Comprehensive Guide To Interpersonal Psychotherapy

Gerald L. Klerman was ahead of his time. Mentor of Dr. Weissman (his wife) and Dr. Markowitz, he was convinced that interpersonal relationships importantly influenced the course and recurrence of illness, and that psychotherapy could potentially stabilize interpersonal relations. Gerry was the force behind the original ideas in the first Interpersonal Psychotherapy (IPT) manual (Klerman et al., 1984) and many of its adaptations. Yet his vision could not have anticipated the great interest in IPT that has developed since then.

Gerry died in April 1992. Even years after his death, his influence on IPT is pervasive. Out of respect for his contribution to the therapy, we are proud to name him a posthumous author of this book.

Preface

Interpersonal Psychotherapy (IPT) was first developed as a time-limited research treatment for depression by the late Gerald L. Klerman, M.D., Myrna Weissman, Ph.D., and colleagues. Since its efficacy has been demonstrated in numerous controlled clinical trials, IPT has been modified to treat different types of mood and non-mood disorders. These research advances, together with the ascendancy of managed care and its concern to reduce mental health costs, have accelerated clinical interest in IPT techniques and applications.

The idea underlying IPT is simple: psychiatric syndromes such as depression, however multidetermined their causes, usually occur in a social and interpersonal context. A marriage breaks up; a friendship dissolves; children leave home; a job is lost; a loved one dies; a person moves, is promoted, or retires. In IPT, patients learn (1) to understand the relationship between the onset and fluctuation in their symptoms and what is currently going on in their life—their current interpersonal problems—and (2) to find ways of dealing with the interpersonal problems, and thereby with the depressive symptoms.

IPT was first described in Interpersonal Psychotherapy of Depression by Gerald L. Klerman, Myrna M. Weissman, Bruce J. Rounsaville, and Eve S. Chevron (Basic Books, 1984). Since then, it has become a growth industry. Accordingly, what began as a modest revision of that book has matured into a comprehensive guide. It opens with an overview and outline of IPT's theoretical framework and strategies, which were designed specifically for the treatment of major depression in outpatients. This core application is then elaborated more fully than in the 1984 manual, with added case material. The clinical scripts assume the general clinical competence of the psychotherapist and must be used judiciously. Cases have been disguised or consolidated to preserve patient confidentiality.

Part I of the book describes the heart of the approach and is required reading for anyone wanting to learn IPT. The subsequent chapters present adaptations or new uses of this basic method. Parts II and III introduce adaptations of the core approach, in various stages of development, for treating mood disorders in different age groups, settings, and special populations, and for non-mood disorders. The rest of the book covers a wide range of resources for the spectrum of professionals who practice IPT: new therapeutic formats, treatment manuals, international references, history, and training procedures.

As this work has evolved over our professional lives, there are many people who contributed to it, including Bruce Rounsaville and Eve Chevron, who participated in writing the 1984 book, and the many IPT therapists and researchers who kept supplying us with their ongoing work. We are also grateful to the universities that supported us as scientists—Harvard and Cornell University Medical Schools, Yale University, and the Columbia University College of Physicians and Surgeons—and to the New York State Psychiatric Institute. We thank the government and private agencies that provided funds to carry out different studies: the National Institute of Mental Health; the National Institute of Drug Abuse; the Anne Lederer Pollack Foundation; the National Alliance for Research on Schizophrenia and Depression (NARSAD); the John D. and Catherine T. MacArthur Foundation; the Nancy Pritzker Foundation; and the fund established in The New York Community Trust by DeWitt-Wallace. We are especially grateful for the support received before we were established investigators and during periods when psychotherapy research was unfashionable.

Overview of IPT

We begin with a description of major depression, as this was the starting point for IPT. The cartoon from The New Yorker illustrates many of the clinical features of depression. It is apparent that the woman is depressed. How do we know? Nonverbal and behavioral features convey her depressed state. She has a downcast gaze and a flattening of the nasolabial folds, depressive facial changes first described by Darwin. She sits slumped in her chair, a sign of “slowing down,” or psychomotor retardation. She looks dowdy, reflecting the scant attention that depressed individuals pay to their dress and grooming. (On the other hand, she is not so paralyzed by her mood that she appears disheveled.)

That the depressed person is a woman is more than fortuitous: epidemiologic studies indicate that depression occurs more frequently in women than in men across diverse cultures. In addition, this woman is middle-aged, and depression occurs increasingly after puberty, peaking between the ages of eighteen and forty-four and declining somewhat in later years. This is probably not her first episode.

We also see that, although it is the woman who is depressed, the problem is a family affair. The man in the cartoon is irritated and frustrated. He has an air of futility as he says, “I do like you. You don’t like you!” This observation captures an important aspect of the clinical phenomenology of depression: the fallen self-esteem, self-deprecation, and sense of helplessness, hopelessness, and worthlessness. Depressed individuals often negatively misinterpret the attitudes of others.

While the wife is depressed and sullen, the husband is impatient and even hostile. This precisely illustrates the effect of protracted clinical depression on interpersonal relationships. In the early stages of a depressive episode, patients may elicit sympathy, nurturance, and reassurance from family members, friends, and acquaintances. But if the depression is not resolved by what we may call “psychotherapy of everyday life,” the response of those in the immediate environment tends to shift from support and encouragement to increasing irritation and frustration. At this point the patient is likely to be accused of “not really trying,” of wanting to “make everybody miserable,” or of “doing it to us on purpose.” These pseudopsychological insights are usually expressed in a pejorative way, reflecting the frustration of those around the depressed person. This is a blaming of the patient for her illness rather than a scientific understanding of the complexities of the illness.

Let’s reconstruct what might have happened to this couple. Over a number of months, the woman has slowly become depressed, perhaps after her children have left home and the “nest is empty.” As part of the psychotherapy of everyday life, the husband has tried to reassure her and to provide optimism about the future. He has said, “I love you as much as when we first met,” or “You are as beautiful as ever.” These reassurances have evidently been of little avail. The wife continues to feel discouraged and worthless—depressed.

Thus far most clinicians and theorists would almost completely agree. However, depending upon theoretical orientation and training, a psychotherapist might conceptualize and intervene in this case in various ways. A strictly biological psychiatrist might interpret this picture as reflecting not psychological difficulty but altered neurotransmitter levels. The biological psychiatrist would invoke the medical model, label the patient as having a major depression, and might recommend treatment with an antidepressant medication. If that failed after six to eight weeks at adequate dosage, alternative medications might be considered or, if the depression were completely unresponsive to medication and the patient became more symptomatic, electroconvulsive therapy.

A psychoanalyst might interpret the patient’s current situation as a reactivation of unresolved childhood difficulties and ambivalent identifications with the mother. Feelings of helplessness and hopelessness might be viewed as the response to inadequate mothering, most likely during the oral phase of psychosexual development. With the coming of menopause and the departure of the children, the patient experiences a loss of gratification from identification with the maternal role and regresses to early, oral, narcissistic stages of fixation. Perhaps psychoanalysis would be directed at uncovering childhood antecedents, particularly in the mothering relationship at the preoedipal phase, and working through the unresolved ambivalence toward the lost image of the idealized mother.

A practitioner of cognitive behavioral therapy (CBT) might note that the depression is producing distorted thoughts and perceptions of the patient’s current situation. The patient believes these mood-congruent, irrational negative thoughts (“I’m worthless”; “Nothing ever goes right for me”; “Things are awful now, and will never get any better”) and thus allows them to negatively influence her actions. If she can learn through homework to examine, test, and challenge the irrational thoughts, she may start to extinguish them and live her life again (Beck et al., 1979).

A family therapist might see this as a problem between husband and wife in the family system. Couples therapy would be recommended with the aim of improving communication between them and helping both partners to express their mutual frustrations and hostilities, in the hope that a new relationship would emerge.

A radical feminist therapist might say that the patient is not depressed but rather oppressed. Rather than seeing herself as ill, she should be encouraged to see her psychological state as reflective of the social position of women in a society dominated by male chauvinism. If she feels worthless and helpless, this is not a neurotic distortion of reality but rather a true perception of the low status of women. Without the childbearing role, she has no legitimate place in society. Lacking marketable skills, she is in fact worthless, and her feelings of helplessness reflect her inability to alter the power relationship between herself and her husband. Rather than needing medications or psychotherapy, she needs to become politically active and assertive, and perhaps independently employed outside the home.

These varied responses to the same clinical picture show the current diversity of psychiatry. There is no single, dominant school of American psychiatry, and no consensus on how best to regard the causes, prevention, and treatment of mental illnesses. Given this situation, how should the mental health professional proceed?

The authors believe that progress requires a pluralistic, undoctrinaire, and empirical approach that builds upon clinical experience and research evidence. Taking a pluralistic approach, we acknowledge the existence of multiple theoretical and clinical points of view; indeed, our work has been nurtured by them. We are convinced, however, that all theories and schools require evidence from testing, and that the most powerful evidence comes from carefully designed, well controlled investigative trials.

Treatment selection should consider a wide range of options—rather than simply the therapist’s personal preference—and weigh the evidence for the likely efficacy of each: that is, treatment should be considered in the light of differential therapeutics (Frances, Clarkin, and Perry, 1984). Hundreds of different psychotherapies have been described, yet only a few have been tested and demonstrated to treat particular disorders. IPT and CBT are both proven approaches to treating major depression, as is antidepressant medication. We would have hoped that, in the interval between editions of this book, more therapists would have moved to such an outlook, but it remains unclear that this is the case. Too much therapy probably continues to be prescribed by therapists with a single approach to all comers.

Although many of its principles derive from the broader school of interpersonal psychotherapy, IPT is a psychological treatment originally designed specifically for the needs of depressed patients. It has since been modified for other disorders. IPT is a focused, time-limited psychotherapy that emphasizes the link between mood and the current interpersonal relations of the depressed patient while recognizing the roles of genetic, biochemical, developmental, and personality factors in the causation of and vulnerability to depression. IPT is not a causal explanation for depression, but a pragmatic treatment for it. We are convinced from clinical experience and research evidence that clinical depression occurs in an interpersonal context, and that acute psychotherapeutic interventions directed at this interpersonal context can facilitate the patient’s recovery from an acute episode and possibly provide some preventive benefit against relapse and recurrence.

The first step in using IPT for depression successfully is to recognize just what depression is—making the distinction between normal and clinical depression, and observing the social, biological, and medical antecedents of clinical depression diagnosed through the use of a medical model. The original IPT book (Klerman et al., 1984) described in detail the then-current scientific understanding of depression and the empirical basis of treating it in an interpersonal context; the importance of attachment, bonding, stress, and interpersonal disputes in the development of depression; as well as the theoretical basis for IPT of depression, deriving from the interpersonal school of psychotherapy.

MAJOR DEPRESSION: CURRENT UNDERSTANDING

The term mood disorder refers to a group of clinical conditions whose common feature is the patient’s disturbed mood, which is either elated (in bipolar disorder) or depressed. This distinction does not imply a common etiology. Mood disorders are probably biologically heterogeneous, comparable in that sense to many medical presentations, such as jaundice. The major differentiation within mood disorders is between bipolar and “unipolar” depressive disorders; and, within the latter, between major depression and dysthymic disorder. IPT was originally developed to treat major depression. The characteristics of the other disorders are described with each adaptation.

The essential feature of major depression is either a dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes. The disturbance is prominent, persistent, and associated with other symptoms including appetite disturbance, change in weight, sleep disturbance, psychomotor agitation or retardation, decreased energy, feelings of worthlessness or guilt, difficulty in concentrating or thinking, indecisiveness, and thoughts of death or suicide, or suicide attempts. Major depression is only diagnosed in the absence of current or past manic symptoms (see Table 2-1 for DSM-IV criteria.) Although it is generally agreed that major depression is a heterogeneous disorder, there is no consensus on the utility of and little empirical basis for most of the subtypes in clinical use, such as endogenous, melancholic, and seasonal depression.

There is now considerable information about the rates of major depression from epidemiologic studies conducted in the 1980s across quite diverse cultures (Weissman et al., 1996). Studies conducted in the mainland United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Korea, and New Zealand all show convincingly that rates of depression are higher in women than in men, with an average twofold difference. Although rates of depression vary by country, its predominance in women is consistent across cultures. This finding has been replicated in studies conducted in the United States in the 1990s (Kessler et al., 1994).

These studies also show that the gender disparity in rates of the first onset of depression begins early, around thirteen to fifteen years of age, and persists throughout life. There is a peak in first onsets during the childbearing years and a decrease after age forty-five (Cross National Collaborative Group, 1992). There is no evidence for an increase in onset during the menopausal years. Longitudinal research suggests that depressed women have longer episodes of depression than men and a lower rate of spontaneous remission. The reasons for the sex differences in rates of depression are unclear (Wolk and Weissman, 1995). The epidemiological data support the importance of treating depression in the childbearing years, as the impact on offspring is enormous (Weissman and Olfson, 1995). There has been interest in adapting IPT for the treatment of depression during pregnancy and the postpartum period (see Chapter 19). Studies have also found an earlier age of onset of depression in more recent generations since World War II. Although women have had higher rates of depression than men in all countries, studies in the United States have suggested that, in recent decades, rates are increasing more rapidly in men.

Major depression is increasingly recognized as a worldwide source of morbidity, impairment, and health expenditures. The World Bank estimated that depression accounts for almost 30 percent of disability from neuropsychiatric disorders among women worldwide, but for only 12 percent among men (World Bank, 1993). The World Health Organization estimates that depression is currently the fourth leading cause of disability, surpassed only by respiratory infections, diarrheal diseases, and perinatal complications of women (Murray and Lopez, 1996). By the year 2020, depression is expected to be the second leading cause of disability.

Major advances in the treatment of depression have led to decreased hospitalization, reduced duration of episodes, and strategies to prevent relapse and recurrence. Most treatment for mood disorders is now ambulatory. Tricyclic antidepressants have been available for four decades, and the serotonin reuptake inhibitors for one. Their therapeutic value for both acute and maintenance treatment of depression is indisputable. There is excellent evidence that depressive symptoms can be reduced in two to four weeks of pharmacological treatment. Soon after antidepressant medications were introduced, however, investigators found that a high percentage of patients relapsed following short-term treatment. Continuation strategies then became common in clinical practice and were the subject of several research studies. The goals of continuation treatment are to sustain the remission brought about by acute treatment, to prevent relapse, and to facilitate social and vocational functioning. Beyond six to twelve months, treatment is considered maintenance or prophylaxis (see Chapter 11).

THEORETICAL AND EMPIRICAL SOURCES

We will briefly summarize the theoretical and empirical foundations of IPT. Among the founders of the interpersonal school were Adolf Meyer of Johns Hopkins University and his associate Harry Stack Sullivan. Meyer’s psychobiological approach to understanding psychiatric disorders placed great emphasis on the patient’s current psychosocial and interpersonal experiences, in distinction to the psychoanalytic focus on the past and the intrapsychic (Meyer, 1957). Sullivan, who linked clinical psychiatry to anthropology, sociology, and social psychology, viewed psychiatry as the scientific study of people and the processes that go on among them, rather than the exclusive study of the mind or of society. Sullivan popularized the term “interpersonal” as a balance to the then-dominant intrapsychic approach (Sullivan, 1953). In the interpersonal approach, the unit of observation and therapeutic intervention is the primary social group, the immediate face-to-face involvement of the patient with one or more significant others.

The IPT emphasis on interpersonal and social factors in the understanding and treatment of depression also draws on the work of many other clinicians, especially Fromm-Reichmann (1960), Cohen et al. (1954), and Arieti and Bemporad (1978). Becker (1974) and Chodoff (1970) also emphasized the social roots of depression and the need to attend to the interpersonal aspects of the disorder. Frank (1973) applied an interpersonal conceptualization to psychotherapy, stressing mastery of current interpersonal situations as an important component.

The interpersonal approach is specifically applied to understanding clinical depression, which we consider to have three component processes:

1. Symptom function: the development of depressive affect and the neurovegetative signs and symptoms (sleep and appetite disturbance, low energy, diurnal mood variation, etc.). These are presumed to have both biological and psychological precipitants.
2. Social and interpersonal relations: interactions in social roles with other persons derived from learning based on childhood experiences, concurrent social reinforcement, and personal mastery and competence.
3. Personality and character problems: enduring traits such as inhibited expression of anger or guilt, poor psychological communication with significant others, and difficulty with self-esteem. These traits determine a person’s reactions to interpersonal experience. Personality patterns form part of the person’s predisposition to depressive symptom episodes.

IPT intervenes in the first two of these three processes, symptom function and social and interpersonal relations. Because of its relatively brief duration and low level of psychotherapeutic intensity, there is little expectation that this treatment will have marked impact upon enduring aspects of personality structure, although personality functioning is assessed. On the other hand, many IPT patients gain new social skills that may help compensate for personality difficulties. Moreover, mood disorder and especially chronic mood disorder—dysthymic disorder—may mimic personality disorder. Thus personality disorder should not be prejudged in depressed patients: it is perilous to diagnose an Axis II disorder in the presence of an Axis I condition.

In our experience, most psychotherapies for depressed patients have paid insufficient attention to techniques directed at symptom reduction and amelioration of the patient’s current social adjustment and interpersonal relations. IPT therapists do not attempt personality reconstruction. They rely upon well-established techniques such as reassurance, clarification of emotional states, improvement of interpersonal communication, and testing of perceptions and performance through interpersonal contact. Role-playing can provide important preparation for the patient making the life changes that will resolve the depressive episode.