Interpersonal Psychotherapy for Patients with Mental Disorders

OUTLINE Introduction Evolution of concept Principles of interpersonal psychotherapy (IPT) Assessment and Structure of IPT Steps in IPT IPT in Depression Interpersonal problem areas and relevant strategies Grief Role disputes Role transition Interpersonal (IP) deficits. Common IPT techniques Adaptations for depression in special populations Adaptations for other mood disorders Adaptations for non mood disorders INTRODUCTION Interpersonal psychotherapy (IPT) is a time-limited and diagnosis-targeted intervention It follows a strict time-limited format IPT has been successfully adapted for various other psychiatric disorders IPT follows a simple paradigm by assigning the patients a sick role by defining their problems as treatable medical conditions and linking their state of affective distress to their IP situations IPT focuses on the “here and now” of the illness by resolving issues related to IP problem areas[1] IPT has nonspecific and specific elements: Nonspecific elements include nonjudgmental approach, empathic listening, maintaining confidentiality, expressing warmth, and engaging the patient in the therapy Specific elements include providing patients a sick role, applying an IP inventory, and making a formulation that links the patients’ IP problem areas with their psychiatric diagnosis. IPT follows a holistic approach, and it is recommended to use IPT in an integrated manner The underlying assumption is that IP relationships of a person either in the past or in the present, play a role in the origin and maintenance of psychopathology. Hence, IPT mainly focuses on IP context and related factors. The goal is to either help patients improve their IP relationships or change their expectations about them and focusing on improvements in their social support networks The specific elements of IPT constitute its basic core, but can be adapted in various ways. IPT can be planned as a short-term, time-limited therapy, maintenance therapy, or long-term, insight-oriented treatment IPT can be adapted for different age groups including adolescents and elderly, and can also be adapted depending on the target diagnosis There can be adaptations in the format of IPT for individuals or groups or couples IPT can be adapted for any psychiatric disorder where IP problems exist[2] Insight-oriented IPT, on the other hand, emphasizes that the therapist cannot be a neutral observer, but is rather a participant. The task for the therapist is to understand his own reactions toward the patients and reflect them therapeutically, by uncovering, resolving, and termination.[2] EVOLUTION OF CONCEPT The principles in the IPT are broadly based on the following models: Biopsychosocial model Some concepts of IPT are based on the Adolf Meyer's school of psychobiology, which sees psychiatric disorders as a consequence of an individual's attempts to adapt to psychosocial environment. The model further emphasizes that a person's current state of psychological functioning is a complex interplay of biological correlates, physiological factors, social relationships, and various psychological correlates such as one's temperament and attachment pattern[3] Thus, IPT is based on the biopsychosocial model of psychological functioning as it views the psychiatric symptoms in a broader aspect IPT emphasizes on the attachment bonds and effective communication as important predictors of good psychological functioning IPT builds on the principle that intimacy is protective against the development of depression, especially when facing stressful life events, which frequently precede depression The biopsychosocial model also stresses upon the patient actively taking the responsibility of making changes in IP relationships and his/her social environment rather than waiting for changes to happen on his/her own. Harry Stack Sullivan's theory of interpersonal relationship and parataxic distortion Harry Stack Sullivan's theory of IP relationship emphasizes on the role of social, cultural, and familial factors in the genesis of psychiatric illnesses[34] Sullivan stressed on that maladaptive behaviors emerge as a result of one's attempt to deal with the social environment He described parataxic distortion as a phenomenon in which the characteristics of previous relationships are imposed upon new ones, which results in distortions in the current relationships. John Bowlby's working model of relationships John Bowlby further built on the concept that the previous relationships an individual has had (whether healthy or otherwise), determine the ways in which he/she behaves in a new relationship.[4] PRINCIPLES OF INTERPERSONAL PSYCHOTHERAPY IPT focuses on identifying relationship between environmental triggers related to IP problem areas and clinical symptom onset or the phenotype of the disease The work of the therapist revolves around helping patients identify these stressors or IP problem areas and relate them to the symptoms or distress. The therapist also encourages patients to find out ways to ameliorate the situation. The interactions are depicted in Box 1. Box 1: Stress diathesis modelFor depression, IPT builds on the following two important principles: Depression does not occur due to an individual's fault and it can affect anyone. It is a medical illness which is treatable. Assigning a sick role to the patient helps in defining the problem and also excuses the patient from blaming himself/herself for the illness The second principle emphasizes that the affective distress and life situations are interrelated. The disturbing life events can either precipitate the symptoms of depression or other mood disorders or can follow the onset of symptoms.[5] Thus, a disturbance in the environment due to unavoidable stressors leads to changes in IP environment, which eventually leads to the symptoms of depression. When depression sets in, the IP functioning of the patient gets further compromised. It may seem very obvious to an observer that the symptoms have set in due to these triggers, but depressed individuals often tend to blame themselves for these events. The task of the therapist is to help the patient resolve these problems and develop his/her social support system.[6] Structure of interpersonal psychotherapy IPT is conducted over 12–20 sessions extending over a period of 4–5 months. In the acute phase, it includes three phases as shown in Box 2 After these three phases are over, a continuation/maintenance phase can be initiated for which a spate contract is made with the patient. An initial assessment for the suitability of IPT is carried out before the initial phase. Box 2: Three phases of interpersonal psychotherapyAssessment for the suitability of IPT The therapist must assess whether the patient is a suitable candidate for IPT prior to initiating the therapy. This phase is carried out for any psychological intervention that a therapist plans to initiate [Box 3]. Patients’ ego strengths and motivation for change are assessed. Certain factors tend to increase the probability that a patient would benefit from the therapy. These include presence of good social support network, presence of an IP focus of distress, ability to relate a coherent narrative of IP network and specific IP interactions, and a secure attachment style. At the end of this phase, a contract is made with the patient regarding the number of sessions that will be carried out and that collectively the therapist will work along with the patient in one or more areas of IP distress.Box 3: Assessing suitability of interpersonal therapyInitial phase As the sessions begin, the therapist focuses on developing a good therapeutic alliance with the patient. The therapist carefully listens to the patient's complaints, carries out a detailed interview, obtains information about the history of presenting complaints, and identifies the diagnosis and the IP context in which the symptoms have occurred. The following steps are followed. Assessing the symptoms A formal diagnosis can be made using the International Classification of Diseases (ICD) 11 or Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). The severity can be assessed using severity-measuring scales for depression, for example, Hamilton Depression Rating Scale (Ham-D). Patients are explained what the scores on these scales mean and that the scales would be repeated during the course of therapy. Making the diagnosis Once the diagnosis is made, its prevalence and presenting features can be discussed with the patient. The therapist also discusses about the expectations from the therapy. Once a diagnosis is assigned to the patient, it works in a dual manner. First, it instills hope that the patient has a medical condition which is identifiable and treatable. Second, it identifies the patient as a person who is in need of help. It is emphasized that the patients’ full focus should be on recovery. Assigning a sick role Providing a diagnosis gives the patient a “sick role,” which would simply mean that the disturbances in patient's functioning have occurred due to his/her current status and the illness has prevented him/her from performing adequately. It is stressed upon that the symptoms have not occurred due to the patient's own faults. The therapist also discusses with the patient that addressing the current problems in IP functioning will improve his/her psychiatric condition. Setting a time limit IPT is strictly a time-limited therapy. Following a strict time limit and initially deciding about a fixed end point helps in keeping the patient motivated to make changes. Prolonged sessions tend to shift the focus from the current IP issues to more intrapsychic conflict exploration, which is not the goal of IPT. Having a time limit and gradual tapering of sessions seems to be better than abrupt discontinuation at the end of 12–20 sessions. The therapist may predecide the number of times a week and number of weeks required for therapy. Reviewing the need for medications Evidence suggests that IPT alone can help patients recover from depression, but depending on the severity of symptoms, medications can be initiated. If required, the patient can be referred to the treating psychiatrist for initiating the treatment if the therapist is not a medical professional (clinical psychologist).[7] Exploring the interpersonal milieu Moving ahead in the initial phase, the therapist explores about the patient's close relationships and social functioning both in the present and in the past. Details of major life events in patient's life, associated changes in mood, changes in IP relations, and their relation to psychiatric symptoms are explored. All these information are obtained in a structured manner with the help of an IP inventory. The inventory helps in reviewing patient's significant relationships, nature of social relationships, and IP functioning. Identifying the focus IP problem areas are identified. Four IP problem areas have been mentioned as shown below. In IPT, one needs to identify the main problem area. Grief defined as loss of relationships or loss of healthy self IP role disputes with significant others such as friends, parents, and siblings IP role transitions including difficulties in adjusting to life changes, which is undesired, unexpected, or for which the patient is not psychologically and emotionally ready IP skill deficits such as maintaining relationships and communicating about feelings. Interpersonal formulation The therapist then prepares an IP formulation linking the target diagnosis to IP focus. It may be possible that more than one problem areas are identified. However, the focus should be on one area at a time or not more than two problem areas. If two problem areas are identified, the one which seems to be more responsive to treatment is dealt with initially. This helps in increasing the patient's competence, helping in recovery. Once the formulation has been prepared, the goals of the therapy and strategies to obtain those goals are discussed with the patient. This helps in formulating a treatment plan, and the strategies can always be referred to while one progresses in the therapy. The initial session usually extends for the first five sessions. Defining treatment goals The problem area that will be focused in the current therapy should be discussed with the patient. If there are more than one areas of focus, the one which seems to be more distressing for the patient is addressed initially. Treatment goals need to be decided and discussed with the patient. Practical issues about confidentiality or handling issues of missed appointments should also be discussed. The above steps can be summarized in a flowchart as shown in Box 4.Box 4: Steps in performing the initial phase of interpersonal therapyMiddle phase In the intermediate phase, sessions are focused upon addressing one or more of the four problem areas using IPT techniques. After the identification of specific problem areas in the initial phase, the therapist tries to obtain more information about these specific problem areas. The therapist and the patient then work together to develop solutions for these problems. Solutions may focus upon various domains of an individual's life such as modifying expectations of the patient, improving their communication skills, or developing social support. A suitable solution is selected, and the patient tries to apply it between the sessions. Throughout the sessions, the therapist keeps the patient focused on the specific problem area. Patients are psychoeducated about their illness and symptoms Every IP session is important in the therapy. The content and emotional tone, how did the patient feel, what did he/she say, and what was his/her tone, are important for the therapist If the patient performed well, the therapist congratulates him/her to reinforce the skills If things did not work well, factors responsible need to be explored Therapeutic alliance needs to be maintained throughout At the end of every session, the gains achieved and summary of sessions need to be highlighted After every session, severity rating scales need to be applied to monitor the progress The key IPT techniques targeting the four IP problem areas have been discussed later individually. Termination phase (credit or blame?) The last few sessions are focused on preparing the patient for termination of the therapy. If the problems have been addressed, the patient needs to be given credit for the success achieved. If the sessions did not turn out to be as successful as planned, blame the treatment. This helps by minimizing the self-blame by the patient. Alternative treatment options such as continuation to the maintenance phase and adding or changing medications are discussed with the patient. Conducting interpersonal therapy in depression The relationship between depression and IP problems can be bidirectional. The disorder can arise in the context of IP problems and depression may also interfere with one's IP functioning. Whatever is the cause and irrespective of what appeared first in the time line, IPT focuses on linking mood to the IP state. The therapist considers that depression has the following three aspects: The first are the symptoms which include low mood, anhedonia, easy fatigability, poor attention and concentration, eating and sleeping disturbances, and negative thinking The second aspect is the patient's social and IP context. IP problems can precede or follow depressive symptoms. In addition, the strong social support is protective and social stressors increase the vulnerability for depressive episode The third aspect is the personality characteristics of the patient. This can either predispose or maintain depression. An enduring pattern of avoiding confrontation, risks, expression, and being dependent may all lead to the occurrence of depressive episode. Irrespective of what contributes to depression, IPT focuses on dealing with the current IP issues and helps the patient to develop self-reliance to deal with these situations outside the therapy. For psychiatric disorders such as depression, the disturbances in these IP areas result in symptoms. The situations that lead to these IP dysfunctions are the areas of focus in IPT. These include: Grief IP role disputes IP role transitions IP deficits. The goals of IPT in depression include: Decreasing the depressive symptoms Helping the patient deal with the IP problems that led to depression in a better manner. The therapist begins by asking questions which can help in understanding about patient's symptoms, such as asking patients: What brings you here? How the symptoms started appearing? Are there any stressors? How the patient is currently dealing with the stressor? What happened before the onset of symptoms? Does the patient feel that something specific happened which triggered the symptoms such as death in the family? Detailed psychiatric assessment needs to be conducted to confirm the diagnosis. Once the diagnosis of depression is made, the task in the initial sessions is to assess the severity of symptoms using rating scales such as HAM-D or Beck Depression Inventory. Patients should be psychoeducated about depression. One example is as follows: “Depression is a common mental disorder and is treatable. We can understand your distress, but complaints of decreased confidence and poor attention concentration are the common symptoms of the illness and will resolve as you begin to recover from the illness. This can happen to anyone and with adequate treatment you will recover. The duration may however vary, as some patients respond early and some may take time to get relief from their symptoms.” Once a sick role has been assigned to the patient, a time limit is decided. The need for starting medications is reviewed. An IP inventory is applied as described previously and the therapist tries to identify the IP problem areas. The therapist then prepares an IP formulation linking the target diagnosis to IP focus Key steps of IPT in depression are outlined in Box 5.Box 5: Key steps of performing interpersonal therapy in depressionMajor depressive disorder: Key steps are as follows: Establishing the diagnosis Identifying the focus areas (grief/IP role disputes, IP role transition, and IP deficits) Setting the goals (decreasing symptoms of depression and improving the coping skills) Assigning the sick role Defining the time limit Applying different types of IPT techniques targeting different focus areas Terminating therapy (consolidating gains and looking for options to deal with failure, such as continuation and addition of pharmacotherapy). In the subsequent section, we will discuss each of the four IP problem areas and ways to proceed in therapy including the IPT techniques. FOUR INTERPERSONAL PROBLEM AREAS AND WAYS TO PROCEED IN THERAPY INCLUDING THE IPT TECHNIQUES Interpersonal psychotherapy techniques Grief Grief is selected as a focus, when patients report depressive symptoms following the death of someone significant in their life. The presence of some depressive symptoms following the death is expected and the symptoms resolve as the person starts accepting the death. The low mood, decreased interest in activities, disturbed sleep, and appetite can be a part of normal mourning. However, in some people, the diagnostic threshold for depression is met as they begin to experience significant depressive symptoms leading to socio-occupational dysfunction. In these cases, IPT can be initiated. If the patient approaches due to his/her distress, but still does not meet the diagnostic threshold for depression, IPT can be initiated. Goals in dealing with grief The therapy begins with the initial sessions comprising of assigning a sick role to Mr. A as explained previously. The IP inventory would provide information about the IP context. It will provide information of the current relationships Mr. A has irrespective of it being problematic or supportive. Subsequently, the IPT therapist prepares an IP formulation. Facilitating mourning and coming to terms with the loss One of the goals in IPT for the management of grief would be catharsis. The therapist encourages the patient to talk about the loss, what they miss the most about the person. Patients are encouraged to describe their relationships, about the sequence of events that occurred prior to the loss, during and after the loss. Patients also tell about all that they experienced since the loss of their loved one. The therapist helps the patient describe all their memories associated with their loved one whom they lost To connect with the existing relationships and re-establish the lost interests The other goal of IPT in grief management is to help the patient figure out relations which can act as a substitute for the lost person and lost relationship. One way is to encourage patient to involve others in the process of remembering their lost one. Strategies in dealing with grief The strategies includeassessing the psychopathology if any, and help patient relate his/her symptoms with the death of the significant person. The therapist educates the patient about grief and depression, helping the patient to express his/her feelings and helping in finding new pleasurable activities and relationships to substitute the loss. Catharsis The strategy that the therapist uses is to encourage patients to talk about their feelings. It is stressed that the expression of feelings does not make a person weak. Some people even fear that once they start expressing their feelings, they may become overwhelmed. Patients are encouraged to focus on the positive and negative aspects of the relationship with the loved one. Reestablishing the support networks Death of a loved one often leaves a void in the patient's life, and it is important that this gap is filled up. Once the therapist has explored about the support system of the patient, important relationships in their life can be reestablished. Patients can be encouraged to connect with important people in their life and share their feelings. The therapist must also encourage patients to engage in activities which they enjoyed before the death. This may be difficult for the patient, but still efforts must be made to engage in relationships. Sometimes, patients may completely withdraw themselves from their social life and so, they must be told that they can just go out with a friend to see how things work. Following this, it must be inquired about what the patient enjoyed, which parts he/she did not, and will he/she be interested in repeating the activity again. As the sessions proceed, the therapist shifts the discussion from being more about the deceased to more about the issues coming up in the new efforts patient is making in reestablishing his/her support system. The end of the therapy includes termination sessions, focusing on consolidating the gains that occurred in the therapy and preparing patient to work outside the therapy in real-life situations. Interpersonal role disputes For a healthy relationship, it is very important that both individuals have a sense of harmony, regard for each other's expectations, and have willingness to compromise for each other. Two people in a relationship may have different aspirations and perspectives, but when their expectations from each other become contrasting or different, it can result in strained relationship. If they do not understand the needs and expectations of each other, it is very likely that disputes will result. If the patient presents with such complaints, the focus of the IPT will be directed toward resolving the role disputes. Often, role transitions may lead to role disputes or the opposite situation. Like shifting to a new job or to a new place may change the expectations, two people in a relationship may have from each other. It can happen the other way around, where differing expectations can interfere with smooth transitions in the role changes one is expected to go through. In either of the circumstances, depression may result from these situations or depression may interfere with the successful handling of these transitions. It is important for the therapist to identify these situations and identify whether role transition or role dispute is the important contributing factor in the initiation or maintenance of depression, and that particular area should be selected as the focus of the therapy. Goals in the treatment of role disputes After going through a long-standing role dispute, the patient starts believing that there is no way out and there is no benefit of initiating any therapy. Often, patients find themselves as the main reason behind the dispute and place the partner at a superior position. Goals of the therapy include helping the patient find the dispute, identify it, and look for options to deal with it. The therapist helps to work out a plan of action. Even if the issues may not resolve completely, therapy will help the patient modify his/her expectations or in those cases where even this is not possible, therapy helps the patient in better communication with the partner about his/her expectations and feelings. Recognizing the dispute After going through the patient's history of presenting illness, the therapist needs to identify the area of dispute. Even though the patient reports that there is no possible solution, it needs to be reemphasized that no matter what the dispute is, some solution is always possible Finding options to decide an action plan After having an agreement with the patient about the dispute area that will be targeted during the therapy, the therapist needs to explore various ways in which the relationship can be renegotiated. If this process is successful, the patient learns to be more assertive and expresses his/her feelings in a more positive and less demeaning way. In cases when the renegotiation does not turn out to be successful, the patients at least learn to communicate their feelings more adequately Rectifying faulty expectations and facilitating better communication to resolve issues The cause of many disputes is the contradictory expectations which two people in a relationship have from each other. The goal of the therapy is to identify these faulty expectations and modify them in a better manner. It is better if the partner is also involved in the therapy, but it may not be possible in all cases when the therapist continues sessions with the patient. Strategies in dealing with role dispute The following steps are undertaken for dealing with role dispute in IPT: Assessing the depressive symptoms The key to initiating any session is detailed exploration of the symptoms with which the patient has presented to us. This will be done in the initial sessions of IPT as described previously. The IP inventory also provides information about the IP issues. Once the depressive symptoms have been assessed, the next step is to draw relations between these symptoms and evident or covert dispute. The IP formulation caters to this. Identifying the stage of the dispute Once the depressive symptoms have been assessed and their relation with the dispute has been drawn, the therapist tries to identify the stage at which the dispute currently is. RenegotiationOften, patients may be aware of the differences in expectations but lack skills to express themselves. They consider their expectations as less important than the other person with whom the dispute is present. The communication between the two people has not stopped. The therapist helps the patient learn that even their expectations are genuine and they need to express it to the other person.ImpasseIn this stage, the relations have reached a point when conversation between the two people has stopped. There are no more discussions and the patient feels that renegotiation is no more an option. Patients feel hopeless about any positive progress in the relationship. At such a stage, discussion can be brought forward clearly in the open.DissolutionThis stage is reached when either one or both the patient and partner are looking out ways and struggling to bring an end to the relation. This is usually not the first stage, but often, patients may report that they do not see a future ahead with their partner and are actively looking out ways to terminate the relationship. At this stage, dissolution is advisable. It must be kept in mind that dissolution may lead to interference in role transition. Strategies that are used in dealing with role dispute are as follows: Exploring the patients’ feelings Validating these feelings Finding out options and deciding out a plan of action depending on the stage of the dispute Role play. Once the therapist is aware of the patient's feeling with the IP encounter he/she have, the therapist tries to validate these feelings by considering them genuine and reasonable. If the patient's dispute is at the stage of renegotiation, the patient is encouraged to express about the differences in expectations and communicate his/her objection to the demands made by the other person. The patient may speak about alternative steps, and the therapist must also help the patient understand the consequences of his/her actions. If the stage of impasse has been reached, the therapist encourages the patient to directly ask for the other person's expectations. The disharmony may initially increase, but this opens a conversation between them which had stopped, and it helps the therapist understand the contradictory expectations better. Sometimes, it is better to go for dissolution of the relationship. This is facilitated by the therapist when he/she realizes that the relationship has become strained and both the partners are aspiring to get out of it. This stage should be reserved for the point when all attempts to reestablish the relationship have been ex