The discovery of Interpersonal Psychotherapy is a great example of scientific serendipity, in that, it was discovered by accident.
The story goes that in 1969 the U.S. National Institute of Mental Health began a new policy of evaluating mental health treatments in the same way other medical treatments are tested. Large scale outcome studies were conducted to evaluate the efficacy of anti-depressant treatments including medications and psychotherapies. Interpersonal Psychotherapy (IPT) was included, but only as a control group.
The results found that IPT punched above its weight proving to be as effective as tricyclic medication and Cognitive Behavioural Therapy. And so a new, evidence-based therapy was born.
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What is Interpersonal Psychotherapy?
When Chris Peterson said, ‘other people matter’ he was referring to the impact our interactions with others have on our wellbeing. Conversely, when Sartre said, ‘hell is other people’ he was also right. And although this seems like a contradiction, it’s more an example of how two things can be true at once.
If you feel positive about your life, it’s likely your interactions with other people are positive and fulfilling. But if you are unhappy or depressed, your interactions with others may be more complicated.
Theory of IPT
The theory behind IPT can be as complex as you want it to be, drawing from attachment theory and the personality theory of Harry Stack Sullivan. Sullivan first noted that personality is shaped by our interactions with other people and encouraged therapists to explore the tensions clients experience in key relationships.
IPT does this by helping clients to pay close attention to their (current) social interactions and explore interpersonal tensions and conflicts.
The Issue is Not the Issue
In IPT the therapist understands people are often reluctant to acknowledge mixed feelings about others, especially loved ones. For example, a person describes feeling stressed about their financial situation.
But when we explore a little further, to ‘unpack it’ so to speak, the worst part is the arguments with their partner over money. Or someone describes their work as stressful. But as we look deeper the main stress is bullying at the office. So IPT assumes stress and depression occur in an interpersonal context.
Joanne is a 26-year-old recently married woman referred by her doctor for counseling and stress management. Joanne had been diagnosed with mild depression and had been experiencing frequent headaches.
As we explored the pattern and frequency of Joanne’s headaches they mostly occurred later in the week. This raised some obvious questions… “what else is happening towards the end of the week?” and “what happens at the end of the week that doesn’t happen at other times?”
Joanne couldn’t think of anything specific, except that on Friday evenings her in-laws often visited and sometimes stayed for dinner. As we explored how Joanne experienced these visits she provided a slightly ‘glossy’ description of family bliss and harmony. However, as we discussed specific examples of these interactions she agreed her mother-in-law, who she insisted was well-meaning, did offer occasional ‘constructive criticisms’ of Joanne’s cooking. She also liked to remind her son how he always enjoyed his favorite meals back when he lived at home.
On other occasions, she would make passive-aggressive remarks about Joanne’s housekeeping, for example suggesting Joanne must have had a very busy week judging from the state of the house.
Moreover, as if to make matters worse, during these condescending exchanges Joanne’s husband would sit back, apparently enjoying both women competing for his attention. By now I’ve got the bloody headache!
One of the ‘moves’ of IPT is to help the client recognize how the way they are being treated is unacceptable, or even abusive. This realization can liberate an emotional ‘how dare they’ epiphany. The therapeutic value of such cathartic release cuts across several therapeutic traditions. For example, Freud believed ‘anger turned inward’ was a cause of depression. Also, stress experts have long believed repressed anger is a cause of somatic problems, especially headaches and other tensions in the body. Or as Woody Allen once said. “I don’t get angry, I get a tumour!”
To help Joanne explore such possible, deeper feelings I asked her what advice she would have for a best friend, or her sister, if they were in a similar situation. This technique creates a few degrees of separation making it easier (and safer) to say ‘No one should have to put up with that!”… ‘You deserve better!”
At this point, it’s helpful to understand when we repress a particular emotion we tend to do it absolutely. The door is shut tight. We are not even a tiny bit angry. Nothing to see here. So it’s a significant development to open the door just a little bit. Over time, once the door is cracked open it continues opening further by itself.
Fritz Peels, the legendary founder of Gestalt therapy, explained this phenomenon with the unlikely metaphor of a roast dinner. When the roast is removed from the oven, and placed on top of the stove it continues to simmer and cook a while longer. Likewise, during the gap between weekly sessions, clients process the insights gained from the session and return a week later with a more robust view of their situation, and more determined to make changes.
Not surprisingly, as Joanne explored how she felt about ‘everyone putting me down’ her anger focussed increasingly on her unsupportive husband. Despite her attempts to gain more support from him he continued to dismiss her concerns and insisted she was overeating. He refused to accept that his mother meant any harm and would not consider relationship counseling.
It is a cornerstone of most therapeutic models that we cannot change other people, but we can work on ourselves. So as Joanne worked on Joanne, she began to place more importance on her own wishes and explored what putting her foot down might look like. We rehearsed some assertive ‘I’ statements and she asserted the following position…
“I know you don’t agree, but I need a break from your parents’ visits. If you insist on having them over that’s fine, but I’ll be at my sister’s house.”
Over the following months, Joanne did, in fact, spend some Friday evenings out shopping with her sister. Just enough to break the cycle of playing hostess to her ungracious visitors. Whether her in-laws got the message doesn’t matter. The goal is not to change other people and they most likely continue to lack boundaries and basic manners. The point is Joanne was now placing more value on her own wishes. He harnessed (sublimated) her anger into positive action and took steps to protect herself. She was less depressed and enjoyed a better sense of control over her life. And her headaches stopped.
Similarities and Differences with other Therapies
A traditional psychoanalytic approach might explore Joanne’s childhood memories including those of the mothering relationship. Her progress might be credited to the new insights (from the id to the ego) and the cathartic release of repressed anger. Sublimating repressed anger into increased assertiveness would be considered a healthier defense mechanism -compared with previous denial and repression.
A CBT approach would emphasise the role of dysfunctional beliefs “I am a bad housewife” in causing her initial symptoms, and her progress would be credited to changes in those beliefs “I’m a good person, even if my in-laws lack manners” or “I deserve to be happy, even if I’m married to a mummy’s boy.”
Relationship counseling might focus on the poor communication between the partners and help them to express themselves better, and build more understanding and negotiate clearer rules for a better relationship.
In this current example of IPT Joanne was helped to see how her symptoms were linked to her current (not childhood) relationships. She came to realize her treatment was unacceptable and gave herself permission to acknowledge her resentment at such treatment. She then harnessed that anger towards empowering herself and asserting a better deal for herself at home.
- Sartre must have been a fun guy.
- Some details of this case study have been changed to protect confidentiality.
- Stress management for headaches should only be attempted after a doctor has eliminated an organic cause for the pain.
- Putting things even more simply there’s a colorful expression you may have seen on a T-shirt.
“Stress is the confusion created when one’s mind overrides the body’s basic desire to choke the crap out of someone who desperately deserves it…”
Now I’m not saying this crass utterance captures any of the subtleties of IPT, but it’s not entirely wrong either.
- Frank E, Levenson JC. Interpersonal Psychotherapy. Washington DC, American Psychological Association, 2010.
- Klerman, G.L., Weissman, M.M., Rounsaville, B., Chevron, E.S. , Interpersonal Psychotherapy of Depression, 1984, New York:Basic Books.
- Weissman MM, Markowitz JC, Klerman GL: Comprehensive Guide to Interpersonal Psychotherapy. New York: Basic Books, 2000.
- Markowitz J,C. ,Weissman,M,M. (2004) Interpersonal psychotherapy: principles and applications. World Psychiatry. Oct; 3(3): 136–139.
- Markowitz JC, Weissman, M,M. (2012) Interpersonal Psychotherapy: Past, Present and Future. Clinical Psych Psychotherapy. Mar-Apr; 19(2): 99–105.
- Robertson, M. et.al. (2008) Interpersonal Psychotherapy: An overview. Psychotherapy in Australia. Vol. 14. No 3.