Interpersonal Therapy for Depression

Interpersonal therapy, or IPT, is a short-term, focused treatment for depression. Studies have shown that IPT, which addresses interpersonal issues, may be at least as effective as short-term treatment with antidepressants for mild to moderate forms of clinical depression. Originally developed to treat depression in adults, it has been shown to be effective in treating adolescent depression and is commonly recommended as a treatment for depression in children.

Events surrounding interpersonal relationships do not cause depression. But depression occurs within an interpersonal context and affects relationships and the roles of people within those relationships. By addressing interpersonal issues, interpersonal therapy for depression puts emphasis on the way symptoms are related to a person's relationships, including family and peers.

The immediate goals of treatment are rapid symptom reduction and improved social adjustment. The long-term goal is to enable people with depression to make their own needed adjustments. When they can do that, they are better able to cope with and reduce depressive symptoms.

What Are the Ideas Behind Interpersonal Therapy for Depression?

Interpersonal therapy is a manual-based treatment. That means the therapist strictly adheres to a treatment process whose effectiveness is supported by evidence.

According to the International Society for Interpersonal Therapy, there are three components to depression.

• Symptom formation
• Social functioning
• Personality issues

IPT is a short-term treatment option that typically consists of 12 to 16 one- hour weekly sessions. The therapist focuses on identifiable problems in how an individual interacts with or doesn't interact with others. When those problems are addressed, the patient realizes a benefit in their experience of symptoms.

Except to check on their severity and the effect of the various treatments, symptoms are not addressed in therapy sessions. Instead the therapist works collaboratively with the patient, either individually or in a group, to identify and then address one or two significant problems in their interactions. The number of problems addressed is deliberately limited to one or two for the whole course of treatment. The result is an intense focus on how to make the necessary adjustments in interpersonal situations that will help reduce symptoms of depression.

The types of problems addressed fall into four categories:

Interpersonal disputes or conflicts. These disputes occur in marital, family, social, school, or work settings. The disputes emerge from differing expectations of a situation. They become a problem that needs to be addressed when the conflicts that come from the expectations lead to significant distress.

Role transitions. Changing circumstances, whether they're developmental, stem from shifts in work or social settings, or result from a life event or end of a relationship, require adaptations from the individual. With depression, those changes are felt as losses and contribute to the depression.

Grief. In IPT, grief is the experience of loss through death. Grief becomes a problem when it is delayed or becomes excessive so that it lasts beyond the normal time for bereavement.

Interpersonal deficits. This refers to the patient reporting "impoverished" personal relationships either in number or in quality.

By focusing on issues from these categories, the therapist can help the person with depression learn how to make the adjustments that are needed to address the interpersonal issue and improve relationships.

What Kind of Adjustments Might Be Made Through IPT to Resolve Interpersonal Issues?

With issues involving interpersonal disputes, the therapist works with the patient to define how serious the issue has become in terms of how difficult it is to move beyond it. For instance, there might be a dispute between husband and wife that stems from the wife's attempts to be more independent. The therapist would lead the patient, in this case the husband, in an effort to discover the sources of misunderstanding. Then the therapist might use problem-solving approaches, communication training, or some other technique to enable the patient to resolve the conflict in a way that doesn't worsen the symptoms of depression.

In role transition issues, the therapist helps the patient determine the differences between the old and the new roles. Then together they would focus on identifying exactly what is causing the difficulties and work to find a solution for the problem.

For issues involving grief, the therapist facilitates the grieving process to help the patient move beyond it. Two important techniques used to do this are:

• Empathetic listening, which provides support and a safe outlet for the patient's feelings
• Clarification, which is a technique for helping the patient examine their own misconceptions about the situation

With interpersonal deficits, the therapist will work with the patient to explore past relationships or the current relationship the patient has with the therapist. The goal is to identify patterns, such as excess dependency or hostility, that interfere with forming and maintaining good relationships. Once those patterns are distinguished, the focus turns to modifying them. Then, with the therapist's guidance and assistance, the patient is urged to make new relationships and to apply the therapeutic adjustments that have been made.

As the sessions progress, the therapist gradually lessens their level of intervention. The goal is for the patient to self-intervene more and make more of their own adjustments. This becomes easier as time goes on, and the patient's ability to self-intervene continues to improve after the sessions end, often not peaking until three to six months after therapy is over.

What Is the Process for Interpersonal Therapy?

Interpersonal therapy typically takes place in one-hour sessions, usually weekly, that continue for 12 to 16 weeks. Depending on the severity of the depression, sessions might be continued for an additional four or more weeks.

If you were being treated for depression with interpersonal therapy, the first few sessions, usually from one to three weeks, would be used for assessing your depression, orienting you to the IPT focus and process, and identifying specific interpersonal issues or problems you have. Together, you and the therapist would create a record of your interpersonal issues, rank them, and decide which one or two issues seemed most important to address in terms of your depression.

At least the next eight sessions would be focused on addressing those issues -- understanding them more, looking for adjustments that you can make, and then applying those adjustments. Throughout this portion of the therapy, the therapist would use a number of different techniques, including among others:

• Clarification, which has the purpose of helping you recognize and get beyond your own biases in understanding and describing your interpersonal issues.
• Supportive listening.
• Role playing.
• Communication analysis.
• Encouragement of affect, which is a process that will let you experience unpleasant or unwanted feelings and emotions surrounding your interpersonal issues in a safe therapeutic environment. When you do, it becomes easier to accept those feelings and emotions as part of your experience.

The entire focus of the sessions will be on addressing the identified issues. This is hard for some individuals to get used to -- especially those who are familiar with more traditional, open-ended and introspective approaches to therapy. It may take you several weeks before your own primary focus shifts to the IPT approach.

Another important aspect of the IPT process is an emphasis on terminating therapy. From the beginning the patient is aware that therapy is defined by a limited amount of time. In the final four or so weeks of therapy, the sessions will turn to termination issues.

With IPT, termination of therapy is seen as a loss to be experienced by the patient. So you would be asked to consider what the loss means to you. What issues does it bring up, and how can you apply the interpersonal adjustments that you've learned to make over the course of therapy to evaluating and getting through the loss? The idea is for the patient to become more aware of their ability to deal with interpersonal problems that have kept them from being able to actively manage the symptoms of depression.

Can IPT Work in a Group Setting?

There are several advantages to interpersonal therapy being applied to group therapy. First, the members of the group have an opportunity to learn through observing what other members in the group are learning. Learning also takes place through a process of modeling the adjustments and behavior of others in the group. There is also more opportunity to see various types of interpersonal interactions and associations. These can help the individual better understand various approaches to making interpersonal adjustments.

Before you would join a group, you would have one or two individual sessions in order to learn about the group process. You would also use those sessions to identify the one or two interpersonal issues that you will want to focus on during therapy.

Initially, the group would go through a process of engagement. This would involve identifying the common goals and common focus of the group. The therapist would then facilitate the group's establishment of a collaborative approach. That would be followed by members of the group differentiating themselves and figuring out how to work on their individual issues. During this second phase, conflicts are likely to arise and partnerships or alliances formed.

As the sessions progress, each individual's focus would be addressed and both the therapist and the other group members would help that person learn how to adjust their approach to the issues. The therapist might suggest role playing or brainstorming to help find the right intervention. Or the therapist might suggest communication training among members of the group. When conflict arises between group members, the therapist will often allow the group members to resolve it themselves while serving as a mediator to help avoid excessive negativity or criticism.

As with the individual therapy, termination is an important part of the process. There is still the same sense of loss, and members of the group are asked to confront that loss and to make themselves aware of the evolution of their own adjustments and how to use them to manage symptoms that may emerge when the sessions end.

What Happens After Interpersonal Therapy Ends?

Because depression is sometimes a recurrent condition, and because some people may experience multiple recurrences, patients are encouraged to supplement IPT with ongoing maintenance. Maintenance takes the form of once-monthly sessions in which the adjustments made during the short-term IPT are reinforced. The goal is to prevent the stress of increased social interaction from leading to new episodes of depression, and to help the individual continue to function at least at the level they were was at when regular sessions ended.

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