Jeremy Safran , Zindel V. Cognitive therapy, with its clear-cut measurable techniques, has been a welcome innovation in recent years. However, the very specificity that lends itself so well to research and training has minimized the role of the therapeutic relationship, making it difficult for therapists to respond flexibly to different clinical situations. What is needed is an approach that focuses on the underlying mechanisms of therapeutic change, not just on interventions.
In this practical and original book, two highly respected clinician-researchers integrate findings from cognitive psychology, infant developmental research, emotion theory, and relational therapy to show how change takes place in the interpersonal context of the therapeutic relationship and involves experiencing the self in new ways, not just altering behavior or cognitions. Making use of extensive clinical transcripts accompanied by moment-to-moment analyses of the change process, the authors illustrate the subtle interaction of cognitive and interpersonal factors.
They show how therapy unfolds at three different levels—in fluctuations in the patient's world, in the therapeutic relationship, and in the therapist's inner experience—and provide clear guidelines for when to focus on a particular level. This is the first trial, to our knowledge, to demonstrate that IPT is superior to a no-treatment control condition in patients with SAD and, as such, provides further support for the efficacy of this approach.
Recently, Lipsitz et al 19 found that IPT and supportive therapy were associated with substantial improvements in SAD and did not differ from each other. Although they did not directly report effect sizes, their IPT outcomes seem to correspond to the effect sizes for social-phobia measures. In addition, responder rates were also comparable with those found in the present study. There is, thus, evidence to assume that the IPT treatment in this study performed as well as in previous studies. In contrast to the results for social anxiety, IPT was associated with a nonsignificantly greater reduction in depression than was CT.
Thus, although IPT was less effective than CT in changing social anxiety, it was at least as successful in reducing depressive symptoms. Because the 2 treatments differ with respect to the explicit targets for psychotherapeutic change, CT might tackle aspects that are of greater relevance to the etiology of SAD.
Experimental studies have provided evidence to suggest that increased self-focused attention, 43 recurrent images, 44 memory biases, 45 and safety behaviors 46 contribute to the maintenance of social-phobic beliefs. Furthermore, cognitive variables have been shown to essentially contribute to the mediation of effects in CBTs of SAD. In IPT, the central mechanism of action is proposed to be the resolution of interpersonal problem areas. Contrary to expectations, we found no significant differences between the 2 treatments at the posttreatment assessment and significantly larger interpersonal improvements in the CT group at 1-year follow-up.
A possible explanation for this result is that interpersonal problems are more likely to be resolved when the underlying dysfunctional cognitions and safety and avoidance behaviors are effectively modified. Rather, IPT could not compensate for the posttreatment differences at 1-year follow-up. Because SAD, similar to dysthymia, is a chronic disorder characterized by marked avoidance behavior, we assume that IPT may not provide sufficiently structured help eg, exercises and homework to overcome avoidance.
Interpersonal psychotherapy was originally tailored for acute major depression. In this disorder, and possibly in bulimia nervosa, 16 , 17 IPT might be more beneficial because acute interpersonal problems are more closely related to their etiology. The present study has several limitations. It is unclear why the self-report measure seems to have been less sensitive to differential treatment effects. However, this pattern of results has also been observed in some trials of pharmacologic treatments for SAD.
Third, although therapist-completed ratings indicated no protocol violations, we cannot exclude the possibility that some interventions that should be unique to one treatment were occasionally used in the other treatment without being detected. The lack of differences between the 2 treatment sites with respect to the efficacy of CT contradicts a potential effect of allegiance and suggests that successful dissemination is possible. For IPT, further developments might help to improve efficacy by more specifically addressing empirically supported interpersonal problems and avoidance in SAD.
Submitted for Publication: March 31, ; final revision received December 24, ; accepted December 28, All Rights Reserved.
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This volume is a poignant rejoinder to those who believe cognitive-behavioral therapies lack emotional immediacy or fail to utilize the therapeutic relationship. Cognitive therapy, with its clear-cut measurable techniques, has been a welcome innovation in recent years. However, the very specificity that lends itself so well.
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