INTERPERSONAL PSYCHOTHERAPY FOR
ADOLESCENTS (IPT-A)
Dr Roslyn Law
IPT-A Module Lead for UCL/KCL and University of Reading
Plan for this hour
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Overview of IPT-A
Structure and objectives
IPT-A in IAPT
What does it look like in practice
Evidence base
Mechanism of change
Questions and discussion
IPT-A : A brief History
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IPT was developed as treatment for depression in
adults and was adapted for use with adolescents
with depression by Laura Mufson et al (1994)
IPT-A was included in the NICE guidelines for
Depression in Children and Young People in 2005
(CG28)
IPT-A: What does it do?
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IPT-A focuses on the relationship difficulties that are often very
important to young people and that are frequently identified as key
features of their depression stories.
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Separation and individuation from parents
Increased focus on peer and romantic relationships
Initial experiences of bereavement
IPT-A is primarily interested in the current conflicts, role changes,
losses and difficulties in establishing and maintaining independent
and satisfying relationships that so often trigger and maintain
episodes of depression for young people
IPT-A Focal areas: select one
Formulation
Transition
Dispute
Life
Sensitivities
Grief
IPT-A: Treatment Objectives
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IPT-A aims to reduce interpersonal difficulties and
improve depressive symptoms through psychoeducation
about depression, understanding depression in an
interpersonal context and developing communication
and interpersonal problem solving skills in family and
peer relationships
IPT-A also aims to boost self esteem and confidence by
helping young people to negotiate and develop
reciprocal and supportive relationships that will protect
against depression in the future
Modifications for adolescents
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Treatment objectives take into account developmental tasks,
such as individuation, developing initial intimate or sexual
relationships, emotional regulation and expression
Concrete and educative techniques are used to monitor
mood and to support skills development such as perspective
taking, negotiating resolution to conflict, problem solving
etc.
Strategies address specific issues such as school refusal, DSH
and suicidality in an interpersonal context
Parent and school involvement
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IPT-A is an individual therapy, however….
Specific focus on changes to family structure and negotiating
relationships with present and absent parent
Parents or carers are invited to participate in each phase of IPT-A,
to educate them about the therapy process and formulation, invite
them to support the young person’s participation in treatment and,
when required, to work directly on the interpersonal problem in
session
Contact may be co-ordinated around the YP’s sessions or scheduled
in addition
Active liaison is also maintained with school to support the young
person to continue to attend
Basic Structure of IPT-A
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Weekly for 12-16 weeks
Goals: reduce depressive symptoms and resolve related interpersonal
problems
Focal areas cover many common concerns and difficulties for adolescents:
grief reactions, parent-child disputes, peer conflict, difficulty making
transitions between life stages, coping with changes in family structure and
communication problems.
Clarify early warning signs for future depression, consolidate
understanding and use of successful strategies, generalize to future
situations, plan for any future treatment requirements.
Symptoms
Interpersonal
Inventory
Focus
Selection
Contract
Diagnosis
Psychoeducation
Populate
timeline of
depression
Inform
formulation
Guide to
symptom
discussion
Clear statement
of focus, goals
and expectations
Weekly
symptom
review
YP as
expert
Review of
current
resources
Review of
current
difficulties
Guide to
interpersonal
discussion
Prepare for future
sessions and
predictable
challenges
Timeline
Decision re
a/d meds &
review
schedule
Clarify moodinterpersonal
link
Clarify moodinterpersonal link
Work on ending
History of
depression
and treatment
Initial
symptom
relief
Assist focus
selection
Sick role
Social
model of
depression
Mobilize
available
resources
Assist focus
selection
Clarify treatment
targets/goals
Role Transition
Role Disputes
Grief
Sensitivities
Weekly symptom review
Weekly symptom review
Weekly symptom review
Weekly symptom review
Link symptoms to focal
area
Link symptoms to focal
area
Link symptoms to focal
area
Link symptoms to focal
area
Review +/- of old and
new roles
Clarify communication
problems
Reconstruct and evaluate
lost relationship
Clarify recurring
interpersonal problems
Explore process of changes
and affect
Identify key issues and
expectations
Review and evaluate social
support then and now
Use therapeutic
relationship as a model
Develop current
relationships and skills
Explore parallels across
relationships
Develop involvement with
current network
Develop new satisfying
relationships
Explicit discussion of ending
Explore feelings about ending and
potential loss
Review progress and highlight competence
Evaluate therapy
Maintenance plan
Relapse prevention plan
Social and communication skills
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Address the immediate interpersonal crisis
Mourn loss
 Resolve conflict
 Adapt to new circumstance
 Develop more satisfying relationships
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Improve communication and problem solving
Select optimal time to talk and be specific
 Communicate feelings and opinions directly
 See problems from another’s perspective
 Clarify objectives in communication and seek mutually
acceptable solutions
 Develop decision making skills
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IPT-A: Competency based training
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A competency map for IPT-A was developed within the
overarching IPT competency map and this has served as the
basis for the curriculum that will be used to training IPT-A
therapists in CYP IAPT
o
Sburlati et al (2012) A Model of Therapist Competencies for
Empirically Supported Interpersonal Psychothrapy for Adolescent
Depression. Clin Chil Fam Psychol Rev 15: 93-112
o
Hall & Mufson (2009) Interpersonal Psychotherapy for Depressed
Adolescents (IPT-A): A Case Illustration. Journal of Clinical Child &
Adolescent Psychology, 38(4), 582–593
IPT-A: Collaborative and goal based
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The IPT-A competency map highlights the central
role of collaborative practice and routine outcome
monitoring in IPT-A, making it highly compatible with
the core service transformation principles at the
heart of CYP IAPT
CYP in IAPT
Evidence
Based
Practice
Collaborative
Practice
IAPT
Meaningful
participation
Active
outcome
monitoring
NICE Guidelines
recommended
Explicitly
collaborative in
session and
transparent
shared decision
making
IPT-A
Parent/carer
participation and
between agencies liaison
and supervision protocol
Weekly symptom
review and
Interpersonal
goals
What does it look like in practice?
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Symptom review
Developing the story
Interpersonal Inventory
Formulation
Goal setting
Communication Analysis
Decision Analysis
Inviting participation and collaboration: Symptom Signature
Feel sad
Feel tired
a lot
Can’t get
to sleep
Not eating
Nothing is
much fun
anymore
Wish I was
dead
Feel guilty
Feel
restless
Can’t think
clearly
Don’t want
to see
people
No energy
for things
Worst symptoms
Moderate symptoms
Worry
about how
I look
Wake
early in
the
morning
Feel bored
Feel
Irritable
Feel
worthless
Not a problem
Colour coded grid is used to identify
the young person’s symptom
signature and to track changes over
treatment.
Personal timeline of episode of depression in interpersonal context
Time line: What still troubles you and what has
been resolved?
W
o
r
s
e
Mum’s
boyfriend
moved in
D
e
p
r
e
s
s
i
o
n
B
e
t
t
e
r
Split up
with
boyfriend
Ex
started
new relp
Failed
exam
?
?
?
Time
?
Weekly review and timeline
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Helicopter overview before
intervening
Where did the depression
bombs drop this week?
Where will it be most useful to
move the IPT camera into close
up?
Establish a timeline of the week
before switching from
reviewing to exploring
Shared decision making on
weekly focus
Depression this week
M
T
W
T
F
S
S
Distant friends e.g.
time, geography
Link to focus?
Opportunities
Link to focus?
Family
Current, immediate,
extended, history
Link to focus?
Common interests
e.g. Sport, music
Link to focus?
Professionals
Teachers, social
services etc.
Link to focus?
Young
Person
School
Lunch, after school,
when absent
Link to focus?
Friends
Current patterns,
history, loss or
change
Link to focus?
Neighbours
Link to focus?
Brother,
Paul
Aunt
Jane
Sister,
Sister,
Louise
Louise
Sister,
Friend,
Michelle
Michelle
Mum
B’friend
B’friend,
Tom
Tom
Friend,
Friend,
Joanne
Joanne
Brother
Teacher
Mr Jackson
Dad
Dad
Formulation: restating the problem to
allow a solution
Sample formulation
Stepping from the spotlight to the director’s chair
In the moment
Reviewing and revising
It is always the
same, you just
moan and do
nothing ... I wish I
could just fix it.
You never listen
to me. I can’t
imagine anything
worse !
I should go
You should try....
Hopeless,
helpless,
irritated
out more. Do
more to help
myself.......
Depressed,
Angry,
resentful,
irritated,
unheard.....
Did I
achieve
my
objective
What
was said
How well
was I
understood
What
wasn’t
said
How I
felt
How well
did I
understand
the other
person
Setting,
timing,
tone,
clarity
How did
the other
person
feel
How could
I have
made my
point more
clearly
Decision Analysis
Pros of opening up emotionally rather than
withdrawing
Cons of opening up emotionally rather than
withdrawing
So I have someone to talk to, I can share my
feelings instead of keeping them bottled up ‘a
problem shared is a problem halved’, might
make me feel better
Could go wrong, people might not understand
me, they might judge me, they could tell other
people private things that I don’t want them to
know
Other person might say helpful things
I could lose friends – people could reject me
Letting a friend know my deeper feelings and
thoughts gives me a stronger emotional
connection, being able to trust a friend with
these feelings makes the friendship stronger
I could lose their respect as they might not see
me in the same way
Might make me happier
What is an empirically based treatment?
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The treatment must be manual based
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Sample characteristics must be detailed
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Depressed adolescents 12-18 years
Treatments must be tested in a randomized clinical trial
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IPT-A for depressed adolescents 2nd ed. (Mufson et al, 2004)
4 published RCTs on IPT-A with depressed adolescents, 3
published trials of modified version of IPT-A
At least two different investigatory teams must demonstrate
intervention effects
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Independent teams have evaluated IPT-A with adolescents and
it has been delivered in community settings by community
clinicians
NICE Guidelines, 2005
Steps 4 and 5: Moderate to severe depression
 Children and young people with moderate to
severe depression should be offered, as a firstline treatment, a specific psychological therapy
(individual cognitive behavioural therapy [CBT],
interpersonal therapy or shorter-term family
therapy; it is suggested that this should be of at
least 3 months’ duration).
Evidence base for IPT-A for depression in CYP
Author
Comparison
Outcome/efficacy
Mufson et al (1999) n=48
Clinical Monitoring
IPT more efficacious
Rosello et al (1999)
n=132
Individual CBT, waiting list
IPT, CBT > WL
IPT>WL on SE and social adaptation
Mufson et al (2004)
N=63
Usual care
IPT > TAU
Young et al (2006)
IPT-AST , School counselling
IPT-AST > SC
Horowitz et al (2007
IPT-AST, CB, No intervention
control
CB = IPT-AST > Control
Not maintained at follow up
Rossello et al 2008
n = 112
IPT-G, CBT-G, IPT,
CBT
Both robust treatments
CBT> IPT-A
Miler L. et al (2008)
n= 25 (2 pilot studies)
Quasi non intervention control IPT-PA > control
Tang et al (2009)
N=73
TAU
IPT-A-IN > TAU on depression,
suicidal ideation, anxiety &
hopelessness
Mechanisms of change in IPT
Lipsitz & Markowitz (2013)
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Enhancing social support
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Decreasing interpersonal stress
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Facilitating emotional processing
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Improving interpersonal skills
Enhancing social support
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o
o
Positive development of interpersonal
resources and personal capacity
Develop a relational context in which to
develop emotional regulation, be
soothed and contained, develop a sense
of meaning from having a place and
purpose, social influence on health
behaviours, positive affect as a result of
companionship
IPT enhances targeted support to
address specific problems rather than by
means of general support and sick role
provides a framework in which social
support is more readily offered i.e. the
person is identified as being in need, the
problem is not the person’s fault and the
person is trying to overcome the problem
Decreasing interpersonal stress
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Amelioration of negative
contextual influence
Most prominent stressors are
interpersonal, the threshold
lowers with subsequent
episodes of depression
Focal areas target key
interpersonal stressors The
stressor itself is the target in
IPT-A rather than the means of
coping with the stressor
Improving interpersonal skills
Facilitating emotional processing
o
o
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Positive development of internal capacity
for emotional awareness and regulation
and a means of engaging interpersonal
resources
IPT addresses emotional processing
primarily as a means of confronting and
resolving focal interpersonal problems;
consequently this varies with the problem
Emphasis on affect and its interpersonal
character and effect. Repeatedly shift
awareness and expression of emotion in
session to the real world context. Problems
with emotional expression are addressed
only in so far as this obstructs resolution of
interpersonal difficulties
o
o
IPT focuses less on these stable
patterns, but considers improving
or adapting interpersonal skills
essential to successful resolution of
the current crisis or predicament.
Improving social skills in IPT may
yield symptomatic change
secondarily, through improved
social support and decreased
stress
IPT typically assumes latent skills
(or potential for such skills)
obstructed by current interpersonal
stress and diagnosis
IPT-A: In summary
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IPT-A is a time limited, evidence based treatment for depression in adolescents.
It targets key interpersonal issues that trouble many young people who seek
treatment and collaboratively formulates a treatment plan to focus on their primary
relationship difficulties
It monitors symptom reduction and progress towards interpersonal goals on a
weekly basis and has been shown to achieve outcomes that are equivalent or
superior to existing treatment approaches for moderate to severe depression in
young people
Sustainability of effect, impact of combining IPT-A with medication and key
mechanisms of change have not yet been established
Questions and comments