What is Interpersonal Psychotherapy (IPT): A Case History

How often do you feel relationships are your biggest source of stress, sadness, and worry?

If the answer is “often”, you may find a solution in the lesser-known but enduring practice of Interpersonal Psychotherapy.

This brief, attachment-focused form of therapy aims to help patients address challenges in managing relationships and ultimately improve the symptoms of mood disorders, such as depression (Van Hees, Rotter, Ellermann, & Evers, 2013).

In this blog post, we’ll cover the key features of this therapy, outline its history, and walk you through a case study before connecting you to resources to get trained and certified as an IPT practitioner.

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An Introduction to Interpersonal Psychotherapy

Interpersonal Psychotherapy (IPT) is a form of therapy developed by Gerald Klerman and Myrna Weissman as a treatment for major depression in the 1960s and 1970s.

While IPT is a short-term form of therapy typically lasting 12-16 weeks, the therapy aims to achieve both short-term and long-term goals.

In the short-term, the goal of IPT is to quickly ease symptoms of depression and help patients adjust to their immediate social situation (Weissman, Markowitz, & Klerman, 2000). For example, an IPT therapist may aim to help a patient communicate and maintain firmer boundaries when dealing with one particular person in their life with whom they are experiencing challenges.

In the long term, however, the goal is usually to help patients develop strategies that can apply to a broader scope of relationships and situations. That is, the patient can gain skills to better manage relationships without the regular assistance of a therapist, thereby helping them avoid the onset of mood-related symptoms stemming from interpersonal interactions in the future (Rafaeli & Markowitz, 2011).

While this form of therapy was initially developed to treat depression, it has been applied to treat a range of mental health issues, including anxiety, eating disorders, and substance abuse (Cuijpers, Donker, Weissman, Ravitz, & Cristea, 2016).

7 Features of Interpersonal Psychotherapy

According to Markowitz, Svartberg, and Swartz (1998), IPT is characterized by seven key features.

1. Time-limited with phases

Firstly, IPT is time-limited, usually spanning 12-16 weeks (Markowitz & Weissman, 2004). This feature of the therapy is always discussed with the patient at the outset of treatment, and its purpose is to place pressure on the patient to achieve the agreed-upon goals of the therapy swiftly.

Across the 12-16 weeks, IPT treatment is split into three crucial phases (IPTUK, n.d.):

2. Applies a medical model

A second key feature of IPT is that the patient’s presenting problem is explicitly defined as a medical illness. That is, the patient’s struggles are emphasized as stemming from a form of mental sickness in combination with a particular interpersonal context.

The advantage of this framing is that it can help relieve the patient from self-criticism and guilt. It creates distance between the patient’s suffering and their sense of self, allowing the patient to recognize that their current experiences are not a feature of their character but a consequence of their current circumstances and illness (Markowitz et al., 1998).

This framing also creates a clear goal post for the patient; a patient can think of themselves as currently being sick and set the goal of becoming healthy again by the end of the treatment.

3. Goals

IPT is characterized by the dual aims of resolving an interpersonal issue and relieving the symptoms of a mood disorder (Markowitz & Weissman, 2004).

The therapist explicitly links these two goals in the assessment phase of treatment to identify the focus of treatment, which will fall into one of four problem areas (ISIPT, n.d.):

1. Grief or Complicated Bereavement

   Chosen as the problem area when the death of someone close to the patient is the cause of a mood disturbance.

2. Role Dispute

   Chosen as the problem area when dissatisfaction with role expectations between the patient and someone in their life is the cause of a mood disturbance.

3. Role Transition

   Chosen as the problem area when mood disturbance is brought on by major life transitions. Difficulty coping with the transition can be observed in domains such as employment, close relationships, physical health, living conditions, and more.

4. Interpersonal Deficits

   Chosen as the problem area when no single event or relationship is driving a mood disturbance. Rather, the patient has experienced difficulty in interpersonal relationships and functioning across a range of contexts throughout time.

A therapist will often explicitly state their understanding of the patient’s presenting issues and formulate a succinct recommendation regarding how to proceed with treatment.

Here is an example of a target diagnosis from Markowitz et al. (1998) that effectively highlights the problem area to be focused on (grief/complicated bereavement) and links the client’s mood disturbance to this area.

As we determined by DSM-IV, you are going through an episode of major depression, a common illness that is not your fault. To me it seems that your depressive episode has something to do with your father’s death and your difficulty in mourning him. Your symptoms started shortly after that.

I suggest that over the next 12 weeks we try to solve your problem with mourning, which we call complicated bereavement. If we solve that, your depression will very likely improve. Markowitz et al. (1998, p., 189)

4. Here-and-now, interpersonal focus

IPT focuses treatment around interpersonal events in the patient’s current life. It is for this reason that IPT is often referred to as having a “here-and-now” focus (Markowitz et al., 1998).

Whereas other forms of therapy, such as psychotherapy, will often delve into a client’s early developmental experiences, sessions in Phase 2 of IPT will begin with the therapist asking how the client has been since the pair last met.

The discussion will then focus on recent interpersonal interactions, which will serve as the context for discussing mood and behaviors. For instance, a client may describe a current argument with a partner that left him feeling depressed.

5. Specific IPT techniques

IPT uses a range of innovative techniques for engaging with clients to bring about relief from mood disturbances and encourage behavior change.

After a client introduces a recent problem they encountered that triggered a mood disturbance, the therapist will encourage the client to explore that problem and their expectations and perceptions surrounding the interaction.

They will then apply techniques, predominantly from psychodynamic practice, to invite the client to explore alternative means to handle the problem and help them identify new, adaptive behaviors for managing similar scenarios in the future (Klerman, Weissman, Rounsaville, & Chevron, 1984).

Such techniques can include, for example, role-playing and communication analysis (Markowitz et al., 1998).

6. Termination

The final phase of IPT involves the lead-up to termination of the therapeutic relationship using a relapse-prevention framework.

In this phase, the therapist will encourage the patient to explore their feelings and reactions to the termination. The therapist will acknowledge the patient’s accomplishments and help them recognize the warning signs that suggest they may need to undergo more treatment.

This phase, and the time-bound nature of IPT overall, is critical as it is often following the course of IPT that the real benefits of the therapy become apparent. That is, it is often only upon termination of the treatment that a patient realizes they can competently manage their interpersonal affairs by applying the skills they have learned and without ongoing therapeutic support (IPTUK, n.d.).

7. Therapeutic Stance

Many forms of therapy require the therapist to operate from a position of neutrality. In contrast, the IPT therapist adopts the role of an openly supportive and optimistic ally–a little like a cheerleader.

Given that IPT was originally developed to treat depressive mood disorders, this optimistic outlook can be critical to counter the negative outlook often presented by depressed patients.

More broadly, problems and negativity are framed as being the fault of either the mental illness or issues in the outside world. This framing is important for minimizing a patient’s tendency to experience guilt or self-blame.

Further, this framing minimizes negative transference and strengthens the therapeutic alliance, such that the client and therapist can be viewed as working together to tackle interpersonal challenges (Markowitz et al., 1998).

The History of Interpersonal Psychotherapy

IPT is a great example of scientific serendipity in that it was discovered by accident.

In 1969, Dr. Gerald Klerman and Dr. Eugene Paykel, together with colleagues, were designing a study to test the effectiveness of various antidepressants alone and in combination with psychotherapy (Weissman, 2006).

Given that the trial was to last for a set window of time, the researchers needed to include a version of psychotherapy that was feasible in a time-limited treatment of depression.

Thus, the researchers began preparing a manual for the therapists involved in the study to deliver psychotherapy in such a way that focused on recent life events as drivers of depressive symptoms.

Several of IPT’s enduring features, such as its emphasis on one of four problem areas and framing of the patient as being ‘sick’ were conceptualized and documented in this first-ever manual (Weissman, 2006).

Originally, the therapy was termed “high-contact” psychotherapy. But when the results of the study revealed the efficacy of the treatment for improving social functioning, a follow-up maintenance study was conducted, and the treatment was renamed “interpersonal psychotherapy”.

The success of the treatment led to further research in collaboration with the U.S. National Institute of Mental Health, and in 1984, the IPT manual was published and available for public use.

The publication of the IPT manual led to a range of studies beyond this research group, exploring the therapy’s applications among different populations, including adolescents, the elderly, and pregnant women. Today, practitioners looking to conduct IPT draw on the Comprehensive Guide to Interpersonal Psychotherapy, published by Dr. Myrna Weissman, Dr. John Markowitz, and the late Dr. Klerman (2000).

IPT is now taught and practiced throughout the world and seemingly requires only minor adaptations to be relevant within different cultures (Weissman, 2006). Further, the practice is simple to learn if you have undergone basic psychotherapy training.

Interpersonal Psychotherapy Theory

In designing their therapeutic intervention, Klerman and Paykel were heavily inspired by the work of Dr. Adolf Meyer, the founder of ergasiology.

This is because his work was one of few at the time that considered mental illness to be driven, in part, by a patient’s relationships to their environment (Weissman, 2006).

Further, Klerman and Paykel drew on Harry Stack Sullivan’s Interpersonal Theory. Sullivan theorized that all psychological disorders stem from interpersonal experiences. Therefore, Sullivan argued that to understand a psychological condition, one must look to a patient’s social environment.

Sullivan was also among the first to observe that personality is shaped by our interactions with other people. In line with this, his writings encouraged therapists to explore the tensions clients experience in key relationships (Chapman, 1976).

Finally, the theory behind IPT also draws on Bowlby’s Attachment Theory. This is because it was Bowlby who observed that those who experience separation (or threat of separation) from those with whom they have strong affectional bonds would often suffer stress and depression (Bowlby, 1969). Bowlby’s works, therefore, support the link IPT scholars make between interpersonal relationships and mood disorders.

An Example of Effective IPT

To understand how clients may benefit from the practice of IPT, let’s look at a case study illustrating how a series of IPT sessions may play out.

This case study is drawn from Markowitz and Weissman’s (2012) Casebook of Interpersonal Psychotherapy and describes the course of IPT undertaken by a patient suffering from depression.

Case Study: Joy (Markowitz & Weissman, 2012)

Joy was a thirty-seven-year-old financial analyst. She reported feelings of depressed mood, low self-worth, decreased energy, and impaired concentration. She described herself as “lazy and unmotivated” and stuck in a “rut”.

Joy suffered from severe hypertension, and in the months leading up to her seeking therapy, she quit her high-stress job, fearing for her health after suffering a recent heart attack.

Subsequently, Joy reported that quitting her job had led to an increase in conflicts with her ex-partner over childcare responsibilities.

Having left her ex two years earlier, Joy would now spend most evenings with her new partner, Ben, whom she described as encouraging and supportive. However, a part of Joy felt that she was undeserving of Ben’s kindness.

When she came to the clinic seeking therapy, Joy explained that she felt out of control of her life, and although she wished to return to work, she was unmotivated to seek out a new career.

Joy’s IPT Sessions

Upon assessment, it was revealed that Joy met the criteria for major depression.

Given that Joy’s depression was occurring in the context of several social stressors, including a new relationship, conflict with a previous partner, and a chronic physical illness, IPT was recommended as the mode of treatment, and Joy agreed.

Initially, Joy expressed shame about experiencing depression. Joy had high expectations for herself, which she was failing to meet, and these perceived failings were contributing to her depression. Thus, in line with the principles of IPT, the therapist likened Joy’s current experience of depression to having the flu, thereby putting joy in the ‘sick’ role and excusing her from self-accusation.

During Phase 1 of the treatment, an interpersonal inventory was conducted, during which Joy was invited to describe her relationships with all the key people in her life and how she wished those relationships could be different.

In this, she spoke warmly about her partner, Ben, but had mixed feelings about the relationship as she was unsure whether he wished to be with her.

She detailed a complex relationship with her ex-partner, Laura, who she described as having been manipulative when they were together. Despite being separated, Laura was increasingly calling upon Joy to pick up her responsibilities on short notice. Joy resented this but would end up helping anyway as she explained that she struggled to assert herself.

Joy acted as a co-parent to Laura’s daughter, Maxine, caring for her two nights a week. However, because she did not have any legal right to Maxine, she feared that if she challenged Laura, she risked being cut off from their daughter.

It was clear from these descriptions that the problem area to be focused on was a role dispute as Joy had different expectations from others in her life about the extent to which she should be expected to intervene and help in various situations.

This focus resonated with Joy and set the scene for the remainder of the sessions.

In Phase 2 of the treatment, the therapist began each session by asking how Joy had been since they last met. This would prompt Joy to describe a recent interpersonal encounter, to which the therapist applied the psychodynamic technique of communication analysis.

Through communication analysis, the therapist had Joy describe a challenging interaction in great detail. As Joy did so, the therapist interjected to inquire about how Joy recalled feeling at different moments during the interaction.

By Phase 3, Joy’s depressive symptoms had subsided significantly. Her mood had improved, and she was now calmer.

Voicing concerns proved helpful for Joy, and the therapist was able to remind Joy of all the things she had done to care for her daughter’s wellbeing, thereby lifting her spirits.

In the days surrounding her final sessions, Joy continued to assert herself with her ex-partner. Joy also showed a visible lift in mood and expressed that she felt consistently positive and optimistic.

Ultimately, upon termination of the therapy, Joy left feeling confident in her ability to manage her relationships and self-care moving forward. She also found a new job and indicated that she had sustained her progress on a six-week follow-up call.

In this example of IPT, Joy was encouraged to see how her symptoms were linked to her current relationships. She came to realize the way others were treating her in her life was unacceptable and permitted herself to acknowledge her resentment at such treatment.

Consequently, Joy harnessed her anger, enabling her to assert herself and protect her boundaries while still being a good mother to her daughter.

Similarities and Differences with other Therapies

Reading the case study above, it is interesting to compare and contrast IPT’s time-limited, relational approach to other forms of therapy.

A traditional psychoanalytic approach might have explored Joy’s childhood memories, including those of the mothering relationship. As such, any progress Joy made would likely have been credited to new insights regarding her early relationships and the cathartic release of repressed emotions.

Through psychotherapy, Joy would likely have been guided to harness her repressed anger into increased assertiveness–a healthier approach to communication compared to her previous denial and repression.

A CBT approach would emphasize the role of Joy’s dysfunctional beliefs in causing her initial symptoms. For instance, Joy would likely have been encouraged to address negative self-talk, such as, “I am a bad parent.”

Progress for Joy would have been credited to changes in these beliefs, which would be replaced with more constructive thoughts, such as, “I’m a good mother to Maxine, even if I don’t always get everything right.”

Lastly, relationship counseling likely would have focused on poor communication between Joy and her ex-partner. This would have helped them express themselves better and negotiate clearer rules, boundaries, and expectations in their co-parenting relationship.

Training and Certification Opportunities

There are many institutions around the world that offer training and certification for those interested in IPT.

A good first point of call is the IPT Institute, which specializes in the training, certification, and supervision of IPT clinicians. The IPT Institute offers a range of courses, currently provided online.

The IPT Institute’s Level A course, ranging from four to eight days, covers the key principles of IPT and existing research around its effectiveness.

Those who undertake the course will learn how to identify whether IPT is a suitable treatment for a particular patient, how to conduct an interpersonal inventory, and techniques and frameworks used throughout the sessions.

This introductory course is currently being offered in the Americas, Europe, India, Africa, and China (with live translation).

The Interpersonal Psychotherapy UK (IPTUK) Network offers a range of similar courses, targeted at different levels of experience throughout the UK. They also offer online training on Interpersonal Social Rhythm Theory (IPSRT), which is a form of IPT that can help patients managing bipolar.

The University of Sydney offers a 14-hour (four-session) in-person and online Level A certification. The course is open to students, practitioners in training, and experienced clinicians. The course covers the three phases of IPT therapy and the various possible foci of the sessions (e.g., grief and loss, role transitions, etc.)

For details of more training available around the world, the International Society of Interpersonal Psychotherapy keeps a list of training available by region on their website.

A Take-Home Message

While once on the fringe of psychological treatment options, IPT is now well-recognized around the world for its effectiveness, particularly for treating depression. It is now included in many treatment guidelines around the world and has been documented in more than 250 randomized controlled studies (ISIPT, 2020).

Arguably, one of the IPT’s strengths is its decoupling of the individual from the symptoms of his or her illness. By doing this the patient is reassured of his or her ability to change their interpersonal situation.

Likewise, IPT therapists are often talented at coaxing out patients’ ambivalence toward those for whom they care. By surfacing these mixed feelings, therapists become able to identify the causes of such feelings and create a space for patients to talk through them without judgment.

Notes:

• Some details of this case study have been changed to protect confidentiality.
• Stress management for headaches should only be attempted after a doctor has eliminated an organic cause for the pain.

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