What is IPT? (Stuart, 2008)

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What is IPT? (Stuart, 2008)

  1. 1. J Contemp Psychother (2008) 38:1–10 DOI 10.1007/s10879-007-9063-z ORIGINAL PAPER What is IPT? The Basic Principles and the Inevitability of Change Scott Stuart Published online: 25 September 2007 Ó Springer Science+Business Media, LLC 2007 Abstract Interpersonal Psychotherapy (IPT) is an Mental Health Treatment of Depression Collaborative empirically validated treatment for a number of psychiatric Research Program (TDCRP) (Elkin et al. 1989). In this disorders. Like all psychotherapies, IPT can be described study, both IPT and Cognitive Behavior Therapy (CBT) by its theoretical foundations and its primary targets, tac- (Beck et al. 1979) compared favorably to imipramine for tics, and techniques. The need for continued creativity in the treatment of major depression. Since that time, IPT has IPT and other treatments is reviewed, and several specific been adapted to a wide variety of psychiatric disorders and proposals for change in IPT based on clinical observations a great deal of empirical evidence has accumulated and theoretical considerations are discussed. A paradigm supporting its efficacy. Within research settings, IPT has for collaboration between academic research and clinical been an unmitigated success. observation required for continued creativity is offered. Statements such as ‘‘an unmitigated success within a Change is inevitable, and the empirically validated thera- research setting,’’ of course, imply less favorable compar- pies such as IPT will be even more effective as they isons in other settings. Such is the case with IPT. The incorporate and test new and creative elements. consequences of its inclusion in the TDCRP and other research programs have been dichotomous. On the one Keywords Interpersonal Á Therapy hand, IPT has been widely adopted and adapted by aca- demicians for a number of psychiatric disorders and diagnostic subgroups. On the other hand, the application Introduction and further development of IPT has been constrained by research protocols and has led to rather rigid manualized descriptions of its use. For instance, research protocols ‘‘Even if you’re on the right track, you’ll get run over have focused on symptom change within specific DSM-IV if you just sit there.’’—Will Rogers diagnoses as opposed to focusing treatment on individual The development and evaluation of Interpersonal Psy- patients and the unique formulations that are developed for chotherapy (IPT) (Stuart and Robertson 2003; Klerman each of them. In such protocols, the length of treatment is et al. 1984; Klerman and Weissman 1993; Weissman et al. artificially determined by research requirements as opposed 2000) is a fascinating case-study. Based on the research to clinical indications. More importantly, techniques that conducted by Klerman, Weissman, and others in the 1970s might otherwise be effective are constrained by the pro- (Klerman et al. 1974; Weissman et al. 1981; Paykel et al. tocol, rather than allowing therapists to utilize their clinical 1976), IPT was manualized by Klerman et al. (Klerman experience and judgment to adapt the approach to indi- et al. 1984) in 1984 for use within the National Institute of vidual patients. Because IPT has been codified in research settings, a critical balance between clinical development and S. Stuart (&) research-based evaluation has been lost. Rather than uti- Department of Psychiatry, University of Iowa, 1-293 Medical Education Building, Iowa City, IA 52242, USA lizing clinical observations to inform potential innovations e-mail: scott-stuart@uiowa.edu and then incorporating and validating these new elements, 123
  2. 2. 2 J Contemp Psychother (2008) 38:1–10 adaptations (as opposed to innovations) have been limited won by individuals who are able to maintain a franchise on to the testing of IPT with diagnostic subgroups, such as a particular psychotherapy. Many institutes, training sem- dysthymic disorders, or for specific patient populations inars, and textbook/manual sales depend on maintaining such as depressed perinatal women, depressed geriatric fidelity to the franchise, and on presenting a therapy as patients, and depressed adolescents. These applications of unique and obtainable only through specific training. Even IPT for subgroups are neither new nor ‘‘novel’’ treatments. more insidious are the riches of research funding— While they provide more specific evidence-based treat- obtaining such funding depends in large part on developing ment, this conservative academic approach to adapting IPT and maintaining a reputation as an expert in a particular hinders creativity. Innovations resulting from ‘‘outside the treatment. box’’ thinking that might radically change the IPT These factors have often conspired to create psycho- approach are not compatible with this academic research therapy ‘‘guilds’’ in which proper training and lineage must paradigm. To paraphrase Mark Twain, ‘‘an academician is be demonstrated for entry. The guild model of psycho- a person who does things because they have been done therapy implies that there is ‘‘ownership’’ of the therapy. before; a clinician is a person who does things because the By extension, it also implies that there are guild masters things that have been done before don’t work.’’ who have the power to decide ‘‘what the therapy is,’’ to Of course IPT is not unique in having conflict between determine who gets ‘‘credit’’ for the therapy, and who rigid adherence to the original version of a treatment and decide who is branded an ‘‘iconoclast or heretic.’’ Guilds the innovations which inevitably arise. This type of conflict are effective for propagation and maintenance of franchise, led to Freud’s excommunication of many of his disciples, but discourage innovation. As Confucius said, ‘‘The cau- and has occurred within the schools of behavior therapy, tious seldom err (Confucious 1893).’’ A new model is cognitive therapy, and specific approaches such as Rational sorely needed. Emotive Therapy (Ellis 1970) and Dialectical Behavior In this paper, the starting point for discussing a new Therapy (Linehan 1987). In many cases, the more specific model is a review of the fundamental principles of IPT as the psychotherapeutic treatment the more the resistance to they are currently conceptualized. Potential innovations are change. Psychotherapies ought to be developed through then discussed, as well as their implications for treatment. constructive dialogue rather than defined by those whose A new paradigm is proposed, in which the interaction arguments are loudest and most vehement. between clinical practice and research is renewed and The history of psychotherapy might well by character- serves as the genesis for creative innovations and ized as a history of charismatic figures in psychiatry and improvements in IPT. Though the examples are specific to psychology. The degree of innovation permitted, tolerated, IPT, the model can potentially be applied to all psycho- or encouraged in a specific therapeutic approach depends therapeutic approaches. on the degree to which the specifics of that approach are considered dogma by its originators. Erikson’s (Erikson 1998) concept of ‘‘generativity versus stagnation’’ captures The Defining Elements of IPT the essence of this process. One might argue that the diverging paths of CBT and RET, for example, have hin- As houses are best built by starting with the foundation and ged largely on the generativity of their charismatic frame, IPT can best be understood by first describing its founders. theoretical foundation and the framework for its delivery.1 There are other factors that have influence the degree to This framework can be divided into the theories supporting which current treatments are rigidly constrained. The first IPT; the targets of IPT; the tactics of IPT (i.e., the concepts is that many are now supported by empirical evidence, and applied in the treatment); and the techniques of IPT (i.e., the argument is easily made that the therapy should be what the therapist says or does in the treatment). Though rigidly applied because ‘‘the evidence supports the man- individual elements in each of these categories may be ual.’’ This reductionistic argument is a great hindrance to shared with other psychotherapeutic approaches, it is their innovation and dissemination, for it ignores the chasm that unique combination which defines IPT (Table 1). exists between the worlds of research and clinical practice (Nathan et al. 2000). Had there been this insistence on rigid adherence to manuals supported by efficacy data in the 1 Additional details regarding IPT can be found in: Interpersonal past, we might be reading those manuals on parchment by Psychotherapy: A Clinician’s Guide by Scott Stuart and Michael candlelight! Robertson, Basic Books, 2003. The text includes information about the practical conduct of IPT and a review of the empirical data In addition, although there are no pharmaceutical com- supporting its use. Unfortunately the scope of this paper precludes a panies influencing psychotherapy development, there are detailed discussion of IPT techniques; the reader is referred to the text nonetheless fortunes to be made and academic glories to be for additional information in this regard. 123
  3. 3. J Contemp Psychother (2008) 38:1–10 3 Table 1 The defining elements of IPT Theory Supporting IPT Theory: Attachment theory Supported by communication theory and social theory In their 2003 Clinician’s Guide (Stuart and Robertson 2003) Stuart and Robertson described a detailed tripartite Targets: Interpersonal relationships, social support theoretical foundation for IPT which included attachment Secondarily impacts psychiatric symptoms theory, communication theory, and social theory. Each was Tactics: Interpersonal Triad given equal credence, and all were supported by research. Biopsychosocial model None of the research, however, was specific to IPT. Interpersonal inventory Prior to that, the emphasis in IPT had been much more Interpersonal problem areas on the empirical evidence of its efficacy than on its theo- Interpersonal Formulation retical foundation. In fact, IPT was largely atheoretical in IPT structure its early iterations, and was originally designed to reflect Non-transferential focus of interventions ‘‘good supportive therapy.’’ It was only after IPT was Present focus found to be efficacious that theory was appended to it—the Collaboration and goal consensus process by which theory has been appended to IPT has Positive regard for the patient been a bit like building the house and then digging the Techniques: foundation. Fortunately, the empirical structure of IPT has Interpersonal incidents been strong enough to sustain the excavation. Communication analysis Within the last several years, attachment theory has been Use of content and process affect increasingly recognized as the primary theoretical pillar of Role playing IPT, with communication and social theory relegated to a ‘‘Common’’ techniques secondary role. IPT specific research on attachment has also supported this position (McBride et al. 2006) (see also Ravitz this issue). Attachment theory describes the way in The Interpersonal Triad: A Model for Psychological which individuals form, maintain, and end relationships, Distress and is based on the premise that humans have an intrinsic drive to form interpersonal relationships with others IPT is based on the premise that interpersonal distress is (Ainsworth 1969; Ainsworth et al. 1978; Bowlby 1969, intimately connected with psychological symptoms. An 1977a, b, 1988). Simply put, attachment forms the basis for acute interpersonal crisis (stressor) begins the process. The an enduring pattern of interpersonal behavior through ability of the patient to manage the crisis psychologically which individuals seek care and reassurance in character- and biologically is heavily influenced by the patient’s istic ways. Bowlby stated that, ‘‘The desire to be loved and biopsychosocial vulnerabilities (diatheses) such as genetic cared for is an integral part of human nature throughout vulnerability to illness, temperament, attachment style, and adult life as well as earlier, and the expression of such personality, which may modulate or exacerbate the crisis. desires is to be expected in every grown-up, especially in Social factors such as a patient’s current significant rela- times of sickness or calamity (Bowlby 1977a, p. 428).’’ It is tionships and general social support provide the context in a concept which is easy to understand, but one which has which the stress-diathesis interaction occurs, and further proven difficult to measure. modify the individual’s ability to cope with his or her Attachment theory posits that individuals become dis- distress. Together, these elements form the Interpersonal tressed when they experience disruptions in their Triad (Fig. 1), which models the basic IPT conceptualiza- relationships with others. Insecurely attached individuals tion of the development of psychological distress. are more vulnerable to losses, to interpersonal conflicts, and to role transitions, both because of their tenuous pri- Acute Interpersonal Crisis (stressor) mary relationships and because of their poor social support networks (Parkes 1965, 1971; Bowlby 1973). These issues—Grief and Loss, Interpersonal Disputes, and Role Biopsychosocial Transitions—are specific Interpersonal Problem Areas DISTRESS Vulnerability addressed in IPT. (diathesis) Two key derivatives of the patient’s attachment style are his or her communication style and social support network. The patient’s interpersonal communication of distress, Social Support (context) whether it be plaintive, distancing, or productively enlist- Fig. 1 The Interpersonal Triad ing of support, is highly dependent upon his or her 123
  4. 4. 4 J Contemp Psychother (2008) 38:1–10 attachment style. Likewise attachment influences the psychological and social factors coalesce within an indi- patient’s ability to generate social support—more securely vidual to produce a unique diathesis and response to stress. attached individuals have larger social networks and many Given this causative model (Fig. 1), the targets of IPT are more people on whom they can call for support. Con- twofold. The conflicts, transitions, and losses in the versely, those with insecure attachment style have a patient’s interpersonal relationships are the first target. paucity of social support and few adaptive interpersonal The second is the patient’s social support. relationships. Both the trees of specific interpersonal The formulation clearly identifies biopsychosocial fac- communication and the forest of social support depend on tors as one of the three legs of the Interpersonal Triad the roots of attachment. predisposing a patient to distress. There is no evidence to Therefore, while both Communication Theory (Kiesler date that IPT has a direct effect upon biological diatheses, and Watkins 1989; Kiesler 1991, 1992, 1996; Benjamin so biological factors are not a primary target. Ongoing 1996a, b) and Social Theory (Henderson et al. 1982; research may produce such evidence (Brody et al. 2001; Brown 1998; Weissman and Paykel 1974) remain impor- Martin et al. 2001), in which case the target of biological tant theoretical elements in IPT, they are conceptualized as functioning can be added to IPT in the future. derivatives of attachment. Patients with more maladaptive In addition, though there are compelling clinical and attachment styles burn their social bridges and alienate theoretical reasons to believe that IPT is likely to have an others when they ask for support. Maladaptive attachment impact on personality and attachment, there is no empirical styles also lead to inappropriate or inadequate interpersonal evidence to date that IPT directly impacts the psycholog- communications which prevent individuals’ attachment ical diatheses that predispose patients to distress. These needs from being met (Stuart and Noyes 1999). Attachment include such factors as personality and attachment style. is the template upon which specific communication occurs; Both have been implicated as moderators of response to communication reflects attachment style. The social milieu IPT (Stuart and Noyes 1999; McBride et al. 2006) (see also in which a patient develops interpersonal relationships Ravitz et al this issue), but it is not yet known whether strongly influences the way in which he or she is able to treatment with IPT produces change in these factors. cope with interpersonal stress. That social milieu, or social Therefore, IPT (at present) is targeted at the acute support network, is directly influenced by the patient’s interpersonal stressors and lack of social support that cause attachment style. distress. It is critical to note that psychiatric symptoms, In sum, IPT is firmly grounded in attachment theory. described as a primary target in the original iteration of Communication theory and social theory are important, but IPT, are now regarded as a secondary target. In other explain phenomena that are derivative from attachment. In words, it is through changes in interpersonal functioning the IPT model, biopsychosocial diatheses render a patient and social support that symptoms are reduced—symptom vulnerable to an acute interpersonal crisis. If intense reduction results from interpersonal and social changes. enough, the crisis will trigger care-seeking behavior driven IPT is therefore conceptually distinct from treatments by attachment needs. If sufficient social support is avail- such as CBT (Beck et al. 1979) and behavior therapy. In able, the crisis may be diffused at this point. Insufficient contrast to CBT, in which the primary focus is the patient’s social support, however, will push the care-seeking internal cognitions, IPT’s primary targets are the patient’s behavior even further. Patients with the ability to con- interpersonal relationships and social support. Though IPT structively communicate their distress and need for care may address cognitions, they are not primary targets. may avoid overwhelming distress by enlisting additional Similarly, though CBT and other approaches deal with support, but those whose attachments are maladaptive will interpersonal issues, they are not primary targets. likely communicate their need for care in ways which will In contrast to IPT, the primary targets of behavioral drive potential care-providers away. Faced with crises in interventions, such as behavioral activation and exposure which social support is not immediately available and therapy, are literally the symptoms of psychopathology. cannot be obtained, such patients experience psychological Anhedonia, for instance, is targeted by tasking the patient distress. If the distress is severe enough, they may even to schedule and engage in pleasurable activities. Phobic lapse into DSM-IV disorder which qualifies them for a avoidance is targeted through graded exposure. Needless to research protocol. say, the theoretical bases for IPT, CBT, and behavioral therapy are all different as well. In contrast to analytically oriented treatments, in which The Targets of IPT the focus is the contribution of early life experiences to psychological functioning, IPT focuses on helping the IPT is based on a Biopsychosocial Model of psychological patient to improve his or her interpersonal relationships and functioning (Engel 1980), which asserts that biological, social support in the present. Neither the psychic 123
  5. 5. J Contemp Psychother (2008) 38:1–10 5 determinism nor unconscious mental processes that char- Biological Factors Social Factors Psychological Factors acterize psychoanalytic psychotherapy (Brenner 1973) are Genetics Intimate Attachment Style Substance Use Relationships Temperament invoked in IPT. The fundamental basis of IPT is that Medical Illnesses Social Support Cognitive Style Medical Treatments Defense Mechanisms current interpersonal stressors in the context of biopsy- chosocial diatheses lead to psychological distress—there is Unique Individual no reliance on unconscious processes to explain psycho- logical dysfunction. Interpersonal Crises Grief and Loss Interpersonal Disputes IPT Tactics Role Transitions Psychotherapy ‘‘tactics’’ can be defined as ‘‘a plan, strat- Psychological Distress egy, or concept used to attain a particular goal,’’ and IPT is characterized by a combination of them. Several, such as Fig. 2 The Interpersonal Formulation the Interpersonal Triad (discussed above), the Interpersonal Inventory, the Interpersonal Formulation, and the Inter- in therapy. It is a critical bridge between attachment theory personal Problem Areas, are specific to IPT. Others, such and the patient’s specific problems. as the Biopsychosocial Model, the Structure of IPT, the The Interpersonal Formulation provides a grounded Non-Transferential Focus of Intervention, and the Present hypothesis explaining the patient’s problems and their Focus of Intervention, are not unique but are necessary onset, clinical manifestation, and course. That hypothesis ingredients. Collaboration and Positive Regard are among should address the following questions: 1) How did the many that are non-specific. A brief review of IPT-specific patient come to be the way he or she is? 2) What factors tactics follows. are maintaining the patient’s problems? and 3) What can be done about them? It should also provide a validation of the patient’s experience, a mutually determined focus for IPT Tactics: The Interpersonal Inventory intervention based on the three problem areas, and a plausible rationale for treatment with IPT. The Interpersonal Inventory (Klerman et al. 1984) is a unique feature of IPT that structures the process of history gathering and formulation of interpersonal problem areas IPT Tactics: Interpersonal Problem Areas as well as providing a reference point for conducting IPT. The Interpersonal Inventory focuses on: 1) the patient’s The IPT Problem Areas include Interpersonal Disputes, contemporary relationships; 2) the history of the patient’s Role Transitions, and Grief and Loss. Interpersonal current interpersonal problems; and 3) information that is Disputes are simply conflicts between individuals that are relevant to resolving the interpersonal problem—e.g., the causing distress. The process of change within relation- patient’s attachment style, communication style, and social ships which occurs as a consequence of contextual changes support. The Interpersonal Inventory is typically compiled within the patient’s life is conceptualized as a Role during the first several sessions; however it is best con- Transition. Grief and Loss can be broadly understood. This sidered a ‘‘work in progress’’ as most therapists and problem area includes reactions to an actual death, antici- patients find that their understanding of the patient’s rela- patory grief, and loss of physical health or of relationships. tionships and the problems associated with them evolve All of the problem areas are tactics used to maintain the during the course of IPT. interpersonal focus of treatment; they are not ‘‘diagnostic labels.’’ IPT Tactics: The Interpersonal Formulation IPT Tactics: Time Limit for Acute Treatment with IPT The IPT Formulation (Stuart and Robertson 2003) syn- thesizes information from the Interpersonal Inventory and IPT has historically been defined as a time-limited treat- psychiatric history, creating a plausible hypothesis ment. In general, a course of 10–20 weekly sessions has explaining the patient’s psychological symptoms (Fig. 2). been used for acute efficacy trials. Clinical experience, In essence, the ‘‘formulation’’ is nothing more than a the- however, has been that tapering sessions over time is oretically grounded understanding of the unique individual generally more effective. In the community, weekly 123
  6. 6. 6 J Contemp Psychother (2008) 38:1–10 therapy may be provided for 6–10 weeks, followed by a of IPT are the terms ‘‘time-limited’’ and ‘‘psychodynami- gradual increase in the time between sessions as the patient cally informed.’’ In reality, the time-limited nature of IPT improves, such that weekly sessions are followed by has had more to do with the requirements imposed by biweekly and monthly meetings. research protocols than a theoretical advantage; as noted Both empirical research and clinical experience with above, both IPT and CBT were artificially constrained by IPT have demonstrated that maintenance treatment, par- their inclusion in the TDCRP (Elkin et al. 1985). In that ticularly for patients with recurrent disorders such as study, a 16-week treatment trial was conducted because it depression, should be provided to reduce relapse risk was believed to be the time required to determine if (Frank et al. 1990). IPT is therefore currently conceptual- medication treatment of depression was efficacious. The ized as a two-phase treatment, in which an intense acute tradition established by that study has remained largely phase focuses on resolution of symptoms, and a mainte- unchallenged in academia, though in clinical practice, nance phase follows to prevent relapse and maintain treatments of much longer duration and longer intervals interpersonal functioning. There is no theoretical or prac- between sessions are often used; research is now beginning tical need in IPT to ‘‘terminate’’ at the end of acute to support the effectiveness of this clinical observation (see treatment; it is clearly not in the interest of many patients to Talbot et al. Grote et al. and Stuart et al. this issue). do so. The theoretical premise that limiting the number of psychotherapy sessions improves psychotherapy outcome has never been demonstrated (Reynolds et al. 1996), and IPT Tactics: Non-Transferential Focus of IPT there are no data suggesting that short-term therapy (i.e., 12–20 sessions) is more effective than longer treatment. In IPT has historically been characterized by the relative fact, psychotherapy studies typically show that though the absence of interventions which directly address the thera- degree of improvement per session diminishes over time, peutic relationship. Though it shares this characteristic with longer treatment leads to better outcomes (Howard et al. CBT and other therapies, IPT clearly differs in this way 1986). While the evidence certainly indicates that from the dynamically oriented psychotherapies. 12–16 weekly sessions is efficacious, there have been no Clinical experience with IPT has supported the premise IPT dose-response studies. Thus it is impossible to say with that focusing on the transference changes the focus of any certainty whether the proposed time limit, weekly treatment from more immediate work on the patient’s sessions,2 or hour-long sessions are optimal, or whether current interpersonal problems and social relationships to lengthening (or shortening) the treatment might be more an intense experience with, and analysis of, the relationship effective. with the therapist (Stuart and Robertson 2003). Addressing The ‘‘dynamically-informed’’ description of IPT is a nod the patent-therapist relationship directly also shifts the to its historical roots, particularly to Harry Stack Sullivan therapy from one that is oriented towards improvement in and Adolf Meyer. As noted above, John Bowlby is a more social support and immediate interpersonal functioning to recent addition to the list of historical luminaries who were one that is oriented towards intrapsychic insight. This shift unaware that their work would later be co-opted by IPT. is a departure from the current targets of IPT. Given the early division of psychotherapy into behavioral For this reason, IPT is structured at present in a way that and psychoanalytic branches and that behavior therapy and transference issues are less likely to emerge. The IPT CBT have laid claim to the behavioral roots, it is little therapist generally takes a supportive stance, rather than surprise that IPT has attempted to distinguish itself by being neutral or opaque. The therapy is generally of short claiming a psychodynamic lineage. This despite the fact duration, which diminishes the intensity of the therapeutic that it bears little resemblance to time-limited psychoana- relationship. Provision of maintenance treatment when lytic precursors such as those described by Davanloo necessary rather than abruptly terminating treatment also (Davanloo 1980) and Sifneos (Sifneos 1987), in which reduces the likelihood that transference will become a explicit discussion of the transference plays a major role. focus in IPT. 2 The only study to address dosing in any fashion was recently Proposed Changes to IPT published by Frank et al. (2007) Randomized Trial of Weekly, Twice-Monthly, and Monthly Interpersonal Psychotherapy as Main- IPT has often been very imprecisely described as a time- tenance Treatment for Women With Recurrent Depression. American Journal of Psychiatry, 164, 761–767. in which women with recurrent limited, dynamically-informed psychotherapy (Klerman depression were assigned after remission to one of 3 maintenance et al. 1984; Weissman et al. 2000; Stuart and Robertson treatments: once-weekly IPT, bi-weekly IPT, or once-monthly IPT. 2003). Largely unspecified in these historical descriptions There was no difference in recurrence rates between groups. 123
  7. 7. J Contemp Psychother (2008) 38:1–10 7 ‘‘Dynamically-informed’’ might be more accurately is a diathesis for distress, and those who are simply over- understood as a recognition in IPT that the nuances of whelmed with tragic circumstances. interpersonal relationships are important. And in this Several characteristics of IPT would need to be radically obvious statement, IPT does point to the lineage of Sulli- modified in cases in which it was targeted towards van and Bowlby, who both described approaches to changing attachment style, personality, or even insight treatment based on that observation. However, there has (another potential byproduct of the current approach which historically in IPT been direct discouragement, if not out- has not been examined). As time-limited therapies, (which right prohibition, of techniques directed towards examining in their primary iteration may be very different), become transference and the patient-therapist relationship, which is longer in duration and as they focus more on relatively still understood as the basis of psychodynamic enduring traits such as personality, they begin to bear psychotherapy. similarity to one another. Among other things, clinical This historical imprecision points to several of the discussion frequently shifts to past events and relation- elements in IPT that merit creative attention. There is now ships, and the therapeutic relationship becomes more sufficient reason to consider attachment as a potential intense and more subject to influence by the patient’s (and target of IPT, particularly given its theoretical foundation. therapist’s) unique characteristics. Would changing the As attachment becomes a focus, the artificial time-limit in treatment focus and lengthening the treatment still be IPT? IPT will need to be addressed, and the current lack of If not, why not? How should this be determined? interventions directly addressing the patient-therapist Attachment theory and clinical experience both support relationship should be reconsidered and tested as well. The the observation that given enough time, a patient will focus on attachment as a target rather than a moderator also display behavior towards his or her therapist which is prompts a re-examination of the Interpersonal Problem reflective of his or her working model of attachment Areas (Table 2). (Bowlby 1988; Sullivan 1953). This is in essence the basis IPT could easily be targeted towards attachment style. for transference as conceptualized in IPT. Both Sullivan Since maladaptive attachment is hypothesized to be at the and Bowlby believed that one of the most powerful ways to core of the distress experienced by many individuals, work on correcting these distorted models of attachment modifying attachment may be a factor in acute response, ions was to examine in detail the relationship between and may have profound preventive effects as well. The therapist and patient. This was done overtly and explicitly, development of a more adaptive and flexible attachment using techniques such as interpretation in which the style as a result of therapy would have a significant impact transference was directly discussed, and clarification, in on reducing vulnerability to stress, as well as the ripple which the therapist would directly ask the patient for his or effects of improving communication and increasing social her reactions to the therapist. support. At present, the patient-therapist relationship, and partic- It is critical to note, however, that the attachment-based ularly the information provided by the transference, are model of IPT does not presupposed that all patients have recognized as extremely important in IPT, but are not maladaptive attachment styles, and by extension, that addressed directly in therapy (Stuart and Robertson 2003). A modification of attachment should or need be the focus of careful review of the evidence, an examination of the treatment for all. Clinical experience is replete with accumulated clinical experience, and a review of the theo- examples of crises of sufficient intensity to trigger distress retical reasons for addressing transference directly make a even in the most securely attached individuals: natural very compelling case that techniques which allow a direct disasters, severe and chronic illnesses, or the death of one’s examination of the patient-therapist relationship might be child are among many. Thus the distinction must be made very helpful additions to the IPT therapist’s armamentarium. between those patients for whom maladaptive attachment Particularly in a course of IPT in which the treatment duration is extended, the therapist is in a unique position to experience and examine the way in which a patient Table 2 Potential revisions to IPT develops and maintains relationships, because the therapist Targets: Add attachment style as a primary target is in a relationship in which he or she is the person upon Tactics: Extend the duration of IPT whom the working models of attachment are imposed. In Include a focus on the patient–therapist relationship some, but not all cases, direct discussion of the therapeutic Eliminate the interpersonal deficits/sensitivity problem area relationship might be very beneficial. This explicit dis- Staging of patients cussion would likely be of most benefit to those patients Techniques: with more maladaptive attachment styles. Include direct discussion of treatment alliance There is little explanation in the early IPT literature regarding the absence of interventions directed towards 123
  8. 8. 8 J Contemp Psychother (2008) 38:1–10 transference. The prominence of biological psychiatry in social interactions. This contrasts greatly with the other the 1970s and 1980s, when IPT was developed, undoubt- three problem areas, which are acute interpersonal stress- edly played a role. It is likely, given the emphasis on ors. Nearly all clinicians agree that the Deficits/Sensitivity empirical validation, that the absence of data at the time problem area is different in quality from the others; some which supported transference-based therapies diminished research also suggests that patients presenting with prob- enthusiasm for them. A desire to distinguish IPT from lems in this ‘‘area’’ are more difficult to work with and psychoanalytic schools may have been an issue, and cer- have poorer outcomes (Barber and Muenz 1996; Wolfson tainly the research protocol emphasis on therapies which et al. 1997; Luty et al. 1998; Reay et al. 2003) (see also were easily described and reliably delivered was a factor. Grote et al and Talbot et al. this issue). The continuing lack of research in IPT in this area is due Another way in which IPT might be revised involves largely to two issues. The first is that there has been little patient and therapist selection. A staging concept would be interest in examining the effects of treatment on personality helpful in this regard. Using such a system, more difficult or other constructs presumed to be more stable; instead the patients might receive IPT of longer duration which targets primary focus of outcome, consistent with the pharmaco- attachment, while those who are easier to treat might logic model, has been change in symptomatic status. receive shorter-term treatment without need to address the Second, the time limit which has been an integral part of patient-therapist relationship directly. Both clinical expe- IPT has led to the assertion, clearly stated, that it is not rience and theoretical considerations suggest that assessing designed to effect change in personality or ego functioning patient ‘‘difficulty’’ on the basis of diagnosis or symp- (and by implication is not likely to do so). Adding tomatic status is quite likely barking up the wrong tree. attachment style as a therapeutic target and extending the Instead, prognosis is much more likely to be correlated duration of treatment would change this equation. with security of attachment and strength of social support. What would make IPT distinct from longer-term A similar system of therapist staging would contribute psychodynamic psychotherapies if attention were drawn even more. A greater reliance on therapist judgment would directly to the patient-therapist relationship? First, the be expected from those with greater experience and primary emphasis in IPT would continue to be helping the expertise. Therapists with less training might be advised to patient to build greater social support in his or her world steer clear of transference issues and to focus more on the outside of therapy. While therapists are wonderful tools supportive elements of IPT. Such a system for both patients when used for their specific purposes, they are no substitute and therapists would allow delivery of those elements of for real people. The primary focus in IPT would remain on IPT that are likely to be maximally beneficial, and allow building social support outside of therapy and improving for the flexibility that is critical for any therapy delivered to interpersonal relationships, with explicit discussion of the real people. In psychotherapy, one size clearly does not fit patient-therapist relationship being a tactic to foster these all. goals—a means to an end. The Interpersonal Problem Areas utilized in IPT also require reconsideration. In the first iteration of IPT (Kler- Conclusion man et al. 1984) there were four: Grief, Interpersonal Disputes, Role Transitions, and Interpersonal Deficits. What is IPT? For the present, the framework presented in They have undergone slight modifications: the term Table 1 is an accurate description. The outline of theory, ‘‘Interpersonal Sensitivity’’ (Stuart and Robertson 2003) targets, tactics, and techniques can be used as a framework has been substituted in some cases for Interpersonal Defi- to describe other therapies or combination of therapies as cit, and the Grief Problem Area has been reframed to well. encompass all grief and loss issues, rather than restricting it There are two critical questions that must be addressed to situations in which a death has occurred (Stuart and in order for IPT to continue to develop: ‘‘What should IPT Robertson 2003). Nonetheless, the basic problem areas be?’’ and ‘‘What is the process by which changes should be have remained largely unchanged. incorporated?’’ The glib answer to these questions is sim- Accumulated clinical experience and theoretical devel- ple: IPT should be whatever maximizes the benefit to opments now indicate that the ‘‘Interpersonal Deficit/ patients, and the process should facilitate this. All would Sensitivity’’ domain is better conceptualized as an attach- agree that this is our final goal. The devil, of course, is in ment style or a character trait and should be discarded as an the details. acute problem area. As originally described, Interpersonal Those details should be addressed in at least two ways. Deficit was used to designate the problems experienced by First, strong consideration should be given to modifying, patients with a longstanding paucity of relationships who adding, or eliminating the elements of IPT as it is currently tended to be avoidant and lacked confidence or skill in conceptualized, and the effects of those changes should be 123
  9. 9. J Contemp Psychother (2008) 38:1–10 9 studied. There are several obvious candidates. The attach- Bowlby, J. (1977b). The making and breaking of affectional bonds: ment theory supporting IPT makes it clear that attachment Etiology and psychopathology in the light of attachment theory. British Journal of Psychiatry, 130, 201–210. style should be tested as a target for treatment with some Bowlby, J. (1988). Developmental psychiatry comes of age. American patients. In turn, this leads to consideration of additional Journal of Psychiatry, 145, 1–10. techniques which address the patient-therapist relationship Brenner, C. (1973). An elementary textbook of psychoanalysis. New directly. And for more difficult patients, a tactical shift to York: Anchor Press. Brody, A. L., Saxena, S., Stoessel, P., et al. (2001). Regional brain extend the duration of treatment is a natural adaptation. metabolic changes in patients with major depression treated with Second, more ‘‘outside the box’’ ideas must be devel- either paroxetine or interpersonal therapy: Preliminary findings. oped and tested. Many of these will emerge from continued Archives of General Psychiatry, 58, 631–640. clinical observation and from the questions generated from Brown, G. W. (1998). Genetic and population perspectives on life events and depression. Social Psychiatry and Psychiatric quality research. It is critical that IPT be considered as a Epidemiology, 33, 363–372. work in progress; to do otherwise and insist on rigid Confucious (1893). Confucian analects, the great learning, and the application or strict adherence to manuals will quash doctrine of the mean (trans. J. Legge). New York: Dover creativity. To paraphrase Mark Twain, ‘‘be careful of Publications, Inc. Davanloo, H. (1980). Short-term dynamic psychotherapy. Northvale: definitive psychotherapy manuals: you might die of a Aronson. misprint.’’ Elkin, I., Parloff, M. B., Hadley, S. W., & Autry, J. H. (1985). NIMH The process by which creativity can be reinvigorated treatment of depression collaborative research program. Back- must be collaborative. Academics should do what they do ground and research plan. Arch Gen Psychiatry, 42, 305–316. Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotcky, S. best: engage in spirited discourse and test their assump- M.,Collins, F. L., Glass, D. R., Pilkonis, P. A., Leber, W. R., tions. Clinicians should do what they do best: closely and Doherty, J. P, Fiester, S. J., & Parloff, M. B. (1989). NIMH critically observe what works with the individuals they treatment of depression collaborative research program: I. treat. And both groups must engage in a dialogue which General effectiveness of treatments. Archives of General Psychiatry, 46, 971–982. informs and inspires the other. The synthesis is the process Ellis, A. (1970). The essence of rational psychotherapy: A compre- which will determine what IPT should be and how it should hensive approach to treatment. New York: Institute for Rational continue to change. Living. Change is not only inevitable but necessary. The gen- Engel, G. L. (1980). The clinical application of biopsychosocial models. American Journal of Psychiatry, 137, 535–544. erativity we embody will be reflected to our colleagues and Erikson, E. H. (1998). The life cycle completed: A review (1985, our patients, and will be of inestimable benefit to both. reprinted 1994). New York, NY: WW Norton & Co. Frank, E., Kupfer, D. J., Buysse, D. J., et al. (2007). Randomized trial Acknowledgement This work was supported by the following of weekly, twice-monthly, and monthly interpersonal psycho- grants: 5K24MH72757-02 (NIMH- Stuart). therapy as maintenance treatment for women with recurrent depression. American Journal of Psychiatry, 164, 761–767. 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