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In the early 1970s, the late Gerald L. Klerman, M.D., and Myrna M. Weissman, Ph.D., developed IPT with their colleagues at Harvard and Yale Universities in order to include psychotherapy in a randomized controlled trial of pharmacotherapy for outpatients who had major depressive disorder. This relatively simple therapy was based on the theoretical work of Sullivan (1953), Bowlby (1973, 1988, 1998), and others who had argued that early and current interpersonal relationships were importantly related to psychopathology. Moreover, it was based on empirical evidence that the death of significant others (complicated bereavement), struggles and estrangement in interpersonal relationships (role disputes), major changes in life course (role transitions), and social isolation (interpersonal deficits) were often either precipitants or consequences of episodes of mood disorder. Social supports protect against depression, whereas their absence increases the risk of illness. The original IPT manual defines a few central treatment principles. Major depression is defined as a treatable medical illness, rather than being the patient’s fault, failure, or inner defect. Giving patients the temporary medical "sick role" absolves them from activities that depression precludes their doing while also underscoring the responsibility of patients to be patients, to work to regain their health. The initial claim for IPT, as a 12- to 16-week treatment, was that it might relieve symptoms of a major depressive episode but would not change character, which was not its intended target.
A second treatment postulate is the connection between mood and life events. Upsetting events lead to negative moods, and depressed moods conversely impair interpersonal functioning, leading to further negative events. This linkage is not proposed as an etiologic explanation for mood disorders, because their cause is both unknown and clearly multidetermined by some combination of genes, early environment, and recent functioning and stressors. Rather, the link between mood and situation becomes the focus of treatment. Precipitants to a depressive episode lead the therapist to define one of four interpersonal problem areas as the treatment focus: A death leads to focusing on resolving complicated bereavement; a relationship struggle, to solving a role dispute; a life change (a new job, geographic move, divorce, etc.), to integrating a role transition; social isolation, to redressing interpersonal deficits. With the patient’s explicit agreement, the specified problem area becomes the theme of the treatment. Each interpersonal problem area evokes a set of related but distinct treatment strategies. Moreover, each session is structured to focus on the patient’s interpersonal successes or failures. If the patient has done well in an interpersonal situation the previous week, the therapist reinforces adaptive social skills. If events have gone badly, the therapist expresses sympathy, ascertains the patient’s feelings about this setback, encourages the patient to explore other available interpersonal options, and role plays them as practice for the upcoming week. It seems logical that a therapy concentrating so thoroughly on the interpersonal might help patients to develop interpersonal skills. In addition, IPT has been shown to relieve depressive symptoms.
This brief summary does not fully describe IPT, which also makes use of the "common factors" of psychotherapy to form a supportive, therapeutically optimistic alliance. To differentiate it from cognitive behavioral therapies, we should note that IPT is considerably less structured; that treatment focuses on affect and interpersonal responses, rather than on cognitions; that IPT therapists do not assign homework, although the resolution of the interpersonal focus (e.g., role transition) is the overarching task of treatment. Psychodynamic psychotherapy is still less structured than IPT and tends to focus on transference and the therapeutic dyad, whereas IPT concentrates on the patient’s life outside the psychotherapist’s office and does not interpret dreams or transference. IPT also differs from other interpersonal psychotherapies, which tend to be more psychodynamically oriented, less focused on diagnosis, and less structured. The history of IPT has involved a series of open and randomized controlled trials testing the efficacy of this straightforward approach to patients who have unipolar, bipolar, dysthymic, and subsyndromal mood disorders; eating disorders; substance disorders (with which IPT was notably inefficacious in two trials); and more recently anxiety disorders. Until recently IPT was almost exclusively a research intervention, but its success in these research studies and inclusion in treatment guidelines have led to greater clinical interest and dissemination.
Rationale: Why Treat Borderline Personality Disorder by Using IPT?
Borderline personality disorder is often comorbid with mood disorders. Hence although IPT therapists have focused on the latter, in treating patients who have mood disorders, IPT therapists have inevitably crossed paths with BPD patients. In IPT studies that have included depressed patients who have comorbid BPD, those who have comorbid BPD have reported greater depressive symptom severity than depressed patients who do not have personality disorders; comorbid personality disorders appear to make it more difficult for therapists to maintain treatment adherence; and depressed patients who have comorbid BPD may have a slightly worse outcome than patients who have major depressive disorder alone. Nonetheless, patients who have comorbid BPD and mood disorders have appeared far from untreatable even in studies not designed to address their personality pathology. Thus even though formal research has been lacking, BPD represents not entirely unfamiliar territory for IPT therapists.
Although the diagnosis of BPD has been used pejoratively by some therapists to label difficult patients, and although the reputedly poor prognosis has tended to elicit fear and resignation from therapists, several recent studies have suggested hopeful outcomes. The pioneering work of Linehan in dialectical behavioral therapy (DBT), an adaptation of cognitive-behavioral therapy for self-destructive patients who generally meet criteria for BPD, found that year-long individual and group treatment lowered rates of self-mutilation, hospitalization days, and overall treatment costs compared to treatment as usual. These results have been replicated by others. Bateman and Fonagy (2001) reported that BPD patients who received 18 months of psychodynamic psychotherapy in a day hospital setting showed similar improvement in parasuicidal behavior as well as in depressive symptoms.
The multisite Collaborative Longitudinal Personality Disorders Study, which prospectively tracks the naturalistic course of individuals who do or do not have personality disorders, found that only 44% of a carefully diagnosed sample of 175 patients who have BPD still met diagnostic criteria after 1 year; it is not clear that all of those subjects were even receiving treatment. Thus, although clinicians have historically feared borderline personality disorder, it may be more treatable, and its prognosis brighter, than many patients and therapists would previously have believed.
Overlap With Mood Disorders: The majority of individuals who meet criteria for BPD also meet criteria for a lifetime or current mood disorder, usually major depressive disorder or dysthymic disorder; that finding is not surprising, inasmuch as mood disorders and BPD overlap in their symptoms. Indeed, Akiskal, Yerevanian, Davis, King, and Lemmi (1985) previously suggested that BPD is a subtype of chronic mood disorder. Because IPT has shown benefits for patients who have mood disorders, it seemed a reasonable candidate for use with patients who have BPD as well.
Interpersonal Aspects of BPD: A principle of IPT is that life events influence mood and vice versa. IPT therapists repeatedly remind patients of this fact, because the connection is a potentially useful one: It is helpful to read one’s emotional reactions as clues to what is happening in daily encounters, and to use such cues to respond appropriately to those situations. Using interpersonal skills effectively leads to better outcomes in such encounters, successes that in turn may improve a patient’s sense of mastery of the interpersonal domain and improve mood. IPT has been shown to improve interpersonal functioning for patients who have mood and anxiety disorders. Yet although interpersonal events are ubiquitous, the use of an interpersonally focused psychotherapy may not always avail in treating patients. Outcome research should determine its utility for particular diagnoses.
Unlike some psychiatric syndromes in which the psychopathology seems primarily internally focused (e.g., obsessive compulsive disorder, schizophrenia, schizoid personality disorder), borderline personality disorder is partly defined by maladaptive interpersonal behaviors. Among its nine diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, in the fourth edition (DSM-IV) are "frantic efforts to avoid abandonment," "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation," and "inappropriate, intense anger or difficulty controlling anger," as repeatedly displayed in confrontations with others (American Psychiatric Association, 1994). These interpersonal difficulties, a hallmark of BPD, provide appropriate targets for IPT intervention. Connecting these dysfunctional patterns should both improve the patient’s life situation and alleviate aspects of the borderline diagnosis. Presumably, gains in the interpersonal sphere would boost the morale of the patient and lead to generalized symptomatic improvement.
Borderline Personality Disorder
- National Institute of Mental Health. Borderline Personality Disorder. U.S. Department of Health and Human Services.
Reflection Exercise Explanation
Reflection Exercise #1