Casebook of Interpersonal Psychotherapy

Casebook of Interpersonal Psychotherapy

edited by John C. Markowitz, MD, and Myrna M. Weissman, PhD. Oxford University Press, New York, NY, 2012, 481 pages, $55.00 (paper).

Although the editor of the book review section of the Journal did not know it, when he asked me to review the Casebook of Interpersonal Psychotherapy, he was providing me with a unique opportunity. In late 1970, I was among the clinicians initially trained in interpersonal psychotherapy (IPT) by Gerald Klerman and Myrna Weissman, and I participated in the early trials of the treatment that included videotaped therapy sessions that were evaluated by them. This initial work focused on the treatment of depression and resulted in the first IPT manual published in 1984.1 Subsequent editions2,3 have extended the application of IPT to other disorders and, in the case of this volume, to diverse populations (eg, medically ill individuals, patients in developing countries) and the delivery of IPT in differing formats (eg, groups and by telephone). One need only scan the list of authors of this Casebook to see that IPT is being utilized throughout the world.

The growth of IPT from a treatment that was initially a research endeavor has been the result of many clinical studies that have shown its efficacy. Each author provides a thorough review of the literature on treatment effectiveness for the particular situation being explored. This aspect of the book is a powerful reminder of how much the field of psychotherapy research has developed since the advent of IPT. In their introduction, the editors note that the absence of readily available videotapes of IPT has left clinicians without adequate clinical data to assist them in the application of the principles and techniques that are described in the IPT manuals. One of the authors’ goals was to provide a companion to the IPT manual, and one of the great strengths of this volume is the extensive, verbatim clinical material that is included in most chapters.

The editors provide a clear framework for understanding the principles 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" (p 4). IPT conceptualizes each patient’s clinical status from the perspective of 1 of 4 problem areas: grief, role dispute, role transition, and interpersonal deficit. Since, by definition, IPT is a brief psychotherapy, framing the patient’s problem is essential to focus both patient and therapist upon the specific task of the therapy. The 22 chapters of the book cover a wide range of clinical problems and effectively demonstrate how to formulate a case and conduct psychotherapy from the IPT perspective. The reader will also gain meaningful knowledge about how best to structure and conduct any brief psychotherapy, regardless of the theoretical orientation.

As one reads this volume, it soon becomes evident that the basic principles of IPT are rigorously applied and that IPT is a clinical method that has been manualized. At times it seems that the therapist as well as the therapy has been manualized. While, to some degree, this is an artifact of the book’s format of multiple authors, this is an unavoidable aspect of learning therapy from a manual and it certainly does not characterize the clinical material. The therapists are attuned, flexible, and thoughtful, and the therapy transcripts convey a personalized atmosphere. Having been invited into the consulting room, the reader is provided a thorough understanding of the techniques central to IPT: using the medical model to provide the patient with a "sick role," taking an interpersonal inventory, clarification, communication analysis, encouragement of assertiveness, facilitating the expression of affect, validation, affirmation, and role playing. With regard to conceptualizing the patient’s symptoms as a medical illness, the authors emphasize only the positive ramifications of this stance: normalizing the condition, alleviating the patient’s experience of shame and responsibility, and monitoring the responsiveness of the illness to treatment. I believe that the book would have been helped had there been some exploration of the fact that this position implies that the patient did not contribute anything to the development of the condition, something that is contradicted by the therapists’ conviction that IPT will facilitate changes in behavior that will result in the alleviation of symptoms and will reduce the likelihood of recurrence.

IPT intently focuses on the present and explicitly avoids exploration of painful experiences from the past. By implication, the authors are to some degree setting up psychoanalytic psychotherapy as a straw man, suggesting that it immerses patients in painful memories and pays inadequate attention to the present, interpersonal world in which they live. While this attitude toward past experience may have been more prevalent at the time when IPT was being developed, it certainly does not reflect current psychoanalytic thought with its emphasis on a two-person psychology, careful attention to here-now experience, and the co-construction of the therapeutic relationship. At times, deciding not to explore the relevant past reflects an overly strict adherence to "the manual." This was most evident in one case in which the patient, whose depression was a response to having an autistic daughter, was not helped to see that the child’s birth recruited the patient’s reaction to growing up with an autistic sister. I think that making this connection explicit would not have resulted in avoidance of her present situation and would have facilitated and reinforced her progress. I would add, however, that it seems likely that the patient probably made this connection on some level and that her "understanding" of the connection contributed to the success of the treatment.

For a treatment that is organized around consideration of the patient’s interpersonal relationships, IPT rarely explores the relationship most accessible to patient and therapist, namely the patient-therapist relationship. As with avoidance of the past, concern that attention to the patient-therapist relationship could siphon attention away from the patient’s interpersonal world sometimes results in ignoring a situation that could be usefully explored. In one instance, the therapist notes that the patient "disregarded what I said" (p 272) and seemed "detached." There is no indication that the therapist directly addressed the patient’s stance, something that I believe might well have brought a particular behavior into focus in the consulting room so that it could more fruitfully be explored with regard to other relationships. The book would benefit from some discussion of how IPT clinicians decide whether to explore the patient-therapist relationship.

Since IPT is centered on a careful examination of the patient’s interpersonal relationships, an important question in every treatment is whether to involve the patient’s significant other(s). In some cases, the spouse is included, but, for the most part, the clinician elects to meet with the patient alone. The positive treatment outcomes attest to the successful impact of this strategy, but the book would be improved by a more extensive discussion of this issue.

This book is an important addition to the literature on brief psychotherapy. It will be useful to both the novice and the experienced psychotherapist. It will prod therapists who primarily provide more extensive psychotherapies to consider more actively when a brief therapy such as IPT may allow the patient to achieve meaningful and lasting change. Additionally, the extensive bibliography is an excellent resource for those wishing to learn more about psychotherapy research.

References

1. Klerman GL, Weissman MM, Rounsaville BJ, et al. Interpersonal Psychotherapy of Depression. New York, NY: Basic Books; 1984.

2. Weissman MM, Markowitz JC, Klerman GL. Comprehensive Guide to Interpersonal Psychotherapy. New York, NY: Basic Books; 2000.

3. Weissman MM, Markowitz JC, Klerman GL. Clinician’s Quick Guide to Interpersonal Psychotherapy. New York, NY: Oxford University Press; 2007.

David I. Joseph, MD

dijoseph@verizon.net

Author affiliation: George Washington University School of Medicine and Health Sciences, Washington, DC.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2013;74(6):e561-e562 (doi:10.4088/JCP.13bk08471).

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