How does interpersonal and social rhythm therapy work

Interpersonal and Social Rhythm Therapy (IPSRT) is designed to help people improve their moods by understanding and working with their biological and social rhythms. Originally developed as a form of psychotherapy for a single clinician and a single patient, the program has since been adapted to work in several different kinds of settings, including inpatient and outpatient groups. IPSRT is a compelling adjunctive therapy for people with mood disorders, and it emphasizes techniques to improve medication adherence, manage stressful life events, and reduce disruptions in social rhythms. IPSRT teaches patients skills that let them protect themselves against the development of future episodes.

A major goal of the IPSRT team is to expand the program’s use and the resources available to clinicians wishing to learn the IPSRT model, as well as to provide additional support to clinicians already trained in IPSRT.

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Interpersonal and social rhythm therapy (ISRT) helps people learn to regulate their mood using their natural biological and social routines.

Social rhythm therapy is based on the idea that changes in routine can trigger mood episodes in people who are medically vulnerable, such as those with bipolar disorder.

Your daily routine and habits are called your social rhythms. When the timing of your routine changes, this can disrupt your circadian rhythm (the biological clock that changes how you feel and act during 24 hours).

The stress of interpersonal problems, like relationship conflict, can also impact how stable your mood is throughout the days and weeks.

What is interpersonal and social rhythm therapy?

IPSRT is an add-on therapy for treating bipolar disorder and other mood disorders.

The therapy aims to minimize disruptions to your daily routines and rhythms since these changes can lead to disrupted sleep and an unstable mood in some people.

IPSRT can help to minimize the impact of stress from relationship conflict. During sessions, your therapist will also examine the impacts of stressful, role-changing life events, such as:

• marriage or divorce
• getting a new job, or losing a job
• having a child

Sleep disruption and stress can both increase the chance of hypomania or mania. Since IPSRT can reduce sleep irregularities and ease stress, it can be an effective treatment for bipolar disorder.

It’s important to note that IPSRT is not meant to replace medication for bipolar disorder. Instead, it helps by regulating your schedule to make medication compliance easier. If you’re currently taking medication that your doctor has prescribed, it’s best to continue as directed.

How does IPSRT work? 

IPSRT assumes that external triggers can activate symptoms in people who have them. For example, if you have allergies and encounter your trigger, you’ll have an allergic reaction.

People prone to mood disruption might notice mood changes from certain triggers, such as:

• changes to your regular schedule
• interrupted sleep
• stress

IPSRT involves regular meetings with a therapist, face to face or via telephone.

There are several stages:

Initial stage

During the initial stage, your therapist will work with you to:

• help you understand that your mood changes are not your fault, and that there is a medical component
• identify your current and previous mood patterns
• examine how certain relationships and behaviors are connected with your mood changes
• agree on a primary interpersonal area (such as a relationship or communication style) that you want to improve

The initial stage usually lasts for several sessions.

Intermediate stage

This is the stage in which you:

• use a social rhythm metric tracking form to log your social rhythm regularity
• review your form with your therapist each week
• apply feedback from your therapist

Maintenance stage

During the maintenance stage, you work on the skills your therapist has helped you learn. As you build your confidence, you apply these skills to manage disruptions, such as work schedule changes.

At this stage, your therapist visits aren’t as frequent. For example, they may decrease from weekly to bimonthly or monthly until therapy is finished.

What is the social rhythm metric?

IPSRT therapists use the social rhythm metric (SRM) to help you track your daily routine. To use this metric, you log daily event times with the goal of developing a consistent schedule.

SRMs can be detailed or basic. It’s easier to maintain a log when you have fewer items to record, so your therapist might suggest a simplified version that includes events relating to sleep patterns and mealtimes.

Examples of social rhythm metrics include:

• the time you get out of bed (not just awakening, but physically up from bed)
• the time of your first contact with another person (interaction matters, so reading a text doesn’t count, but having a text conversation does)
• the time you start your main activity, such as work, school, or family care
• the time you eat dinner
• the time you go to bed

Depending on your circumstance, your therapist might suggest other events to add to the list.

Your SRM is scored based on how many events occur at the same or close to the same time each day. For example, if you wake up at 7 a.m. each day, this counts toward your score.

According to research from 2014, a higher SRM score is associated with:

• better sleep
• increased morning alertness
• fewer depressive symptoms

What is the social zeitgeber theory?

An important part of IPSRT is social zeitgeber theory. Zeitgeber is German for “time giver” and refers to any environmental cue influencing your circadian system.

The most well-known zeitgeber is changing daylight brought about by sunrise and sunset. Other zeitgebers include:

• meals
• physical activity
• social encounters

“Zeitstörer” means time disrupter and covers such circadian interrupters as time zone travel and nighttime screen use.

Who can IPSRT help? 

IPSRT can benefit people living with conditions like mood disorders. It can help with:

• medication adherence
• learning and using coping strategies for managing stressful events
• minimizing social rhythm disruptions

A 2020 study involving people with bipolar disorder found that participants who received IPSRT experienced improvements to:

• anxious, depressive, and manic symptoms
• global functioning
• response to mood stabilizers

IPSRT may also be an effective strategy for preventing new-onset bipolar disorder in young people with a parent who has bipolar disorder, as demonstrated in a 2018 study.

Although it was originally designed to treat bipolar disorder, studies are assessing IPSRT as a possible therapy for other conditions, such as:

• major depressive disorder
• post-traumatic stress disorder (PTSD)
• bereavement in senior adults

Let’s recap

IPSRT is a therapy designed to help people with mood disorders. It helps to regulate sleep and circadian schedules and teaches coping skills that reduce the impact of stressful life events.

It was originally developed by Ellen Frank, PhD, to treat people with bipolar disorder. This therapy aims to promote consistent daily routines to stabilize circadian timing.

IPSRT isn’t meant to replace medication but instead to add on additional support.

You can visit IPSRT.org for more information and learn about tips and current research.

Treatment for people with bipolar disorder

Interpersonal and social rhythm therapy (IPSRT) is an intervention for people with bipolar disorder (BD). Its primary focus is stabilizing the circadian rhythm disruptions that are common among people with bipolar disorder[1][2][3] (BD). IPSRT draws upon principles from interpersonal psychotherapy, an evidence-based treatment for depression[4] and emphasizes the importance of daily routine (rhythm).[5]

IPSRT was developed by Ellen Frank, PhD at the University of Pittsburgh who published a book on her theories: Treating Bipolar Disorder, a Clinician’s Guide Interpersonal and Social Rhythm Therapy.[6] Her research on IPSRT[7][8] has shown that, in combination with medication, solving interpersonal problems and maintaining regular daily rhythms of sleeping, waking, eating, and exercise can increase quality of life, reduce mood symptoms, and help prevent relapse in people with BD.

Social Zeitgeber Hypothesis

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Zeitgebers (“time givers”) are environmental cues that synchronize biological rhythms to the 24-hour light/dark cycle. As the sun is a physical zeitgeber, social factors are considered social zeitgebers. These include personal relationships, social demands, or life tasks that entrain circadian rhythms.[9] Disruptions in circadian rhythms can lead to somatic and cognitive symptoms, as seen in jet lag or during daylight saving time. Individuals diagnosed with, or at risk for, mood disorders may be especially sensitive to these disruptions and thus, vulnerable to episodes of depression or mania when circadian rhythm disruptions occur.[10][11][12][13]

Changes in daily routines place stress on the body’s maintenance of sleep-wake cycles, appetite, energy, and alertness,[8] all of which are affected during mood episodes. For example, depressive symptoms include disturbed sleep patterns (sleeping too much or difficulty falling asleep), changes in appetite, fatigue, and slowed movement or agitation. Manic symptoms include decreased need for sleep, excessive energy, and increase in goal-directed activity. When the body’s rhythms becomes desynchronized, it can result in episodes of depression and mania.[14][15]

Aims of Treatment

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Goals of IPSRT are to stabilize social rhythms (e.g., eating meals with other people) while improving the quality of interpersonal relationships and satisfaction with social roles.[8] Stabilizing social rhythms helps to protect against disruptions of biological rhythms; individuals are more likely to maintain a rhythm when other people are involved to hold them accountable.

Interpersonal work can involve addressing unresolved grief experiences including grief for the lost healthy self, negotiating a transition in a major life role, and resolving a role dispute with a significant other. These experiences can be disruptive to social rhythms and thus, serve as targets of treatment to prevent the onset and recurrence of mood episodes seen in bipolar disorder.

Phases of Treatment

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IPSRT typically proceeds in four phases:[6][8]

1. The initial phase involves a review of the patient’s mental health history in order to elucidate patterns in the associations between social routine disruptions, interpersonal problems and affective episodes. Psychoeducation about BD and the importance of stable routines to mood maintenance is provided. Additionally, The Interpersonal Inventory is used to assess the quality of the patient’s interpersonal relationships. One of four interpersonal problem areas is chosen to focus on:
   1. Grief (e.g. loss of loved one, loss of healthy self)
   2. Role transitions (e.g. married-to-divorced, parenthood)
   3. Role disputes (e.g. conflict with spouse or parents)
   4. Interpersonal deficits (e.g. persistent social isolation) The Social Rhythm Metric (SRM) is used to assess the regularity of social routines. Target and actual time of the following activities are tracked on a daily basis: got out of bed; first contact with another person; started work, school, or housework; ate dinner; and went into bed. The intensity of involvement with other people is also rated: 0 = alone, 1 = others present, 2 = others actively involved, and 3 = others very stimulating. Finally, mood is rated on a scale of -5 to +5 at the end of each day.
2. The intermediate phase focuses on bringing regularity to social rhythms and intervening in the interpersonal problem area of interest.
   1. Social Rhythm Metric is heavily used to assess amount of activity being engaged in and the impact of activity on mood. The regularity (or irregularity) of activities is examined, and the patient and therapist collaboratively plan how to stabilize the daily routine by making incremental behavioral modifications until a regular target time at which these activities are done is achieved.
   2. Sources of interpersonal distress are explored, and individuals in the patient’s life who destabilize routine, along with those who are supportive, are identified. Frequency and intensity of social interactions, as well as other social rhythms (e.g. time at which returning home from school/work and then interacting with family), are discussed.
3. The maintenance phase aims to reinforce the techniques learned earlier in treatment in order to maintain social rhythms and positive interpersonal relationships.
   1. Discussion of early warning signs of episodes are reviewed.
   2. Symptomatic and functional change is monitored at each session by asking the patient to rate their mood and note any shifts in routine using the SRM.
4. The final phase involves termination in which sessions are gradually reduced in frequency.

Interpersonal Strategies

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Once the interpersonal problem area of focus is chosen, the following strategies may be used:[16]

1. Grief – This refers to symptoms resulting from incomplete mourning or unresolved feelings about the death of an important person. This can also refer to grief for the loss of a healthy self (i.e., the person before the illness or the person one could have become, if not for BD). Strategies include encouraging expression of painful feelings about lost hopes, ruined relationships, interrupted careers, and passed opportunities. This is followed by encouragement to develop new relationships, establish new, more realistic goals, and focus on future opportunities.
2. Interpersonal role disputes – This refers to any close relationship in which there are nonreciprocal expectations, such as in marital conflict and arguments with parental figures. Strategies include learning how to be more patient, tolerant, and accepting of limitations in self and others.[6] This, in turn, can lead to fewer critical and argumentative instincts.
3. Role transition – This refers to any major life role change, such as new employment, graduation, retirement, marriage, divorce, and giving birth. This can also refer to the loss of previously pleasurable hypomania. Strategies can include noting the negative consequences of hypomania and encouraging the identification of rewarding life goals as suitable alternatives.
4. Interpersonal deficits – This refers to a long-standing history of impoverished or contentious social relationships, leading to an overall feeling of dissatisfaction. Strategies include identifying the common thread in the multiple disputes across one’s life and possibly working to restore “burnt bridges”.[6]

Social Rhythm Strategies

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Individuals with BD benefit from a higher level of stability in their sleep and daily routines than those with no history of affective illness.[6] It is important to identify situations in which routines can be thrown off balance, whether by excessive activity and overstimulation or lack of activity and under-stimulation. Once destabilizing triggers are identified, reasonable goals for change are established. Specific strategies include:

1. Encouraging proper sleep hygiene to introduce regularity to sleep-wake cycle
   1. Establish a regular wake and sleep time
   2. Avoid caffeine or other stimulants
   3. Use the bed only for sleep and sex, not for watching TV, doing homework, reading etc.
   4. Align sunlight exposure with wake time to help set circadian clock
2. Maintaining regular meal times throughout the day
   1. Plan ahead by meal prepping the day before
   2. Include snack times if needed to encourage consistent eating habits
3. Encouraging medication adherence and establishing a regular schedule
   1. Use alarms on phone as reminders for when to take pills
   2. Use daily pillboxes to keep track of which pills to take at certain times
4. Monitoring frequency and intensity of social interactions using Social Rhythm Metric
   1. Note time at which interactions happen and adjust accordingly to establish regularity
5. Minimizing overstimulation of social interactions
   1. Avoid frequent parties or events
   2. Use recovery days as needed
6. Addressing under-stimulation with behavioral activation
   1. Engage in activities that are pleasurable and that give one a sense of mastery
   2. Focus on small, manageable goals that can lead to engagement in other activities (e.g., start jogging to get in shape prior to joining a basketball team)
7. Identifying interpersonal sources of stabilizing and destabilizing influence
   1. Spend time with those who are supportive and stabilizing
   2. Reduce time with those who are disruptive

Evidence of IPSRT Efficacy

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In a randomized controlled trial, those who received IPSRT during the acute treatment phase went longer without a new affective episode (depression or mania) than those who received intensive clinical management. Participants in the IPSRT group also had higher regularity of social rhythms at the end of acute treatment, which was associated with reduced likelihood of relapse during maintenance phase.[7] Additionally, those who received IPSRT showed more rapid improvement in occupational functioning than those assigned to intensive clinical management. However, at the end of two years of maintenance treatment, there were no differences between treatment groups.[17]

IPSRT was studied as one of three intensive psychosocial treatments in the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder[18] (STEP-BD). STEP-BD was a long-term outpatient study investigating the benefits of psychotherapies in conjunction with pharmacotherapy in treating episodes of depression and mania, as well as preventing relapse in people with bipolar disorder.[19] Patients were 1.58 times more likely to be well in any study month if they received intensive psychotherapy (cognitive-behavioral therapy, family focused therapy, or IPSRT) than if they received collaborative care in addition to pharmacotherapy.[18] They also had significantly higher year-end recovery rates and shorter times to recovery.

In a trial conducted by a separate research group, 100 participants aged 15-36 years with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified were randomized to IPSRT (n = 49) or specialist supportive care (n = 51). Both groups experienced improvement in depressive symptoms, social functioning, and manic symptoms, but there were no significant differences between the groups.[20]

Adolescents

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IPSRT was adapted to be delivered to adolescents with BD[21] (IPSRT-A). In an open trial (N=12), feasibility and acceptability of IPSRT-A were high; 11/12 participants completed treatment, 97% of sessions were attended, and adolescent-rated satisfaction scores were high. IPSRT-A participants experienced significant decreases in manic, depressive, and general psychiatric symptoms over the 20 weeks of treatment. Participants’ global functioning increased significantly as well.

In an open trial aimed at prevention, adolescents (N=13) who were identified as high risk for bipolar disorder, due to having a first-degree relative with BD, received IPSRT.[22] Significant changes in sleep/circadian patterns (i.e. less weekend sleeping in and oversleeping) were observed. Families reported high satisfaction with IPSRT, yet, on average, participants attended about half of scheduled sessions. Missed sessions were primarily associated with parental BD illness severity.

Group Therapy

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IPSRT was adapted for a group therapy setting;[23] administered over 16 sessions, in a semi-structured format. Patients (N=22) made interpersonal goals, reflected on how they managed their illness, and empathized with fellow group members. Patients were encouraged to react to each other from their own experience, express their feelings about what was said, and to give constructive feedback. Patients spent significantly less time depressed in the year following treatment than they did in the year prior to treatment.

In another small trial, patients with BD who experiencing a depressive episode (N = 9) received six IPSRT-G sessions across two weeks. Topics of discussion in group included defining interpersonal focus area, defining target times for daily routines, discussing grief and medication adherence, addressing interpersonal disputes and role transitions, and reviewing IPSRT strategies and relapse prevention. Depressive symptoms improved significantly at the end of the treatment; improvements were maintained 10 weeks following treatment end.[24]

References

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