Introduction

JOHN C. MARKOWITZ AND MYRNA M. WEISSMAN

Interpersonal psychotherapy (IPT) is a time-limited, diagnosis-targeted, empirically validated treatment that has been tested in numerous randomized controlled outcome studies (Weissman, Markowitz, & Klerman, 2000, 2007). National and international treatment guidelines recommend it as a first-line treatment for major depressive disorder and for bulimia nervosa, and it shows promise as a treatment for other psychiatric diagnoses as well. Developed in the 1970s (Weissman, 2006, 2007), IPT remained for perhaps too long an almost purely research intervention. Although results of IPT trials were repeatedly published in psychiatric and psychology journals, only a handful of clinicians actually practiced it. This was due in part to the paucity of programs in psychiatry, psychology, and social work in the United States offering training in evidence-based psychotherapy, and particularly in IPT (Weissman, Verdeli, Gameroff, et al., 2006).

In the past decade or so, the success of IPT in the research arena has led to its increasing dissemination among practitioners. The International Society for Interpersonal Psychotherapy (ISIPT; http://www.interpersonalpsychotherapy.org) has held three highly successful and well-attended meetings for researchers and clinicians. IPT workshops are conducted at professional meetings and as freestanding events in the United States and around the world. Various IPT manuals have been translated into Danish, French, German, Italian, Japanese, Portuguese, and Spanish. With greater clinical interest comes the need for greater information about IPT. Clinicians learn techniques from IPT manuals (Weissman et al., 2000, 2007) but often want more. There is a dearth of videotapes illustrating IPT practice. This casebook is intended as a response to this need for more clinical information.

A casebook can serve several functions. As a companion to the IPT treatment manual (Weissman et al., 2007), this book expands available clinical illustrations of treatment techniques, providing a wealth of additional clinical material. This casebook offers detailed narratives from master clinicians, specialists in particular areas and adaptations of IPT, in action with actual (appropriately disguised) patients. The goal has been to put you in the office with them, to observe and to understand the process of IPT cases over expert shoulders — in other words, to let these experts teach through demonstration. We believe the casebook fills a clinical need for further, fuller exploration of the conduct of IPT.

IPT has a simple paradigm: it defines the patient’s problems as a treatable medical diagnosis, and links the patient’s affective distress to interpersonal situations in order to help the patient better understand and handle them. This model has worked extremely well and flexibly in a variety of situations, as the current volume should demonstrate. Nonetheless, psychotherapy must always be tailored to the specifics of the encounter, and it makes sense to adjust the model to different diagnoses, cultural situations, chronicity of symptoms, treatment formats, etc. The cases in this book describe the various adaptations of IPT and also depict problem areas that inevitably arise in working with patients. These are not clean, idealized treatments, but real-life, warts-and-all portraits of IPT. The authors have illustrated not only broad themes and particular techniques of IPT, but also turning points in treatment: some hint of why treatment has worked in a particular clinical context. We hope that these case presentations will provide useful clinical and conceptual examples to clinicians who are interested in IPT in particular, and in psychotherapy more generally.

The book contains four sections: Mood Disorders, Other Psychiatric Disorders, Treating Major Depression in Diverse Populations, and Using IPT in Differing Formats. We begin with mood disorders because major depressive disorder was the original target of IPT (Klerman, DiMascio, Weissman, et al., 1974; Weissman, 2006) and remains the diagnosis both best supported by outcome research and for which IPT is probably most widely used. Authors present cases to illustrate each of the four IPT problem areas—grief, role dispute, role transition, and interpersonal deficits. Other chapters present adaptations of IPT for dysthymic and bipolar disorders.

The second section comprises chapters in which cases illustrate the application of IPT to non-mood disorders: bulimia, posttraumatic stress disorder, social phobia, and borderline personality disorder. The third section explores adaptations of IPT for particular patient subgroups, including adolescent and geriatric depression, depressed patients with medical illness, and patients in different cultural settings. The final section deals with variations in IPT formats: maintenance IPT, inpatient, group, and telephone delivery.

Each chapter follows the same general format. It opens with a brief discussion of the empirical evidence supporting IPT for the patient population of interest. The authors do not undertake lengthy reviews of the empirical literature, but this introductory section should inform the reader of how confident he or she can be in treating this kind of patient with IPT. Where appropriate, there follows a discussion of the rationale for and adaptations of IPT for this patient population.

This brings the reader to the heart of the matter: a detailed case illustration of IPT applied to a particular clinical diagnosis or setting. Cases derive from actual practice and are generally complex. The authors have attempted to illustrate the problems they faced as therapists treating often severely ill patients, and the maneuvers they employed to resolve them. Elements of the case history include:

  • 1. History of present illness
  • 2. An interpersonal inventory, cataloguing the patient’s key relationships, supports, interpersonal difficulties, and patterns of relating
  • 3. Psychiatric, family, and medical history
  • 4. Differential diagnosis and indication for IPT
  • 5. The therapist’s thinking in developing a formulation, and a description of the formulation actually presented to the patient
  • 6. Detailed exposition of the middle phase of treatment, describing specific interventions employed and problems that arose: What did the patient say? What did the therapist say? Then what happened?
  • 7. Termination, including discussion of the issue of maintenance treatment and any follow-up therapists had on the patient’s subsequent course
  • 8. Use of rating scales demonstrating change in symptoms, functioning, and other domains
  • 9. The authors then discuss their cases, making observations specific to the treatment population and on the benefits and limitations of the course of treatment

The range of material shows how widely IPT has spread in its relatively short existence. Different diagnoses require differing expertise and clinical wisdom. Mixed through the cases the reader will find a series of clinical dilemmas that may compound the conduct of IPT, or any therapy: working with patients’ negative affects (Markowitz & Milrod, 2011), emerging clinical risks, comorbidities, cultural factors, therapist and patient disagreements, and the like. Therapists describe their own emotional reactions to difficult clinical situations. We have enjoyed and learned from reviewing our expert colleagues’ excellent, if not always easy, treatment reports. We trust that you will as well.

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