Comprehensive Guide to Interpersonal Psychotherapy

This updated version of Interpersonal Psychotherapy of Depression(1) pays homage to the late Gerald L. Klerman, who has been included by Weissman and Markowitz as posthumous coauthor of this truly comprehensive guide.

The book starts with an overview of the sections that structure the first half of it: the explanation of the four foci of interpersonal psychotherapy (grief, role disputes, role transitions, and role deficits), the termination of treatment, specific techniques, treatment problems, and evaluation studies of interpersonal psychotherapy. The second half of the book deals with numerous adaptations of interpersonal psychotherapy to diagnostic categories other than its original target, major depression. The adaptations also concern special comorbid disorders such as depression and HIV, specific age groups such as adolescents and geriatric patients, and formats other than individual therapy, such as group therapy, marital therapy, couple focus, and telephone consultation. A discussion of interpersonal psychotherapy in other languages and cultures is included, as well as interpersonal psychotherapy in specific settings like primary health care. Even the future of interpersonal psychotherapy is dealt with in the last chapter, on the decline of psychotherapy in the United States and the problem of diminishing proficiency of psychotherapists under the pressure of the economics of health care. The authors hope that interpersonal psychotherapy will maintain its status by its short and effective low-effort style of interventions.

The authors provide a brief historical look back to Adolf Meyer and the description of symptoms and developmental antecedents of depression in an “everyday psychopathology.” They mention the scanty evidence for subtypes of depression as well as some of the epidemiological facts. After dwelling on bereavement, role transition, and marital disputes, the authors emphasize as specific attributes of interpersonal psychotherapy time limitation, focused work, reference to the “here and now,” and its almost exclusive concentration on interpersonal aspects. Personality is said to be taken into consideration but not as the focus for treatment. The therapist should be the patient’s advocate; therefore, transference should be worked upon only if it is negative or otherwise an impediment for therapy. The authors make a great effort to say what is not interpersonal psychotherapy, e.g., homework techniques or a focus on the self rather than an interpersonal focus.

One major task of interpersonal psychotherapy is to link symptoms to interpersonal relations. One of the best and most detailed passages in the introductory part of this book concerns role expectations and marital disputes, but neither here nor later in the book is the theoretical frame laid out or the ample literature on social role concepts and marital relationship in sociology and psychology cited. Role explication also concerns the role of the patient in the therapeutic relationship. This resembles transference analysis, but in interpersonal psychotherapy it is restricted to present behavior and thus to “maximizing self disclosure and preventing sabotaging treatment.”

One element that recurs frequently in this manual is the therapist’s encouragement of the patient to express feelings. This is fostered by concrete questions that are suggested. For example, in the case of bereavement, one can ask what has been done with the heritage of the deceased. Opposite to its psychoanalytic roots, interpersonal psychotherapy recommends active, even directive, interventions. For example, to help the patient overcome the “empty space problem” in grief reactions, dating (!) or making use of the church or of several specific organizations to facilitate new contacts is suggested. The authors also deal with “overgrieving” by presenting an example on hysterical palsy after a bereavement and the necessity to get access to anger and demands for dependency. The case vignettes demonstrate in an excellent way the benefit that can be taken from the termination of treatment, which exerts pressure on the patient for authenticity and on the therapist for stringent focusing.

The chapter on role disputes deals with nonreciprocal role expectations and the dangers of “silent treatment” of the other. Renegotiation is the aim of interpersonal psychotherapy, in this case using the resources of former relationships. Examination of similar structures of relationships in the past is reminiscent of the psychoanalytic roots of interpersonal psychotherapy, in this case the repetition compulsion hypothesis. An important element of interpersonal psychotherapy that is conveyed by the numerous case reports is avoidance of putting the blame on the patient or partner. Another important topic is the restricted repertoire of role performance of some patients. In this case, again, the psychoeducational aspects of interpersonal psychotherapy are emphasized through directive suggestions and exercises that, however, are not as formalized as those in cognitive behavior therapy. The problem of transfer of skills learned in therapy to situations of daily living is not discussed in this manual. Patients who are socially impoverished or have only unsustaining relationships need this type of psychoeducational approach.

The chapter on specific techniques again emphasizes the differences between interpersonal and psychodynamic psychotherapy, although they have many rules in common. The authors emphasize that interpersonal psychotherapy does not work with insight orientation. However, the alternative mode of learning, namely, procedural learning instead of or as complement for declarative learning, is not really laid out.

The chapter on eliciting facts and clarification also touches on values of the interpersonal psychotherapy style. The authors emphasize that eliciting details needs to be relevant; otherwise it may slide into curiosity. Their advice on how to handle contradictory information from the patient demonstrates how to respect the patient and lead the patient toward using such slips as useful tools for self-understanding without a derogatory component for the patient’s self-esteem. The directive interventions encompass decision analysis and role playing.

The chapter on common problems deals with interpersonal psychotherapy for double depression. Reference to the work on well-being therapy of such other groups as Ryff and Singer (2) is missed. The authors conclude the first section of the book by presenting data on efficacy, including preliminary data on imaging studies of response to imipramine compared with interpersonal psychotherapy.

The chapter on adaptations of interpersonal psychotherapy starts with the description of interpersonal psychotherapy for maintenance, based mainly on the studies on recurrent depression by Ellen Frank at the National Institute of Mental Health, which examined maintenance interpersonal psychotherapy sessions conducted once a month for 3 years. Apart from the frequency, the philosophy of the treatment seems not to have changed much in the maintenance version. A number of other adaptations are listed, such as interpersonal psychotherapy for dysthymic disorder, one objective of which is to “seek pockets of well-being.” The adaptation for primary care is particularly noteworthy and includes two studies on cost-effectiveness. The interpersonal counseling “for medical personnel without special training” should also be mentioned. It implies a special focus on somatoform disorders and “subdysthymic” personalities. The adaptation of interpersonal psychotherapy for HIV patients is said to be more effective than cognitive behavior therapy in that its goal is to help the patient accept grief instead of reinforcing an optimistic view when it is definitely not applicable.

The adaptations of interpersonal psychotherapy for substance abuse, eating disorders, anxiety disorders, borderline personality disorders, and many other diagnoses focus on partial aspects of interpersonal problems, such as role insecurity or social hypersensitivity. It seems doubtful whether such an expansion of interpersonal psychotherapy to all sorts of other disorders does justice to the capacity of interpersonal psychotherapy and to the therapeutic requirements of these disorders.

The book ends with an overview of the resources of interpersonal psychotherapy in group format: the interpersonal laboratory. For transcultural adaptations the book simply gives the addresses of the respective work groups who have translated interpersonal psychotherapy and worked with it. If studies have been conducted the publications are listed. No details about the cross-cultural diversity of concepts or therapies are given, although the sociological and ethnological literature provides ample material on transcultural differences of role performance. The authors raise the question of whether the pragmatism and optimism dispersed by interpersonal psychotherapy may cause a perception of “Coca-Cola”-like Americanism. The chapter on training promotes a very short term of instruction (2–5 days) for professionals, depending on their experience.

Given the great merits of the authors, particularly the life work of Drs. Weissman and Klerman, it is hard to criticize this manual because they have been so instrumental in establishing evidence-based psychotherapy in the scientific community. And yet some limitations ought to be discussed. The language of the manual and the basic concepts are clear, plausible, and simple. The authors have done away with speculative psychodynamic interpretations. What is an advantage in terms of practice, however, may be a disadvantage in terms of theorizing. Some readers will perhaps miss a more elaborate description of the theoretical underpinnings of the manual, e.g., in the passages about life-cycle-dependent role transitions and the implicit effects on self-image and self-esteem caused by improved interpersonal competence. Theoretical underpinnings are also missing when adaptations of the manual to bipolar disorder and to borderline personality disorder are suggested.

Interpersonal psychotherapy is at its best when it points out how role performance can be practiced and how role disputes may be settled and when it deals with terminating the treatment. Text and case vignettes about marital disputes convey best the style of asking and intervening that strictly avoids any kind of covert blaming of the patient, up to the statement that if the patient breaks off therapy one should consider failure of the therapy, not of the patient. Although concrete suggestions are made, the therapist does not make value judgments. This implies an ethical basis of respect and freedom for the patient that is not made explicit but strongly conveyed by many examples of interventions. The passage where it is most clearly pointed out is in the chapter on common problems, where “powerful feelings” of the psychotherapist toward the patient are discussed, nothing else than what was formerly called countertransference. The objective must be the patient’s behavior.

The manual does not reflect the fact that the sociology of role performance, role interplay in marital disputes, and the variegation of cross-cultural patterns of role performance have been researched extensively in sociology and psychology. A number of models for quantitative sociometry have been worked on (3). The interplay between identity and social role adaptations has also been researched.

Another problem concerns the extension of interpersonal psychotherapy to virtually every other diagnostic group by means of rational adaptations. Given the pragmatic attitude of the authors and their contributions to evidence-based psychotherapy, they would not be expected to overgeneralize their approaches as most other schools have. It may have been more convincing to apply an adaptation of interpersonal psychotherapy to only a few diagnostic groups or to restrict its application to interpersonal problems across diagnostic boundaries. The same problem occurs in the delineation of interpersonal psychotherapy from other therapeutic techniques by pointing out what interpersonal psychotherapy should not do. This is particularly questionable when a highly efficacious psychotherapeutic technique is available, as for borderline personality disorder. In such a case, combining methods could be discussed and researched.

On the whole this is a very informative book on the practice of interpersonal psychotherapy with very good case vignettes that convey the ethical standards of respecting the person behind deviant behavior. However, it contains little theoretical discussion and has a tendency to overstretch indications.