An excerpt from the upcoming book:

Interpersonal Psychotherapy: A Clinician’s Guide 3rd Edition (Chpt 1, in press).

   “Defining” IPT is challenging.  In fact, the rest of this book is a response to that challenge.

   The question, in a nutshell, is “what makes IPT uniquely IPT?”  And more specifically, how can IPT continue to be true to its empirical roots while fostering innovation and increased effectiveness when used in real clinical situations?  On a grand scheme, the advice of Albert Einstein is apropos; he was famously quoted as saying, “Everything should be made as simple as possible, but not simpler.”       

   A good start then, is to define what the key elements of IPT are— what elements absolutely must be present in order for a therapy to be IPT–  and to describe how these elements can be flexibly applied across both research and clinical settings.  A metaphor and some Greek lessons are a great way to begin that task…

   Airplanes.

   Take a moment……  to consider an airplane.  Picture an airplane in your mind’s eye.

   When asked to consider an airplane, you almost certainly, and likely instantaneously, generate a mental picture of a particular airplane.  Maybe it is a 747 jumbo jet, maybe an F-16 fighter, maybe a small commuter plane.  Our minds go to particular instances and examples rather than concepts.

   But how would you define what an airplane is?  What are its indispensable core components?  At what point does it cease to be an airplane and become something else?

   You might start with the principle that an airplane has wings.  But how should wings be defined?  Must they be fixed wings, or could they be flexible or movable?  While stealth planes are clearly airplanes, it’s hard to define exactly where their wings are.  How would this be incorporated into your definition of an airplane?

   How about the principle that an airplane has a power source to generate flight?  Certainly this is a characteristic of many planes, but there is no power source for gliders. 

   Is a paper airplane an airplane?  If not, why not?  What about a photograph or drawing of an airplane?  Is there such a thing as a faux or “fake” airplane?  What makes an airplane a “real” airplane?

   According to the dictionary, an airplane is a “powered heavier-than air aircraft with fixed wings.”  This is in essence a tautological definition; it defines an airplane as an airplane.  Frankly, it’s pretty useless.  Similarly the Socratic approach of referencing idealized forms as a way of defining an object or concept is fine for philosophy, but it’s not particularly practical or useful when you need to fly to Chicago.

   Aeronautical engineers care a great deal about the specifics of airplanes.  They are interested in whether the wings sweep back at a 45 or 46 degree angle.  They care about the number of propeller blades and the bolts holding the engine to the fuselage.  They use wind tunnels and computer simulations to test their designs, and then translate those into real machines.  They want to ensure that airplanes, no matter how they are defined, can actually fly.  They have essential jobs.

   But when I fly in an airplane, I could care less about the angle of the wings or the composite material they are made out of—I simply want to get from point A to point B.  And I am immensely concerned about the safety of the plane and about the experience and quality of the pilot.  I am quite interested in the cost of the flight, and carefully weigh the time flying will save me relative to a car or boat.  I care about the logistics: the comfort of the plane, the ease of getting tickets, the availability of parking at the airport, and whether or not my luggage is likely to get lost.  In short, I care a lot about what the plane does—its function—but not so much about the details of what it is.

   A good metaphor leaves the reader (or patient) space to interpose his own meaning.  But in this case, let me expand a bit.  What does all of this airplane stuff have to do with psychotherapy, and IPT in particular? 

   Our patients’ primary concern (and by extension our primary concern) is that the psychotherapy we provide is functional.  Our patients want to feel better.  They want to be better understood.  They want to have more satisfying interpersonal interactions.  They want better social support.  They want to live a life with meaning, or at least a life that is more tolerable.  If it doesn’t get our patients from point A to B, the therapy is pointless.

   For this reason, things we can do in therapy that increase the likelihood of getting our patients from point A to B more efficiently should be encouraged.  Those that do not should be jettisoned.  They are extra weight.  They decrease fuel efficiency.

   Our patients are also concerned that the therapy works for them personally.  Our patients want a psychotherapy plane that will fit their particular needs.  And our patients want a pilot they can trust.  One who is well educated, has experience, is reassuring, and who can manage a storm or engine failure competently without panicking.  They want a therapist who won’t crash the plane.

   Our patients could care less that there is empirical evidence supporting the efficacy of the therapy for an average “subject” in a research trial; they have no idea what statistical significance is or what a p value means.  What our patients really want to know is that the therapy we provide is likely to work for them personally.  That the specific therapy fits them well.  That it makes sense to them.  And frankly, they are in a far better position to judge if a therapy makes sense to them personally than we will ever be.

   There are many different types of planes.  Some are for short distances, some for long.  Some for a lot of passengers, some for a few.  Many are on fixed routes, some are chartered.  Some have more legroom and other amenities, some are much more economical.  One size does not fit all.

   What is the IPT plane like?  For starters, it is for short to mid-range flights—it is mostly for acute treatment.  It is designed to be fuel efficient, and to get from A to B quickly.  And it is built for many passengers—interaction with others during the flight is critical.  There are not many amenities, and there is certainly no free lunch.  The passengers are expected to do a lot of work during the flight.  There’s sufficient room to stretch out your legs and reflect a bit, but the seats are functional and not comfortable enough that you’d want to sit in them for hours.  Eventually you’ll have to get up and move around.

   Passengers are expected to map out the travel route with the pilot.  The logistics are important, particularly ensuring access to the flight.  It is important to be on time.  And some personal baggage, if the flight goes as planned, will be jettisoned along the way.

   Plane and pilot; therapy and therapist.  Patients have important places to go; the flight of therapy is only a means to get from A to B.  But there is much to be learned during the journey.

   So what is IPT?  A good definition recognizes both the practical components of IPT and the “Ethos” or way of being a therapist while doing IPT (the piloting of IPT).  Both are essential—they are the necessary components to fly the IPT “airplane.”  These essentials, applied flexibly, will bridge the gap between manualized approaches to IPT developed in the lab and clinical approaches to IPT refined and delivered in the community.  We’ll start in this chapter with an overview, and develop each of the elements in more detail later.

 

The Essential Elements of IPT

   As airplanes are best built by starting with a frame, so IPT can best be understood by first describing its structure.  This framework can be divided into the Theories supporting IPT (the reason why it works); the Targets of IPT (what the therapy is trying to change); the Tactics of IPT (the concepts applied in the therapy); and the Techniques of IPT (what the therapist says or does).  Though individual elements in each of these categories may be shared with other psychotherapies, their unique combination defines IPT (Table 1). 

Table 1: The Defining Elements of IPT

Theory:  

   Attachment Theory

   Interpersonal Theory

   Biopsychosocial/Cultural/Spiritual Model of Distress

   Interpersonal Triad

Targets:

   Interpersonal Relationships

   Social Support

   Distress (including Psychiatric Symptoms)

Tactics:

   IPT Structure

   Interpersonal Problem Areas

   Interpersonal Inventory

   Interpersonal Formulation

   Interpersonal Summary

Techniques:

   Interpersonal Incidents

   Communication Analysis

   Use of Affect

   Role Playing

   Problem Solving

more to come…