Transcript Slide 1

Interpersonal Psychotherapy
for Group
Denise E. Wilfley, Ph.D, Juliette M. Iacovino, M.A.,
Monica S. Mills, M.A., & R. Robinson Welch, Ph.D.
Washington University in St. Louis
School of Medicine
Friday, June 24, 2011
R29MH051384; R01MH064153; K24MH070446; T32HL00745626
Disclosures
• Research Support
– Shire Pharmaceuticals
• Advisory/Consultant
–
–
–
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GlaxoSmithKline Consumer Healthcare
Minnesota Obesity Consortium
United Health Group, Childhood Obesity Initiative
Wellspring Healthy Living Academy
Theoretical Underpinnings of IPT
for Eating Disorders
• Assumption: Eating disorders develop within
social and interpersonal contexts
• Relationships between the patient and significant
others impact the maintenance of the disorder and
response to treatment
• Focus: Identifying and modifying the
interpersonal context in which the eating
problem has been developed and maintained
Wilfley, Comprehensive Textbook of Psychiatry Volume Two. 8th Ed., 2005
An Eating Disorder-Specific Model of IPT
Grief, Role Transition, Interpersonal
Dispute &/or Interpersonal Deficit
Trigger …
Individual
Vulnerability
Factors
Negative Social Evaluation
General
Cultural Values
Regarding Eating,
Shape, and Weight
Specific to Eating,
Shape, or Weight
Shape and WeightBased Self Worth
Individual
Vulnerability
Factors
Outcome
Expectancies
Self Disturbance
Negative Self (may include Body) Evaluation
and Associated Negative Affect
Regarding Eating,
Shape, and Weight
Eating Disorder Behaviors
Self-starvation; Dietary Restriction and other
Extreme Weight Control Behaviors; Binge Eating
Rieger, VanBuren, Bishop, Tanofsky-Kraff, Welch, & Wilfley. Clin Psychol Rev, 2010
Rationale for IPT-G
• “Interpersonal laboratory”
– Multiple opportunities to practice interpersonal skills
– Skills can be readily applied to outside relationships
• Breaks patterns of social isolation and stigma
• Provides a social corrective and supportive
atmosphere
• Cost-effective treatment modality
Wilfley, Frank, Welch, Spurrell, & Rounsaville, Psychotherapy Research, 1998
Key Elements of the Group Format
• Semi-structured
• Circumscribed treatment focus
• Focused on changing outside interpersonal relationships
• Active group leadership
Group Composition
• 7-10 group members
• Homogeneous groups (e.g., diagnosis)
–
–
–
–
–
Mutual motivation
Rapid cohesion
Common target problems
Immediately feeling understood
More time for applied work
• Heterogeneous with regard to interactional style
Relevant Considerations in Translating IPT
from an Individual to a Group Format
• Provide a focus on each individual’s problem area(s)
– Individual meetings
• Pre-group: Conduct interpersonal inventory; identify problem
area(s) & translate into specific goals; prepare for group
“Throughout the time that you are in the group, it will be helpful for you to
begin making connections with people in your outside social life. Use the
group to share how your efforts are progressing. As you work to get your
binge eating under control, you will feel better about yourself and will be
more open for relationships with others”
• Mid-group: Discuss progress; refine interpersonal goals
• Post-group: Individualized plan for continued work
• Attend to group process
Overview of Treatment Structure
PRE-GROUP
GROUP SESSIONS
INITIAL
ASSESS
1
PRE-GROUP
MEETING
POST-GROUP
MIDDLE
5 6
10
11
MID-GROUP
MEETING
FINAL
15 16
20
ASSESS
POST-GROUP
MEETING
The Phases of IPT and Stages of Group Development
Phase of IPT
INITIAL
Stage of Group Development
Stage 1: Engagement
- Create a functioning group
Stage 2: Differentiation
- Resolve conflicts
MIDDLE
Stage 3: Work
- Focus on individual issues while
encouraging inter-member work
FINAL
Stage 4: Termination
- Identify and reinforce
termination themes
Wilfley et al., Psychotherapy Research, 1998
Common IPT Techniques Translated
to Group Format
• Clarification
– Group member can repeat or rephrase a statement
• Communication analysis
– Group can suggest alternatives to poor communication
• Summarizing
– Review important group themes that emerge
– Highlight themes related to members’ identified goals
Two Models of Symptom Maintenance
CBT MODEL FOR BINGE EATING
Societal Pressure for Thinness
IPT MODEL FOR BINGE EATING
Interpersonal Problems
IPT
Distorted Attitudes Toward
Eating, Shape, and Weight
Low Self-Esteem
Dysphoria
CBT
Dietary Restraint
Bingeing
Food Used to Cope With
Negative Feelings
Bingeing
Wilfley et al., J Gender Culture Health, 1997
IPT-G for Binge Eating Disorder
is Efficacious
• Superior to wait-list (Wilfley et al., JCCP, 1993)
• Comparable to Group CBT (Wilfley et al., JCCP, 1993; Arch Gen
Psychiatry, 2002)
• Comparable short- and long-term abstinent rates to
individual CBT guided self help and individual IPT;
superior long-term rates to individual Behavioral
Weight Loss (Wilson, Agras, & Wilfley, Arch Gen Psychiatry 2010)
IPT-G Long-term Efficacy for BED:
100
100
90
90
80
80
70
70
60
60
Recovered, %
Remitted, %
4-6 Year Follow-up from Wilfley et al. (2002) Study
50
40
30
20
50
40
30
20
10
10
0
0
Pretreatment
Posttreatment
One-Year Follow- Long-Term FollowUp
Up
Cognitive-Behavioral Therapy
Pretreatment
Posttreatment
One-Year Follow- Long-Term FollowUp
Up
Interpersonal Psychotherapy
Adaptations of IPT-G
• Interpersonal focus relevant for other populations
• IPT-G shown to be efficacious for a number of
problems
Efficacious Applications of IPT-G: Adults
• Major depression (Levkovitz, J Affect Disord, 2000; Bolton et al., JAMA, 2003)
• Female prisoners with co-morbid depression and
substance use disorder (Johnson & Zlotnick, J Substance Abuse Treat, 2008)
• Post-traumatic stress disorder (Krupnick et al., Psychother Res, 2008)
• Eating disorder not otherwise specified (Nevonen & Broberg,
Eur Eat Disord Rev, 2005)
• Bulimia nervosa (Nevonen & Broberg, Int J Eat Disord, 2006)
IPT-G in Uganda: Adults with Depression
• Cluster-randomized RCT compared IPT-G to no-treatment
• Group leaders were community members with no
previous counseling experience and were trained in IPT-G
• IPT-G associated with significantly greater reductions in
depressive symptoms & dysfunction
• Significantly fewer in IPT-G met criteria for depression
• All differences maintained at 6-month follow-up
Bolton et al., JAMA, 2003
Adaptations of IPT-G: Adolescents
• Group IPT for adolescents: IPT-AG (Mufson et al., Am J
Psychother, 2004; Child and Adol Mental Health, 2010)
– IPT-A adapted to a group format
– Pilot study found no differences between IPT-AG and IPT-A in
reducing symptoms of depression
– Sig. greater improvements in global functioning in IPT-AG
– Maintained at 4-month follow-up
• IPT-adolescent skills training (IPT-AST)
– Prevention for adolescents at high-risk for depression
– Superior to treatment-as-usual school counseling maintained at
6-month follow-up (Young et al., J Child Psychol Psychiatry, 2006)
– Superior to school counseling post-intervention but not at 12month follow up (Young et al., Depress Anxiety, 2010)
IPT-G: Adolescents
IPT for the Prevention of Excess Weight Gain (IPT-WG)
• Adolescent girls at risk for adult obesity
– BMI≥85th percentile
– Report ≥1 loss of control (LOC) eating episode in past
month
• Why IPT-G?
– Efficacy for binge eating disorder in adults (Wilfley et al., Arch
Gen Psychiatry, 2002)
– Overweight youth are target of negative social interactions
– Adolescent peer relationships crucial to self-evaluation
IPT-WG: Proposed Mechanism of Change
Model
Interpersonal Problems
IPT
Improve Interpersonal Functioning
Negative Affect
Decrease Negative Affect
LOC Eating
Reduce LOC Eating
Excess Weight Gain
Weight Stabilization
Tanofsky-Kraff, Wilfley et al., Obesity 2007
< expected BMI growth (%)
1y Follow-Up: Less than Expected BMI Growth
90
*
75
60
45
30
15
0
IPT-WG
*p=0.03, adjusted for age and race
HE
Tanofsky-Kraff, Wilfley et al., Int J Eat Disord, 2009
Greater Reductions in LOC Episodes
IPT-WG
HE
LOC Episodes
8
6
4
2
0
1
Baseline
Group x time, p = 0.04, Partial η2=0.12,
adjusted for age and race
2
6m Follow-up
Tanofsky-Kraff, Wilfley et al., Int J Eat Disord, 2009
IPT-WG: Future Directions
POWER-UP: Preventing Weight Gain and Enhancing
Relationships in Underserved Communities
Funded by the National Center for Mental Health Disparities
• There is a need to disseminate evidence-based
treatments into community settings
• Focus groups will inform adapted treatment manuals
for African-American and Latina girls
• We will train community leaders to deliver IPT-WG in
two community clinics
Conclusions
• IPT-G is an evidence-based treatment that has been
successfully adapted for a number of problems
• No evidence to suggest that IPT-G is less efficacious than
individual IPT, and a number of strengths exist in the group
format
• IPT-G is ripe for larger RCTs, comparative effectiveness trials,
and dissemination and implementation studies
• Future research should examine mediators and moderators of
change, as well as the relative cost-effectiveness of the group
modality
References
Bolton, P., Bass, J., Neugebauer, R., Verdeli, H., Clougherty, K. F., Wickramaratne, P., et al. (2003).
Group interpersonal psychotherapy for depression in rural Uganda. JAMA: The Journal of the
American Medical Association, 289(23), 3117-3124.
Johnson, J. E., & Zlotnick, C. (2008). A pilot study of group interpersonal psychotherapy for
depression in substance-abusing female prisoners. Journal of Substance Abuse Treatment, 34(4),
371-377.
Krupnick, J. L., Green, B. L., Stockton, P., Miranda, J., Krause, E., & Mete, M. (2008). Group
interpersonal psychotherapy for low-income women with posttraumatic stress disorder.
Psychother Res, 18(5), 497-507.
Levkovitz, Y., Shahar, G., Native, G., Hirsfeld, E., Treves, I., Krieger, I., et al. (2000). Group interpersonal
psychotherapy for patients with major depression disorder - pilot study. Journal of Affective
Disorders, 60(3), 191-195.
Mufson, L., Gallagher, T., Dorta, K. P., & Young, J. F. (2004). A group adaptation of interpersonal
psychotherapy for depressed adolescents. Am J Psychother, 58(2), 220-237.
Mufson, L. (2010). interpersonal psychotherapy for depressed adolescents (IPT- A): extending the
reach from academic to community settings. Child and Adolescent Mental Health, 15(2), 66-72.
Nevonen, L., & Broberg, A. G. (2005). A comparison of sequenced individual and group
psychotherapy for eating disorder not otherwise specified. European Eating Disorders Review,
13(1), 29-37.
References (cont)
Nevonen, L., & Broberg, A. G. (2006). A comparison of sequenced individual and group
psychotherapy for patients with bulimia nervosa. International Journal of Eating Disorders,
39(2), 117-127.
Rieger, E., VanBuren, D.J., Bishop, M., Tanofsky-Kraff, M., Welch, R., Wilfley , D.E. (2010). An eating
disorder-specific model of interpersonal psychotherapy (IPT-ED): Causal pathways and
treatment implications, Clin Psychol Rev, 30(4), 400-10.
Tanofsky-Kraff, M., Wilfley, D. E., Young, J. F., Mufson, L., Yanovski, S. Z., Glasofer, D. R., et al. (2009).
A pilot study of interpersonal psychotherapy for preventing excess weight gain in adolescent
girls at-risk for obesity. Int J Eat Disord.
Tanofsky-Kraff M., Wilfley D.E., Young J.F., Mufson L, Yanovski S.Z., Glasofer D.R., Salaita C.G. (2007).
Preventing excessive weight gain in adolescents: Interpersonal psychotherapy for binge eating.
Obesity, 15(6), 1345 - 1355.
Wilfley, D.E. (2005). Interpersonal psychotherapy. In: Kaplan & Sadock’s comprehensive textbook of
psychiatry volume two. 8th ed., (Sadock BJ, Sadock VA, eds.), Lippincott Williams & Wilkins,
Baltimore, pp 2610-2619.
Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., et al. (1993). Group
cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic
individual: A controlled comparison. J Consult Clin Psychol, 61(2), 296-305.
References (cont)
Wilfley, D., Frank, M., Welch, R., Spurrell, E., & Rounsaville, B. (1998). Adapting interpersonal
psychotherapy to a group format (IPT-G) for binge eating disorder: Toward a model for adapting
empirically supported treatments. Psychotherapy Research, 8(4), 379 - 391.
Wilfley, D. E., MacKenzie, K. R., Welch, R. R., Ayres, V. E., & Weissman, M. M. (2000). Interpersonal
Psychotherapy for Group. New York: Basic Books.
Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., et al. (2002). A
randomized comparison of group cognitive-behavioral therapy and group interpersonal
psychotherapy for the treatment of overweight individuals with binge-eating disorder. Arch Gen
Psychiatry, 59(8), 713-721.
Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S. W. (2010). Psychological treatments of binge
eating disorder. Arch Gen Psychiatry, 67(1), 94-101.
Young, J. F., Mufson, L., & Davies, M. (2006). Efficacy of interpersonal psychotherapy-adolescent
skills training: An indicated preventive intervention for depression. Journal of Child Psychology
and Psychiatry, 47(12), 1254-1262.
Young, J. F., Mufson, L., & Gallop, R. (2010). Preventing depression: A randomized trial of
interpersonal psychotherapy-adolescent skills training. Depression & Anxiety, 27(5), 426-433.