Because IPT already has a grief focus with goals that are consistent with treating CG, and our group has extensive experience using IPT effectively, we decided to base our targeted CGT in an IPT framework. Goals for treating CG were similar to IPT grief-focus goals, and we included the core three-phase IPT method as an organizing framework. We integrated CBT strategies for treatment of PTSD as well as cognitive strategies for dealing with separation distress into this framework. We found that these additional complicated grief-specific components could be easily blended in an IPT grief-focused treatment that is time-limited and present-oriented.
Both CBT and IPT are short-term, focused treatments that are present-oriented and practical. Both are very different from psychodynamic psychotherapy. Neither attempts to ameliorate psychological symptoms through addressing intrapsychic problems, such as conflict or defense, nor is an attempt made to interpret transference. IPT differs from CBT in placing interpersonal relationships at the center of the therapeutic work, and in eschewing formal structure (e.g., systematic homework) as a means to uncover distorted thoughts. Whereas it is usual for the IPT therapist to provide suggestions that the patient try new behaviors or pay attention to feelings between sessions, the CBT therapist assigns "homework." Nevertheless, as documented in a recent report (Ablon & Jones, 2002), striking similarities exist between IPT and CBT when the nature of the interaction between the patient and therapist is the focus of comparison. As Ablon and Jones (2002) point out:
In both treatments, the therapist assumes an authoritative role and coaches patients to think or conduct themselves differently and encourages them to test out these new ways of thinking and behavior in everyday life. . . . Taken together, the results of our two studies suggest that what was shared between the two forms of therapy in the NIMH Treatment of Depression Collaborative Research Program was more salient and defining of the treatments than what was different. (p. 781)
This similarity in therapist behavior supports the feasibility of a merged intervention. We have successfully integrated behavioral and cognitive techniques in two other IPT projects, one targeting bipolar disorder (Frank, Swartz, & Kupfer, 2000) and one that addresses comorbid panic and depression (Cyranowski et al., 2004). Thus, in developing CGT, we began with standard grief-focused IPT and developed some CBT-informed modifications, drawing especially upon Foa's approach to PTSD (Jaycox, Zoellner, & Foa, 2002; Zoellner, Fitzgibbons, & Foa, 2001).
The CGT therapist does utilize IPT facilitative, supportive, cognitive, and behavioral techniques. These core IPT therapeutic techniques, as outlined in the Weissman et al. (2000) manual, include nondirective exploration, encouragement and acceptance of affect, helping the patient generate suppressed and/or avoided affect, and clarification and communication analysis. Directive behavioral change techniques are also outlined and include education, advice and suggestions, modeling and direct help. Into this matrix CGT inserts techniques drawn from CBT for PTSD. Daily symptom monitoring is encouraged. The CGT revisiting procedures are modified versions of prolonged imaginal and in vivo exposure techniques. Two cognitive therapy techniques that are used are (1) "memories forms," in which the client is asked to recall specific types of memories of the deceased, and (2) for the client to have an imaginal conversation with the deceased. A segment on personal goals is adapted from motivational interviewing.
The use of these CBT-informed techniques entails more structured plans for continuing therapeutic activities between sessions. The CGT therapist uses a less rigorous approach than CBT, but a more structured one than IPT. The CGT therapist offers a simple monitoring form to track the ups and downs of the patient's grief, and asks the patient to complete this form daily. Taped revisiting and imaginal conversation exercises are sent home with the encouragement to listen to them. Memories forms are provided to guide the patient's reminiscences during a part of the treatment. Weekly plans are discussed with the patient at the end of each session, and these plans are recorded and given to the patient to serve as reminders of the discussion. CGT utilizes assessment forms to examine the kinds of beliefs about grief the person might harbor and to begin to identify what is being avoided. These are completed prior to some sessions, in the waiting room. A mid-treatment assessment of progress is conducted. These procedures are easily integrated because they are similar to the weekly depression ratings often used in IPT In general, IPT therapists are encouraged to track symptoms systematically and to use assessment tools to do so. in the section that follows we describe the five key augmentation strategies used in CGT, explaining their rationale and providing a general description of procedures.
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