Interpersonal Psychotherapy for Depression

1. Interpersonal Psychotherapy for Depression Bob Hill, Ph.D. Appalachian State University Boone, NC 28608 Email: hillrw@appstate.edu

2. Overview • Depression • Theoretical Sources for IPT • Prominent Features of IPT • Outline of IPT • Phases of IPT Treatment • Clinical Examples • Empirical Support

3. Depression • IPT clearly effective for treating Depression • Diagnostic Criteria for Depression: • A.Five (or more) of the following symptoms have been present during the same 2-week period; at least one of the symptoms is either • 1.depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. Note in children, can be irritable mood. • 2. anhedonia: markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

4. Depression Criteria continued (2+ needed): 3.significant weight loss when not dieting or weight gain or decrease or increase in appetite.. 4.insomnia or hypersomnia nearly every day 5.psychomotor agitation or retardation observable by others 6.fatigue or loss of energy nearly every day 7.feelings of worthlessness or excessive or inappropriate guilt 8.diminished ability to think or concentrate, or indecisiveness 9.recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan, or suicidal intent.

5. Reasons to consider Medication • Client too depressed to participate in treatment • Client not psychological, resistant to talking tx • Client who is at risk for suicide • Client with recurrent Depressive episodes, with symptoms of Melancholic Features • May respond more quickly with medication and IPT combined

6. Depression with Melancholic Features • 1) anhedonia • 2) lack of reactivity to usually pleasant stimuli • 3) Three or more of: • Distinct quality of depressed mood • Depression is worse in a.m. • Early morning awakening (at least 2 hrs) • Marked psychomotor agitation or retardation • Significant anorexia or weight loss • Excessive or inappropriate guilt • Psychotic symptoms • Suicide risk

7. Disorder Females Males Total Depression 21.3 % 12.7 % 17.1 % Dysthymia 8.0 % 4.8 % 6.4 % Prevalence of Depression National Comorbidity Survey (1994)

8. Historical Influences of IPT • Psychoanalysis • Harry Stack Sullivan • Object Relations Therapy • Interpersonal Theory (Leary, Kiesler)

9. IPT: Roots in Psychodynamic Theory • Primary instincts of sex and aggression involve relating to others • Relationships with others contribute to personality development • Psychological Problems due to deficits in early relations • Transference and counter-transference are interpersonal

10. Object Relations Influence • “Object” is human being • “Relations” are internal, external, fantasied or real interactions with others • Early parent-child relations are internalized as expectations for future relationships • Identity/personality derived from pattern of early relationship experiences • Expectations of others impacts quality of current interpersonal relationships and mood

11. Manualized Interpersonal Therapy • Klerman, G. (1984). Interpersonal Psychotherapy for Depression. • Weissman, M. (2002). Comprehensive Guide to Interpersonal Psychotherapy.

12. Prominent Features of IPT • IPT designed for symptom reduction and improved interpersonal relationships • Focus on current disputes, frustrations, anxieties in the interpersonal context which impact mood and self esteem

13. IPT Compared to Other Therapies • Time-limited- outcome studies document efficacy of short-term (12-16 weeks) tx • Not designed for personality change • Focused on current interpersonal disputes, anxieties, frustrations • Addresses 1-2 problem areas in interpersonal functioning

14. IPT Compared to Other Therapies • Interpersonal, not intrapsychic • Interpersonal, not Cognitive Behavioral • Goal is to change feelings, thoughts, actions in problematic relationships • Negative/irrational cognitions are addressed only in interpersonal function • IPT attends to distorted thinking in relation to significant others • Goal is to change relationship pattern rather than depressive cognitions

15. IPT Compared to CBT • Focus on affect and expression of emotions • Explores avoidance and resistance behavior • Identification of patterns in client’s behavior, thinking, feeling and relationships • Attention to past experiences • Focus on interpersonal experience • Emphasis on the therapeutic relationship • Exploration of client’s wishes, dreams, fantasies Blagys & Hilsenroth, 2000

16. IPT and Personality Change • IPT does not target alteration of personality • Personality pathology may limit IPT outcome • IPT may help patient recognize maladaptive personality features • IPT may improve social skills and thus ameliorate maladaptive personality traits

17. Role of IPT Therapist • Therapist is patient advocate, not neutral • Expresses unconditional positive regard • Intentionally cultivates positive expectations of treatment • Optimistic, positive, reassuring • Therapist is active in keeping interpersonal problem areas to focus

18. Outline of IPT Intervention Initial Sessions (Overview) • Assess Depressive symptoms • Complete Interpersonal Assessment • Identify Major Interpersonal Problem Area • Explain IPT and make treatment contract

19. Initial Sessions (“Sick Role”) • Review Sxs, Dx of depression to communicate “sick role” • Functions of “Sick Role” • Sick person exempt from responsibilities • Sick person in need of help • Sick is undesirable and needs to be improved • Sick person obliged to cooperate with Tx • Sick role shifts blame from client to illness • Mitigates self blame

20. Relate Depression to Interpersonal Context What interpersonal events related to depression? Review current & past interpersonal relationships • Who does client interact with? • Frequency of contact, activities shared? • Assess quality and themes of relationships • Assess expectations of client (and other) in relationships • Assess satisfying and unsatisfying aspects of relationships • Discuss changes client wants in relationships

21. Inventory of Interpersonal Problems • 64 items assess diverse interpersonal problems: • Being too controlling or manipulative • Being self-centered and resentful • Having minimal feelings of affection for, and little connection with, other people • Being socially avoidant • Being nonassertive • Being gullible and easily taken advantage of • Being excessively selfless, generous, trusting, • Being too intrusive

22. Interpersonal ProblemsCircumplex

23. IIP Circumplex Evan

24. IIP Scale Profile

25. Identification of Major Problem Area Assess interpersonal experience and depression to identify of one of Four Problem Areas: • Interpersonal Role Dispute: with spouse, lover, family member, friends, co-worker • Role Transition: e.g. new job, relocation, divorce • Interpersonal Deficits: evidenced by social impoverishment, loneliness, isolation • Grief: following death if abnormally severe, protracted or impairing

26. Problem Area Focus • Four problems areas are: • Not exhaustive, nor mutually exclusive • Not “deep” conceptual theory • Communicate to client Problem area focus • Problem area ensures focus on recognized problem rather than personal weakness • E.g. ‘try to discover what you want and need from others and help you learn how to get it’

27. Explain Interpersonal Focus • Tx focus will be interpersonal satisfaction, not intrapsychic exploration • Educate about link between depressed mood and difficulty getting what we want/need from others • Therapist describes nature of clients interpersonal difficulty • Agree on goal of improved interpersonal relations • Set expectation: make changes btwn sessions

28. Setting Treatment Contract • Set 2 –3 treatment goals with client related to problem area focus • Ask client what would be the: • Best possible outcome • Most expectable outcome • Worst possible outcome • Describe expected Duration and Frequency of treatment (12-16 weeks)

29. Teaching Client Their Role in IPT • “Talk about things that affect you emotionally • “Your responsibility to select topics that are most important to you” • “No right or wrong thing to talk about” • “When important feelings emerge, raise them” • “including feeling about me or the therapy”

30. Starting Intermediate Sessions • Initial Assessment and Development of Treatment Contract Typically 2-3 Sessions • Important tasks of Intermediate Sessions: • Help client discuss topics pertinent to problem area • Attend to clients affective state • Assist client in discussing therapeutic relationship • Prevent client from sabotaging treatment

31. Interpersonal Disputes: Diagnosis • Current Overt or Covert disputes with a significant other • Client and other have non-reciprocal expectations • Dispute related to onset or perpetuation of depression • Client demoralized about relationship • Poor patterns of communication • or irreconcilable differences

32. Interpersonal Disputes: Goals • Identify the dispute • Make choices about a plan of action • Modify communication patterns or • Reassess Expectations • Consider satisfying needs outside relationship

33. Interpersonal Disputes: Strategies • Assess stage of Role Dispute: • Impasse- discussion stopped, low-level resentment exists • Tx may initially increase disharmony • Renegotiation- aware of differences, actively trying to change • Tx may require calming parties to facilitate resolution • Dissolution- implies the relationship is irretrievably disrupted • Treatment may resemble grief therapy

34. Interpersonal Disputes: Issues • Differences in expectations/values between client and other? • Clients wishes in relationship? Other wishes? • What are the client’s options? • How have they resolved disagreements in past? • Strengths and weaknesses in relationship? • What changes are realistically possible?

35. Interpersonal Disputes: Strategies • Find Parallels in previous relationships • What does client gain by the behavior? • What are unspoken assumptions that lie behind behavior? • Optimistic tone: “lets figure out what went wrong here so we can decide how to help you make it better” • Often communication problems are revealed- Tx involves improving skills

36. Interpersonal Disputes: Strategies • Help identify “mixed feelings” e.g. anger, fear, sadness • Devise strategies for managing feelings e.g. direct communications, reducing irrational suspicions • Role Play • Rehearse expressing feelings and wishes • Anticipate communication problems • Consider Conjoint sessions with significant other

37. Problem Area: Role Transitions • Diagnosis: Depression and interpersonal problems related to role changes • e. g. separation/divorce, children left home, start/end job or school, retired, promoted, financial or health problems • Assess: How did life change? What people in you life changed or left?

38. Role Transition: Tx Strategies • Facilitate evaluation of lost role • “Tell me about the old ___. What were the good, and bad, things? What has changed? • Encourage expression of affect • How did it feel to give up ___? • Identify positive aspects of new role • Are there potential benefits?

39. Role Transition: Tx Strategies • Develop Social Skills needed for new role • What is required in new role? • Are assumptions of role demands accurate? • Role play or rehearse difficult situations • Assist with managing performance anxiety • Establish new relationships and social support • Facilitate discovery of new opportunities for social support

40. Interpersonal Deficits: Diagnosis • History of social impoverishment, chronic inadequate or unsustained relationships • Consider Dysthymia (or Double Depression) • IPT adaptation for dysthymia • Long standing or temporary deficits in social skills yields low self-esteem, withdrawal

41. Interpersonal Deficits: Goals • Reduce Client’s social isolation • Enable: • close relationships with intimates or family members • satisfying relationships with friends • adequate relationships in work role

42. Interpersonal Deficits: Strategies • Review past significant relationships • including childhood relationships with family members • depressed patients minimize or forget positive experiences • explore repetitive or parallel problems in past relationships • define interpersonal situations that lead to difficulties

43. Interpersonal Deficits: Strategies • Use therapist-client relationship • explore client’s positive and negative feelings toward therapist • discuss distorted or unrealistic thoughts or feelings toward therapist • model resolution of relationship tension by open and genuine communication

44. Interpersonal Deficits: Strategies • Encourage patient to increase social interactions • review attempts in treatment to identify deficits • identify deficits in communication skills • look for assumptions client makes about others thoughts and feelings

45. Use Communication Analysis • Get detailed account of conversation or argument • identify communication difficulties • ambiguous, indirect, & non-verbal as substitute for open confrontation • incorrect assumptions re communication • assuming that others know their feelings • accompanied by anger, frustration, silence • failing to make sure they are heard, understood

46. Use Communication Analysis • Incorrect interpretation of others statements • perceive criticism where none intended • indirect verbal communication • inhibited directly expressing expectations or criticism • instead use hints and ambiguous messages • prone to build resentments toward others who are unaware of offense • silence - unaware of destructive impact

47. Use Communication Analysis • Use role playing • rehearse difficult interactions with client • explore style of communicating with others • practice new skills • e.g. expressing anger or being assertive • rehearsal with therapist increases client’s interpersonal confidence

48. Interpersonal Deficits: Prognosis • Treatment of interpersonal deficits difficult • client often lacks relationships to practice and develop skills • treatment goals limited to making early gains interpersonally, not resolving interpersonal deficits

49. Grief Problem Area Focus • Normal Grief involves: • Symptoms including sadness, disturbed sleep, agitation, impairment, etc. • Symptoms usually resolve in 2 –4 weeks without treatment

50. Abnormal Grief Evidence • Inadequate grief in bereavement period • Multiple losses • Avoidance behavior (re funeral, grave, talk) • Symptoms around significant anniversary • Preserving environment of deceased • Fear of illness that caused death • Absence of social support during bereavement