Evidence-Based IPT and
Depression
Jody L. Brown, M.D.
Disclaimer: As usual, I claim no authorship for the
presentation or the content within. I unabashedly &
remorselessly pilfered from reliable sources.
Outline




What is Interpersonal Therapy?
History of IPT
Basic Principles
Course of Treatment
Initial Phase
 Middle Phase
 Termination Phase


IPT-A
What is Interpersonal Therapy?

Interpersonal psychotherapy (IPT) is a brief,
time limited psychotherapy that was initially
developed in the late 1960s for the treatment of
adult depression (Weissman, Markowitz, &
Klerman, 2000).

IPT focuses on the interpersonal context and on
building interpersonal skills.
What is Interpersonal Therapy?

IPT is based on the belief that interpersonal factors
may contribute heavily to psychological problems.

IPT is commonly distinguished from other forms of
therapy in its emphasis on the interpersonal rather than
the intrapsychic.

IPT aims to change the person's interpersonal behavior
by fostering adaptation to current interpersonal roles
and situations.
What is Interpersonal Therapy?

The underlying assumption of IPT is that the quality of
interpersonal relationships can cause, maintain, or
buffer against depression.

When someone is depressed, it affects one's
interpersonal relationships, and the quality and stability
of one's relationships in turn affect one's mood.

This view is consistent with interpersonal theories of
depression articulated by Harry Stack Sullivan (Sullivan,
1953) and Adolf Meyer (Meyer, 1957).
What is Interpersonal Therapy?

In addition to these theories, IPT has its roots in
Bowlby's attachment theory, specifically in its
emphasis on the importance of relational bonds
for mental health.

When there are conflicts in relationships or
losses of important attachment bonds, the
outcome is emotional distress and often
specifically depression.
What is Interpersonal Therapy?

IPT has been shown to be an effective treatment
for adult (Weissman et al., 1979; Elkin et al.,
1989) and adolescent depression (Mufson et al.,
1999; 2004).

It has also been adapted for use with a number
of other conditions, including eating disorders,
bipolar disorder, and postpartum depression.
History of IPT
History of IPT

Interpersonal psychotherapy largely stems from
the interpersonal psychoanalysis work of Harry
Stack Sullivan, who, although coming from a
psychodynamic background, was strongly
influenced by ideas in sociology and social
psychology.

Sullivan thought that the most significant factors
in triggering emotional reactions in individuals
was the interpersonal behaviors of others.
History of IPT

Interpersonal therapy was first developed as a
theoretical placebo for the use in psychotherapy
research by Gerald Klerman, et al.

IPT was, however, found to be quite effective in the
treatment of several psychological problems.

IPT was later developed in the 1970s and 80s as an
outpatient treatment for adults who were diagnosed
with moderate or severe non-delusional clinical
depression.
History of IPT

Although originally developed as an individual therapy
for adults, IPT has been modified for use with
adolescents and older adults, bipolar disorder, bulimia,
post-partum depression and couples counseling.

Over the last 30 years, a number of empirical studies
have demonstrated the efficacy of IPT in the treatment
of depression and various other disorders.
History of IPT

IPT takes structure from psychodynamic
psychotherapy, but also from contemporary
cognitive behavioral approaches in that it is
time-limited and employs homework, structured
interviews, and assessment tools.
Basic Principles

The two main goals of IPT are to:
1) Decrease depression symptoms and
 2) Improve social functioning within significant
relationships.


IPT views depression as a medical illness and
approaches the treatment from this perspective
to remove blame for the illness from the client.
Basic Principles

The primary strategies for achieving treatment
goals include the following:
1) identifying a specific problem area;
 2) identifying effective communication and problemsolving techniques to use with the problem area; and
 3) practicing in session and eventually
experimenting outside the session with the use of
these techniques in the context of significant
relationships. The four problem areas include grief,
interpersonal role disputes, role transitions, and
interpersonal deficits.

Course of Treatment

The treatment is divided into three phases:
Initial
 Middle
 Termination

Course of Treatment
Initial Phase

The Initial Phase focuses on:
Diagnosing the depression
 Providing psychoeducation about the illness
 Exploring the patient's significant relationships with
family members and peers and,
 Identifying the problem area that will be the focus of
the remainder of treatment.

Course of Treatment
Middle Phase

During the Middle Phase of treatment:
The therapist educates the patient about the link
between one's mood and problems that are
occurring in one's relationships.
 The therapist also teaches the patient how new skills
in communication and problem-solving can improve
these relationships which can then lead to recovery
from depression.

Course of Treatment
Middle Phase

The therapist focuses on identifying specific
strategies that can help the patient negotiate
his/her interpersonal difficulties more
successfully.

For example, the patient may be taught
communication skills to express his/her feelings
regarding conflicts or disappointments in his/her
relationships and/or life circumstances (e.g., the
death of a parent, conflict with his spouse, or loss of
a job).
Course of Treatment
Middle Phase

Techniques include:
Expression of affect
 Clarification of expectations for relationships
 Communication analysis
 Interpersonal problem-solving
 Role playing new methods of interaction

Course of Treatment
Middle Phase

Over the course of treatment, the therapist links
improvement in the patient's mood to constructive and
direct communication and effective decision-making.

In the intermediate stages of IPT, the patient and
therapist, focusing on the present, work on the major
problem areas identified.
IPT Problem Areas

The four problem areas include:
 Grief
 Interpersonal
Role Disputes
 Role Transitions
 Interpersonal Deficits
Problem Area #1:
Grief

The first problem area is grief, and clients
typically present with delayed or distorted grief
reactions. Treatment aims include facilitating the
grieving process, the patient's acceptance of
difficult emotions, and their replacement of lost
relationships.
Problem Area #2:
Interpersonal Role Disputes

The second major problem area is role dispute, in
which a patient is experiencing nonreciprocal
expectations about a relationship with someone
else. Here, treatment focuses on understanding
the nature of the dispute, the current
communication difficulties, and works to modify
the patient's communication strategies while
remaining in accord with their core values.
Problem Area #3:
Role Transitions

A third major problem area is role transition, in
which an individual is in the process of giving
up an old role and taking on a new one. In this
case, treatment attempts to facilitate the patient's
giving up of the old role, expressing emotions
about this loss, and acquiring skills and support
in the new role they must take on.
Problem Area #4:
Interpersonal Deficits

A final problem area commonly broached with
IPT is interpersonal deficits. Patients presenting
interpersonal deficits commonly engage in an
analysis of their communication patterns,
participate in role playing exercises with the
therapist, and work to reduce their overall
isolation, if applicable.
Course of Treatment
Termination Phase

Finally, the goal of the termination phase is to:
Clarify warning symptoms of future depressive
episodes
 Identify successful strategies used in the middle
phase
 Foster generalization of skills to future situations
 Emphasize mastery of new interpersonal skills
 Discuss the need for further treatment

Course of Treatment
Termination Phase

In the termination stages of IPT, the therapist
works to consolidate the client's gains, discuss
areas which still require work, talk about relapse
prevention, and process any emotions related to
termination of therapy.
Modification of IPT for
Adolescent Depression (IPT-A)
Modification of IPT for
Adolescent Depression (IPT-A)
IPT-A

Moreau et al. (1991) asserted that the goals of
IPT-A closely mirror those of IPT for depressed
adults. Like IPT, IPT-A seeks to identify and
change interpersonal problem areas associated
with the onset of the adolescent's depression as
well as alleviate depressive symptomatology
(Mufson et al., 1996).
IPT-A

The four interpersonal areas (interpersonal deficits, role
transition, interpersonal role disputes, and grief) used by IPT in
the treatment of adult depression are also addressed in IPT-A
(Mufson & Moreau, 1998).

A fifth problem area, single-parent families, has been added to
IPT-A by Mufson, Moreau, and Weissman (1996) because of the
frequency of single-parent families among depressed adolescents
and the necessity to address the conflicts resulting from a
parent's absence in the family.
IPT-A

Moreau et al. (1991) also emphasized that IPT-A has
been designed to meet the unique developmental needs
of adolescents. Issues addressed in IPT-A are specific
to concerns and issues adolescents face (Mufson et al.,
1996). Some issues identified in IPT-A include
individuating from parents, peer pressures, romantic
relationships, experiences with death, and issues of
control and authority with parents (Moreau et al., 1991).
IPT-A

IPT-A is a time-limited therapy that calls for a once weekly, 12week treatment schedule (Mufson & Moreau, 1998). The goals of
IPT-A are met by identifying interpersonal problem areas with
which the adolescent is struggling and by focusing on how those
problems are currently impacting their relationships (Mufson &
Moreau, 1998).

There are three treatment phases identified as part of the IPT-A
model--initial, middle, and termination (Mufson et al., 1996). A
more detailed discussion of IPT-A intervention strategies can be
found in the IPT-A treatment manual (Mufson, Moreau,
Weissman, & Klerman, 1993).
Highlighted Features of IPT-A
Initial Phase

The initial phase of IPT-A treatment described by Mufson &
Moreau (1999) occurs during sessions one through four.

During this phase, the goals of IPT-A are to:






Conduct a complete diagnostic assessment
Explain treatment options
Obtain a complete history of current interpersonal relationships
Identify the interpersonal problem area(s) that may have precipitated the
onset of the depression
Discuss goals and techniques of IPT-A treatment
Contract for treatment
Highlighted Features of IPT-A
Initial Phase

During the initial phase, evaluations for drug abuse and suicidal ideation are
generally conducted because of the high co-morbidity of these problems with
adolescent depression (Moreau et al., 1991)

Moreau et al. (1991) suggested bringing parents into counseling in initial
sessions to be educated about their child's diagnosis, including information
about its treatment, course, and prognosis

Contacts between the counselor and the adolescent's school may be made at
this time so that the mental health counselor can educate the adolescent's
teachers about the relationship between the adolescent's depression and his or
her functioning in school (Mufson & Moreau, 1998).
Highlighted Features of IPT-A
Initial Phase




In order to keep adolescents from withdrawing because of their depression
and to keep parental support, adolescents who are depressed are also given
the restricted "sick role" during initial sessions (Moreau et al., 1991).
Mufson and Moreau (1999) suggested that when giving adolescents sick roles,
the mental health counselors explain that clients have a mental health
problem that might affect their ability to participate fully in everyday activities
(Mufson & Moreau, 1999).
They suggested that the mental health counselor encourage clients to
continue to participate in day-to-day activities because it will help alleviate
symptoms sooner.
The sick role is given to encourage adolescents to continue participating in
normal activities and to prevent parents from becoming overly impatient or
critical of their child's performance (Moreau et al., 1991).
Highlighted Features of IPT-A
Initial Phase

Mufson, Moreau, and Weissman (1996) indicated the initial stage
of therapy concludes with the development of a treatment
contract between the mental health counselor and patient.

This treatment contract specifically addresses:





The interpersonal problem area(s) to be addressed in treatment
Limits of confidentiality
Number and timing of sessions
What will be done in the case of missed appointments
The role of the patients' parents' in the therapeutic process.
Highlighted Features of IPT-A
Middle Phase




The middle phase of IPT-A treatment consists of sessions five through eight
and it is during this time that the mental health counselor and patient begin to
directly work on the interpersonal problem areas identified during the initial
stages of treatment (Mufson et al., 1996).
The main goal of the middle phase of IPT-A treatment is to associate these
interpersonal problem areas to the depressive symptomology currently being
experienced by the adolescent (Moreau et al., 1991).
Five interpersonal problem areas are examined during this time: grief,
interpersonal role disputes, role transitions, interpersonal deficits, and singleparent families (Mufson & Moreau, 1999).
The focus of these interpersonal problem areas has been modified from IPT
to meet the developmental needs and issues of depressed adolescents
(Mufson & Moreau, 1998).
IPT-A Middle Phase:
Grief


Adolescents who have lost a parent due to death may experience depression.
Depression can often be the result of three types of abnormal grief (Mufson
& Moreau, 1998):

Distorted
Delayed

Chronic



Adolescents who are experiencing problems coping with grief may exhibit
such symptoms as withdrawal, feelings of abandonment, substance abuse,
sexual promiscuity and reverting to earlier developmental stages (Mufson &
Moreau, 1998).
According to IPT-A, failure to successfully navigate through the stages of
grief can lead to depression (Mufson & Moreau, 1999)
IPT-A Middle Phase:
Grief

Mufson and Moreau (1999) noted that IPT-A treatment method
seeks to help adolescents discuss and accept loss in their lives
and identify feelings that coincide with that loss.

There are several key factors that therapists are advised to attend
to when dealing with the interpersonal problem area of grief.
These factors include:




The social support system of the adolescents
Their place in the family structure
Psychosocial development
The quality of the relationship lost
IPT-A Middle Phase:
Interpersonal Role Disputes


When there are different expectations between two individuals about their
relationship, interpersonal role disputes are evident (Mufson & Moreau,
1999).
Interpersonal role disputes are identified by Moreau et al. (1991) as common
to the developmental issues of adolescents and may occur with parents over
issues of:





Sexuality
Power
Finances
Morals
Specific issues may include different expectations about:




premarital sex
Curfews
Allowances
values about homosexuality.
IPT-A Middle Phase:
Interpersonal Role Disputes

Treatment of role disputes with adolescents often involves bringing in parents
to discuss the disputes and to navigate the relationship (Mufson & Moreau,
1998).

In addressing interpersonal role disputes, IPT-A counselors seek to help
adolescents explain their expectations for the relationship, consider which
expectations may be impractical and help adolescents cope with nonnegotiable expectations (Mufson et al., 1996).

Several techniques are employed to meet these objectives including helping
adolescents identify the dispute, negotiate options with parents, examine and
change relationship expectations, and clarify and alter communication styles
(Mufson & Moreau, 1998).
IPT-A Middle Phase:
Role Transitions


Role transitions: Role transitions are another frequent problem
area for adolescents with depression (Moreau et al., 1991).
Some role transitions are common to the developmental levels of
adolescents. Transitions that can prove problematic for
adolescents include (Mufson & Moreau, 1999):





initiation of romantic relationships
Puberty
Parting from parents and family
Transition into work or higher education
Problems arise in this area when the adolescent is unable to cope
with the role transition or when the parents are unable to handle
the new role of their child (Mufson et al., 1996).
IPT-A Middle Phase:
Role Transitions

If parents are involved in the adolescent's struggles with role transitions, then
they may also be included in some of the counseling sessions (Moreau et al.,
1991).

The mental health counselor's function in these sessions is to help the family
adjust to the adolescent's new role and to elicit support and encouragement
from the parents in the adolescent's attempts to adjust to the new role
(Mufson & Moreau, 1999).

Mental health counselors working with adolescents who are experiencing
problems with role transitions might also help adolescents to process their old
roles and associated feelings and identify why the transition is necessary
(Moreau et al., 1991).
IPT-A Middle Phase:
Interpersonal Deficits

Interpersonal deficits are particularly important to address during the
adolescent years, because these deficits can have a great impact on
adolescents' achievement of developmental tasks (Moreau et al., 1991).

Developmental tasks that can be impacted by adolescents' interpersonal
deficits include (Mufson & Moreau, 1999):





Making friends
Beginning romantic relationships
Forming social ties
Making choices about romantic commitment, vocation, and sexuality
Lack of interpersonal skills may lead to adolescents becoming socially isolated
from their peers (Mufson et al., 1996). As a result of being ostracized from
peers, adolescents may withdraw, leading to a further delay in the acquisition
of appropriate social skills (Mufson & Moreau, 1999).
IPT-A Middle Phase:
Interpersonal Deficits

Deficits identified in the IPT-A approach are those that result from
depression rather than from inherent personality traits (Mufson et al., 1996).

There are several techniques used to address interpersonal deficits (Mufson &
Moreau, 1999). Some approaches include (Mufson & Moreau, 1999):



helping adolescents identify what specific role deficits have played in current and past
interpersonal relationships
consideration of what deficits need to be changed
encouragement of those changes in significant relationships
IPT-A Middle Phase:
Interpersonal Deficits

Role-plays are often used to help adolescents identify
their interpersonal deficits and to help them practice
new skills (Mufson et al., 1996).

Asking adolescents to practice new behaviors outside of
counseling sessions may also help them generalize new
skills to other situations (Moreau et al., 1991).
IPT-A Middle Phase:
Single Parent Families

Single-parent homes are identified as another common problem area for
many depressed adolescents.

Mufson and Moreau (1999) suggest that the conflicts a single-parent home
can engender can lead to depression among adolescents.

Typically, factors such as the finality of the parting of the parent, its
abruptness in happening, and whether a parent has parted before can impact
the severity of the adolescent's depression.

When considering the nature of the adolescent's depression, the mental health
counselor also needs to be cognizant of the adolescent's relationship with
both the custodial and absent parent.
IPT-A Middle Phase:
Single Parent Families

IPT-A has developed six treatment goals for addressing this problem area
with adolescents (Moreau et al., 1991).






First, mental health counselors help adolescents recognize the impact the exit of the parent
had on their life (Mufson et al., 1996).
Secondly, adolescents receive help processing their feelings of bereavement, rejection,
desertion, and/or punishment resulting from the parting of the parent (Moreau et al., 1991).
Third, mental health counselors also help adolescents' process hopes for a relationship with
the missing parent (Mufson et al., 1996).
Fourth, mental health counselors facilitate development of an effective relationship with the
remaining parent (Moreau et al., 1991).
Fifth, if possible, the establishment of a relationship with the absent parent may be explored
(Mufson et al., 1996).
Sixth and finally, mental health counselors help adolescents understand and accept the
finality of the situation (Moreau et al., 1991).
IPT-A Termination Phase

The termination phase of IPT-A occurs between sessions nine through twelve
(Mufson & Moreau, 1999).

Termination should be discussed throughout the counseling process (Moreau
et al., 1991).

In the termination phase, adolescents are helped to individuate from the
mental health counselor and to gain a sense of efficacy for coping with future
problems (Mufson & Moreau, 1999).

During the termination session, mental health counselors and adolescents
process what has occurred in counseling, discuss possible areas that could
cause future problems, and explore problem-solving strategies related to those
areas (Moreau et al., 1991).
IPT-A Termination Phase

IPT-A also includes considerations for termination that are
specific to working with adolescents (Moreau et al., 1991).

These considerations include terminating work with family
members who have been involved in the counseling process and
discussing with those members modifications in family
interactions that have occurred since counseling began (Mufson
et al., 1996).
IPT-A Termination Phase

Moreau et al. (1991) indicated termination in this model also includes
discussion of symptoms and conflicts within four categories. These categories
include:





Symptoms related to depression
Secondary symptoms
Areas of conflict that are lasting and represent pervasive personality patterns
Areas of discord between adolescents and their families.
Families and adolescents need to be educated about the possibility of a
recurrence of symptomology for a short time after counseling has been
terminated, and indications that suggest the need for future treatment should
also be discussed.
References &
Recommended Readings
References &
Recommended Readings







Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., Glass, D. R., Pilkonis, P. A.,
Leber, W. R., Docherty, J. P., Fiester, S. J., & Parloff, M. B. (1989). National Institute of Mental Health
Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of
General Psychiatry, 46, 971-983.
Joiner, T. E., Brown, J. S., & Kistner, J. (2006). The interpersonal, cognitive, and social nature of depression. Mahwah,
N.J.: Lawrence Erlbaum Associates.
Levenson, Hanna, Powers, Theodore A., Butler, Stephen F., Beitman , Bernard D.(2002). "Concise Guide to
Brief Dynamic and Interpersonal Therapy". American Psychiatric Publishing, Inc..
http://books.google.com/books?id=Vm_rIxiIOYUC&printsec=frontcover&dq=interpersonal+therapy&ei=R
lWRSrT5JZKUyQT90sGVBw#v=onepage&q=&f=false
Moreau D, Mufson L, Weissman MM, Klerman GL, (1991), Interpersonal psychotherapy for adolescent
depression: description of modification and preliminary application. J Am Acad Child Adolesc Psychiatry 30:642651.
Meyer, A. (1957). Psychobiology: A science of man. Springfield, IL: Charles C. Thomas Mufson, L., Dorta, K. P.,
Moreau, D., & Weissman, M. M. (2004). Interpersonal psychotherapy for depressed adolescents. New York: Guilford
Press.
Mufson, L., Dorta, K. P., Wickramaratne, P., Nomura, Y., Olfson, M., & Weissman, M. M. (2004). A
randomized effectiveness trial of interpersonal psychotherapy for depressed adolescents. Archives of General
Psychiatry, 61, 577-584.
References &
Recommended Readings









Mufson, L., Weissman, M. M., Moreau, D., & Garfinkel, R. (1999). Efficacy of interpersonal psychotherapy for
depressed adolescents. Archives of General Psychiatry, 56, 573-579.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W.W. Norton.
Sundberg, Norman (2001). Clinical Psychology: Evolving Theory, Practice, and Research. Englewood Cliffs: Prentice
Hall. ISBN 0130871192.
Swartz, H. (1999). Interpersonal therapy. In M. Hersen and A. S. Bellack (Eds). Handbook of Comparative
Interventions for Adult Disorders, 2nd ed. (pp. 139 – 159). New York: John Wiley & Sons, Inc.
Weissman, MM (2006), A Brief History of Interpersonal Psychotherapy, Psychiatric Annals (PDF)
http://www.psychiatry.wisc.edu/mridepressionstudy/briefhistoryIPT.pdf
Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). A comprehensive guide to interpersonal psychotherapy.
New York: Basic Books.
Weissman, M. M. & Markowitz, J. C. (1998). An Overview of Interpersonal Psychotherapy. In J. Markowitz,
Interpersonal Psychotherapy (pp. 1 – 33).Washington D.C.: American Psychiatric Press.
Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2007). Clinician's quick guide to interpersonal psychotherapy.
New York: Oxford University Press.
Weissman, M. M., Prusoff, B. A., DiMascio, A., Neu, C., Goklaney, M., & Klerman, G.L. (1979). The efficacy
of drugs and psychotherapy in the treatment of acute depressive episodes. American Journal of Psychiatry, 136,
555-558.