NJ-ACT - Jami Young

Jami Young Leads NJ-ACT Workshop

On Interpersonal Psychotherapy

By Lynn Mollick

On Sunday October 3, fifty-seven NJ-ACT members heard psychologist Jami Young describe Interpersonal Psychotherapy (IPT).

Originally developed for depression, IPT is an empirically-supported, time limited (16-20 sessions), manualized treatment. It has been adapted for other mood disorders including bipolar disorder, ante- and post-partum depression, and HIV-positive adults, as well as bulimia nervosa, binge eating disorder, social phobia, and PTSD.

IPT assumes that depression causes relationship problems, and relationship problems cause depression. Treatment focuses on patients’ current relationships and the link between their relationships and depressive symptoms. IPT attempts to alleviate four types of problems that exacerbate depression:

1) Grief – when there has been a death or major loss, and depressive symptoms which may be delayed.

2) Role Transitions – when patients or their families have difficulty adjusting to a life change that requires a new role, e.g. when a woman becomes a mother, when an adolescent becomes a college student, when an adult becomes unemployed.

3) Interpersonal Disputes – when each person in a relationship has different expectations for the relationship, either overtly or covertly.

4) Interpersonal Deficits – when the patient lacks intimacy skills. This problem is the most difficult to treat in adults.

IPT also seeks to improve patients’ social support by problem-solving about how to develop new relationships and improve old relationships. An extended assessment precedes IPT’s three treatment phases:

Initial Phase:

The Initial Phase educates patients about depression and orients them to IPT. During the Initial Phase:

1) Tell patients that they are “sick,” and give them permission to perform below par until they recover.

2) Assess significant relationships in depth, i.e. find out about interactions, expectations, communication, positive and negative aspects, desired changes, and the impact of the depression and other recent events on each relationship. Draw a “closeness circle” -- ask patients to indicate how close or distant they feel from a person by placing the person in one of several concentric circles which have the patient at their center.

3) Determine which problem area will be the focus of treatment – grief, role transitions, interpersonal disputes, or interpersonal deficits. Because it is time-limited, IPT usually focuses on one problem area.

4) Develop a treatment contract which lists goals that can be achieved in 16 to 20 weeks.

Middle Phase:

Because it is individualized, IPT’s Middle Phase is less structured. Each session begins with symptom review, linking recent relationship events to the patient’s moods.

If patients say they have been depressed but don’t know why, the therapist should make a detailed inquiry into the week’s events to identify a trigger. If patients describe events without emotion, the therapist should inquire about feelings that follow each event and discuss unreported feelings that might have been provoked by the event. Important Middle Phase techniques include:

1) Communication Analysis – helping patients observe how their words affect others.

2) Decision Analysis – generating possible solutions to relationship problems, evaluating pro’s and con’s of solutions.

3) Role-playing -- acting out (not discussing) possible interactions during therapy sessions. To be effective, role-playing should evoke anxiety. Very anxious patients may require persuasion and/or feel more comfortable not playing their own role initially.

4) Homework – occurs only when in-session work on an interpersonal dispute is complete and the patient is ready to experiment in the real relationship. Check on their experience the following week.

Interventions for each problem area:

Grief – Educate patients about the mourning process. Ask patients to describe events before, during and after the death. Review negatives as well as positives about the person who died. Reintegrate patients into their social network by helping them express feelings, deepen existing relationships, and develop new interests to replace the loss.

Interpersonal Disputes – Identify and describe individuals’ behavior and expectations in the dispute. Improve communication and negotiation skills. Help patients develop more realistic expectations or accept that some interpersonal differences cannot be resolved.

Role Transitions – Grieve the old role by discussing its positives and negatives. Understand demands of the new role and how some of them present difficulty. Ask what might be gained in the new role. Develop new attachments, social skills, and interests.

Interpersonal Deficits – Relate depressive symptoms to social and emotional isolation. Look for positive and negative patterns in current and past relationships. Develop social skills that facilitate emotional intimacy.

Termination Phase:

1) Help patients give up the therapist by discussing feelings about termination.

2) Develop a sense of competence by reviewing successes and strategies learned.

3) Anticipate future difficulties and discuss how to use the new strategies to avoid depression.

4) Educate patients about the warning signs of depression.

5) Determine the need for additional or follow-up treatment.

IPT Adaptations:

For adolescents:

1) Insist on school attendance despite temporarily permitting reduced expectations.

2) Involve parents in all three treatment phases to explain the assessment, to work on communication, to improve social support, and to make parents aware of future needs.

3) Work with schools as needed.

For bipolar disorder:

1) Use the Social Rhythm Metric to assess daily life structure and routines. (Form for adults available in Frank, Ellen, Treating Bipolar Disorder, Guilford, 2007. Form for adolescents available online at:

www.clinicalneuropsychiatry.org/pdf/04_frank.pdf

2) Help patient develop daily routines to stabilize “rhythms.” A lack of daily structure is presumed to precipitate bipolar episodes.

3) Establish medication compliance.

For bulimia (but not anorexia):

1) Explain that interpersonal problems maintain eating problems because they isolate patients from their peers.

2) Discourage discussion of eating problems.

3) Inform patients that results may not occur for 4 to 8 months.

For binge eating disorder:

1) Change the goal to eliminating incidents of binge eating instead of improving symptoms of depression.

2) Identify interpersonal problems that maintain binge eating rather than those that precipitate them. Link interpersonal problems to binge eating.

(The empirically-supported IPT treatment for binge eating is primarily a group treatment, although it includes a few individual sessions that focus patients on their unique interpersonal issues.)