Interpersonal psychotherapy has been defined as a time-limited, dynamically-informed psychotherapy which aims to alleviate clients’ suffering while improving their interpersonal functioning. It is concerned with the interpersonal context: the relational factors that predispose, precipitate, and perpetuate the client’s distress. It is widely, but not exclusively, used to treat mood disorders. Rather than examine internal cognitions, as the other empirically-based intervention for mood disorders – Cognitive-Behavioural Therapy – does, IPT focuses specifically on interpersonal relationships, with the goal of assisting clients to either improve their relationships or else change their expectations about them. Moreover, IPT helps clients to build up their social supports so that they can manage themselves better through times of interpersonal distress (Stuart, 2006; Robertson, Rushton, & Wurm, 2008).

The evolutionary path: From control intervention to therapy in its own right

Most psychotherapies begin with a theory and grow in prominence and popularity as the theory attracts followers and begins to show results. IPT developed in the opposite direction, appearing on the scene first as a control treatment for studies examining the efficacy of antidepressant medications. Thus until recently nearly all practitioners of IPT were researchers (Markowitz & Weissman, 2004)! But let us take it from the beginning.

Psychopharmacological research circa 1970

From the early 1970s, American psychiatry became interested in evidence-based medicine, coming to worship at the feet of the RCT (randomised, controlled trial). Researchers and clinicians had observed that most genres of psychotherapy seemed to work (eventually) with depression; the field was simultaneously experiencing the advent of tricyclic antidepressant medications. Thus it was deemed necessary to test the efficacy of these medications against established psychological therapies (Robertson et al, 2008).

Factoring in another reality, researchers knew that many clients treated with the then-available antidepressants relapsed after the medication was withdrawn, but what was not clear was how long the psychopharmacologic treatment should continue in order to avoid relapse. Beyond that, although psychodynamic psychotherapy was generally prescribed for both acute and maintenance phases of depression, there was little data to demonstrate its efficacy in general; there was even less evidence addressing the role of psychotherapy in preventing relapse.

At this time behavioural treatments comprised the chief psychotherapy studies. Several large-scale psychodynamic studies had been published, but unfortunately they failed to meet then-current diagnostic criteria for depression; they also did not have standardised outcome measures. Moreover, they were limited in scope and sample size. The movement to generate standardised, manualised psychotherapeutic treatments gathered momentum; researchers and clinicians both desired treatments for depression which could be tested and reliably replicated, such as Beck’s CBT (International Society for Interpersonal Psychotherapy [isIPT], 2014).

The need for standardised, manualised, shorter psychotherapy

There was a problem, though. Sixteen weeks seemed about right to test whether the antidepressant was having an effect, but the typical psychodynamic psychotherapy that would be prescribed along with it would only be starting to gain traction during that time. Thus, with the goal of standardising what seemed to make up the components of good psychotherapy, Gerald Klerman, Myrna Weissman, and colleagues of Yale University came up with a briefer treatment which integrated what was believed to be the essence of medical psychotherapy. From these elements, they constructed a treatment program that would fit nicely within the confines of a treatment trial.

With the additional observation that depression invariably affected not only the mood of the client, but also his or her communication and through that, relationships in social and work spheres – the marital, family, friend, work-based, and community interactions – it became clear that interpersonal relationships should be the focus of the new therapy. Thus IPT was born: a therapy based upon academic rather than clinical considerations (Robertson et al, 2008).

IPT debuted in a large, multi-site study of medication and psychotherapy for the treatment of depression in mixed-age adults. The study, the United States National Institute of Mental Health (NIMH) Collaborative Research Program, was a seminal investigation because of its varied study sites, randomised-controlled clinical design, and large sample size (Elkin, Shea, Watkins et al, 1989). Researchers’ interest in IPT was piqued with the demonstrated efficacy of IPT in such an important study (Hinrichsen, 2008). The IPT treatment manual, Interpersonal Psychotherapy of Depression (Klerman, Weissman, Rounsaville, & Chevron, 1984) became the “bible” and chief training resource for IPT researchers and clinicians. In 1993, New Applications of Interpersonal Psychotherapy (Klerman & Weissman, 1993) was published. It described then-current research developments and pointed to new uses for IPT.

The 1990’s were about expansion beyond IPT’s original focus on acute treatment of depression for younger and middle-aged adults to different age groups, presenting issues, formats, and specific clinical applications. In 2007 the “must-have” IPT book list expanded to include the Clinician’s Quick Guide to Interpersonal Psychotherapy; it is a concise statement of how to conduct IPT and supporting research (Weissman et al, 2007). The reader may also note in the research section that the study sites are no longer merely US- or British-based, with studies coming to being conducted in South Africa, Europe, New Zealand, and of course Australia. There is now an International Society for Interpersonal Psychotherapy (Hinrichsen, 2008).

The supporting theories

That IPT is not developed in the traditional manner of theory leading to practice does not mean that it does not have solid theoretical foundations. Specifically, IPT is supported by three theoretical pillars: attachment theory, communication theory, and social theory. The most important of the three is probably attachment theory.

Attachment theory

Proposed by John Bowlby, attachment theory describes the manner in which individuals form, maintain, and end relationships. Human beings, said Bowlby, have an innate tendency to seek attachments; the quest for them contributes not only to individual satisfaction, but to the survival of the species. Attachment forms the basis for the life-long patterns of interpersonal behaviour which lead an individual to seek care and reassurance in a particular way. Attachments lead to reciprocal, personal, social bonds with significant others, and because they generate experiences of warmth, nurturance, and protection, they also decrease the need for vigilance and rigid muscle tone (indicating hyper-alertness for defence).

Recognising the intense human emotions generated by attachments, Bowlby noted that the desire to be loved and cared for is integral to human nature. This, he claimed, is true not only throughout adult life, but much earlier as well. The expression of such desires is, in fact, so central to human growth, development, and happiness that attachment behaviours are to be expected in every adult, especially in times of sickness or calamity. Human beings of all ages are most happy, effective, and competent when they have the confidence that one or more trusted persons in their lives will be available for help in times of trouble.

Understandably, proponents of attachment theory recognise an individual’s vulnerability to depression if: (a) attachments do not develop early in life and/or (b) attachment bonds are disrupted, say through death, divorce, or abandonment. The distress associated with disruptions in attachments may be due to problems within the specific relationship, but is also heightened when an individual’s social support network is not able to sustain him or her during the loss, conflict, or transition. Insecurely attached individuals are more likely to become distressed than securely attached people during interpersonal conflicts, after the loss of a relationship, or following role transitions, both because they are less secure in their primary attachments and because they have poor social support networks.

These problem areas for interpersonal relating – interpersonal disputes, grief/loss, and role transitions, along with the ongoing issue of what is called “interpersonal sensitivity” (a general deficit in interpersonal skills) – form the basis for determining the direction of the work in interpersonal therapy (Encyclopedia of Mental Disorders, 2014; Stuart, 2006; Linton, n.d.). IPT’s second pillar, communication theory, is about how individuals express their attachment needs.

Communication theory

While some psychotherapies may try to change an insecurely attached individual’s basic attachment style, IPT works with that as a given. IPT focuses, rather, on the ways the client communicates attachment needs, and on how the person can build a more supportive social support network. Comparing these two foundational pillars of IPT, we could say that attachment theory is linked to the broad, or macro-context of a person. Communication theory, in its quest to describe how individuals communicate their attachment needs to significant others, informs individual relationships on a micro-level. “Attachment,” notes Stuart, “is the template on which specific communication occurs” (Stuart, 2006, p 544).

Like attachment theory, however, communication theory deals in aspects of interpersonal relationships that are below the level of conscious awareness, and thus sometimes difficult to identify. Kiesler explains that IPT clients often elicit negative or unsupportive responses from others unintentionally. This occurs because those who have maladaptive attachment styles engage in specific communications which bring forth responses that do not meet their attachment needs effectively. When the poorly-attached person then reacts to the non-need-meeting response, it often escalates tensions, deepening the cycle and preventing those needs ever being met (Kiesler, 1979).

Social theory

The final pillar of IPT’s support foundation focuses on the role that interpersonal factors have in creating maladaptive responses to life events which then generate depression and/or anxiety. Factors such as loss or disrupted or poor social support create the social milieu in which a person develops interpersonal relationships, which in turn strongly influences how a person copes with interpersonal stress. Social theory emphasises that it is the current environment which is crucial. Thus poor social support is seen to be causal in the generating of psychological distress (Stuart, 2006).

We can hold up the sharp contrast between this supporting social theory of IPT and psychoanalytic theory. The latter is based on two chief interrelated principles: psychic determinism – the theory that all mental processes are not spontaneous but are determined by unconscious or pre-existing mental complexes (Wikipedia, 2014) – and the notion that unconscious mental processes are a primary driver of conscious thoughts and behaviours. The social theory of IPT involves neither of these, maintaining as fundamental the notion that it is current interpersonal stressors, not psychic determinism or unconscious processes, which create psychological dysfunction (Stuart, 2006).

© 2015 Mental Health Academy

This article was adapted from the upcoming Mental Health Academy CPD course “Basics of Interpersonal Therapy”. Click here to learn more about MHA.

References

• Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., et al. (1989). National Institute of Mental Health treatment of depression collaborative research program: General effectiveness of treatments. Archives of General Psychiatry; 1989, 46: 971–982.
• Encyclopedia of Mental Disorders. (2014). Interpersonal therapy. Encyclopedia of Mental Disorders: Advameg., Inc. Retrieved on 18 November, 2014, from: hyperlink.
• Hinrichsen, G.A. (2008). Interpersonal psychotherapy for late-life depression: current status and new applications. Journal of Rational-Emotive Cognitive-Behavioral Therapy; 2008, 26: 263–275. DOI 10.1007/s10942-008-0086-5.
• International Society for Interpersonal Psychotherapy. (2014). About IPT. International Society for Interpersonal Psychotherapy. Retrieved on 13 November, 2014, from: hyperlink.
• Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal psychotherapy of depression. Northvale, NJ: Jason Aronson.
• Linton, J. (n.d.). Interpersonal therapy. Retrieved on 18 November, 2014, from: hyperlink.
• Markowitz, J.C. & Weissman, M.M. (2004). Interpersonal psychotherapy: Principles and applications. World Psychiatry; October 2004, 3(3): 136-139.
• Robertson, M., Rushton, P., & Wurm, C. (2008). Interpersonal psychotherapy: An overview. Psychotherapy in Australia; May, 2008, 14(3): 46-54.
• Stuart, S. (2006). Interpersonal psychotherapy: A guide to the basics. Psychiatric Annals; August, 2006, 36(8): 542-550.
• Weissman, M.M., Prusoff, B.A., Dimascio, A., Neu, C., Goklaney, M., & Klerman, G.L. (1979). The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. American Journal of Psychiatry; 1979, 136(4B): 555-558.
• Wikipedia. (2014). Psychic determinism. Wikipedia. Wikimedia Foundation, Inc. Retrieved on 19 November, 2014, from: hyperlink.