Premise Of The Therapy
Interpersonal psychotherapy (IPT) is a short-term empirically tested treatment that is especially effective for adolescents with depression and other mood disorders. IPT recognizes that biological, biochemical, developmental, and personality factors contribute to the vulnerability to developing depression, but the approach especially emphasizes that disturbances in social roles can create precursors for psychopathology and also having a mental disorder itself can create impairments in social functioning in an individual’s daily life (Klerman et al., 1984). This shows the theory’s reciprocal model, in which when a person is depressed the seek excessive reassurance within their interpersonal relationships but are unable to accept it, which leads to a cycle and furthers their depressive symptoms (Lipsitz et al., 2013). The early childhood experiences that define functioning adults, when disturbed, predispose children to certain mental disorders. This approach gets its roots from John Bowlby’s attachment theory, who proposes that there is an innate tendency for humans to seek out attachments with people who can care for them, and this serves as an evolutionary survival mechanism (Klerman et al., 1984).
The assumptions that interpersonal relationships determine the development of the clinical depression are supported by the ideas of Adolf Meyer and Harry Stalk Sullivan. Meyer had a psychobiological approach to psychopathology and stated that early experiences in one’s childhood could influence the way they respond to environmental changes, so poor social support can influence their ability to deal with stress. Sullivan extended on Meyer’s theory and placed importance on interpersonal problems, in both the historical and present context, to treat mental disorders (Mufson et al., 2004). These ideas, along with Bowlby’s attachment theory, show the importance of interpersonal relationships, and later models have utilized this and proposed the diathesis-stress model to explain the occurrence of psychiatric disorders. The diathesis part recognizes the genetic, biological, and personality factors that can determine the predisposition to developing a mental disorder, while the stress factor emphasizes the role of both interpersonal stress and decreased social support that leads to difficulties managing emotion and precipitates and maintains the disorder. This stress and decreased social support result from environmental factors like life events and different stages of development, but also interpersonal styles and tendencies, attachment styles, and social skills that can lead to interpersonal problems, role disputes, role transitions problems, grief, and role deficits (Lipsitz et al., 2013)
Klerman et al. (1984) have proposed several precipitating that occur during one’s childhood that can predispose them to developing clinical depression later on in life. First, they describe grief as a normal part of the clinically depressed patient, but though short term grief is normal, people who are at risk for developing depression as a result of it see themselves as lacking significant close relationships with people and not having a strong financial and social support system in place. They go on to explain that death of a parent in one’s childhood can lead to depression, not because of the incident itself, but because of exposure to a certain stressor later on in adulthood. In addition, they explain that children of depressed adults and children without close relationships to their parents have a greater chance of developing depression. Stressful life events can cause a significant increase in the chance of developing depression, in addition to lack of social supports, which normally provide intimacy, social integration, nurturance, and guidance.
When one first becomes sad, there is usually positive reinforcement in the beginning with support and sympathy given to the individual. However, as time goes on, being around depressing individuals can become harder, and though these depressed individuals seek reassurance from their peers they often do not receive or accept it. Thus, this can create a cycle of seeking reassurance and not receiving it, which makes the individuals further depressed and maintains the disorder (Klerman et al., 1984).
Interpersonal Psychotherapy for Depressed Adolescents (IPT-A) is a slightly modified approach of IPT specifically targeted at the adolescent population, because of the high risk of letting depression go untreated in an adolescent. Research has shown that adolescents have a higher risk for alcohol and drug abuse, suicide, affect academic performance, and impact familial and social relationships (Mufson et al., 2004). All adolescents experience loneliness and conflicts, but many do not experience the long-term periods of turmoil that impair functioning. Of those who do, it has been found that strained parent-child relationships and impairments in interpersonal relationships predict the occurrence of depression most often (Mufson et al., 2004). In addition, after the depression for the main event has been resolved, the interpersonal problems still remain, and this problem is what IPT-A is designed to help.
Structure and Goals of the Therapy
IPT can be done in individual, group, or family settings, but IPT-A in particular is focused on individual therapy. There are several adaptations made for IPT-A in order to serve the adolescent population better. Specifically, it is more structured and emphasizes psychoeducation, while the client develops problem-solving skills in order to find ways to deal with problems (Mufson et al., 2006). There is also an emphasis in the development of autonomy and interpersonal relationships with romantic partners, coping, and peer pressure (Mufson et al., 2004). In IPT-A, there is a varying degree of involvement of parents into the treatment (though it is individual) and the role of the parent during each phase can be different. For example, during the initial phase of the treatment, the parent would be educated about the disorder ((Mufson et al., 2004). Another aspect that is added is a discussion of role transitions within the family, such as divorce, which can present major interpersonal problems for the client and can change their perspective (Mufson et al., 2006).
IPT-A is a 12-week long course where the therapist and adolescent client meet once a week. There are three phases to the treatment: Initial, Middle, and Termination phase. The Initial phase lasts from Sessions 1 till 4 and involving the parent in this phase is especially important. One goals of the Initial sessions are to explain depression and how it manifests in adolescents to both the patient and to the parent so they know what to expect and can expect that recovery is highly likely. Another is to clarify that though it may be hard for the patient to function as he or she normally would, there should still be support and understanding that continue going to school and trying to socialize, thus establishing a sick role (Mufson et al., 2006). They should also explore interpersonal relationships occurring in the patient’s life currently and also establish a relationship with the patient by explaining the core treatment principles of IPT-A, so they can know what to expect (Mufson et al., 2004). During these initial sessions, interpersonal inventories will be done to figure out which areas are problematic and once a specific area is identified there will be a verbal contract to describe the plan for treatment (Mufson et al., 2006).
The Middle phase of treatment in Sessions 5-9 is more about specifically targeting the disorder. The goals of this phase are to make sure that the focus of the treatment remains on the specific problem area found in the Initial phase, find strategist to target this problem area, and start using specific techniques to solve the problem (these will be explored in detail later) (Mufson et al., 2006). Four main problem areas have been identified in IPT-A, which are grief from death, interpersonal role disputes due to familial relationships, role transitions going from one social role to another, and interpersonal deficits in which some adolescents may be socially isolated (Mufson et al., 2006). Thus, the relationship between IPT and IPT-A can clearly be seen, though specific modifications are in place.
The final phase of treatment, the Termination phase, occurs between Sessions 9-12 and focus on the looking back at the progress the therapist and the client have made and finding the specific strategies the adolescent found the most helpful to reduce depressive symptoms. They should also discuss coping mechanisms, additional areas that may need improvement, and signs that may indicate the individual is going into relapse so they can catch it early. Parental involvement in this step is also encouraged so that they can understand the progress his or her child has made and also know the strategies so they can help their child practice them at home. Though traditional IPT-A is 12 weeks long, it can be shortened or extended based on what the patient needs but only if this time frame is decided at the beginning of treatment (Mufson et al., 2006).
The overall goals of the treatment are to reduce the occurrence of depressive symptoms and try to help alleviate their interpersonal problems. To do this, the therapist, especially in the Initial phase, will want to get a good representation of what the positive and negative relationships are in the client’s life and if these relationships are affecting their mood. Then, during the Middle phase the therapist and client will use specific strategies to improve the negative interpersonal relationships and therefore improve the client’s mood. The interpersonal inventory will allow the therapist to find out what triggered the onset of depressive symptoms, why the client decided to get help, and what relationships may have played a role in the precipitation and maintenance of the symptoms. At the end of the inventory, the therapist can point out patterns of interpersonal relationships and the focus can be shifted to specific situations and finding alternative solutions to problems and eventually modifying behaviors with these new ways of solving them. By helping modify interpersonal problems by changing the way they feel and behave toward the person, and IPT-A therapist hopes to alleviate the depressive mood that comes along with it (Mufson et al., 2004).