Tag: IPT: Interpersonal Psychotherapy

What is Interpersonal and Social Rhythm Therapy?

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Introduction

Interpersonal and social rhythm therapy (IPSRT) is an intervention for people with bipolar disorder (BD).

Its primary focus is stabilising the circadian rhythm disruptions that are common among people with bipolar disorder. IPSRT draws upon principles from interpersonal psychotherapy, an evidence-based treatment for depression and emphasizes the importance of daily routine (rhythm).

IPSRT was developed by Ellen Frank, PhD at the University of Pittsburgh who published a book on her theories: Treating Bipolar Disorder, a Clinician’s Guide Interpersonal and Social Rhythm Therapy. Her research on IPSRT has shown that, in combination with medication, solving interpersonal problems and maintaining regular daily rhythms of sleeping, waking, eating, and exercise can increase quality of life, reduce mood symptoms, and help prevent relapse in people with BD.

Social Zeitgeber Hypothesis

Zeitgebers (“time givers”) are environmental cues that synchronize biological rhythms to the 24-hour light/dark cycle. As the sun is a physical zeitgeber, social factors are considered social zeitgebers. These include personal relationships, social demands, or life tasks that entrain circadian rhythms. Disruptions in circadian rhythms can lead to somatic and cognitive symptoms, as seen in jet lag or during daylight saving time. Individuals diagnosed with, or at risk for, mood disorders may be especially sensitive to these disruptions and thus, vulnerable to episodes of depression or mania when circadian rhythm disruptions occur.

Changes in daily routines place stress on the body’s maintenance of sleep-wake cycles, appetite, energy, and alertness, all of which are affected during mood episodes. For example, depressive symptoms include disturbed sleep patterns (sleeping too much or difficulty falling asleep), changes in appetite, fatigue, and slowed movement or agitation. Manic symptoms include decreased need for sleep, excessive energy, and increase in goal-directed activity. When the body’s rhythms becomes desynchronised, it can result in episodes of depression and mania.

Aims of Treatment

Goals of IPSRT are to stabilise social rhythms (e.g. eating meals with other people) while improving the quality of interpersonal relationships and satisfaction with social roles. Stabilising social rhythms helps to protect against disruptions of biological rhythms; individuals are more likely to maintain a rhythm when other people are involved to hold them accountable.

Interpersonal work can involve addressing unresolved grief experiences including grief for the lost healthy self, negotiating a transition in a major life role, and resolving a role dispute with a significant other. These experiences can be disruptive to social rhythms and thus, serve as targets of treatment to prevent the onset and recurrence of mood episodes seen in bipolar disorder.

Phases of Treatment

IPSRT typically proceeds in four phases:

  1. The initial phase involves a review of the patient’s mental health history in order to elucidate patterns in the associations between social routine disruptions, interpersonal problems and affective episodes. Psychoeducation about BD and the importance of stable routines to mood maintenance is provided. Additionally, The Interpersonal Inventory is used to assess the quality of the patient’s interpersonal relationships. One of four interpersonal problem areas is chosen to focus on:
    • Grief (e.g. loss of loved one, loss of healthy self).
    • Role transitions (e.g. married-to-divorced, parenthood).
    • Role disputes (e.g. conflict with spouse or parents).
    • Interpersonal deficits (e.g. persistent social isolation).
      • The Social Rhythm Metric (SRM) is used to assess the regularity of social routines.
      • Target and actual time of the following activities are tracked on a daily basis: got out of bed; first contact with another person; started work, school, or housework; ate dinner; and went into bed.
      • The intensity of involvement with other people is also rated: 0 = alone, 1 = others present, 2 = others actively involved, and 3 = others very stimulating.
      • Finally, mood is rated on a scale of -5 to +5 at the end of each day.
  2. The intermediate phase focuses on bringing regularity to social rhythms and intervening in the interpersonal problem area of interest.
    • SRM is heavily used to assess amount of activity being engaged in and the impact of activity on mood. The regularity (or irregularity) of activities is examined, and the patient and therapist collaboratively plan how to stabilise the daily routine by making incremental behavioural modifications until a regular target time at which these activities are done is achieved.
    • Sources of interpersonal distress are explored, and individuals in the patient’s life who destabilise routine, along with those who are supportive, are identified. Frequency and intensity of social interactions, as well as other social rhythms (e.g. time at which returning home from school/work and then interacting with family), are discussed.
  3. The maintenance phase aims to reinforce the techniques learned earlier in treatment in order to maintain social rhythms and positive interpersonal relationships.
    • Discussion of early warning signs of episodes are reviewed.
    • Symptomatic and functional change is monitored at each session by asking the patient to rate their mood and note any shifts in routine using the SRM.
  4. The final phase involves termination in which sessions are gradually reduced in frequency.

Interpersonal Strategies

Once the interpersonal problem area of focus is chosen, the following strategies may be used:

  1. Grief:
    • This refers to symptoms resulting from incomplete mourning or unresolved feelings about the death of an important person.
    • This can also refer to grief for the loss of a healthy self (i.e. the person before the illness or the person one could have become, if not for BD).
    • Strategies include encouraging expression of painful feelings about lost hopes, ruined relationships, interrupted careers, and passed opportunities.
    • This is followed by encouragement to develop new relationships, establish new, more realistic goals, and focus on future opportunities.
  2. Interpersonal role disputes:
    • This refers to any close relationship in which there are nonreciprocal expectations, such as in marital conflict and arguments with parental figures.
    • Strategies include learning how to be more patient, tolerant, and accepting of limitations in self and others.
    • This, in turn, can lead to fewer critical and argumentative instincts.
  3. Role transition:
    • This refers to any major life role change, such as new employment, graduation, retirement, marriage, divorce, and giving birth.
    • This can also refer to the loss of previously pleasurable hypomania.
    • Strategies can include noting the negative consequences of hypomania and encouraging the identification of rewarding life goals as suitable alternatives.
  4. Interpersonal deficits:
    • This refers to a long-standing history of impoverished or contentious social relationships, leading to an overall feeling of dissatisfaction.
    • Strategies include identifying the common thread in the multiple disputes across one’s life and possibly working to restore “burnt bridges”.

Social Rhythm Strategies

Individuals with BD benefit from a higher level of stability in their sleep and daily routines than those with no history of affective illness. It is important to identify situations in which routines can be thrown off balance, whether by excessive activity and overstimulation or lack of activity and under-stimulation. Once destabilizing triggers are identified, reasonable goals for change are established. Specific strategies include:

  1. Encouraging proper sleep hygiene to introduce regularity to sleep-wake cycle.
    • Establish a regular wake and sleep time.
    • Avoid caffeine or other stimulants.
    • Use the bed only for sleep and sex, not for watching TV, doing homework, reading etc.
    • Align sunlight exposure with wake time to help set circadian clock.
  2. Maintaining regular meal times throughout the day.
    • Plan ahead by meal prepping the day before.
    • Include snack times if needed to encourage consistent eating habits.
  3. Encouraging medication adherence and establishing a regular schedule.
    • Use alarms on phone as reminders for when to take pills.
    • Use daily pillboxes to keep track of which pills to take at certain times.
  4. Monitoring frequency and intensity of social interactions using Social Rhythm Metric.
    • Note time at which interactions happen and adjust accordingly to establish regularity.
  5. Minimising overstimulation of social interactions.
    • Avoid frequent parties or events.
    • Use recovery days as needed.
  6. Addressing under-stimulation with behavioural activation.
    • Engage in activities that are pleasurable and that give one a sense of mastery.
    • Focus on small, manageable goals that can lead to engagement in other activities (e.g. start jogging to get in shape prior to joining a basketball team).
  7. Identifying interpersonal sources of stabilizing and destabilising influence.
    • Spend time with those who are supportive and stabilising.
    • Reduce time with those who are disruptive.

Evidence of IPSRT Efficacy

In a randomized controlled trial, those who received IPSRT during the acute treatment phase went longer without a new affective episode (depression or mania) than those who received intensive clinical management. Participants in the IPSRT group also had higher regularity of social rhythms at the end of acute treatment, which was associated with reduced likelihood of relapse during maintenance phase. Additionally, those who received IPSRT showed more rapid improvement in occupational functioning than those assigned to intensive clinical management. However, at the end of two years of maintenance treatment, there were no differences between treatment groups.

IPSRT was studied as one of three intensive psychosocial treatments in the NIMH-funded Systematic Treatment Enhancement Programme for Bipolar Disorder. STEP-BD was a long-term outpatient study investigating the benefits of psychotherapies in conjunction with pharmacotherapy in treating episodes of depression and mania, as well as preventing relapse in people with bipolar disorder. Patients were 1.58 times more likely to be well in any study month if they received intensive psychotherapy (cognitive-behavioural therapy, family focused therapy, or IPSRT) than if they received collaborative care in addition to pharmacotherapy. They also had significantly higher year-end recovery rates and shorter times to recovery.

In a trial conducted by a separate research group, 100 participants aged 15-36 years with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified were randomised to IPSRT (n = 49) or specialist supportive care (n = 51). Both groups experienced improvement in depressive symptoms, social functioning, and manic symptoms, but there were no significant differences between the groups.

Adolescents

IPSRT was adapted to be delivered to adolescents with BD. In an open trial (N=12), feasibility and acceptability of IPSRT-A were high; 11/12 participants completed treatment, 97% of sessions were attended, and adolescent-rated satisfaction scores were high. IPSRT-A participants experienced significant decreases in manic, depressive, and general psychiatric symptoms over the 20 weeks of treatment. Participants’ global functioning increased significantly as well.

In an open trial aimed at prevention, adolescents (N=13) who were identified as high risk for bipolar disorder, due to having a first-degree relative with BD, received IPSRT. Significant changes in sleep/circadian patterns (i.e. less weekend sleeping in and oversleeping) were observed. Families reported high satisfaction with IPSRT, yet, on average, participants attended about half of scheduled sessions. Missed sessions were primarily associated with parental BD illness severity.

Group Therapy

IPSRT was adapted for a group therapy setting; administered over 16 sessions, in a semi-structured format. Patients (N=22) made interpersonal goals, reflected on how they managed their illness, and empathised with fellow group members. Patients were encouraged to react to each other from their own experience, express their feelings about what was said, and to give constructive feedback. Patients spent significantly less time depressed in the year following treatment than they did in the year prior to treatment.

In another small trial, patients with BD who experiencing a depressive episode (N = 9) received six IPSRT-G sessions across two weeks. Topics of discussion in group included defining interpersonal focus area, defining target times for daily routines, discussing grief and medication adherence, addressing interpersonal disputes and role transitions, and reviewing IPSRT strategies and relapse prevention. Depressive symptoms improved significantly at the end of the treatment; improvements were maintained 10 weeks following treatment end.

What is Cognitive Analytic Therapy?

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Introduction

Cognitive analytic therapy (CAT) is a form of psychological therapy initially developed in the United Kingdom by Anthony Ryle.

This time-limited therapy was developed in the context of the UK’s National Health Service (NHS) with the aim of providing effective and affordable psychological treatment which could be realistically provided in a resource constrained public health system. It is distinctive due to its intensive use of reformulation, its integration of cognitive and analytic practice and its collaborative nature, involving the patient very actively in their treatment.

The CAT practitioner aims to work with the patient to identify procedural sequences; chains of events, thoughts, emotions and motivations that explain how a target problem (for example self-harm) is established and maintained. In addition to the procedural sequence model, a second distinguishing feature of CAT is the use of reciprocal roles (RRs). These identify problems as occurring between people and not within the patient. RRs may be set up in early life and then be replayed in later life; for example someone who as a child felt neglected by parents perceived as abandoning might be vulnerable to feelings of abandonment in later life (or indeed neglect themselves).

Background

As the name implies, CAT evolved as an integrative therapy based on ideas from cognitive and analytic therapies. CAT was also influenced in part by George Kelly’s constructivism. Kelly had developed personal construct theory and the repertory grid method, and Kelly’s approach to therapy “offered a model of nonauthoritarian practice” that psychotherapist Anthony Ryle found appealing.

Ryle, a general practitioner and analytically trained psychotherapist, was undertaking research into psychotherapy practice using repertory grids in the 1970s. He found that the themes eventually addressed in analytic work were in fact present in transcripts from the very first sessions. However the slow, exploratory nature of traditional analytic therapy meant that these were not always addressed early and assertively, with the result that therapy, while effective, took a long time to produce results. In a 1979 paper, he proposed a shorter, more active form of therapy which integrated elements from cognitive therapy practice (such as goal setting and Socratic questioning) into analytic practice. This would include explicitly formulating the problems experienced by the patient, and sharing this formulation with the patient to engage them in psychotherapy as a co-operative enterprise.

Subsequently CAT has been influenced by ideas from the work of Soviet psychologist Lev Vygotsky and Russian philosopher Mikhail Bakhtin. From Vygotsky come concepts such as the zone of proximal development (ZPD) and scaffolding. The ZPD implies that new tasks set for the patient (for example, tolerating anxiety about social situations) should extend what they do beyond their current capabilities, but only by a small and achievable amount. Scaffolding involves the therapist providing support for the patient’s efforts to change, but varying this level of support as the patient’s needs change.

Bakhtin provided concepts such as dialogism from which come techniques such as Dialogical Sequence Analysis. This is a structured attempt to identify and visually display sequences of behaviour, thinking, and emotions so that the patient becomes more aware of these and can start to modify them.

In Practice

The model emphasises collaborative work with the client, and focuses on the understanding of the patterns of maladaptive behaviours. The aim of the therapy is to enable the client to recognise these patterns, understand their origins, and subsequently to learn alternative strategies in order to cope better.

The approach is always time-limited, typically taking place over 8-24 weekly sessions (the precise number being agreed at the start of therapy). Sixteen sessions is probably the most common length. In the first quarter of the therapy (the Reformulation phase) the therapist collects all the relevant information, asking the patient about present day problems and also earlier life experiences. At that point the therapist writes a reformulation letter to the client. This letter summarises the therapist’s understanding of the client’s problems. Particular attention is given to understanding the connection between childhood patterns of behaviour and their impact on adult life. The letter is agreed between patient and therapist and forms the basis for the rest of the work.

After the reformulation letter the patient may be asked to complete diaries or rating sheets to record the occurrence of problems and their context. During this period (known as the Recognition phase) patient and therapist construct a diagrammatic formulation to illustrate the unhelpful procedures which maintain problems for the patient. The aim of this phase is to enable the patient to recognise when and how problems occur.

In the second half of the therapy work moves into the Revision phase, where patient and therapist identify and practice “exits” from the procedural diagram established in the previous phase. For example, a problematic procedure might move a patient from feeling angry to taking an overdose. An exit might involve expressing the anger in some way as an alternative to self-injuring behaviour.

At the end of the therapy, patient and therapist each write “goodbye letters” which they exchange, summarising what has been achieved in the therapy and what remains to be done. After the end of the agreed number of weekly sessions, planned follow-up sessions take place to monitor and support the changes that have been made. Typically, a 16-session CAT might be followed up by a single session one month after the end of therapy, and a final one three months later.

Evidence Base

CAT has been the subject of a number of research studies published in peer-reviewed journals. These include randomised controlled trials (RCTs) and other kinds of study. The approach is too new for any systematic reviews of RCTs to have been conducted, and therefore is not yet explicitly recommended by name by the UK National Institute for Health and Clinical Excellence (NICE). However NICE has recommended that there should be further research of CAT, for example in borderline personality disorder. A review of CAT research evidence published in 2014 reported that although there were five randomised controlled trials published, research evidence into the approach was dominated by small-scale, practice-based studies. These tended to be with complex and severe clinical groups; 44% of studies reviewed involved personality disorder. A review of CAT looking back over the 30 years to its beginnings contains a meta-analysis of 11 outcome studies of CAT. The overall number of patients treated in the studies was 324 and the average effect size across all studies was 0.83 (95% confidence interval 0.66-1.00). This is a large effect and suggests that CAT is efficacious in treating mental health problems.

Evidence from Randomised Controlled Trials

CAT has been shown to lead to subjective improvement in people with anorexia nervosa. It has also been shown to produce significant improvements in adolescents with a diagnosis of borderline personality disorder. A different trial suggested that CAT for adult patients with personality disorders also showed improvements in symptoms and interpersonal functioning, as against controls who deteriorated on these measures. CAT has also been shown to improve patients’ management of diabetes. An RCT of the use of a CAT-informed assessment for young people who had self-harmed suggested that it was effective in increasing rates of attendance at community follow-up.

Evidence from Other Methodologies

Comparative studies have suggested CAT to be at least as effective as other forms of brief psychotherapy, person-centred therapy and cognitive behavioural therapy, and interpersonal psychotherapy.

Case series and single case studies have also been published describing the use of CAT in:

  • Depression.
  • Dissociative psychosis.
  • The treatment of offenders.
  • Brain injury.
  • Deliberate self-harm.
  • Dissociative identity disorder.
  • Histrionic personality disorder.
  • Panic disorder.
  • Psychological problems in multiple sclerosis.
  • With carers of people with dementia.
  • Morbid jealousy.
  • Borderline personality disorder.
  • Paranoid personality disorder.
  • Survivors of child sexual abuse.

What is Interpersonal Psychotherapy?

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Introduction

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centres on resolving interpersonal problems and symptomatic recovery.

It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12-16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true.

It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications.

Along with cognitive behavioural therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice.

Brief History

Originally named “high contact” therapy, IPT was first developed in 1969 at Yale University as part of a study designed by Gerald Klerman, Myrna Weissman and colleagues to test the efficacy of an antidepressant with and without psychotherapy as maintenance treatment of depression. IPT has been studied in many research protocols since its development. The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Programme (TDCRP) demonstrated the efficacy of IPT as a maintenance treatment and delineated some contributing factors.

Foundations

IPT was influenced by CBT as well as psychodynamic approaches. It takes its structure from CBT in that it is time-limited, employs structured interviews and assessment tools. In general, however, IPT focuses directly on affects, or feelings, whereas CBT focuses on cognitions with strong associated affects. Unlike CBT, IPT makes no attempt to uncover distorted thoughts systematically by giving homework or other assignments, nor does it help the patient develop alternative thought patterns through prescribed practice. Rather, as evidence arises during the course of therapy, the therapist calls attention to distorted thinking in relation to significant others. The goal is to change the relationship pattern rather than associated depressive cognitions, which are acknowledged as depressive symptoms.

The content of IPT’s therapy was inspired by Attachment theory and Harry Stack Sullivan’s Interpersonal psychoanalysis. Social theory is also influenced in a lesser role to emphasis on qualitative impact of social support networks for recovery. Unlike psychodynamic approaches, IPT does not include a personality theory or attempt to conceptualise or treat personality but focuses on humanistic applications of interpersonal sensitivity.

  • Attachment Theory, forms the basis for understanding patients’ relationship difficulties, attachment schema and optimal functioning when attachment needs are met.
  • Interpersonal Theory, describes the ways in which patients’ maladaptive metacommunication patterns (Low to high Affiliation & Inclusion and dominant to submissive Status) lead to or evoke difficulty in their here-and-now interpersonal relationships.

The aim of IPT is to help the patient to improve interpersonal and intrapersonal communication skills within relationships and to develop social support network with realistic expectations to deal with the crises precipitated in distress and to weather ‘interpersonal storms’.

Clinical Applications

It has been demonstrated to be an effective treatment for depression and has been modified to treat other psychiatric disorders such as substance use disorders and eating disorders. It is incumbent upon the therapist in the treatment to quickly establish a therapeutic alliance with positive countertransference of warmth, empathy, affective attunement and positive regard for encouraging a positive transferential relationship, from which the patient is able to seek help from the therapist despite resistance. It is primarily used as a short-term therapy completed in 12-16 weeks, but it has also been used as a maintenance therapy for patients with recurrent depression. A shorter, 6-week therapy suited to primary care settings called Interpersonal counselling (IPC) has been derived from IPT.

Interpersonal psychotherapy has been found to be an effective treatment for the following:

  • Bipolar disorder.
  • Bulimia nervosa.
  • Post-partum depression.
  • Major depressive disorder.
  • Cyclothymia.

Adolescents

Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults.

IPT for children is based on the premise that depression occurs in the context of an individual’s relationships regardless of its origins in biology or genetics. More specifically, depression affects people’s relationships and these relationships further affect our mood. The IPT model identifies four general areas in which a person may be having relationship difficulties:

  • Grief after the loss of a loved one;
  • Conflict in significant relationships, including a client’s relationship with his or her own self;
  • Difficulties adapting to changes in relationships or life circumstances; and
  • Difficulties stemming from social isolation.

The IPT therapist helps identify areas in need of skill-building to improve the client’s relationships and decrease the depressive symptoms. Over time, the client learns to link changes in mood to events occurring in his/her relationships, communicate feelings and expectations for the relationships, and problem-solve solutions to difficulties in the relationships.

IPT has been adapted for the treatment of depressed adolescents (IPT-A) to address developmental issues most common to teenagers such as separation from parents, development of romantic relationships, and initial experience with death of a relative or friend. IPT-A helps the adolescent identify and develop more adaptive methods for dealing with the interpersonal issues associated with the onset or maintenance of their depression. IPT-A is typically a 12- to 16-week treatment. Although the treatment involves primarily individual sessions with the teenager, parents are asked to participate in a few sessions to receive education about depression, to address any relationship difficulties that may be occurring between the adolescent and his/her parents, and to help support the adolescent’s treatment.

Elderly

IPT has been used as a psychotherapy for depressed elderly, with its emphasis on addressing interpersonally relevant problems. IPT appears especially well suited to the life changes that many people experience in their later years.

Book: Psychotherapy in Later Life

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Book Title:

Psychotherapy in Later Life.

Author(s): Rajesh R. Tampi, Brandon Yarns, Kristina F. Zdanys, and Deena J. Tampi (Editors).

Year: 2020.

Edition: First (1st).

Publisher: Cambridge University Press.

Type(s): Paperback and Kindle.

Synopsis:

Psychotherapy in Later Life is a practical how-to-guide for psychiatrists, psychologists and mental health workers on choosing and delivering evidence-based psychological therapies to older adults.

It covers all the main evidence-based psychological therapies such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT), as well as specialist topics such as combining psychotherapy with pharmacological treatments, working with diverse populations and individual versus group therapy.

The World Health Organisation estimates that over the next four decades, the proportion of the world’s older adults will nearly double, from 12% to 22%, and that one in five older adults has a diagnosable mental health disorder.

Given the increasing number of older adults requiring mental health treatment, incorporating talking therapies into treatment plans is key to tackling issues related to polypharmacy, medication interactions and side effects. Written by experts in geriatric mental health, this book provides the most authoritative information on the use of psychotherapy in older adults.