Interpersonal Psychotherapy for Depression
Interpersonal psychotherapy (IPT) is a specific treatment strategy that demonstrates effectiveness in patients with depression and related mood disorders, such as personality, eating, and anxiety issues. In the given chapter, Barlow (2014) focuses on the original protocol of IPT that includes three sections and 12-16 therapy sessions. To introduce the topic of IPT, the author begins with its definition: past and present relationships affect one’s current patterns that can be changed in a positive manner. In other words, instead of altering personality, the mentioned therapy aims to understand how and what impacts one’s interpersonal and romantic relationships.
According to a psychodynamic perspective, the attachment style largely determines personality characteristics and relationship conflicts. The underlying reason for using the IPT is that psychological health requires some extent of positive social interaction. In this process, the exploration of the contemporary satiations allows revealing the way they affect a person’s emotionality, feelings of depression, and self-understanding.
The adoption of IPT can be performed on one of the four problem areas, such as role disputes, interpersonal deficits, role transitions, and grief. The latter implies that a patient encountered the death of his or her family members or friends. The relationships with that close one should be explored to help the patient in overcoming the mourning process and achieving catharsis. The therapist is expected to find positive links between the patient and the deceased one to relief the feelings of grief and loss. It is one more strong point of the chapter that the author clarifies the prospective actions of a therapist, who can show how to form new relationships.
Role disputes and role transitions refer to conflicts and changes with a close one, respectively. The purpose of treatment is to identify a problem and suggest a range of possible solutions, be it taking a new role in a positive way or learning to find a compromise. The author notes that relationships with a therapist can serve as role modelling for patients. As for interpersonal deficits, this condition is characterized by social isolation and associated problems.
Another major point of the chapter is related to the role of a therapist in IPT implementation. Among potential settings, there can be a hospital, office, or private areas. According to the protocol, the therapist should take a neutral role and a directive approach to interact with the patient having depressive symptoms. The key goal of the therapist is to teach the patient social skills so that the latter can understand how to resolve his or her problems.
In case the IPT therapist would directly illustrate the patients all the solutions, it can reinforce their feelings of inadequacy. In doing so, the therapist should employ optimism, enthusiasm, empathy, support, and encouragement. Often, people with depression may have difficulties with expressing their feelings, which also requires the attention of the therapist. In addition, another situation that causes challenges is when a person has depression without any significant recent life events. As a rule, IPT therapists do not work with patients’ families and friends.
The detailed explanations of the IPT model of depression and characteristics of the identified therapy promote a better understanding of how to apply it for depression. In particular, such a principle as simplicity makes it possible to use the therapy even for those with low concentration, and, at the same time, it is regarded that depression is a medical condition. The author rationally stresses that IPT is empirically-grounded and diagnosis-targeted, focusing on “here and now” problems and life events. Compared to the cognitive behavioral therapy (CBT), IPT is less structured and implies no obligatory homework.
Moreover, unlike CBT, it does not consider depression as the consequence of dysfunctional thoughts and provides more encouragement. In comparison to the social cognitive therapy (SCT), IPT does not rely much on observation as a way to learn from others and remember the consequences of events. Instead, the key distinguishing feature of ICT is eliciting past and present experiences of a particular patient. Nevertheless, among the common characteristics of IPT, SCT, and CBT, there are skill-building, role-playing, and a focus on the interpersonal area.
The chapter contains the case study that represents Sara with major depression and the step-by-step application of IPT to assist her. Beginning with background information, the author discusses the acute phase, providing some citations from the conversation, which is important to understand the manner of the dialogue. The middle phase includes psychoeducation, thoughts about loss, and another attempt to reconsider the patient’s life.
While the detailed process of IPT discussed by the author is the evident strength of this chapter, the common problems can also be regarded as rather beneficial. For instance, it can be difficult to interact with a person who has depression and dysthymic disorder, and it requires empathy and optimism in such cases. The case with Sara clearly demonstrates the steps that should be used by the therapist, with some adjustments depending on a particular patient’s situation.
The critical review of the given chapter shows that the author provides a well-structured description of interpersonal psychotherapy in treating depression. First, Barlow (2014) emphasizes that IPT is an evidence-based intervention, supporting his statements and theories with references. Second, the author uses is concise in presenting and discussing information, which helps the readers to understand the essence of IPT. Third, the topic is examined from different perspectives, including opposing opinions and current gaps that exist in the literature. For example, the limitations of the mentioned therapy along with some response patterns are provided. It is also stressed that further research needs to be conducted, yet the author lacks clarifications on potential research questions and hypotheses. It would be better if some direction could be offered to stimulate the readers’ thinking.
Although the given chapter thoroughly examines the nature and roles of IPT in depression treatment, it plays little attention to the area of research. One should emphasize that the chapter contains the list of properly-cited references and in-text citations to guide the readers and provide them with the opportunity to access the sources used. However, many of them can be regarded as outdated since they were published more than 20 years ago. While some fundamental works remain relevant regardless of time, other research articles need to be reconsidered. In this connection, it would be better if the author also included more contemporary sources: books, peer-reviewed articles, official statistics from credible websites, et cetera. It is important to keep theoretical data consistent with the latest findings in the field of psychotherapy to provide the best care services possible and ensure positive outcomes of therapeutic sessions.
In chapter 8, Wright, Turkington, Kingdon, and Basco (2008) focus on mania and CBT techniques to manage its symptoms and prevent future episodes. The mania prevention plan offered by the authors includes managing sleep, medications, substance use, stress, activity, and symptom triggers. It is a common misunderstanding among patients that mania is not likely to recur once they handled it.
Therefore, it is critical to adopt lifestyle management to reduce the factors that can trigger mania and use it to recognize symptoms. The latter is one more vital point that is stressed in this chapter since those patients who are aware of their condition and possible complications are more likely to cope with mania effectively. By understanding whether a person faces mild, moderate, or severe symptoms, a therapist can select proper strategies. Symptom monitoring may involve patients’ hobbies, interests, routines, motivations, and current preferences, changes in which can signalize an increase or decrease in the maniac behaviors.
A variety of useful tables is the main benefit of this chapter since they can be used by practitioners to evaluate a patient and prepare for sessions. By reprinting these tables, one can monitor and note any changes and progress of treatment, which can be adjusted if the patient remains passive or resistant to the offered interventions. More to the point, the chapter presents the plan for temptations to assist patients in identifying their weaknesses and maximizing the advantages to avoid mania in the future.
The video illustrations for this chapter provide the examples and tips for both clinicians and patients. These vignettes contain such techniques of regulation as Socratic questions and emotion-focused interventions. As for weaknesses, the chapter pays little attention to the symptoms of mania specifically in bipolar disorder, yet there is a task that requires students to practicing in this area based on the information provided. One can suggest that more details should be noted to help learners with this assignment.
In chapter 9, the authors examine common problems in interpersonal relationships, such as loss, a lack of social support, skill deficits, et cetera. It is stated that relationship skills can be improved by means of role modeling in communication. For example, feedback is a powerful technique that allows a therapist to show the patient his or her strong sides to use them for the relief of negative symptoms. Anxiety, irritability, and other adverse feelings refer to symptom intrusions that often cause misunderstanding in communication. To assist patients in increasing their understanding of how their emotions affect their behavior and interpersonal relationships, the authors recommend CBT interventions.
For instance, the method of cognitive restructuring can be used to alleviate grief symptoms, which can be continued by the employment of coping strategies, be it behavioral activation or problem-solving. Furthermore, the authors identify the disclosure of the disorder to others as an important step of treatment. Self-disclosure is associated with being honest and having the support of others, but it also has a threat of being rejected by them.
The second part of chapter 9 presents the problems of interpersonal relationships in terms of specific diseases. Along with schizophrenia and depression, the most beneficial information is given about bipolar disorder. The latter causes sensitivity, irritability, impaired judgment, and impulsivity, leading to conflicts, which is especially pronounced in the depressive phase of the disease. The authors discuss the symptoms of the upcoming conflict and emphasize that irritability may be hidden, while the emotion intensity scale can help the therapist to assess a patient (Wright et al., 2008). Once the level of irritability is established, it is possible to use a differential relaxation strategy to physically relax muscles in difficult situations.
Another option is to apply a set of standard assertive responses to start or continue a positive or, at least, neutral dialogue. The ultimate goal of these strategies is a qualitative change in relationships. It is also essential for patients with bipolar disorder to learn differentiating between perceived problems that are stimulated by mania and actual challenges.
This chapter proposes a rather important discussion of relationship problems with regard to mental disorders. Among the key advantages, there is a variety of specific examples and coping strategies. In particular, chapter 9 points to the need to increase a patient’s self-awareness, address automatic thoughts, and practice self-disclosure through assertive responses. In addition, the authors provide brief plans for handling one or another symptom using CBT techniques. The vignettes of the chapter include learning exercises and excerpts from conversations with patients, which are useful to learn on. Nevertheless, it would be better if more references could be added to this chapter. A lack of relevant literature makes it difficult to access other sources that can guide readers in exploring, for example, bipolar disorder in detail.
The video by Jamison (n.d.) analyzes bipolar disorder, claiming that it is a medical problem, yet its treatment should contain both medication and psychological assistance. More than half of patients are likely to face more than one of the complications and recurrent symptoms during their lives. Therefore, the author argues about the need for therapists to be persuasive to convince patients that their lives can be better.
Otherwise, brain damage, substance abuse, suicidal attempts, and other threats become the aggravating factors in bipolar disorder. In other words, the video prioritizes the fact that, first of all, therapists should understand the role of explaining patients the value of treatment they offer. It is also emphasized that there many misconceptions about the identified disease that often has a lethal outcome. The author also discusses the nature of the disease, its causes, diagnosis, and treatment options. The critical tasks for therapists and conversations about medication compliance in bipolar disorder became clear after watching this video.
The very message of this video is relevant to the modern state of psychotherapy and bipolar disorder treatment. Many patients still lack awareness of their condition, while also being stigmatized by society. It is significant to recognize the risks of this disease and properly address the symptoms, working with patients based on the extensive research findings. The idea of integrating medication and therapy is another strong point of the given video as the combination of these methods is likely to promote the most promising results. Ultimately, the author of the video is a survivor of bipolar disorder, and her experience contributes to the better understating of this health problem. It is possible to suggest that the use of subtitles would help foreign viewers to make sure that they understand all the ideas. It would also be better if the author noted experience of other survivors who effectively work with clients since it would make the discussion more comprehensive.
Chapter 2 in “Bipolar Disorder: A Cognitive Therapy Approach” considers bipolar disorder treatment from the perspective of working with a patient’s cognition. Depression in the framework of this disease is characterized by a high level of psychomotor inhibition, lability of emotions, and hypersomnia. Irritability, even without a decrease in mood, is likely to be combined with depressive cognitions, also known as self-incriminating ideas. Damage from bipolar depression exceeds the damage from mania: since patients spend more time in depression, they have more disorders in professional, social, and family life, while the risk of suicide remains high (Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2002). The paramount goal of presenting the chosen treatment model to patients is explaining that learning skills of evaluating and adjusting their condition would help them to manage their disease.
The cognitive model suggests that dysfunctional thinking that affects the mood and behavior of the patient is characteristic of all types of mental disorders. When people learn to evaluate their mindset more realistically and adaptively, their emotional state and behavior improve. For example, if there was a lack of money, and a person was depressed at that moment, he or she may develop an automatic thought: “I cannot do anything right”.
However, if one would try to assess the validity of this idea, he or she can conclude that too general conclusion was made. According to the assumptions of Newman et al. (2002), evaluating his or her experience from this new point of view, one will most likely feel better and be more constructive. To achieve long-term improvement in the patient’s mood and behavior, cognitive therapists work with deeper levels of thinking: people’s deep beliefs about themselves, their world, and others.
Another major point made by the authors refers to the role of therapy homework, when a patient continues alleviating his or her symptoms independently. The psychological and social skills are to be taught by the therapist, but the collaboration of the patient largely determines the outcome of the treatment. To ensure that maintenance of the obtained skills would be maximized, the therapist should encourage the patient to practice them in everyday life. Even though homework is not prescribed to patients of cognitive therapy as obligatory, the evidence shows that the use of skills between sessions increases the likelihood of positive results.
At best, it is preferable that patients apply relevant skills automatically once they find that they have mania, irritation, or other distressing emotions. Self-monitoring is probably the most multipurpose and common strategy for tracking automatic thoughts and developing positive responses (Swartz & Swanson, 2014). The advanced problem-solving serves as another method to anticipate potential problems and brainstorm the ways to prevent them. The homework adherence can be maximized via assessing self-confidence, collaborating with the therapist, and engaging in cognitive rehearsal.
Despite its seemingly easy implementation, the implementation of the cognitive model treatment can be associated with some challenges. The cognitive bias may be expressed in bipolar disorder: when a person has a maniac episode, he or she can think that he or she is a genius, while the depression phase would made him or her feel like the most foolish person. The biological changes compose another challenge that is related to behavioral changes, which makes it important to consider treatment from the biopsychological stance. The role of the altering environment and life events should not be underestimated as surrounding triggers may impact the therapeutic sessions.
Accordingly, the author concludes that the cognitive therapy must connect biology, behavior, beliefs, patterns, and environment in working with a patient’s individual interpretations. A child growing in a family where one of the members has bipolar disorder is a vivid example of how the environment plays a critical role in the course of this disease. The schemas adopted by this child can manifest themselves in adolescence and adulthood in the form of emotional distress.
Polarized thinking, one of the most critical symptoms of bipolar disorder, is often activated by life hardships or emotional events. It is intriguing that the author considers that negative life events can trigger mania and depression, especially in those patients who exercise problematic schemas. The results of investigations in the field of the attributional theory report that there is a link between cognitive factors, life events, and the onset of bipolar disorder symptoms (Newman et al., 2002).
The authors note that the practical value of these findings lies in the potential correction of patients’ thinking patterns. In particular, the therapist can explain that some life events are beyond the direct impact of a patient, and, therefore, they cannot be fully controlled. In case when there are no evident stressful events that are likely to impact the course of bipolar disorder, it becomes more challenging for the therapist to understand the underlying reasons. The self-induced stress and spontaneous episodes of mania seem to point to autonomous disease progression, which is explored in the context of sociotropy.
The review of this chapter reveals that the authors present a well-structured discussion of bipolar disorder, paying attention to cognitions and the cognitive therapy. It is especially useful that they gathered various opinions from the literature and synthesized them within this chapter. While reading the authors’ ideas and theories, it becomes evident that the field of cognitive psychotherapy is currently at the stage of active development, and much is to be done to advance it. One more advantage of the chapter is related to a critical approach to different views on one or another topic. In other words, the authors do not merely describe various cognitions and examples, but also examine them from their point of view. The patients’ beliefs, schemas, and patterns are objectively assigned a paramount role in working with stress nature of bipolar disorder.
Although this chapter contributes to the theory of psychotherapy and bipolar disorder, one should note that the authors fail to offer solutions or possible research directions for those questions that are not yet answered. For example, they pose the question on spontaneous symptoms of the disease, mentioning that such situations are not associated with certain negative life events. It would be better of the authors also identified some perspectives and hypotheses for further studies. It should also be stressed that one more weak point is a lack of practical steps that can be taken by therapists in practice. However, it seems that this chapter mainly focuses on the theoretical considerations, which makes the above weakness minor. In general, the authors conclude that cognitive factors and variables need to be taken into account to understand the reasons and solutions to alleviate the symptoms and prevent episodes of bipolar disorder.
CBT for Interpersonal and Cognitive Problems in Bipolar Disorder
Impaired cognitive functioning is the most common characteristic of bipolar disorder, which can be corrected by means of cognitive behavioral therapy (CBT). Chapter 10 in Wright et al. (2008) aims to illustrate the techniques that proved their effectiveness in managing mood shifts, disorganization of thoughts, and other symptoms. First of all, the authors focus on schizophrenia that can be especially expressive during the episodes when a person with bipolar disorder loses the connection with reality. The key forms of thought disorder include pseudophilosophical thinking, tangential thoughts, wooliness of thoughts, impaired association, and so on.
Based on the principles of CBT, the authors recommend normalizing the problems with thinking clearly, which the therapist should do after identifying a patient’s messages. More clear communication is especially valuable for patients who cannot distinguish between their states when they get off track and when they find it difficult to translate their ideas to others. It is also advised to use diagrams or other visual means to show disruptions and ponder over them. In cooperation, a therapist and patient should find the links between ideas and eliminate thought blocks.
The vignettes used in chapter 10 demonstrate the examples of working with patients with mild and severe impaired cognitive functioning. For example, Knight’s move thinking, fusion, neologisms, derailment, and word salad are shown as major thought disorders. Accordingly, the method of thought linkage is given to focus on the key theme, determine the connection between its components, and practice restructuring.
Some other CBT strategies that are mentioned in this chapter involve homework assignments, irrational thinking correction, and feedback. In mania and hypomania, cognitive difficulties may be expressed in tangentially, racing thoughts, distractibility, grandiosity, et cetera. The step-by-step plan provided by Wright et al. (2008) seems to be beneficial for using by therapists since it clarifies the expected actions. Each of the options selected for particular cases should be discussed in terms of its advantages and disadvantages, which allows for critical considerations. In depression, patients tend to struggle with concentration problems, which can be reduced via structuring processes and problem-solving.
Speaking of chapter 10, one should state that the authors properly define both difficulties and related solutions for such conditions as schizophrenia, depression, and mania / hypomania. All of these conditions are intertwined with bipolar disorder, which makes the chapter insights especially significant for therapists. The fact that the authors outline the key information and place it separately from the main text increases readability and comprehension of their ideas. Moreover, the summary of the key points for clinicians promotes better memorization. The skills and concepts for patients to learn present a useful list of what should be taught during sessions.
The methods that are discussed in this chapter are comprehensive since they target different dimensions of disease treatment. For example, sleep, irrational thoughts, thinking discrepancies, homework tasks, and communication options. It is also emphasized that the CBT techniques that are discussed in this chapter can serve as role models for patients. The accurate presentation of symptoms and coping strategies makes chapter 10 rather important. The limited list of references can be noted as the only weakness.
In chapter 12, the main point is the improvement of medication adherence in patients with mental illnesses. The point of the authors is to apply the CBT as a way to increase patient awareness and promote the idea of taking drugs not only for common sense but for reasons that are of great importance for an individual patient. The evidence shows that patients with bipolar disorder who received CBT were more likely to practice medication adherence compared to those who did not have such an opportunity.
Namely, it is stated that 12-20 sessions in a period of 6 months lead to the mentioned results. To introduce the readers with the topic, the authors discuss some types of nonadherence to treatment, including full, periodic, partial, and never. In addition, the reasons are illness rejection, religion, disorganization, previous failures, forgetfulness, negative family experience, and so on. In terms of CBT, it is suggested to adopt behavioral reminder strategies, the main purpose of which is to explaining the medication regimen, using a pillbox, and placing medication at the same place. One of the vignettes displays the use of the problem-solving strategy.
Interpersonal relationships can be regarded as another area for improvement for patients with bipolar disorder. While working with cognitions, the therapists should note if patients’ dysfunctional thoughts are caused by relationship problems. For instance, people with bipolar disorder often have challenges when their romantic relationships broke, feeling helplessness, hopelessness, loneliness, and worthlessness much stronger than others. In this case, it is the responsibility of the therapist to support the patient’s self-esteem and taught the ways to cope. Wright et al. (2008) argue that therapists can also act like coaches to establish the plan for lifelong treatment and ensure that the patient would follow it.
To increase adherence, the authors also assume such alternatives as changing medication, joining a support group, altering something in life, as well as talking with friends and family. The chapter contains the example of a written plan with obstacles and solutions. This plan is based on the method of collaborative questioning when the therapist encourages the patient to pose and answer questions.
CBT homework is distinguished by the authors as the factor that helps patients not only to enhance their medication adherence but also work better independently. The latter implies that patients with mental illnesses can practice CBT to change their lives for the better. For example, one of the chapter cases shows how the patient tries to reduce coffee drinking, which is challenging for her. Other issues may be associated with substance abuse, procrastination patterns, as well as dieting. In this connection, the therapist should ask about homework tasks and changes during each of the sessions. The rehearsal of the planned actions is another method that includes preparing and collaborative discussion to make the necessary adjustments as an ongoing process.
The strong points of chapter 12 are its link between bipolar disorder, treatment adherence, and interpersonal relationships. For patients, such a comprehensive view on their disorder is likely to produce the best outcomes possible. One should note that the tables and vignettes that are used by the authors add more value to the chapter. The summary of the key points allows for revising information learned and making sure that all important insights were obtained. The limited and relatively outdated references compose the weakness of chapter 12, which can be improved by extending it in future editions. Both chapter 10 and chapter 12 can be considered as useful for understanding the steps, strategies, and barriers therapists encounter while treating patients with bipolar disorder.
Barlow, D. H. (2014). Clinical handbook of psychological disorders: A step-by-step treatment manual (5th ed.). New York, NY: Guilford.
Jamison, K. (n.d.). Assessment & psychological treatment of bipolar disorder. Web.
Newman, C. F., Leahy, R. L., Beck, A. T., Reilly-Harrington, N. A., & Gyulai, L. (2002). The role of cognition in bipolar disorder and its treatment. In Bipolar disorder: A cognitive therapy approach (pp. 25-46). New York, NY: American Psychological Association.
Swartz, H. A., & Swanson, J. (2014). Psychotherapy for bipolar disorder in adults: A review of the evidence. Focus, 12(3), 251-266.
Wright, J., Turkington, D., Kingdon, D., & Basco, M. (2008). Cognitive therapy for severe mental illness: An illustrative guide. Washington, DC: BMA.