Clinical & empirical perspectives of Clinical & empirical perspectives of Interpersonal PsychotherapyInterpersonal Psychotherapy

The low down on IPTThe low down on IPT……why, who, what, and how?why, who, what, and how?

February 16th, 2008February 16th, 2008

Ontario College of Family PhysiciansOntario College of Family PhysiciansCollaborative Mental Health Care NetworkCollaborative Mental Health Care Network

Paula Ravitz & Michael ParePaula Ravitz & Michael Pare

DisclosureDisclosureNo industry supportNo industry supportHowever influenced by several schools and However influenced by several schools and developments of IPT developments of IPT

Columbia purists (Weissman & Markowitz), for adolescents Columbia purists (Weissman & Markowitz), for adolescents (Mufson) & in rural Uganda ((Mufson) & in rural Uganda (VerdeliVerdeli & & CloughertyClougherty) ) Pittsburgh: for chronic & bipolar patients along with brief IPT Pittsburgh: for chronic & bipolar patients along with brief IPT (Frank; Swartz)(Frank; Swartz)Iowa: postIowa: post--partum depressed moms (Stuart & Opartum depressed moms (Stuart & O’’Hara)Hara)Toronto: process research looking at interpersonal moderators Toronto: process research looking at interpersonal moderators and mediators of outcome (McBride, Ravitz, Maunder, and mediators of outcome (McBride, Ravitz, Maunder, BagbyBagby))Ethiopia:Toronto Abbis Ababa Psychiatry Project (Pain & Ravitz)Ethiopia:Toronto Abbis Ababa Psychiatry Project (Pain & Ravitz)

Plus influenced by Mt. Sinai Psychotherapy InstitutePlus influenced by Mt. Sinai Psychotherapy Institute’’s s evolving integrative and relational evolving integrative and relational ‘‘Effectiveness ModelEffectiveness Model’’(Hunter, (Hunter, LeszczLeszcz, Maunder, Pain, Ravitz), Maunder, Pain, Ravitz)

Learning ObjectivesLearning ObjectivesAt the end of this presentation, participants will:

• Understand the rationale, suitability criteria, potential applications and therapeutic guidelines of IPT

• Appreciate how attachment & interpersonal theories can assist you to better understand your patients and their interpersonal problems

““ClinicianClinician’’s Quick Guide to s Quick Guide to Interpersonal PsychotherapyInterpersonal Psychotherapy””

Myrna M. WeissmanMyrna M. WeissmanJohn C. MarkowitzJohn C. MarkowitzGerald L. KlermanGerald L. Klerman

New York: Oxford Press 2007New York: Oxford Press 2007

Why IPT?Why IPT?

Addresses commonly encountered Addresses commonly encountered problemsproblemsHas a strong empiric base to support its Has a strong empiric base to support its efficacy and effectivenessefficacy and effectivenessDerived and grounded in empirically Derived and grounded in empirically supported interpersonal theories that supported interpersonal theories that provide alternative, clinically helpful provide alternative, clinically helpful perspectives perspectives

Listening to our patients: Listening to our patients: What life events do they What life events do they

experience as distressing?experience as distressing?

IPTIPT

Brings attention to illness in the context of Brings attention to illness in the context of universal life experiencesuniversal life experiences

LossLossChangeChangeConflictConflict

CAMH IPT Depression ClinicCAMH IPT Depression Clinic::

themes of change, loss, conflictthemes of change, loss, conflictMr. XY: 40 something year old teacher, referred by FDMr. XY: 40 something year old teacher, referred by FD

HPI:HPI: Depressed x 2 years, anxious; not able to work for past 5 Depressed x 2 years, anxious; not able to work for past 5 yearsyearsStressors:Stressors:

1.1. Coming out as gay male; experience of disapproval from family Coming out as gay male; experience of disapproval from family & ambivalence regarding church; conflict between his wish for & ambivalence regarding church; conflict between his wish for intimacy & high anxiety around physical overtures from menintimacy & high anxiety around physical overtures from men

2.2. Death of father who was described as a violent man & alcoholicDeath of father who was described as a violent man & alcoholic3.3. Move away from flatMove away from flat--mate 2 yrs ago, whom had looked after mate 2 yrs ago, whom had looked after

him when acutely ill and in hospital withhim when acutely ill and in hospital with……4.4. ……Inflammatory Bowel Disease Inflammatory Bowel Disease –– delayed diagnosis, difficulties delayed diagnosis, difficulties

with medical stabilization and with finding the right dose & typwith medical stabilization and with finding the right dose & type e of medicationof medication

5.5. Unemployed and wishing to reUnemployed and wishing to re--enter workforceenter workforce

Interpersonal Psychotherapy (IPT)Interpersonal Psychotherapy (IPT)Weissman, Markowitz, Klerman 2007Weissman, Markowitz, Klerman 2007

An effective treatment for depression An effective treatment for depression throughout the lifespan and in differing throughout the lifespan and in differing cultural settings cultural settings

(Bolton 2003 & 2007, Elkin1989, Frank 1990, Markowitz 1999; (Bolton 2003 & 2007, Elkin1989, Frank 1990, Markowitz 1999; Mufson 2004 &1999, O'Hara1999, Reynolds )Mufson 2004 &1999, O'Hara1999, Reynolds )

Included in international consensus Included in international consensus guidelines for treatment of depression guidelines for treatment of depression

CANMAT, APA, NICE (UK), AustralasiaCANMAT, APA, NICE (UK), Australasia

IPT: Theoretical GroundIPT: Theoretical Ground

2020thth CenturyCentury

Harry Stack SullivanHarry Stack SullivanInterpersonal >Interpersonal >intrapsychicintrapsychic

John BowlbyJohn BowlbyAttachment & the impact Attachment & the impact of loss or disruptionsof loss or disruptions

2121stst Century additionCentury addition

Donald Kiesler & Timothy Donald Kiesler & Timothy LearyLearyContemporary Contemporary Interpersonal or Interpersonal or Communications TheoryCommunications Theory

Agency, AffiliationAgency, AffiliationCircular causality & Circular causality & reciprocal influences reciprocal influences

Bowlby; Ainsworth; MainBowlby; Ainsworth; Main

AttachmentAttachmentCritically important for survival & adaptation of all mammals

Begins in early life & persists throughout life

Attachment experiences lead to an Internal Working Model of interpersonal expectations & appraisals

Attachment behaviours recruit proximity in times of distress

Effects physiological homeostasis, subjective feelings of security, affect regulation, relationships, and resilience

Secure: sufficient positive early relational experiences, able to trust, form & sustain relationships, able to regulate emotions & mentalize

Insecure: early invalidating environment; history of misattunement, neglect, or abuse can impair one’s capacity to engage in relationships and to effectively recruit or utilize supports when distressed; can lead to hypo- or hyper-activation of affect, insecure sense of self, poor capacity to mentalize

Waters et al. 2000; Weinfield et al. 2000Waters et al. 2000; Weinfield et al. 2000

The Internal Working ModelThe Internal Working Model

a perpetual a perpetual ““workwork--inin--progressprogress”” –– relatively stable relatively stable but nonetheless open to change in the face of but nonetheless open to change in the face of sufficiently salient and persistent new sufficiently salient and persistent new experiencesexperiences

A model of adult attachment dimensions (adapted from Bartholomew)

Model of other

positive

negative

avoidance

Model of selfpositive negative

dependence/anxiety

SecurePreoccupied(inconsistently available care)

Dismissing (consistentlyunavailable care)

Fearful

Maunder & Hunter 2001Maunder & Hunter 2001

Adult attachment & stressAdult attachment & stress

Insecure attachment affects appraisal of stressful events & can result in ineffective help-seeking behavior reducing the potential of social support to buffer stress.

Remember that these interpersonal styles were earlier attempts to adapt.

Attachment anxiety (Preoccupied)

↓ threshold for activating attachment behaviors intended to signal distress and recruit proximity & support from attachment figures.May inadvertently extinguish or overwhelm others with excessive or intense entreaties

Attachment avoidance (Dismissing)

distrusting of others, with needless self-sufficiency Intimacy and offers of support may be experienced as aversive, and support is not sought or is rejected.

KieslerKiesler

Contemporary Interpersonal TheoryContemporary Interpersonal Theory

Examines the impact of Examines the impact of a broad class of a broad class of interpersonal interpersonal interactions & difficulties interactions & difficulties in relationships in relationships

NormativeNormative interpersonal interpersonal behavior represents behavior represents blends of two blends of two motivational forces & motivational forces & needs, negotiated in all needs, negotiated in all encounters encounters

AffiliationAffiliation

ControlControlAgencyAgency

Circular causality & Circular causality & ‘‘pullspulls’’KieslerKiesler’’s Interpersonal Circumplexs Interpersonal Circumplex

Disengaged Affiliative

Dominance

Submissive

DOMINANTDOMINANT

NONNON--ASSERTIVEASSERTIVE

INTRUSIVEINTRUSIVE

SELFSELF--SACRIFICINGSACRIFICING

OVERLYOVERLY--ACCOMODATINGACCOMODATING

VINDICTIVEVINDICTIVE

COLDCOLD

SOCIALLY INHIBITEDSOCIALLY INHIBITED

‘Pulls’ can become Interpersonal Problems (Horowitz)

Joiner & Coyne 1999; McCullough Joiner & Coyne 1999; McCullough 2000; Ravitz, Maunder, McBride 20082000; Ravitz, Maunder, McBride 2008

A vicious interpersonal cycleof Depression

A vicious interpersonal cycleA vicious interpersonal cycleof Depression of Depression

Disengaged from their social Disengaged from their social environment & unable to environment & unable to fulfill their role/responsibility fulfill their role/responsibility →→→→ isolation and despairisolation and despair

Symptoms of negativity, Symptoms of negativity, irritability, hopelessness take irritability, hopelessness take toll on relationships & toll on relationships & extinguish rather than recruit extinguish rather than recruit supports in time of needsupports in time of need

Add to the impact of Add to the impact of depression, attachment depression, attachment styles and interpersonal pulls styles and interpersonal pulls in the context stressful life in the context stressful life events and interpersonal events and interpersonal problemsproblems……

Maladaptive Transaction CyclesMaladaptive Transaction CyclesInsecure attachment can Insecure attachment can exacerbate maladaptive exacerbate maladaptive communication which:communication which:

prevents individualsprevents individuals’’needs from being metneeds from being metreinforces negative reinforces negative interpersonal working interpersonal working models & expectations by models & expectations by the responses they evoke the responses they evoke inadvertently authors what inadvertently authors what patients dreadpatients dreadFurther perpetuates Further perpetuates depressogenic pulls that depressogenic pulls that are disengaging and are disengaging and disempoweringdisempowering

Others won’t careAnxious/Avoidant

Hostile, critical, indirect communication

Rejection frompotential caregivers

IPT: For whom?IPT: For whom?Depressed patients, across the life cycle and from Depressed patients, across the life cycle and from differing cultures, in the context of life eventsdiffering cultures, in the context of life events

Other psychiatric problems and Other psychiatric problems and comorbiditycomorbidity often require often require integration of other therapeutic strategiesintegration of other therapeutic strategies……one size one size does not fit all (i.e. Motivational Interviewing for does not fit all (i.e. Motivational Interviewing for substance abusing patients; CBT for panic & anxiety substance abusing patients; CBT for panic & anxiety symptoms) and combining with pharmacotherapy is symptoms) and combining with pharmacotherapy is recommended for those with chronic or severe illnessrecommended for those with chronic or severe illness

However, the interpersonal lens can be applied in a However, the interpersonal lens can be applied in a single session for any patient with interpersonal single session for any patient with interpersonal problems problems

What is IPT?What is IPT?Phase Specific TasksPhase Specific Tasks

Focus Specific & Focus Specific & ‘‘panpan--focalfocal’’ GuidelinesGuidelines

What is IPT?What is IPT?What is IPT?

Time limited Time limited (8(8--16 sessions; 1 on 1 or group)16 sessions; 1 on 1 or group)

ManualizedManualizedBrings attention to illness in Brings attention to illness in the context of universal life the context of universal life experiences of loss, experiences of loss, change& conflictchange& conflict

IP eventsIP events

MoodMood

Goals of IPTGoals of IPTGoals of IPT

Remit symptoms & improve functioningRemit symptoms & improve functioningResolve interpersonal problemsResolve interpersonal problems

Facilitate adaptation to & working through of Facilitate adaptation to & working through of changes, losses or disagreementschanges, losses or disagreementsRepair or assist to build Repair or assist to build supportssupportsImprove Improve communicationcommunicationEncourage Encourage reciprocityreciprocity, , empathic understandingempathic understandingand acceptance of limitations within relationshipsand acceptance of limitations within relationships

IPT IPT ‘‘classicclassic’’: 12: 12--16 hour16 hour--long sessionslong sessions

BeginningBeginning (sessions 1(sessions 1--2)2)

psychiatric assessment (symptoms, story, psychiatric assessment (symptoms, story, interpersonal inventory)interpersonal inventory)establish alliance & focus establish alliance & focus

MiddleMiddle (sessions 3(sessions 3--10)10)

work through interpersonal problem areawork through interpersonal problem areaapplying focus specific content guidelines applying focus specific content guidelines ‘‘panpan--focalfocal’’ work on interactions & communication work on interactions & communication

EndEnd (sessions 11(sessions 11--12)12)

consolidate gains; contingency plan consolidate gains; contingency plan

The IPT view of clinician & patient roles

The IPT view of The IPT view of clinician & patient rolesclinician & patient roles

The clinicianThe clinician: : assists the patient to actively work towards assists the patient to actively work towards recovery using this brief and structured model; carries a recovery using this brief and structured model; carries a ‘‘flag of hopeflag of hope’’ until the patient can carry it herself; monitors until the patient can carry it herself; monitors symptoms & adjusts intervention accordinglysymptoms & adjusts intervention accordingly

We discuss the patient role in the early phase:We discuss the patient role in the early phase:Providing Providing psychoeducationpsychoeducation about depression as a about depression as a common illness & well understood problem with common illness & well understood problem with numerous effective solutions (including IPT) helps to numerous effective solutions (including IPT) helps to remove blame, instills hope & remove blame, instills hope & destigmatizesdestigmatizes, yet assigns , yet assigns responsibilityresponsibility to work towards recoveryto work towards recoveryRight for temporary reprieve & supportRight for temporary reprieve & support

The Interpersonal InventoryThe Interpersonal InventoryProvides implicit and explicit dataProvides implicit and explicit data

Explore significant Explore significant relationships in some detail, relationships in some detail, with exampleswith examples of of interactions (can take 1interactions (can take 1--2 2 sessions)sessions)Explore how people Explore how people identified help patient to identified help patient to manage their problems or manage their problems or make problems worsemake problems worseDuring this process, note During this process, note affect, narrative coherence affect, narrative coherence & attachment experiences& attachment experiencesHelps to: Helps to:

identify focusidentify focusformulate attachment & formulate attachment & interpersonal problems/pullsinterpersonal problems/pulls

The Interpersonal Context The Interpersonal Context ––finding focus for brief interventionfinding focus for brief intervention

Identify current interpersonal Identify current interpersonal relationships and issues that are:relationships and issues that are:

most affectively charged most affectively charged central to the patientcentral to the patient’’s current depressive s current depressive episodeepisodeopen to changeopen to change

…….to .to define primary problem define primary problem area(sarea(s))& primary relationship that might & primary relationship that might change change

Most life events can be related Most life events can be related to loss, change & conflict to loss, change & conflict

Role Disputes - Non-reciprocal expectations; conflicted relations with a significant other

Transitions – Life events that involve significant changes in social role

Grief - Prolonged, depression related bereavement

Deficits – Absence of life events; paucity of supports; loneliness; interpersonal sensitivity

Social Role Transitions: Social Role Transitions: Life changesa challenge to adapt toa challenge to adapt to……all is not lostall is not lost

Review Review detailsdetails of changes with its associated of changes with its associated disrupted attachmentsdisrupted attachmentsLink depression with change in social roleLink depression with change in social roleMourn & realistically evaluate Mourn & realistically evaluate what waswhat wasExamine challenges (feeling deskilled) & Examine challenges (feeling deskilled) & opportunities (supports) of opportunities (supports) of what iswhat is

Might include existential task of adapting to & Might include existential task of adapting to & accepting that which might not changeaccepting that which might not change

Focus on elements under individualFocus on elements under individual’’s control to s control to toto influence influence what might bewhat might be including improved including improved or expanded supportsor expanded supports

IPT Strategies: GriefIPT Strategies: Grief

•• Review Depressive SymptomsReview Depressive Symptoms•• Relate symptoms onset to deathRelate symptoms onset to death•• Reconstruct relationship with the deceasedReconstruct relationship with the deceased•• In detail, discuss the sequence and In detail, discuss the sequence and

consequences of events prior, during, and consequences of events prior, during, and after the deathafter the death

•• Explore associated affects (+ & Explore associated affects (+ & --))•• Consider ways to reduce isolation and replace Consider ways to reduce isolation and replace

aspects of whataspects of what’’s lost s lost

Tasks: Resolving DisputesTasks: Resolving DisputesInvolves a search for understanding & Involves a search for understanding &

compromise by both partiescompromise by both parties

First steps - ExplorationIdentify core issue(s) – differing values & expectations, i.e. infidelity, finances, child rearing Stage the dispute

Impasse – need to warmRenegotiation – need to coolDissolution – need to help with transition to separation

The road to resolutionThe road to resolution……towards towards action and changeaction and change

Explore expectations & values of both parties: ?reasonable ? Realistic ?mutual perspective

Evaluate communication patterns (verbal and non-verbal) & brainstorm on alternatives to improve communication

Negotiate a Settlement: Modify expectations and behaviour of pt +/or other OR accept that which cannot change: lower expectations OR dissolution: change of focus to role transition.

A common problem: A common problem: Inadvertently authoring what one dreadsInadvertently authoring what one dreads

Working on communicationWorking on communicationExploreExplore detailsdetailsOften part of a pattern that parallels difficulties in other Often part of a pattern that parallels difficulties in other relationships relationships Make the Make the ‘‘symptomssymptoms’’ of ineffective communication of ineffective communication dysphoricdysphoric

by linking to negative outcome, motivates changeby linking to negative outcome, motivates changeemphasize the unwished for impact: emphasize the unwished for impact: ““That didnThat didn’’t work so well.t work so well.””explore the role the patient inadvertently plays explore the role the patient inadvertently plays engender understanding & explore expectations (reasonable, realiengender understanding & explore expectations (reasonable, realistic, stic, room for compromise, perspective of other)room for compromise, perspective of other)brainstorm on strategic options for change & assign brainstorm on strategic options for change & assign ‘‘work at homework at home’’: : ““Can you have that conversation?Can you have that conversation?””

role plays +/role plays +/-- conjoint session(s)conjoint session(s)

Parallels in Other RelationshipsParallels in Other RelationshipsIneffective communication patternsIneffective communication patterns

patients can get repeatedly patients can get repeatedly ‘‘pulled or pulled or ‘‘pullpull’’reactions in a way that inadvertently worsens conflictreactions in a way that inadvertently worsens conflictHelp patients to differentiate: what was true Help patients to differentiate: what was true ‘‘then & therethen & there’’ is not necessarily so is not necessarily so ‘‘here & nowhere & now’’, , at least not with all others.at least not with all others.*NB: Important not to blame the self*NB: Important not to blame the self--critical depressed critical depressed patient, noting that depression may be contributory patient, noting that depression may be contributory

Communication Communication Analysis:Analysis:

ExploreExplore→→ AnalyzeAnalyze→→ ActAct

Detailed Detailed account of affectively charged conversation: account of affectively charged conversation: What is said, not said, felt, intended, wished for, What is said, not said, felt, intended, wished for, understood?understood?Intent vs. ImpactIntent vs. Impact

Watch for patterns & acts of commission or omissionWatch for patterns & acts of commission or omissionLink maladaptive or ineffective communication with Link maladaptive or ineffective communication with symptomssymptoms

Communication Analysis Communication Analysis ––the best tool in the IPT kitthe best tool in the IPT kit

Explore recent interpersonal interaction Explore recent interpersonal interaction in detailin detail; ; clarify needs, wishes and expectations of clarify needs, wishes and expectations of others (?realistic ?reasonable)others (?realistic ?reasonable)

““What did you say? And how they they respond? How did What did you say? And how they they respond? How did that make you feel? How did you respond?that make you feel? How did you respond?…”…”Link to affective experiencesLink to affective experiencesLook for problematic patterns (hostility, acts of Look for problematic patterns (hostility, acts of omission or commission)omission or commission)Assist to improve both understanding of and Assist to improve both understanding of and communication with otherscommunication with othersEncourage change Encourage change –– interpersonal behavioral interpersonal behavioral activation & selective affiliationactivation & selective affiliation

Communication AnalysisCommunication Analysishelps patients identify and close helps patients identify and close gaps between intent and impactgaps between intent and impact

Following exploration and brainstormingFollowing exploration and brainstorming……....

ImaginalImaginal or real role plays help to generate alternative or real role plays help to generate alternative approaches and/or changed expectations that can lead approaches and/or changed expectations that can lead to improved interpersonal outcomesto improved interpersonal outcomes

““What would you likeWhat would you like…….to understand?.to understand?””

IPT targets depression IPT targets depression throughthrough……

focus on communication & interpersonal focus on communication & interpersonal problemsproblemsfacilitating better coping via: facilitating better coping via: ↑↑affiliation affiliation ↑↑agency agency ↓↓ experienced interpersonal problemsexperienced interpersonal problems↑↑experience of security in attachmentsexperience of security in attachments

Communication Analysis is a Communication Analysis is a therapeutic opportunity to:therapeutic opportunity to:

alter the internal working model alter the internal working model in the nomenclature of attachment theory, in the nomenclature of attachment theory,

alter transactional impactsalter transactional impactsin the nomenclature of contemporary interpersonal theoryin the nomenclature of contemporary interpersonal theory

Reflecting on a time when distress is high (attachment behaviors activated) we retrospectively examine an interpersonal interaction (expectations, perceived support, communication of needs and emotions and the reciprocal interpersonal impacts), planning future interactions in which the patient might have a different, more effective experience of both seeking and receiving social support.

How does IPT work?How does IPT work?

Patients at CAMH IPT ClinicPatients at CAMH IPT Clinic

N=145 (103 female, 42 male; age 38.5) with N=145 (103 female, 42 male; age 38.5) with diagnosis of diagnosis of unipolarunipolar, non, non--psychotic major psychotic major depression (depression (DSMDSM--IVIV--RR; American Psychiatric ; American Psychiatric Association, 2000) Association, 2000) –– naturalistic setting and 40% naturalistic setting and 40% of patients had of patients had comorbiditycomorbidity ((dysthymiadysthymia, , substance, eating & anxiety disorders)substance, eating & anxiety disorders)

Exclusion criteria: bipolar disorder, post Exclusion criteria: bipolar disorder, post traumatic stress disorder, borderline or antisocial traumatic stress disorder, borderline or antisocial personality disorder, organic brain syndrome, personality disorder, organic brain syndrome, psychotic symptoms and acute suicidality. psychotic symptoms and acute suicidality.

InterventionIntervention

16 weeks of IPT16 weeks of IPTPrePre--post measures of: post measures of:

depression (depression (SCID; HRSD, Hamilton, 1960, 1967; BDISCID; HRSD, Hamilton, 1960, 1967; BDI--II, II,

Beck, Steer, & Brown 1996)Beck, Steer, & Brown 1996)

attachment insecurity attachment insecurity (ECR(ECR--R, Fraley, Waller, & R, Fraley, Waller, & Brennan, 2002) Brennan, 2002)

interpersonal problems interpersonal problems (IIP(IIP--64, 64, Horowitz et al., 1988)Horowitz et al., 1988)

OutcomeOutcomeDepressed adults treated with IPTDepressed adults treated with IPT

Full remission: Full remission: 71 (49.0 % of treatment completers) 71 (49.0 % of treatment completers)

Partial remission (>50% reduction in symptoms): Partial remission (>50% reduction in symptoms): 52 (35.9 % of treatment completers). 52 (35.9 % of treatment completers).

Thus, 84.9 % of patients who completed Thus, 84.9 % of patients who completed treatment experienced full or partial remission of treatment experienced full or partial remission of depressive symptoms (67.2 % of all patients depressive symptoms (67.2 % of all patients who qualified for treatment) who qualified for treatment)

Pre-treatment Interpersonal problems: Southern hemisphere of the circumplex social inhibition, nonassertiveness, overly accommodating and self-sacrificing

Severity of Interpersonal Problems Severity of Interpersonal Problems in Depressed Adultsin Depressed Adults

Changes in attachment scores & Changes in attachment scores & interpersonal problemsinterpersonal problems

Grouped by treatment response, improvements in interpersonal problems across the full range of the interpersonal circumplex were limited to patients with a partial or full treatment response.

Attachment anxiety and attachment avoidance were significantly reduced only in patients with a full treatment response.

IPT does lead to IPT does lead to ↓↓IPIP problemsproblems

While this finding is consistent with IPTWhile this finding is consistent with IPT’’s goals s goals of improving depression by addressing of improving depression by addressing interpersonal problems, the causal direction of interpersonal problems, the causal direction of this association remains untested. this association remains untested.

due to depression remitting? due to depression remitting? or due to specific IPT effects?or due to specific IPT effects?RCT of CBT v. IPT in progress (McBride) to test this. RCT of CBT v. IPT in progress (McBride) to test this.

Back to the question:Back to the question:How does IPT work?How does IPT work?

In practice the tasks of IPT may act to increase In practice the tasks of IPT may act to increase the experience of security in relationshipsthe experience of security in relationships

In specific, IPT aims to help patients In specific, IPT aims to help patients communicate their needs and emotions more communicate their needs and emotions more effectively effectively →→→→ positive experience of current positive experience of current needs being met, of interpersonal mastery and needs being met, of interpersonal mastery and experiential disconfirmation of negative experiential disconfirmation of negative expectancies of others expectancies of others

How does IPT work?How does IPT work?

IPT also enhances adaptive discriminationIPT also enhances adaptive discrimination——for for example, learning through experience that what example, learning through experience that what was true was true ‘‘then and therethen and there’’ in earlier relationships, in earlier relationships, is not necessarily so is not necessarily so ‘‘here and nowhere and now‘‘ in current in current relationships. relationships. If such learning does not change the internal If such learning does not change the internal working model, it may at least interfere with the working model, it may at least interfere with the vicious cycle of interpersonal alienation in a vicious cycle of interpersonal alienation in a manner which allows less frequent manifestation manner which allows less frequent manifestation of maladaptive interpersonal behavior. of maladaptive interpersonal behavior.

Mr. XYMr. XY

depression fully remitted & improved GAFdepression fully remitted & improved GAFfearfully attached at start of treatment, with fearfully attached at start of treatment, with no expectations of help from others; poor no expectations of help from others; poor narrative coherence; highly avoidant and narrative coherence; highly avoidant and highly anxioushighly anxiousAt end of treatment, improved narrative At end of treatment, improved narrative coherence & less avoidant; Experiential coherence & less avoidant; Experiential disconfirmation of belief that othersdisconfirmation of belief that others’’ will be will be consistently unhelpful or harmful; remains consistently unhelpful or harmful; remains moderately anxiousmoderately anxious

IPT: why, who, what?IPT:IPT: why, who, what?why, who, what?Helpful, empirically supported & efficient Helpful, empirically supported & efficient Addresses universal and common Addresses universal and common difficult relational experiencesdifficult relational experiencesFocus on relationships & Focus on relationships & communication with pragmatic focus communication with pragmatic focus specific therapeutic guidelines specific therapeutic guidelines

IPT IPT

Attend to links between symptoms with relational Attend to links between symptoms with relational experiences & interpersonal problemsexperiences & interpersonal problemsAttend to details of communication, rather than (Attend to details of communication, rather than (oror in in addition to) cognition, including expression of expectations addition to) cognition, including expression of expectations and feelings in relationships and feelings in relationships (communication analyses)(communication analyses)Emphasize present more than past relationshipsEmphasize present more than past relationshipsFormulate using attachment and the bioFormulate using attachment and the bio--psychopsycho--social social model focusing on the social context and the impact of model focusing on the social context and the impact of illness on relationships illness on relationships Focus on interpersonal experiences in pursuit of health Focus on interpersonal experiences in pursuit of health

IPT: how?IPT: how?

Works as a result of:Works as a result of:altering the internal working modelaltering the internal working model

improving repertoire of improving repertoire of ‘‘antianti--depressantdepressant’’interpersonal behaviours, of which interpersonal behaviours, of which effective communication is effective communication is representativerepresentative……helping the patient move helping the patient move toward greater affiliation and agencytoward greater affiliation and agency

The practice of psychotherapy The practice of psychotherapy ““requires all the requires all the intuition, imagination and empathy of which intuition, imagination and empathy of which we are capable. But it also requires a firm we are capable. But it also requires a firm grasp of what the patientgrasp of what the patient’’s problems are and s problems are and what we are trying to dowhat we are trying to do”” BowlbyBowlby

Ending this workshop and Ending this workshop and beginning to apply IPTbeginning to apply IPT……

What we call the beginning is often the What we call the beginning is often the end. And to make an end is to make a end. And to make an end is to make a beginning. The end is where we start beginning. The end is where we start from.from.

T.S. Elliot (on the inside flap of T.S. Elliot (on the inside flap of WinnicottWinnicott’’ss unfinished autobiographyunfinished autobiography))

For further learning, training, or For further learning, training, or supervisionsupervision……

Numerous workshops are available: Numerous workshops are available: Oakville @ end of March; CAMH early Oakville @ end of March; CAMH early August; supervision is available through August; supervision is available through the MSPI or by contacting individual IPT the MSPI or by contacting individual IPT trainerstrainersMufson et al; Stuart & Robertson; Mufson et al; Stuart & Robertson; Weissman, Markowitz & Klerman; plus Weissman, Markowitz & Klerman; plus texts related to patient specific populationstexts related to patient specific populations

Thank you for your Thank you for your attention!attention!

Paula.Ravitz@utoronto.caPaula.Ravitz@utoronto.caMichael PareMichael Pare