Group-based interpersonal psychotherapy for posttraumatic stress disorder: theoretical and clinical aspects

Posttraumatic stress disorder (PTSD) is a condition that engenders both symptomatic distress and severe disruption in interpersonal and social functioning. Most of the empirical research on treatment has emphasized interventions that aim to alleviate the symptoms of PTSD, despite the persisting impairments in social, occupational, and interpersonal functioning. In clinical practice, achieving relief from symptoms such as irritability or phobic avoidance is a worthwhile goal, yet significant distress and disability derived from disruptions to interpersonal attachments, social networks, and confiding intimate relationships persist. Interpersonal psychotherapy (IPT) has been shown to be efficacious in research settings for depression and eating disorders, in both group and individual formats. Recent pilot data also suggests the potential usefulness of IPT in anxiety disorders. The aim of this paper is to provide a rationale for the use of group-based IPT as an intervention for PTSD as part of a management package, arguing from theoretical and clinical viewpoints. The integration of IPT therapeutic processes with the therapeutic group process is discussed, and a detailed case discussion is presented as an illustration.     

Sudden gains in interpersonal psychotherapy for depression

Sudden, precipitous improvements in depressive symptom severity have been identified as occurring among unipolar depressed individuals. These "sudden gains" have been associated with superior acute treatment outcome in several treatment modalities, including cognitive therapy. A better understanding of sudden gains may provide insight into the mechanisms of action in these and other psychotherapies. One efficacious therapy that has been overlooked in sudden gains research is interpersonal psychotherapy (IPT; Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books). The present research examined the rates and concomitant features of sudden, precipitous improvements in depressive symptomotology among 185 women receiving IPT for recurrent depression. Sudden gains, defined using extant criteria for the Beck Depression Inventory, were assessed over 12 weeks of acute IPT treatment for depression and occurred for 33.5% of the sample. Sudden gains were not associated with diagnostic and demographic characteristics or with differential likelihood of achieving depression remission with IPT monotherapy during active treatment. Further, those with sudden gains were no more likely to maintain their recovery through maintenance treatment. The lack of impact of sudden gains on eventual outcome is discussed in terms of potentially disparate emphases and mechanisms of change between IPT and cognitive-behavioral therapy (CBT).     

Individual and group CBT and IPT for Puerto Rican adolescents with depressive symptoms

This study compared individual (I) to group (G) formats of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for the treatment of depression in adolescents. One hundred and 12 Puerto Rican adolescents were randomized to four conditions (CBT-I, CBT-G, IPT-I, IPT-G). Participants were assessed at pretreatment and posttreatment with structured interviews to establish diagnosis and with self-report measures to assess treatment outcome. The results suggest that CBT and IPT are robust treatments in both group and individual formats. However, CBT produced significantly greater decreases in depressive symptoms and improved self-concept than IPT. The implications of these findings are discussed.     

Treating Hypochondriasis with Interpersonal Psychotherapy

The treatment of hypochondriacal patients can be conceptualized as taking one of three approaches. These typically address one of the following questions: 1) “Should the patient be preoccupied?” 2) “Why is the patient preoccupied?” 3) “What are the interpersonal consequences of being preoccupied?” Interpersonal Psychotherapy (IPT) is specifically designed to address the last of these questions. IPT focuses on understanding the patient’s real distress, exploring the patient’s maladaptive communications, and modifying those communications so that others are more able to meet the patient’s attachment needs. With a focus on communication in a time-limited frame, fostered by a strong collaborative relationship, IPT appears to be an effective method of reducing hypochondriacal behavior.     

Adult attachment dimensions and specificity of emotional distress symptoms: prospective investigations of cognitive risk and interpersonal stress generation as mediating mechanisms

Three prospective studies examined the relation between adult attachment dimensions and symptoms of emotional distress (anxiety and depression). Across all three studies, avoidant and anxious attachment prospectively predicted depressive symptoms, and anxious attachment was associated concurrently with anxiety symptoms. Study 2 tested a cognitive risk factors mediational model, and Study 3 tested an interpersonal stress generation mediational model. Both cognitive and interpersonal mediating processes were supported. The cognitive risk factors pathway, including elevated dysfunctional attitudes and low self-esteem, specifically mediated the relation between insecure attachment and prospective elevations in depression but not anxiety. For the interpersonal stress generation model, experiencing additional interpersonal, but not achievement, stressors over time mediated the association between insecure attachment and prospective elevations in depressive and anxious symptoms. Results advance theory and empirical knowledge about why these interpersonal and cognitive mechanisms explain how insecurely attached people become depressed and anxious.     

Interpersonal psychotherapy: A review and multicultural critique

Interpersonal psychotherapy (IPT) is a therapeutic approach focusing on the role of interpersonal dynamics in creating psychological difficulties that may be particularly relevant to the field of counselling psychology. IPT’s development within randomized controlled trials in the 1970s resulted in a strong empirical foundation without a cohesive theory. Regardless, theorists have since created a theoretical framework for IPT, which has received empirical support. Counselling psychologists have contributed to this research base and may have unique expertise to enhance IPT. Specifically, counselling psychologists can help integrate multicultural and diversity perspectives into IPT with the goal of creating a more culturally competent approach. For example, several aspects of IPT can be expanded to reflect these perspectives, such as integrating cultural sensitivity, cultural knowledge, cultural empathy, and cultural guidance. The authors conclude that IPT is a well-researched and effective treatment approach that holds potential for continued development within counselling psychology.     

Interpersonal Psychotherapy for Late Life Depression: Current Status and New Applications

Interpersonal Psychotherapy (IPT) is an empirically-supported treatment for depression and other mental disorders. This article discusses the structure of IPT, its use with older adults, and research that supports its efficacy with depressed older people. Depressed older persons with significant health problems or cognitive impairment present special challenges for those conducting IPT and other psychotherapies. Promising new psychotherapies developed for depressed older adults with cognitive impairment and those living in nursing homes are reviewed. Recommendations are made for use of IPT with older adults in nursing homes.     

Interpersonal psychotherapy for eating disorders with co-morbid depression: A pilot study

Objective: Patients with eating disorders (ED) often suffer from co-morbid depression, which may complicate the ED treatment. Previous studies have found that ED interventions seem to have limited capacity to reduce depressive symptoms. Several studies of interpersonal psychotherapy (IPT), have found that when patients have been treated for depression, co-morbid symptoms have diminished. As depression and EDs are commonly co-occurring conditions, this pilot study aimed to examine the effect of an IPT treatment for these conditions, with the focus on the depressive symptoms.

Method: In this multi-centre study, 16 patients with EDs and co-occurring major depression received 16 weeks of depression-focused IPT.

Results: Significant improvements with substantial effect sizes were found for both depression (d = 1.48) and ED (d = .93). Symptom reduction in the two syndromes were strongly correlated (r = .625, p = .004). Patients with a restrictive ED did not improve on either depression or ED symptoms.

Conclusion: These findings point to the usefulness of IPT for concurrent depression and ED with a bingeing/purging symptomatology. Working with negative affect and problem-solving related to current interpersonal problems may alleviate general psychological distress among these patients.     

Interpersonal Style, Stress, and Depression: An Examination of Transactional and Diathesis-Stress Models

The present study examines a transactional, interpersonal model of depression in which stress generation (Hammen, 1991) in romantic relationships mediates the association between aspects of interpersonal style (i.e., attachment, dependency, and reassurance seeking) and depressive symptoms. It also examines an alternative, diathesis-stress model in which interpersonal style interacts with romantic stressors in predicting depressive symptoms. These models were tested in a sample of college women, both prospectively over a four-week period, as well as on a day-today basis using a daily diary methodology. Overall, there was strong evidence for a transactional, mediation model in which interpersonal style predicted romantic conflict stress, and in turn depressive symptoms. The alternative diathesis-stress model of depression was not supported. These results are interpreted in relation to previous research, and key limitations that should be addressed by future research are discussed.     

Adult attachment styles,self‐esteem,and depressive symptoms: A comparison between postpartum and nonpostpartum women in Korea

Life stress related to child bearing has been suggested to increase the risk of maternal depression in vulnerable women who have an insecure relationship. This study examined the relationship between adult attachment security and maternal depression in postpartum women as compared to nonpostpartum women. A total of 254 Korean women were recruited from pediatric hospitals, of whom 119 were in the postpartum period. Participants completed the Relationship Questionnaire, the Beck Depression Inventory, and the Rosenberg Self‐Esteem Scale. Both preoccupied and fearful attachment styles were associated with low self‐esteem and higher levels of depressive symptoms, but a dismissing attachment style was not related to self‐esteem and depression severity. Low self‐esteem was found to mediate the relation between insecure attachment and depression severity; however, this mediating effect differed depending on the insecure attachment style. For preoccupied attachment, the role of self‐esteem as a mediator was observed only in postpartum women, not in nonpostpartum women (moderated mediation). In contrast, for fearful attachment, the mediating effects emerged in both groups. The results highlight the fact that there is a complex mechanism behind the link between interpersonal relationships and risk of maternal depression.     

The development and content of an interpersonal psychotherapy group for postnatal depression

Postnatal depression (PND) usually causes distressing symptoms for sufferers and significant impairments in relationships. Group Interpersonal Psychotherapy (IPT-G) provides the experienced therapist with a brief, focused, and manualized approach to helping women recover from the debilitating effects of PND. This paper describes the background and development of IPT-G for PND. The evidence for the effectiveness of individual and group IPT formats with this population is summarized. The triad of theories underpinning IPT are discussed with an emphasis on the important role of attachment styles during the transition to parenthood. Its strengths, which include its unique package of targets, tactics, and techniques, are highlighted. The benefits and challenges of IPT-G are also explored, and the results of a randomized controlled trial are summarized. Finally, a case study illustrates how IPT-G specifically addresses the social role transitions, conflicts, losses, and social isolation that mothers commonly experience.     

Personality Disorder Attributes as Supplemental Goals for Change in Interpersonal Psychotherapy

Interpersonal Psychotherapy (IPT) is a manualized, short-term (usually 12–16 sessions) based on the assumption that psychological disorders often emerge secondary to social and interpersonal problems that require active intervention to achieve symptom remission. The time-limited nature of IPT compels therapists to establish the goal of diminishing, on a weekly basis, a small number of focused interpersonal problems with a decided emphasis on proximal rather than historic conflicts and associated patterns of behavior. This strategy discourages the adoption of diffuse therapy goals and directions that have more opportunity to emerge in long-term, unstructured treatment modalities. The role of traditional personality testing in short-term therapy, when it occurs, is to identify and quantify symptom clusters that warrant attention as dependent measures in the treatment process. The role of personality factors in the genesis or maintenance of psychological disturbance is rarely addressed. The present article explores theoretical and pragmatic objections to the use of personality testing in IPT. A method is proposed for the limited but systematic incorporation of personality testing in the IPT treatment process using the Millon Clinical Multiaxial Inventory (MCMI-III). While unreasonable to expect personality transformation through short-term therapy, the partial attenuation of maladaptive behavioral, attitudinal, and emotional reactions to stressors could prove exceedingly helpful to short-term treatments such as IPT.     

Attachment Patterns in Medically Serious Suicide Attempts: The Mediating Role of Self‐Disclosure and Loneliness

Although the study of medically serious suicide behavior is an important strategy for understanding the nature of suicide, little is known about its underlying psychological mechanisms. This gap is addressed here by applying insights from attachment theory to severe suicidal behavior. The results show that both anxious and avoidant attachment patterns predict medical lethality. Path analysis indicated that interpersonal difficulties mediated the paths between insecure attachment patterns and lethality of suicide attempts. These results suggest that the psychological mechanisms of medically serious suicide behavior involve high levels of mental pain amplified by insecure attachment patterns and interpersonal difficulties. Implications for prevention and therapeutic intervention strategies are discussed.     

Interpersonal predictors of onset of depression during the transition to adulthood

There is evidence that depression during adolescence and early adulthood is marked by deficits in interpersonal functioning. However, few studies have prospectively examined whether interpersonal difficulties are a risk factor for depression onset, so it is unclear whether these deficits in interpersonal functioning are products or predictors of depression. The present study aimed to clarify the direction of association between interpersonal factors and depression by examining whether social factors longitudinally predicted onset of depression in a diverse sample of young women with no history of depression. Hierarchical multiple regression analyses controlling for baseline depressive symptoms indicated that poorer family relationship quality and anxious attachment cognitions predicted onset of depressive episodes during the 2‐year period. Further, a wide variety of interpersonal factors predicted depressive symptoms over 6 months, including poor peer and family relationship quality, difficulty being close to others, and difficulty depending on others, controlling for baseline depressive symptoms and college attendance. The results provide evidence for the importance of an interpersonal perspective on vulnerability to depression.     

A mediation model linking attachment to God,self-compassion,and mental health

Attachment theory posits that insecure attachment is a risk factor for the development of anxiety and depression and ample evidence supports this idea. Research has also demonstrated links between attachment to God and mental health, but little is known about the emotion regulatory mechanism that underlies this relationship. The present study explored the explanatory role of self-compassion in the relation between attachment to God and anxiety, depression, and life satisfaction in a sample of 181 adults who completed an online survey. Elevated attachment anxiety and avoidance were associated with higher depression and anxiety, and lower life satisfaction. Self-compassion mediated these associations (in an inverse direction for anxiety and depression), suggesting that people who feel uncomfortable depending on God, or who fear God's rejection, have difficulty extending kindness to themselves. Possible interventions are discussed in the context of these results.     

Childhood Maltreatment,Adult Attachment,and Depression as Predictors of Parental Self-Efficacy in At-Risk Mothers

Childhood abuse and neglect can have far-reaching effects on adult relationships, mental health, and parenting. This study examined relations between maltreatment types, anxious and avoidant adult attachment, maternal depression, and parental self-efficacy in a community sample of 76 at-risk mothers. After controlling for other forms of maltreatment, emotional abuse uniquely predicted higher levels of anxious attachment and maternal depression. Structural equation modeling revealed that childhood maltreatment predicted lower parental self-efficacy through indirect pathways involving anxious attachment and depression. Specifically, maltreatment's influence on maternal depression was mediated by attachment anxiety, while its influence on parental self-efficacy was mediated by depressive symptoms. Results are discussed in terms of attachment theory and ways in which parental self-efficacy contributes to adaptive caregiving behavior.     

An interpersonal analysis of adult attachment style: circumplex descriptions,recoiled developmental experiences,self-representations,and interpersonal functioning in adulthood

Previous research suggests that the structure of adult attachment is dimensional, but the specific dimensions remain unclear. Given its relational nature, studies should examine attachment structure in association with conceptually related interpersonal constructs. The interpersonal model (Kiesler, 1996) provides an integrative framework to examine this structure and associations between dimensions of attachment security (i.e., Anxiety and Avoidance) and: 1) the dimensions of the interpersonal circumplex, 2) the five-factor model of personality, 3) recollections of mothers and fathers, and 4) current self-processes and adult social functioning. In two samples of undergraduates, the Anxiety and Avoidance dimensions were associated with a hostile-submissive interpersonal style. Canonical correlation analyses revealed that dimensions representing combinations of Anxiety and Avoidance, and roughly corresponding to the dimensions from Secure (i.e., low Anxiety and Avoidance) to Fearful (i.e., high Anxiety and Avoidance) attachment and from Preoccupied (i.e., high Anxiety and low Avoidance) to Dismissive (i.e., low Anxiety and high Avoidance) attachment related to the interpersonal constructs. The Secure to Fearful dimension (i.e., overall attachment security) seemed to share relatively more variance with the interpersonal constructs. These dimensions were associated with theoretically consistent characteristics, recollections of early experiences with parents, self-representations, and social functioning.     

An Interpersonal Analysis of Adult Attachment Style: Circumplex Descriptions, Recalled Developmental Experiences, Self-Representations, and Interpersonal Functioning in Adulthood

Previous research suggests that the structure of adult attachment is dimensional, but the specific dimensions remain unclear. Given its relational nature, studies should examine attachment structure in association with conceptually related interpersonal constructs. The interpersonal model ( Kiesler, 1996 ) provides an integrative framework to examine this structure and associations between dimensions of attachment security (i.e., Anxiety and Avoidance) and: 1) the dimensions of the interpersonal circumplex, 2) the five‐factor model of personality, 3) recollections of mothers and fathers, and 4) current self‐processes and adult social functioning. In two samples of undergraduates, the Anxiety and Avoidance dimensions were associated with a hostile‐submissive interpersonal style. Canonical correlation analyses revealed that dimensions representing combinations of Anxiety and Avoidance, and roughly corresponding to the dimensions from Secure (i.e., low Anxiety and Avoidance) to Fearful (i.e., high Anxiety and Avoidance) attachment and from Preoccupied (i.e., high Anxiety and low Avoidance) to Dismissive (i.e., low Anxiety and high Avoidance) attachment related to the interpersonal constructs. The Secure to Fearful dimension (i.e., overall attachment security) seemed to share relatively more variance with the interpersonal constructs. These dimensions were associated with theoretically consistent characteristics, recollections of early experiences with parents, self‐representations, and social functioning.