Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show, we will be talking about an approach known as Interpersonal Psychotherapy, or IPT, with Dr. Myrna Weissman. Dr. Weissman has a Ph.D in chronic disease epidemiology from Yale University in 1974, and she has clinical training. She was a professor of psychiatry and epidemiology at Yale, and Director of the Depression Research Unit before going to Columbia University, where she is now, a professor of epidemiology and psychiatry, and Chief of the Division of Clinical and Genetic Epidemiology at New York State Psychiatric Institute.
Dr. Weissman is a faculty member in epidemiology at the School of Public Health, as well as, in the Department of Psychiatry at the College of Physicians and Surgeons at Columbia. Dr. Weissman is also the lead author of the 2007 Oxford Press book, "A Clinician's Quick Guide to Interpersonal Psychotherapy". Now here's the interview.
Dr. Myrna Weissman, welcome to the Wise Counsel podcast. You are one of the founders and developers of an approach known as Interpersonal Psychotherapy, or IPT. So let's start out by having you tell us what is Interpersonal Psychotherapy?
Dr. Myrna Weissman: Interpersonal Psychotherapy was developed about 30 years ago, and the idea is that there is a strong relationship between the development of depressive symptoms and what is going on in one's interpersonal life. Regardless of what might have caused depression - we think that depression has a strong genetic base - the development of the symptoms is usually in some interpersonal context. What IPT does is to try to understand what was going on in the person's life, when the symptoms first developed. This allows us to have a handle on what might be helpful in getting the patient back to their usual self.
We categorize the problem areas into four groups; grief, which is the death of somebody close, and disputes, which are usually some ongoing disagreement with somebody who is important to us. That disagreement might be in the stage of an impasse; people just can't agree, or there may be dissolution of the relationship because of the impasse. One tries to help the dissolution go forward or have a period of renegotiation, where there are efforts to try to make thing better for these disputes.
The third problem area is called transitions, which are changes in one's life which can be moves, retirement, a new job, a child leaving home or any of the developmental landmarks in one's life, which can cause great disruptions. Finally, a parsity of attachments; those are people who have difficulty forming relationships or sustaining them, and have few people in their life.
David: OK. You know there are already so many therapeutic approaches out there. Why did you feel the world needed another one?
Myrna: Well there aren't so many out there.
David: Did you say there are or are not?
Myrna: No, there aren't that many out there, that have been tested in controlled, clinical trials. There's a lot of therapy. Three percent of the adult population gets therapy every year. But there have really been few that have been utilized into a manual, and have been tested in controlled, clinical trials. The best-known one is cognitive therapy.
David: Right, and cognitive therapy has that's has been reported... at one time, there were big empirical claims made for cognitive therapy as being *THE* effective way to deal with depression.
Myrna: It's one effective way as shown by clinical trials. You know the same way that we have many different drugs; we need different therapies that have been tested. Because when you put them head on together, they may not look very different, but we do know that people respond to different things differently.
David: Yes, now I heard you mention the word "manual." I forget the exact phrasing that you use, but I know that the American Psychological Association has been pushing for manualized therapies. Maybe you could tell our audience a bit what that's about.
Myrna: Right, "manualize" sounds very cool, doesn't it?
David: It really does.
Myrna: But all it means is that these strategies and the techniques have been written out precisely. That doesn't mean that it's administered in a cookbook way, but there's some effort to make sure that there's a plan and a protocol, that the patient gets all that they ought to get, and it's done in a systematic way. This is also important in training, because we want to make sure that, if we train 50 people in IPT, they're all at least being exposed to the same thing.
David: OK, I'm glad to hear that it's not a cookbook.
Myrna: No. People who are inexperienced will use a manual like a cookbook, but an experienced therapist will know the nuances of how to gather information. What the manual does, is say what information you need to gather in order to help the patient sort out the different problem areas.
We actually have a brand new book, that's come out, that makes it very simple. It's called "A Clinician's Quick Guide to Interpersonal Psychotherapy", and it's published by Oxford Press. It just came out this month, it has the strategies and the techniques of IPT with lots of case examples.
David: Wonderful, and congratulations on having your new book come out. I know that probably represents the culmination of a lot of work.
Myrna: Thank you very much.
David: So backing up just a little bit, tell me more about the origins of Interpersonal Psychotherapy, which you also sometimes refer to as IPT. To what extent has it drawn on other approaches?
Myrna: It certainly has a strategy and technique all of its own. Sometimes it's hard to know what other approaches are, because they haven't been written down, except in a general way. So it's probably closest to supportive psychotherapy, but there are many different supportive psychotherapies, and they haven't really been tested in a formal way.
So it uses many of the techniques that you find in supportive psychotherapy such as communication analysis, expression of affect etc. It uses many of the same techniques, but it strategizes them in a different way. There have been studies that have taken patients receiving IPT and CBT and have had blind raters look at the tapes. They have been able to differentiate the treatments.
David: And CBT being Cognitive Behavioral Therapy again.
Myrna: That's right, yes.
David: OK, and what's the role of antidepressant medication to you?
Myrna: Well, you know the more strategies we had, the better, the more we can help people who had depression and the IPT is typically consistent with using medication. It can be used with or without medication and the usual recommendation is to one, listen temptations preference. Two, is to see the previous response, if the person has had a great response to medication then you might want to recommend it. And then, three, is the more they're out at educated science and symptoms of depression, the sleep disturbance, the appetite loss, the more medication may be indicated.
But if a person is definitely set on no medication, they should be listened to. They should at least be given an 8-week course and see what happens.
David: Is depression the only condition that IPT is used for?
Myrna: Well, first of all, for depression, their clinical trial showing it's efficacy in adolescent, in geriatric depression, there's actually books on adolescent and geriatric depression using IPT. It's been used in primary care, it's been used with pregnant women and in the post pregnant period.
So it's been used as maintenance treatment as well as acute treatment. It's been used in HIV patients who are depressed, and other patients with medical illnesses in primary care who are depressed. So there's a whole number of studies with different types of patient who have depression.
Now it has been less well tested with other disorders. There's good studies with bulimia which showed that it was effective and there was, there are three studies with drug abuse which showed it wasn't effective so we don't recommend that depressed drug addicts get IPT, frankly didn't want to take it.
There's some studies with the anxiety disorders with PTSD, but they're not very large studies. There is one with social anxiety disorder which may or may not have been covered recently. I think it hasn't. So the evidence here is I'd say less strong. Now there is a good study that used IPT as agent treatment for bipolar disorder and in that study they used IPT to help to moderate the patient's social rhythms.
Because, if a person has bipolar disorder and they are also are subjected to a lot of stress, such as; even the stress of international travel and jet lag, or the stress of a new job, or the stress of something in their life, they are more apt to be thrown into a manic episode. What this does is help the patient to monitor those social rhythms, and IPT is used as an agent treatment to medication. It's not recommended that it be used in studied medication.
David: Well, it sounds like there's been a lot of research done on this. So, it must have been around for a while. How long has IPT been around?
Myrna: Oh, it started about 30 years ago. It was part of the first study by Jerry Clement to look at maintenance treatment of depression using drugs and psychotherapy. At that time, the only treatment that had been formalized was CBT by Aaron Beck. Jerry thought that while Aaron Beck did a marvelous job in spelling out in a manual what the procedures are for CBT, most patients were not getting anything like CBT. They were getting something called supported psychotherapy although it wasn't clear what that was because it wasn't spelled out.
So what he wanted, was a treatment that would be more consistent with general practice, but he said it had to be formalized and spelled out in a manual, the way CBT was. Then of course, it had to be tested in a clinical trial and that's how IPT started. The underlying idea was that depression does not occur in a vacuum, and the social and interpersonal vacuum that it occurs in, is very important to understand if one is to begin to help the patient in the short run.
It is based on a medical model in that the patient receives a diagnosis, depression is explained, different treatments are explored, and there is a strong diagnostic practice in the beginning of the treatment.
David: I am still interested in it's roots, I mean some ways it sounds, it reminds me of family therapy which looks a lot at the social context of the person that's embedded in, it sounds like maybe it's got some roots in psycho-dynamic approaches, the newer formulations of psychoanalytic thought, I can't tell if it's got some integration of material from behavioral therapy. Can you say a little bit more about, you know what theoretically....
Myrna: Well it's got, mostly, it's based on some of the writings of Harry Stack Sullivan; who said that the personality of a patient is really manifest in the social relationships and that it's the social relationships that one has to work on to afford a change in psychotherapy.
It's also based on the ideas of Bolde; that attachments and the severing of attachments are what is usually involved in the developing of depressions. Those attachments can be through death, through disputes or through transitions, through changes in one's life. Somebody moves to a new neighborhood and all their close friends are... those relationships change.
David: You mentioned that there was a study in which IPT was compared to cognitive behavioral therapy and that the raters could tell the difference. If I were a fly on the wall, what would I see that would let me know that this was different from cognitive behavioral therapy or Rogerian therapy or some other approach?
Myrna: OK, well if this were cognitive behavior therapy, the patient would be asked, would be, their thoughts would be evaluated and their cognitions. They would be helped to evaluate whether their cognitions and thoughts were realistic. Now, when they say, well my, all is lost, I lost my job, they don't care for me anymore, I am over the hill, then that those thoughts, those automatic thoughts would be challenged, you know how true is that.
David: Right, yes.
Myrna: In IPT if one lost one's job, one would talk about, one would need to deal with the disputes that led to that or to the transition and how to move on to the next phase of life. In Rogerian therapy, and the IPT therapist is active. The Rogerian therapist isn't, reflects what the patient says.
Also, in psycho-dynamic psychotherapy, you deal with the transference. With early childhood, IPT does not deals with early childhood or with the transference.
David: So it sounds like it's very pragmatic in its orientation?
Myrna: Yes, I would say so.
David: How long is the typical course of treatment?
Myrna: Well, the question is hard to answer because it's varied because of different research studies, everything from 12, eight weeks, 12 weeks, 16 weeks to three years monthly, and those are different research projects. The important idea is that you have a contract with the patient at the beginning. So there is a time limit and you set goals. In acute treatment it's usually four months, 16 weeks. But it's varies greatly in primary case studies. It's been much shorter but the important thing is the contract is established at the beginning.
David: Yes, OK. Would it be possible for you to take us through a bit of a case history, either a natural one or one that's kind of a composite?
Myrna: I wouldn't do an actual one. You know what, I am still more comfortable doing it from my book. Could you hold on a second?
Myrna: OK, the reason I prefer to do it from the book is that the book is not, is absolutely not a patient, it's a composite...
Myrna: ...and if I do it from my head, you know I might start to not be that disciplined.
David: I understand.
Myrna: ...and I...OK so let me just get you one. This is a case of... I called it "Over-burdened and not appreciated" and it's a dispute, OK?
Myrna: Joan is a 42-year-old, and this doesn't, this represents the composite. It's a 42-year-old college graduate, three teenage children, recently started a new part-time administrative job. Her depression involves their old dispute with her husband. She felt that he didn't helped her around the house, he criticized her cooking, her dress and generally he made her feel terrible.
Since her return to work with her response to his concerns that she help with the finances, she thought he would give her more attention with working. However, he felt that he could not afford to send the children to college on one income, and that he had more disproportionate burden. John on the other hand thought he had never appreciated the time and energy it took to raise the children feeding, clothing, dressing etc.
David: That sounds like a very typical situation actually.
Myrna: Oh yeah.
Myrna: Since all this constituted a full time job outside and employment really increased her burden. Her new part time job made her feel over worked and not appreciated even more. Although she had really financial pressure, the marital relationship deteriorated, sexual relationship stopped, they barely spoke to one another. They were in an impact, so they were like shifts in the nights.
Joan started to feel resentful around the house and she argued with the kids. She started to have problems falling sleep, she was over eating, she gained eight lbs and her husband had, who had exacted opinions about her physical appearance, then criticized her about the weight. Her Hamilton score was 22 which is moderate, it's really depressed.
The therapy began with a discussion of her symptoms and their onset. It was clear that the symptoms had started after she began working, and that the harder to dispute laying her feeling unappreciated and over work. The therapist encouraged her to discuss these feelings with her husband and role played them with her during the session.
When she approached, broke the topic at home, the discussion resulted in far better communication in which her husband was able to express on that his feeling of disappointment in the relationship as well as his positive feelings about the home and the security she had created for him.
They spontaneously planned to spend at least two nights a month together, doing something just for fun. Over the course of 12 weeks her depression lifted and things were better. Now that's, one of the successful stages, they don't know it worked that way.
David: That's great.
Myrna: But that is a case of a dispute. Now how do we get to disputes and what do we say, "Let's see, some of the things we might have asked her was how she felt about what was going around with her husband, what she would like, how she would like to change things and what she thought her husband's point of view might be."
Myrna: We would discuss reluctance to approach him, how they handled differences and find ways to handle them in a non-destructive way. So some of the techniques that I spelt out here.
David: Yeah, well, thank you.
Myrna: He was in an...OK?
David: Yeah, yeah, thank you for sharing that example. I think it helps us to have a clearer, more concrete understanding of how the process might work. Let me ask you, where do you see IPT going in the future?
Myrna: Well, what we're trying to do is to develop research, to get the essence of what helps people. Most people, psychotherapy may be designed to be a lifetime profession but as that most people get very few sessions, I think five is about next on the average. So what we are trying to do is to understand what is the essence of what can be helpful and to make shorter treatments for people, so they can afford them and get them and they don't intrude in their life.
Now, obviously that isn't for people who have a lot of very serious problems, but most patients were depressed, or many, have a current issue that if you could help them over it, they might get over the depression.
David: OK, yeah, that certainly makes sense. Can I ask about your educational background?
Myrna: Well, I have a Masters in Social Work and a Ph.D. in epidemiology from Yale.
David: OK. So the therapist part of you came out of the social work training then? Is that right?
Myrna: Yeah, though the training wasn't very much.
David: And if you had...yeah go ahead.
Myrna: But it did gave me exposure to patients and made me feel more confident.
David: Yes, so it's an interesting background, I didn't realize that epidemiology could lead to the sort of career that you've had in terms of researching and writing about psychotherapy.
Myrna: Well, you know you learn a lot in the job.
David: Yeah, is that an unusual, has your career been unusual in that respect?
Myrna: As an epidemiologist I can't answer that without data. I don't know.
Myrna: I know a few people that have done that.
David: Ah-ha, well let me ask you; if you hadn't gone down this particular career path, what other career would have drawn you in?
Myrna: Oh boy. Probably medicine.
David: Ah-ha. OK.
Myrna: But I was a woman and you know, woman just, you wouldn't encouraged to do that.
David: Yeah, yeah, so how many practitioners of IPT are there out there now?
Myrna: I have the vaguest idea but there's a lot in Europe and...
David: Ah-ha. So there is an international movement then?
Myrna: There is an international society, international society has people from all over the world and they have been meeting every two years, the last meeting was in Toronto in the winter.
David: OK. Then how do they get trained?
Myrna: Well, that's a real problem, because there's a gap between evidence based psychotherapy and what's taught in the training programs in psychiatry, psychology and social work. We actually did a national survey and documented that. It was published last year in Archaistic general psychiatry. Most psychotherapies that are tried are not evidence based but it's changing greatly.
David: So you don't have a training program that you folks are running then?
Myrna: We don't, but there are training programs. Well, every year at the APA there are workshops, and there is a training program that's run out of Toronto with Paula Ravitz.
David: OK. What if a listener wanted to find an interpersonal psychotherapy therapist in their local area? How would they go about doing that?
Myrna: They usually write to me, and I put them on the network and see if we can find anybody.
Myrna: Some places are much better, like San Francisco, there's a lot, Canada and Toronto there's a lot.
Myrna: In Pittsburgh, there are a lot.
David: Great. Well I'll be putting your email address in the show notes if anybody's interested, and also a website that you are going to give me.
David: I know you wanted to talk a bit about some current research that you are involved in right now, having to do with I think genetic origins.
Myrna: Yes. Now you might ask, how does someone who does psychotherapy study genetics?
David: That's a good question.
Myrna: Yeah, it's a good question, and it's actually very simple. I don't have a conflict about that in my head. You know the brain is very responsive to the environment, and it's the environment that we might be able to change. It's pretty hard to change your genes, or certainly not yet, is it possible to do very much.
On the other hand, understanding the genetics of a disorder might help us to develop much more targeted medications. In terms of depression, we know it runs in families. I've been studying three generations, and it's highly familiar. Now, we also know that some people who have that familiar risk never get depressed. That's probably because they are not exposed to those kind of environmental things, which bring on the depression.
So I think of depression the following way; like diabetes. Adult onset diabetes is a genetic disorder, however many people don't get diabetes. On the other hand if you have a huge number of the risk factors, for example; you overeat, you don't exercise - you may develop adult onset diabetes as an adolescent. In fact we are seeing an epidemic of adolescent onset adult diabetes, because of the increase in obesity, and decrease in exercise.
Myrna: So depression is like that; that it's a genetic disorder. But it's a complex genetic disorder, and environment means a great deal. In psychotherapy, we work on the environmental triggers; grief, loss, disputes, transitions. But I'm also interested in trying to find cause, and I've been involved in a national study on the genetics of the current early onset depression. That's depression that occurs before the age of 30 and re-occurs, and we are making quite a bit of progress.
But we are looking for people throughout the country; who are over 21, have had two or more periods of depression, and their depression started before they were 30, and they have at least some family member who had something like it. We screen and interview people over the telephone. If they meet criteria, we draw blood; we have a service come to their house or they go to their family doctor. People get paid for their time and effort for this.
So, if you know of anyone who's interested or thinks they might be eligible, they should email our national coordinating center, and that is; email@example.com, or they can call toll free 877-407-9529.
David: Well, that's wonderful. I know...
Myrna: Or one other thing, if they want to just get information, they can go to http://web.stanford.edu/group/gbf/. The study is being done in seven sites throughout the United States, and the website will explain it. If they call in, and if they are eligible, they can be referred to any one of the sites in their neighborhood, in their area - but it's all done on the phone.
David: Well, that's fascinating. I'll be happy to help get the word out. In fact...
Myrna: We appreciate it. We are especially interested in getting some male depressives.
David: I have one in mind. [laughs]
Myrna: Send him to us. [laughs]
David: Yeah, who I will send to you - who I think will be interested.
David: Yeah. So Myrna Weissman, I want to thank you so much for being my guest today.
Myrna: Thank you. I appreciate have being given the opportunity to let people know about IPT, and also about the Genetic Study.
David: I hope you enjoyed this interview with my guest, Dr. Myrna Weissman of Columbia University. As I reflect back on the interview, here are the points that stand out for me. First of all, IPT is based on 30 years of research. It's primarily appropriate for people suffering from depression, and may be used in conjunction with antidepressant medications. Depression is viewed as a rising and an interpersonal context. It's not an approach that focuses on childhood traumas or transference countertransference issues between therapist and client, rather it's a very pragmatic approach.
The therapist takes a very active role, suggesting practical strategies for resolving the precipitating interpersonal difficulties. It tends to be a short-term approach. The typical course of treatment being 16 weekly sessions. If you wish to learn more, you may want to consult the new book that Dr. Weissman mentioned at the beginning of the session.
You've been listening to Wise Council, a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Council.