Eating Disorders

This chapter provides an overview of the use of IPT for patients with eating disorders. The most common eating disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder. The chapter discusses the adaptations of IPT that have been used for the treatment of eating disorders and evaluates their performance in research studies. The assumption for testing IPT with eating disorders is that they occur in response to distress at poor social and interpersonal functioning and consequent negative mood, to which the patient responds with maladaptive eating behaviors. For anorexia nervosa, few data provide evidence for the benefit of IPT. For bulimia and binge eating disorder, however, IPT is considered a viable option for treatment and is recommended in numerous guidelines. A case example of a woman with bulimia nervosa is provided.

Persistent Depressive Disorder/Dysthymia

This chapter describes the adaptation of IPT for the treatment of patients with persistent depressive disorder/dysthymia. The usual IPT model connects a recent event in the patient’s life with current mood and symptoms, but for patients who have been depressed for years, this model makes less sense. Instead, the IPT therapist makes the treatment itself a role transition from longstanding depression to euthymia in which patients learn to recognize depressive symptoms of long duration and how they have affected their social functioning. The therapist offers a formulation that shifts the blame for the patient’s situation from the patient to the illness. Treatment includes sixteen weekly sessions to drive these points home, although monthly continuation sessions and maintenance therapy are frequently offered so that patients’ new self-image and track record of healthy interpersonal functioning can sink in. A case example is given of a chronically depressed woman who improves with IPT.

Depression in Medical Patients

Depression treatment that is coordinated with care for comorbid chronic conditions improves control of both the depression and the chronic medical disease. Interpersonal counseling (IPC) and briefer forms of IPT for depression have been introduced in medical practice and primary care to accommodate providers’ time constraints and different levels of training of mental health care providers. IPC is best used with patients who have low levels of depressive symptoms, or distress, and where more highly trained therapists are not available but health personnel are interested in providing counseling. There is high interest in developing briefer approaches for depression treatment in medical patients, a wealth of evidence-based choices, and much work to be done. A case example is given of a college student with comorbid depression and diabetes.

Common Therapeutic Issues and Patient Questions

This chapter reviews common therapeutic issues and various questions asked by patients during IPT. Common therapeutic issues include deciding whether a patient’s main problem is a psychiatric illness or a personality disorder, dealing effectively with passive or intellectualizing patients, keeping to the agreed-on focus and time limit of treatment, and making therapeutic use of silence in session. Technical issues such as rating scales and recording sessions are discussed, and IPT was contrasted with other types of psychotherapy such as CBT. Common patient questions include how IPT works, therapist credentials, lateness to sessions, family members attending treatment sessions, the genetic and biological basis of depression, the use of alcohol and drugs, recurrence of depression, and suicide. Some problems that are more often seen in primary care settings are also covered, such as depression manifesting through physical symptoms and poor adherence to treatment.

Beginning IPT

This chapter describes the tasks of the first few IPT sessions. The therapist’s tasks in the opening sessions are to review the depressive symptoms and make a diagnosis; explain depression as a medical illness and describe treatment options; evaluate the need for medication; review the patient’s “interpersonal inventory”; present a formulation, linking the patient’s illness to an interpersonal focus; make a treatment contract based on the formulation, and explain what to expect in treatment; define the framework and structure of treatment; and give the patient the “sick role.” After this, the work of IPT begins on the defined problem area. In these sessions the therapist focuses consistently on mood and interpersonal interaction. The therapist helps the patient to see the link between them, reinforces adaptive interpersonal functioning, and helps the patient to explore and gain comfort with new options where old strategies have not been working.

Group, Conjoint, Telephone, and Internet Formats

IPT was developed as an individual, face-to-face psychotherapy, but its principles are flexible enough to work in other formats. This chapter describes adaptations of IPT to four other formats: group IPT, conjoint (couples) IPT, telephone IPT, and Internet (self-guided) IPT. The research that has been done to evaluate each of these formats with various populations and in various settings is described. For instance, group IPT reduces interpersonal isolation; allows patients to see that others share their illness, validating the IPT sick role; and allows therapists to treat larger numbers of patients. However, patients receive less individual attention, difficulties in assembling adequate numbers of patients to form a group may delay treatment, and patients may present with different focal interpersonal problem areas. Recommendations for therapists who choose to use these adaptations are offered.

Substance-Related and Addictive Disorders

This chapter includes an overview of the use of IPT for patients with substance abuse (e.g., alcohol, opiates, cocaine, and nicotine) and addictive disorders. The available data do not allow us to recommend IPT as a treatment for patients with a substance use disorder. There have been several negative IPT trials in this population, and in this setting IPT has been found to be no better than a control condition. However, some small studies in process are more optimistic for its use in narrowly defined samples. Based on the published literature, approaches other than IPT that focus on sobriety or relapse prevention may be preferable for patients with substance use disorders. IPT has never been intended as a treatment for all patients with all conditions, and substance abuse may be an area where its application has limited utility.

IPT Techniques and the Therapist’s Role

The time spent in IPT focuses on discussing feelings, normalizing them as responses to interpersonal interactions and as useful interpersonal information, and using them to take action to change the patient’s interactions in order to resolve the identified problem area. Therapists can use the techniques discussed in this chapter to accomplish this. IPT techniques are nondirective exploration, direct elicitation, encouragement of affect, clarification, communication analysis, decision analysis, and role play. The therapeutic relationship and the therapist’s role in IPT are also described. The therapeutic relationship may reflect how the patient thinks and acts in other close relationships. For example, the therapeutic relationship can be used in role disputes to give feedback on how patients come across to others and to help them understand maladaptive approaches to interactions.

Interpersonal Deficits (Social Isolation; No Life Events)

This chapter covers the definition, goals, and strategies of the problem area regarding interpersonal deficits. Interpersonal deficits, loneliness, social isolation, or a paucity of attachments may be chosen as the focus of IPT if none of the other interpersonal problem areas exist. If any of the other problem areas can be found (grief, role disputes, or role transitions), the therapist should not use interpersonal deficits as the focus of therapy. IPT is a treatment designed to address life events, but this category covers those patients who present without acute life events. Case examples are included to illustrate the presenting problems and treatment strategies for two patients in whom this focus of interpersonal deficits was used: one had trouble making friends after college and the other had difficulties establishing romantic relationships with women.

What Is IPT?

IPT is a time-limited, specified psychotherapy developed initially for patients with major depressive disorder and later adapted for other disorders as well. IPT is based on the idea that the symptoms of depression have multiple causes, genetic and environmental. Whatever the causes, however, depression does not arise in a vacuum. Depressive symptoms are usually associated with something going on in the patient’s current personal life, usually in association with people the patient feels close to. The goals of IPT are to reduce the symptoms of depression and to help the patient deal better with the people and life situations associated with the onset of symptoms. This chapter provides an overview of the underlying theory and discusses the concepts and goals of this treatment. The types of depression are defined: major depression, MDD, dysthymic (persistent depressive) disorder, bipolar disorder, and mild depression.