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Interpersonal Psychotherapy for Dysthymic Disorder

This book is the newest addition to the collection of interpersonal psychotherapy (IPT) treatment manuals. In the tradition established by cognitive-behavioral therapy (CBT) researchers, IPT is now being adapted to the treatment of a variety of psychiatric disorders. In addition to the original IPT manual for the treatment of depression,l a textbook has been written regarding the use of IPT with adolescents,2 and the recently published New Applications of Interpersonal Psychotherapy3 includes chapters describing an IPT approach to medically ill depressed patients, depressed pregnant women, depressed geriatric patients, and patients with HIV infection, among others. 
 
The book is divided into two sections: a comprehensive review of the literature regarding the epidemiology and treatment of dysthymic disorder and a detailed description of the use of IPT for dysthymia. The initial chapters include a thorough description of the historical development of the diagnosis and emphasize research suggesting that dysthymia does respond to aggressive treatment. Markowitz is even-handed in his review of treatment studies, noting that the preponderance of this literature involves psychopharmacologic intervention; as a result, he advocates strong consideration of antidepressant medication or a combined psychotherapy and medication approach to treatment. 
 
An important emphasis in the review section—in fact, throughout the book—is Markowitz's contention that dysthymia is an affective disorder rather than a self-defeating or masochistic personality disorder. This view has significant implications both for patients and clinicians. For patients, identifying their distress as a treatable medical illness strongly implies that they are not to blame for their suffering and provides them with a potential means of exiting a cycle of self-blame and increasing dysphoria. For clinicians, recognition of dysthymia as an Axis I disorder dictates aggressive, symptom-focused treatment and supports a sense of optimism regarding prognosis, which can be shared with patients. This is particularly important because the treatment of dysthymic patients can often be an arduous and frustrating task. 
 
The section describing the use of IPT for dysthymic disorder details the techniques that are used in IPT and provides illustrative case histories of treated dysthymic patients. The problem areas traditionally used as the foci for IPT (grief, interpersonal disputes, role transitions, and interpersonal deficits) are described as they apply to dysthymia. Markowitz's unique and very clever contribution to the treatment of dysthymia is to conceptualize it as role transition in which the patient is moving from a “sick” or chronically ill role to a mentally healthy role. This “iatrogenic role transition” is generated by the therapist, who suggests to the patient that he or she will recover and in the process must begin to view him- or herself as making a transition from sickness to health. This formulation meshes with the optimistic stance of the therapist described above and also serves to instill in the patient a feeling of hope about treatment. 
 
This new use of the role transition focus emphasizes the activity of the IPT therapist. Rather than simply responding to material brought to sessions by the patient, the IPT therapist actively generates a new framework for viewing the patient's suffering. Additionally, the therapist uses this framework strategically to impose an optimistic perspective on the patient, either implicitly or explicitly. 
 
Although this approach is new within an IPT context, it actually stems from a long-standing emphasis on the importance of the instillation of hope. Frank,4 for example, has described this as the primary factor in bringing about positive change. It is notable that as the manualized therapies such as IPT and CBT are modified for more difficult patients with chronic problems, they begin to resemble the psychodynamic therapies that have been increasingly ignored as empirically validated treatments are emphasized. As this occurs, it becomes very difficult to distinguish which elements of the manualized therapy are unique to that therapy and which are simply restatements of long-held psychotherapeutic principles. 
 
While these proliferating “brand-name” psychotherapeutic manuals include many valuable texts that are helpful in presenting condensed information about a particular approach or a particular patient population, they tend to place their emphasis on adherence to the treatment model rather than listening to the stories of individual clients. We may be in danger of training a new generation of therapists who are able to proficiently follow a manual-guided therapy but who lack the capacity to truly understand the people with whom they work. Perhaps there is more value than is recognized by empiricists in the texts of antiquity, which typically dispensed the accumulated anecdotal wisdom of experienced therapists and emphasized the need to tailor treatments to each patient. 
 
Despite the limitations inherent in “treatment manual” textbooks, Markowitz's text is a useful addition to the literature regarding dysthymia and chronic depression. It should be considered essential for researchers interested in the treatment of dysthymic disorder. Therapists in more eclectic practice settings will also find many useful ideas to incorporate into their work.