A Pocket Guide to IPT
39
can be approached in either direction: that is, the event may trigger the de-
pressive episode, or a depressive episode may trigger negative life events. The
direction does not matter as much as the connection: the therapist wants the
patient to understand that events affect mood, and
vice versa
.
There are four interpersonal problem areas, all based on empirical psycho-
social evidence about depression, that IPT uses to focus treatment. Each rep-
resents a life crisis: the death of a significant other (
grief
, or
complicated be-
reavement
), a struggle in a relationship with a significant other (a
role dispute
),
or a major life change such
as starting or ending a job, starting or ending a
relationship, receiving the diagnosis of a serious illness, etc. (a
role transition
).
In the absence of these life events, a misleadingly named residual category has
been (unfortunately) titled
interpersonal deficits
. This is better understood as
an
absence of life events, a debilitating situation of often- chronic social isola-
tion (Weissman et al., 2007).
After taking a careful history in the early sessions (generally sessions 1– 3
in a 12– 16- session weekly treatment; fewer than three sessions if possible), the
therapist asks the patient if the therapist can present a formulation (Markowitz
and Swartz, 2007).
“You’ve given me a lot of helpful information. Can I ask you whether
I understand your situation?”
The therapist then summarizes the patient’s history of present illness, estab-
lishing that the patient is suffering from a major depressive episode and link-
ing this episode to a life event.
“As we’ve discussed, you have all the symptoms of major depression,
and you scored a 25 on the Hamilton Depression Scale, which indicates
your depression is pretty severe. It may feel hopeless— that’s one of the
symptoms of depression— but it’s
a treatable condition, and you have a
good chance of getting better. From what you’ve told me, your symp-
toms seem to have begun after your daughter died, an overwhelmingly
upsetting situation that we call ‘complicated bereavement.’ It seems to
have brought your life nearly to a halt. What I would suggest is that we
spend the remaining nine weeks of treatment focusing on what this ter-
rible loss means for you, how to handle the
painful feelings it brings up,
and how you can begin to move on with your life. Does that make sense
to you?”
Usually it does make a lot of sense, the patient agrees to the formulation, and
it thereafter becomes the focus of treatment. So on a broad, structural level,
40
I P T F O R P T S D
the linkage of mood (disorder) and life events becomes the focus of IPT treat-
ment. The formulation makes this explicit in a helpful, organizing way for be-
wildered and overwhelmed patients (Markowitz & Swartz, 2007; Weissman
et al., 2007).
Although it is possible that the patient’s story will
yield several plausible
formulations, you will only want to choose one problem areas as a focus (or,
in rare cases, two). Part of the organizing effect of the formulation should be
to simplify the patient’s complex story into a manageable package: Something
bad happened, you’ve been traumatized, and now let’s look at what PTSD is
doing to your interpersonal life. In general, you will want to choose the focus
that seems most emotionally salient.
On a “micro” level, the therapist connects mood and events in each treat-
ment session. Every session after the first one begins with the question:
“How have things been since we last met?”
This elicits one of two answers: either a mood (“I’ve been feeling terrible”; “I’ve
been so depressed”) or an event (“It was my birthday”; “I
was fired from my
job”; “I had another fight with my wife”). If the patient responds with a mood,
the therapist replies:
“I’m sorry to hear that. Did something happen that worsened your mood?”
If the patient has presented an event, the complementary question is:
“How did that make you feel?”
Thus after two questions, the IPT therapist has pinpointed a recent, affectively
charged life event, which represents an ideal target for psychotherapy. If, as is
usually the case early in treatment, the mood
and event are both negative, the
therapist sympathizes, then tries to reconstruct the event with the patient to
understand why and where things went wrong.
“What did you say?
…
What did he say?
…
Then how did you feel?
…
Then what did you say?”
This sequence helps determine fluctuations in the patient’s mood, dissonances
between what the patient felt and what the patient said, and a sense of the pa-
tient’s interpersonal style in an encounter. Following this reconstruction, the
therapist helps the patient recognize maladaptive interpersonal patterns, often
shifting undue blame from the patient to the weight
of depressive symptoms
A Pocket Guide to IPT
41
or to the other party in the encounter. (“It’s hard to confront other people
when you’re feeling so depressed.”) Therapist and patient then explore alter-
native options for handling such situations, and subsequently role- play them
so that the patient can build comfort and familiarity with self- assertion, con-
frontation, and other non- depressed interpersonal maneuvers (Weissman
et al., 2007).
This is the heart of IPT. Some of the principles inherent in this approach are:
• Mood disorders have an interpersonal context, and can be treated
through improving the interpersonal environment.
• Resolving an interpersonal crisis should
improve not only your life
circumstances but also your mood.
• Even in the midst of an overwhelming personal crisis, when one is
feeling passive, helpless, and hopeless, one can take charge of one’s life
and improve one’s situation.
•
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