Dr Oluyemi Adekunte: MSc (ClinRes), MSc (MedEd), Fellow HEA, MRCPsych.
Dr Paul Wilkinson: MRCPsych, MD, IPT-UK practitioner/supervisor/trainer
Broadly, the term ‘psychotherapy’ refers to interpersonal interaction between a therapist and a patient. Traditionally, it relies on verbal and ‘face-to-face’ communications among the parties involved but the influence of the internet and social media has brought in newer dimensions to the delivery approach. Psychotherapy aims to make changes to ways of thinking, feeling and behaving that interfere with the individual’s psychological wellbeing. The purpose of this handbook is to provide insight (with some practical applications) into some of the psychotherapies that are recommended by the NICE and are readily available in NHS. Supportive psychotherapy has also been included because of its practical relevance.
Cognitive Behavioural Therapy (CBT)
Cognitive therapy was initially developed by American psychiatrist Aaron T. Beck, and has developed continuously since then. CBT is a time-limited, structured, ‘here and now-oriented’ psychotherapy. It helps patients to identify challenging and unhelpful thoughts (including beliefs and attitudes) and behaviours with the goal of improving emotions and emotional regulation and the development of positive coping strategies. The CBT model is based on the combination of the basic principles of behavioural and cognitive psychology. CBT helps patients to change how they think (‘Cognitive’) and what they do (‘Behaviour’). The balance of cognitive and behavioural strategies for a patient depends on factors such as the disorder and the patient’s developmental stage. These cognitive and behavioural changes help them to feel better. Unlike some of the other psychotherapies, CBT focuses on the ‘here and now’ difficulties and rather than emphasising on the origins of symptoms from the past, it facilitates the discovery of coping strategies in the present. CBT works on the idea that the cognition, emotions, behaviour and physiological symptoms interact together.
Behavioural Interventions are based on learning theory:
1. Classical Conditioning: This is defined as learning through association and it was discovered by Pavlov. The learning occurs when two stimuli are repeatedly paired and a response which is at first elicited by the one stimulus is eventually elicited by the second stimulus alone – Pavlov’s experiment.
2. Operant Conditioning: Based on Skinner’s theory, this is a learning method that occurs through rewards and punishments of behaviour. An individual makes a connection between a particular behaviour and the consequences.
3. Social Learning Theory: Proposed by Bandura as a theory of learning process and social behaviour. The theory is based on the tenets that new behaviours can be learned by observing and imitating others.
Principles of Behavioural Therapy:
- Maladaptive behaviours are acquired through learning.
- Motives for the behaviours are not important in the therapy.
- The behaviours can be improved by engaging the learning principles.
- Treatment targets are the maintenance factors, not historical factors
Examples of Behavioural Interventions (BI) based on classical conditioning
- Systematic Desensitization (Wolpe): This is commonly used in the treatment of phobias, in particular to stop avoidance. The patient and therapist together make a hierarchy of anxiety-provoking stimuli (e.g. from leaving house to spending a whole day in school). The patient starts trying the easiest. If they succeed in this, they will be less anxious about trying this again. They will also be less anxious about trying the next easiest task in the hierarchy, and so try that. And so on, building up to the hardest task being less anxiety-provoking, and not avoided. Sometimes it is too difficult for the patient to do these tasks, due to anxiety. In that case, cognitive techniques are employed to try to reduce the anxiety, and hence avoidance.
- Flooding: This is an approach in which an individual is put in a situation that is feared the most, but under controlled conditions. The idea is that the fear and maladaptive anxiety will go into extinction. This is rarely used in modern CBT.
- Exposure and Response Prevention (ERP): This is a core psychological intervention in the treatment of Obsessive-Compulsive Disorder (OCD). It involves exposure to a feared stimulus (e.g. dirt) and simultaneous prevention of behaviour (e.g. hand washing).
- Interoceptive Exposure: This is an effective treatment modality for panic disorder. This involves inducing physical symptoms of panic attack by engaging in activities like hyperventilation and high muscle tension. The goal is to eradicate patient’s conditioned response that the physical sensations will lead to episode of panic attack. There are 2 important terminologies that are relevant in this learning process.
Extinction: Reduction of a conditioned response with repeated and prolonged exposure to a feared stimulus until it sometimes disappears.
Habituation: Reduction in the intensity of the fear or anxiety response with repeated presentation of the physiological sensations.
Examples of Behavioural Interventions (BI) based on operant conditioning
- Behavioural Modification: This entails making adjustments to behavioural patterns through operant strategies – biofeedback and positive or negative reinforcement. The goal is to substitute undesirable behaviours with acceptable ones. The strategies that are used include –
- Schedules of reinforcement: Continuous or intermittent.
- Shaping: This is described as reinforcement of successive approximations to ultimate behaviour.
- Chaining: This involves teaching a sequence of behaviours until the final behaviour is reinforced.
- Contingency Management: This strategy which has been found effective in some programs provides rewards for desired behaviours. For example, a patient’s behaviour in an addiction service may be rewarded (or sometimes punished) based on adherence/nonadherence to program regulations or treatment plan. The program will normally spell out a series of behaviours to be expected and contingencies for adherence/non-adherence. Token Economy is an example of contingency management.
Cognitive Therapy in depression is based on Beck’s Cognitive Model and it describes how people’s perceptions or unprompted thoughts of a situation can influence their emotions and behaviours.
The negative cognitive triad in depression:
- Negative view of self (“I am worthless”)
- Negative view of world (“the world is unfair”)
- Negative view of future (“my future is hopeless”)
Distorted Thinking in CBT
Thoughts or images ‘flash’ into all our minds without conscious efforts and they occur as a response to situations, actions or events. When people are mentally ill, these may be unhelpful, where they are called negative automatic thoughts. As an example, a depressed person may see a friend the other side of the road, and that friend does not say anything to them. They may think, ‘That person does not like me’. While that may be true, there are a range of other possible explanations, e.g., ‘That person didn’t see me’ or ‘That person is very anxious and was worried that I would not acknowledge them’. These negative automatic thoughts lead to a worsening of mood and are the initial cognitive target in CBT. It is important the patient writes them down as part of Daily Thought Records. They can then be discussed in the session, and alternative explanations can be discussed, together with how the patient could think differently in future negative situations. The individual ability to identify, evaluate and respond more adaptively to automatic thoughts often results in a positive shift in affect.
According to cognitive theory, negative automatic thoughts are underlaid by dysfunctional conditional assumptions (e.g. ‘People need to like me for me to be a useful member of society’), which themselves are underlaid by core beliefs (e.g. ‘I am an unworthy member of society’).
Cognitive theory has identified a range of cognitive distortions, which are identified and discussed in CBT. These can apply to NATs, dysfunctional conditional assumptions and core beliefs.
- All-or-nothing thinking: ‘If I’m not an excellent student, then I’m a failure’
- Catastrophizing: ‘I’ll be so distraught; I won’t be able to function at all’
- Emotional reasoning: ‘I know I do a lot of things well at home, but I still feel like a failure’
- Labelling: ‘It’s not a mistake, I am a loser’
- Minimization: ‘Getting high marks doesn’t mean I’m smart’
- Selective abstraction: Despite many positive comments about someone’s performance, the person chooses to focus on a mild criticism. The preoccupation to the mild criticism was such that the person ignores all the positive feedback
- Mind reading: ‘Others are probably thinking that I am not good enough to be a medical student’.
- Overgeneralization: ‘Because I felt nervous at the conference, I will never be asked to come back’.
- Personalization: Seeing oneself as the cause of a negative external incident despite not had been primarily responsible for it.
Important points to note in CBT based on its principles
- Formulation of patient’s difficulties in cognitive terms.
- Goal oriented and problem-focused intervention
- Structured sessions
- Collaboration and active participation
- Time-limitation: 12 – 24 sessions
- Teaching patients to identify, evaluate and respond to their dysfunctional thoughts and beliefs.
- Activity Scheduling
- Thought Records
- Behavioural Interventions
The Structure of CBT session
- Bridge from previous session and review of mood symptoms.
- Setting the agenda
- Core of CBT session
- Homework review
- Working collaboratively
- Prioritization of agenda items
- Adopt a problem-solving approach to agenda item and use key CBT interventions (e.g. Activity scheduling, Thought Records review, role play, identifying cognitive distortions, behavioural activation, problem solving etc)
- Ending: Assign Homework/Action Plan
- Link homework to the work in session and treatment goals
Sample: Automatic Thought Worksheets
|Situation||Mood||Automatic Thought||Evidence for||Evidence against||Alternative Balanced Thought|
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 10th Edition. (2017). Chapter 33. Psychotherapies. Lippincott Williams & Wilkins.
Essential components of cognitive-behaviour therapy for depression. APA. 2001. By, Dr. Jackie Persons, Michael A. Tompkins, Joan Davison
Feeling Good Handbook, J. Beck. 1995. Cognitive Therapy: Basics & Beyond New York: Guilford.
Interpersonal Psychotherapy (IPT)
IPT was developed by Gerald Klerman and Myrna Weissman for the treatment of major depression. A large amount of RCT evidence demonstrates it to be effective for depression in all ages (and it is therefore recommended in the NICE guidelines for depression at all ages). However, it has now been modified for the treatment of other psychiatric disorders, particularly PTSD and bulimia nervosa. IPT lays emphasis on ‘interpersonal context’, described as the relational element which predisposes, precipitates and perpetuates the patient’s difficulties (Robertson et al. 2008).
IPT is empirically validated and it is based on the understanding of psychosocial aspects of depression. The psychosocial understanding of depression acknowledges that:
- The development of depression occurs in an interpersonal context and it involves disturbance of important attachments and social roles.
- The loss of a significant other (grief), hostile relationships (role disputes), life interruptions/changes (role transitions), and lack of social support (interpersonal deficits) are deleterious life events that increase the risks of depression in vulnerable individuals.
- Appropriate level of social supports guards against psychopathology.
- Making a positive change in social functioning in the ‘here and now’ will improve depressive symptoms.
IPT is time-limited: it is usually delivered in 16 weekly sessions (12 for adolescents). It recognises the influence of genetics, biochemical changes and personality factors in the development of depression and the related vulnerabilities. Depression is a treatable medical illness and it is neither due to patient’s fault nor personal defect (Markowitz and Weissman, 2004). There is a bidirectional relationship between interpersonal relationships and depressive symptoms. In other words, depression has effects on the patient’s relationships and social interactions, and the nature and quality of patient’s social interactions and relationships affect depressive symptoms.
Structure of Treatment
IPT has three phases: Beginning (4 sessions), middle and ending (2-4 sessions).
This is the initial phase and it can last up to 4 sessions. The hallmark of this phase includes:
- Diagnosis of depression: Depression is explicitly diagnosed as an illness, and the patient is provided with psychoeducation, including on the sick role. This fits very well with the ‘medical model’ of mental illness.
- Time line: the therapist and patient go through the life story, in particular looking for important changes in interpersonal relationships and depressive symptoms.
- Interpersonal inventory: This is an assessment of patient’s relationships (and patterns) and capacity for intimacy. An interpersonal network is drawn and the therapist gathers information about all important relationships, looking for problems, potential supports and patterns across relationships.
- Focus area and formulation. The detailed assessment up to then leads to a detailed interpersonal formulation of the depression. A single focus area for treatment is chosen collaboratively. There are four focal areas: Grief, Role disputes, Role transition and Interpersonal deficits/interpersonal sensitivity. For example, a significant person may have died (Grief/complicated bereavement), there may be a difficult relationship with a significant other (role dispute), the patient may have experienced important life change (role transition) or there may be a long-term pattern of no/poor interpersonal relationships. The latter includes cases where the patient superficially has a lot of relationships, but these may be unstable and/or characterised by recurrent maladaptive patterns; this is quite often seen in adolescents with depression. The use of a focus area both focuses the work on the important problems; and guides the therapist to a specific set of focus-specific techniques. Specific interpersonal goals are agreed.
Middle Phase (Sessions 5-12)
The middle phase involves intensive work on the focus area and goals. This revolves around depressive symptoms, interpersonal relationships and their links. General strategies are used across focal areas, including expressing and processing affect, role play, communication analysis, problem solving and improving the social network. Specific strategies are used for each focal area; for example, in role transition, attention needs to be paid to forming a balanced view of the old life, exploring the process of the change, forming a balanced view of the new life and improving the new life.
Ending/Termination Phase (Sessions 13-16)
The goal of the termination phase is to ensure a healthy separation from a relationship that the patient has found productive. Termination in psychotherapy has been known to trigger a re-experiencing of previous losses and unresolved grief (Hardy & Woodhouse, 2008). IPT explicitly discusses feelings around termination and helps the patient to process these. Importantly, IPT helps the patient to contrast the normal grief at the ending of this relationship with a recurrence of depression.
Where IPT has been successful, the termination phase helps the patient to reflect on how things have improved, in terms of depressive symptoms, interpersonal relationships and the specific goals of therapy. The patient and therapist discuss what aspects of IPT (or other things in the patient’s life) have led to improvement, and how these things can be continued after therapy has ended. The risk of recurrence is discussed and warning signs for this are identified. Actions to be taken in the event of recurrence are agreed, with a focus on using interpersonal supports.
Following the end of successful IPT, a patient may be discharged, or may have maintenance IPT to help them consolidate improvement.
Where IPT has not been successful, the termination phase is used to consider potential other treatments. It also discusses areas of IPT which have been helpful or could be helpful in future.
Adaptations of IPT
IPT was designed for, and is mainly used for, depression. There is also evidence for its use in the following. However, most IPT therapists only use it for depression.
- Bulimia nervosa. The IPT focusses on improving interpersonal relationships, which should lead to improved emotions/affect and hence fewer binges/purges. The patient often uses a self-harm book to help them address their bulimic symptoms alongside the IPT. (NOTE: there is no evidence that IPT is effective for anorexia nervosa.)
- PTSD. IPT focusses on improving social relationships, which are often weakened in PTSD, partly due to avoidance. The only major RCT on this demonstrated IPT to be equivalent to trauma-focused CBT in terms of improvement, but IPT had much lower drop-out.
- Bipolar Disorder. IPT does not treat mania. However, IPT Social Rhythm Therapy is used to reduce manic relapse rates when the patient is euthymic. And IPT is used to treat bipolar depression in the same way as it is for unipolar depression.
- Suicidality/Self-Harm. IPT-Adolescent-Intensive has been shown to reduce suicidal thoughts and self-harm, as well as depressive symptoms.
- Group IPT. This has been particularly used in resource-poor settings, for example being shown to be very effective in some Ugandan studies.
- Interpersonal Counselling. IPC differs from IPT in three ways: it is for milder depression, is shorter (3-6 sessions), and can be delivered by therapists with a lower level of training. It is therefore useful for treating milder disorder and is likely to be considerably cheaper (shorter therapy, lower staff salaries). It has been shown to be more effective than antidepressants in mild adult depression. An adolescent form has been developed and is currently being researched locally (Wilkinson et al 2018).
Videos of some of the important parts of IPT are on MedEd, in the year 5 learning resources.
Any students particularly interested in IPT practice and/or research are welcome to contact Dr Paul Wilkinson, email@example.com
Markowitz JC, Weissman MM, editors. Casebook of interpersonal psychotherapy. Oxford University Press; New York: 2012
Wilkinson PO, Cestaro V, Pinchen I. Pilot mixed-methods evaluation of interpersonal counselling for young people with depressive symptoms in non-specialist services. EBMH. 2018. 21(4): 134-138
Robertson et al. (2008). Interpersonal Therapy: An Overview. Psychotherapy in Australia; 14(3): 46-54;
Markowitz and Weissman (2012). Interpersonal Therapy: Past, Present and Future. Clin Psychol Psychotherapy; 19(2): 99-105.
Markowitz and Weissman (2004). Interpersonal psychotherapy: principles and applications World Psychiatry. Oct; 3(3): 136–139
Weissman et al. (2000). Comprehensive Guide to Interpersonal Psychotherapy.
Hardy, J. A., & Woodhouse, S. S. (2008, April). How we say goodbye: Research on psychotherapy termination. [Web article].