy of Depression. New York, NY:
19. Benjamin LS. Interpersonal Diagnosis and
The Guilford Press; 1979.
Treatment of Personality Disorders. 2nd ed.
6. Bowlby J. Attachment. New York, NY: Basic
New York, NY: The Guilford Press; 1996.
20. Benjamin LS. Introduction to the special sec-
7. Bowlby J. The making and breaking of af-
tion on structural analysis of social behavior.
fectional bonds. I. Aetiology and psychopa-
J Consult Clin Psychol. 1996;64(6):1203-
thology in the light of attachment theory. An
expanded version of the Fiftieth Maudsley
21. Kiesler DJ. An interpersonal communication
Lecture, delivered before the Royal College
analysis of relationship in psychotherapy.
of Psychiatrists, 19 November 1976. Br J
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