23 Mar 2015
Conduct a literature review of interpersonal Psychotherapy comparing its efficacy in comparison to other psychotherapies in the treatment of depression.
Interpersonal Psychotherapy (IPT) was created in the 1970's, it is important to note that its origins differs from other theories of psychotherapy which have their development based on a set of clinical observations, instead IPT was designed at Yale University by Gerald Klerman, Myrna Weissman, andÂ Eugene Payke as a placebo control for a psychopharmacological treatment trial for major depression; accidentally it was found latter about its efficacy to treat such disorder.
The original IPT manual was published in 1984 as a protocol for the aforementioned research project (Klerman GL, Weissman MM, Rousanville BJ, & Chevron E, 1984).
Since then, IPT is being also utilised to treat other psychiatric disorders (Weisman MM, Markowitz JC, Klerman GL, 2000) as dysthymic disorder (Markowitz JC, 1998), anxiety (Lipsitz JD, Markowitz JC, Cherry S, Fyer AJ, 1999), bipolar disorder (Frank E, Hlastala S, Ritenour A, Houck P, & et al, 1997), post-traumatic stress disorder (Krupnick JL, 2002), among others.
IPT was initially intended to have a fixed length (12 sessions) and to be applied in out-patients (non-institutionalized) suffering of depression (Klerman GL, Weissman MM, Rousanville BJ, & Chevron E, 1984); such proposal is based on the ideology of the interpersonal school (Sullivan H, 1953), however, it does not make etiological assumptions regarding to the root cause of the depression. Nevertheless, as the pragmatic focus of the treatment, IPT connects the beginning of the current interpersonal relationships rather than past relationships, focusing on the actual patient's social context. The interpersonal therapist try to intervene more into the construction of the symptoms and the social dysfunction associated with the depression, relegating the features of the patient's personality that may have their origin in early experiences (Weissman MM & Markowitz JC, 1998).
As we can infer, due it is origins, IPT was extensively applied as a combined therapy, mainly by psychiatrists, where IPT was the psychological support for a pharmacotherapy, to overcome a major depression, being IPT, alone and afterwards, utilised to definitively resolve the pathology.
Later on, a detailed theoretical foundation for IPT was described by Stuart and Robertson (Scott Stuart & Michael Robertson, 2003) in the Clinician's Guide. It fundamentally comprises of three pillars, namely, the attachment theory, the communication theory, and the social theory. Each one of the theories was assumed to have equivalent weight, and all of them, also, were validated by research. Nevertheless, no one of conducted research was specific to IPT.
Over the years, the attachment theory has been progressively more accepted as the primary theoretical pillar of IPT, with communication and social theory referred to secondary roles.
Attachment theory defines the approach wherein human beings construct, sustain, and finish relationships, and is based on the principle that individuals have an inherent initiative to build interpersonal relationship with others (Ainsworth, Object Relations, Dependency, and Attachment: A Theoretical Review of the Infant-Mother Relationship, 1969), (Ainsworth, Blehar, Waters, & Wall, 1978), (Bowlby, 1969), (Morris, 1982).
Bowlby stated "The desire to be loved and cared for is an integral part of human nature throughout adult life as well as earlier, and the expression of such desires is to be expected in every grown-up, especially in times of sickness or calamity." (Bowlby J. , 1977), consequently we can deduce that the attachment forms are the base for persistent patterns of interpersonal behaviour whereby individuals look for care and reassurance in the typical ways.
The attachment theory suggests that individuals become distressed when they experience disturbances in their relationships with others. For insecurely attached individuals is harder to cope with losses, to endure interpersonal conflicts, and changes; because of the fragile nature of their primary relationships and of their poor social support systems.
The keys for attachment style are the person's communication and social support network. The more securely attached the person, the larger is the social network. On the other hand people displaying an insecure attachment style have a lack of social support and little adaptive interpersonal relationship.
Ultimately, the interpersonal and social relationships are the determinant descriptive factors for the type of the attachment.
Patients with more maladaptive attachment styles tend to obliterate the social connections and isolate others when asking for support. Maladaptive attachment styles also lead to inappropriate or inadequate interpersonal communications which prevent the individual's attachment needs from being satisfied (Stuart, & Noyes, 1999).
IPT has been adapted to a wide range of psychiatric disorders and a copious amount of experimental evidence has being gathered, which supports its efficacy and the fact that IPT is positively anchored in attachment theory.
The IPT targets primarily the individual's conflicts, transitions and losses in life and successively the individual's social support.
IPT has a different concept from the Cognitive Behaviour Therapy (CBT) and the Behaviour Therapy (BT); in CBT the focus is in the individual's internal cognition while IPT targets the interpersonal relationship and social support, despite the fact that IPT can also address the cognition, such is not its first target.
Likewise, CBT and other approaches deal with interpersonal issues; but conversely, they are not their first target. In IPT the therapist is less directive than in CBT.
The focal point of IPT is to help the individual to improve the interpersonal relationships and social support at the present moment, contrarily of the analytically focused therapies, whose focus is in the early experiences of life.
According to Stuart (Stuart S. , 2006), the fundamental basis of IPT is that "current interpersonal stressors in the context of bio psychosocial diatheses lead to psychological distress, there is no reliance on unconscious processes to explain psychological dysfunction".
In terms of pragmatic approach, IPT provides a structured and formalised treatment plan based in a comprehensive assessment of the client's attachment style, areas of interpersonal difficulties and symptomatology of the emotional distress.
The therapist helps the clients to improve the communication in their relationship or to change the expectations in such relationships; the therapist also helps the client to explore the social network. The objective is to enable the client to find support in the context of his/her social network, which can help him/her to deal with the crises and distress.
As stated beforehand, IPT was initially developed as a treatment for depression, however today IPT is often applied in psychopathologies, as:
Bipolar mood disorders,
Substance abuse problems,
Preventive therapy for suicidal.
IPT is not recommended to be used with individuals suffering from:
Chronic Substance Abuse,
Severe cognitive deficits,
Acute suicide risk.
IPT uses three different strategies to achieve the client's goals:
The interpersonal inventory:
According to Klerman et al (Klerman GL, Weissman MM, Rousanville BJ, & Chevron E, 1984), the interpersonal inventory is the "unique feature of IPT that structures the process of history gathering and formulation of interpersonal problem areas as well as providing a reference point for conducting IPT".
The interpersonal inventory main focus is on the client's contemporary relationships, the history of interpersonal conflicts and relevant information which helps the client to solve the conflict.
The interpersonal formulation:
In accordance with Stuart and Robertson (Scott Stuart & Michael Robertson, 2003), "IPT formulation synthesizes the information from the Interpersonal Inventory and psychiatric history, creating a plausible hypothesis explaining the patient's psychological symptoms". Said hypothesis should address questions resembling: How the client turned to be the manner that he/she is now? What are the sustaining factors for client's difficulties? And, what can be done about it?
Interpersonal problem areas:
It includes Interpersonal disputes, roles transitions and grief and/or loss.
Disputes are defined as the conflicts between the individuals which causes the distress.
In practice, IPT is applied generally between 6-10 weeks, with a gradual increase in the time gap between sessions, according to the patient improvement. The maintenance treatment is also important to assure the risk of relapse, especially for those clients suffering from recurrent depression. IPT is recommended to be split into two phases treatment, the first phase focus in the resolution of symptoms and the second phase to prevent relapse and maintain interpersonal functioning.
IPT similarly to CBT utilizes an assessment and problem formulation treatment form; the widely known and most used referencing literature to help the therapist to conduct the client assessment was developed by Scott Stuart and Michael Robertson in 2003, named "Interpersonal Psychotherapy: A Clinician's Guide" (Scott Stuart & Michael Robertson, 2003).
The methodology of the assessment outlines that firstly it is assessed the client's attachment and communication style, being this part of assessment is subdivided in 4 subparts:
Investigates how the client describes the relationships, more specifically, how the client begins and maintains them, also how the client communicates his/her needs to others.
The therapist explores the client's narrative. As denoted, this task is far easier when dealing with clients who have greater ability to relay narrative.
Explores the client's description of other individuals. In this sub-part of the assessment the therapist will qualify the client's type of attachment: secure attachment, attachment anxiety and attachment avoidance.
Searches for the client-therapist relationship. The attachment style will manifest itself in this relationship. It is important for the therapist to be aware of the client attachment and the therapist own attachment in order to provide an effective treatment.
The second part of the assessment is the own IPT suitability, and includes:
Severity of the illness: Clients with severe psychopathology are less suitable for IPT,
Motivation: More motivate is the client, greater are the chances of efficacy of the treatment,
Therapeutic relationship: A good therapeutic relationship increases the positive outcomes,
Resilience: The client's ability to tolerate internal and external stress, which helps in the therapeutic process.
The third part of assessment is to conduct an Interpersonal Inventory (IPI): the purpose of the interpersonal inventory is to investigate the client's relationships, their quality, the expectations and conflicts; it also explores the communications patterns. The IPI is used in three distinctive phases of the therapy: Initial Phase, when it is developed and orients the therapy, Middle Phase, as a referential mark to correct the focus of the therapy and at the Conclusion as a metric for the client's development and also to provide guidance by identifying potential problem areas in the future.
The fourth part of the assessment is to determinate the treatments focus: Based in the repertoire of themes identified in the interpersonal inventory, the client and the therapist will identify one or two problems associated to relationships to work with.
The fifth part of the assessment is the interpersonal formulation, it comprises of nothing more than to formulate a hypothesis for the problem. The hypothesis must indicate how the client came to be the way that he/she is, what the contributing factors which sustain the problem are and what can be done about it.
The sixth and last part of the assessment is to develop the treatment contract, comprising of:
Number, frequency, duration of sessions. Those factors depend on the severity of the problems and the attachment style.
Agreed clinical focus. It encompasses the problematic areas to be addressed and the limitations of the therapeutic contract.
Expectations. It is the treatment bottom line with the qualitative and quantitative prospects of extends the IPT will change the client functioning in the social environment.
Contingency planning. The therapist and client come to an agreement of what happens in the event of lateness and missed sessions.
Treatment Boundaries. The understanding and limitations of the nature of the therapeutic relationship.
The overall IPT's treatment plan is structured as:
1-2 sessions - comprising of the assessment phase
3-8 sessions - a treatment phase, where the problem is addressed and worked on
9-10 sessions - it is the conclusion phase when the therapist and client will review the progress and the symptomatology and will develop the maintenance contract.
Noteworthy that in terms of applied techniques, IPT can use:
Use of content and process affect
And, "common" techniques
IPT is considered as a work in progress, along the years many techniques are being added to the therapeutic arsenal of the IPT, which are positively contributing to enhance the efficacy and increase the spectrum of pathologies able to be treated by IPT. The negative aspect of a dogmatic approach with the rigid application and strict devotion to the manuals is to be avoided as elements which repress the creativity and freezes the scientific progress.
The real efficacy of the IPT as a treatment for depression still remains unclear, manly, due the limitations (or lack) of comparative research into psychotherapies.
In according with Parker, G et all (Parker, Parker, Brotchie, & Stuart, 2006), IPT alone, cannot be considered as an universal therapy for depression, however clinical trials also could not quantify what therapy performs better for such pathology mainly due the varying depressive conditions.
IPT seems to be generically comparable in outcomes to CBT, but IPT has not yet been found to have particular advantages over any other psychotherapy and more researches are required.
IPT might be a superior specific treatment for those with adjustment and reactive depressive disorders. For those with other sub-types of depression its benefits are not yet known.
Two groups where the particular benefits of IPT could be tested include people who are vulnerable to developing depression because of their psychological make-up (personality style); and people with distressing mental conditions who experience stressful life events.
Difficulties in assessing the specific effects of IPT (and other psychotherapies) might be overcome if interventions were better matched to:
the psychological disorder,
the patient characteristics,
the actual treatment settings.
Research shows that pharmacotherapy added to IPT is more beneficial than adding IPT to the pharmacotherapy, but it is also important to remember that people have different types of depression. Progress depends on identifying when antidepressants and various other types of psychotherapies are most useful.
More studies is necessary to measure the efficacy of IPT and the others psychotherapeutic approaches, as well.
However, despite the axiomatic efficacy of IPT to treat depression to be much more anecdotal than scientifically proven, the factual results are undeniable. It may be the case that IPT better copes to the demands of our today's society, when all nuances of life must be qualified, quantified and whatever has a start point must have a clear finish line; in such a terms IPT fulfil all the requisites, conversely of other therapies that goes deeper and deeper into the individual's psyche, but fails to promote fast relief; and it is irrefutable that IPT delivers what it promises, within the contractual timeframe.
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