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Interpersonal Psychotherapy. A Guide To The Basics. (Stuart, 2006)

Interpersonal Psychotherapy. A Guide To The Basics. (Stuart, 2006)






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    Interpersonal Psychotherapy. A Guide To The Basics. (Stuart, 2006) Interpersonal Psychotherapy. A Guide To The Basics. (Stuart, 2006) Document Transcript

    • CM E Interpersonal Psychotherapy: A Guide to the Basics Scott Stuart, MD I 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, 542 PSYCHIATRIC ANNALS 36:8 | AUGUST 2006
    • 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 25 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 PSYCHIATRIC ANNALS 36:8 | AUGUST 2006 543
    • 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 Interpersonal Formulation 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. Role Playing ● Impasse — attempts at resolving the “Common” Techniques 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 scott-stuart@uiowa.edu. 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 544 PSYCHIATRIC ANNALS 36:8 | AUGUST 2006
    • 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, 546 PSYCHIATRIC ANNALS 36:8 | AUGUST 2006
    • and analysis of, the relationship with the therapist. Addressing the patient–thera- Biological Factors Psychological Factors Social Factors pist relationship directly as a primary Genetics Attachment Style Intimate Relationships technique shifts the therapy from one Substance Use Temperament Social Support 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 tionships. 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 548 PSYCHIATRIC ANNALS 36:8 | AUGUST 2006
    • Psychiatry. 1979;42(4):299-311. 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- 372. 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 137(5):535-544. 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- try. 1999;156(11):1814-1816. 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. 1990;47(12):1093-1099. 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. 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