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 Second edition

Classics in Psychotherapy Classics in Psychotherapy

Interpersonal Psychotherapy
Interpersonal
Psychotherapy Interpersonal
a clinician’s guide Psychotherapy
a clinician’s guide
Scott Stuart and Michael Robertson

Stuart and Robertson

This ground-breaking text has firmly established itself as a touchstone for all
therapists using interpersonal psychotherapy (IPT).
Key features and benefits:
■ A wealth of clinically-based descriptions and vignettes help bring the theory
to life
■ Numerous case studies highlight the key issues in IPT
■ Reproducible diagrams and flowcharts for use by therapists and their patients
■ Comprehensive coverage of key theoretical issues and an up-to-date critical
appraisal of IPT research
For this, the second edition, there is extended coverage of the clinical
adaptation of IPT to post-traumatic mental health and other new applications
Second edition

of IPT, more on depression and common problems encountered in IPT training

and dissemination, as well as how to manage joint sessions and integrate
techniques from other approaches and models.
Interpersonal Psychotherapy: a clinician’s guide remains invaluable for all mental
health workers including the clinical trainee seeking an introduction to IPT,
instructors of psychiatry residents, psychology interns, graduate students, and
social work students.

I S B N 978-1-4441-3754-5

9 781444 137545

137545_INTER_PSYO_V6.indd 1 03/08/2012 14:25

 Second Edition

Interpersonal
Psychotherapy
A Clinician’s Guide

Scott Stuart md
Professor of Psychiatry, Psychology and Obstetrics and Gynecology,
University of Iowa, Iowa City, Iowa, USA
Director, IPT Institute

Michael Robertson franzcp

Clinical Associate Professor, Centre for Valves, Ethics and Law in
Medicine, University of Sydney, Sydney, Australia
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2012 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20150220

International Standard Book Number-13: 978-1-4441-3755-2 (eBook - PDF)

This book contains information obtained from authentic and highly regarded sources. While all reasonable
efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can
accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish
to make clear that any views or opinions expressed in this book by individual editors, authors or contributors
are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or
guidance contained in this book is intended for use by medical, scientific or health-care professionals and is
provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of
the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guide-
lines. Because of the rapid advances in medical science, any information or advice on dosages, procedures
or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national
drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and
their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this
book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular
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 Contents
Preface iv
Acknowledgements xvi
Section 1: Introduction
Chapter 1. Introduction 3
Chapter 2. Theory and Clinical Applications 17

Section 2: Assessment/Initial Sessions

Chapter 3. The Structure of Interpersonal Psychotherapy 45
Chapter 4. Assessment and Patient Selection 54
Chapter 5. The Interpersonal Inventory 72
Chapter 6. The Interpersonal Formulation 83
Chapter 7. The Treatment Agreement 96

Section 3: IPT Techniques

Chapter 8. Clarification 107
Chapter 9. Communication Analysis 114
Chapter 10. Problem Solving 139
Chapter 11. Use of Affect 152
Chapter 12. Role Playing 159
Chapter 13. Homework and Other Directives 167

Section 4: Problem Areas

Chapter 14. Interpersonal Disputes 179
Chapter 15. Role Transitions 202
Chapter 16. Grief and Loss 223

Section 5: Concluding IPT

Chapter 17. Concluding Acute Treatment and Maintenance
Treatment 239

Section 6: Additional Aspects of IPT

Chapter 18. Psychodynamic Processes 257
Chapter 19. Applications of Interpersonal Psychotherapy 266
Chapter 20. Research in Interpersonal Psychotherapy 283
Chapter 21. Integrated Case Example 286

Appendices
A. IPT Institute and Certified Training in
Interpersonal Psychotherapy 306
B. Interpersonal Inventory Form 309
C. Interpersonal Formulation Form 310
D. International Society of Interpersonal Psychotherapy (ISIPT) 311
 Preface
We present herein the second edition of our guide to conducting Interpersonal
Psychotherapy (IPT). We are grateful that many clinicians and academicians have used the
original edition of this book in their clinical work and teaching over the past decade, as well
as in various research projects around the world. Our original intent was (and current intent
still is) to publish a text that is useful for clinicians. We seek to encourage clinicians to utilize
IPT as a framework in which they can exercise their judgment, recognizing that at least to
date, none of the many psychotherapy manuals that have been published (including ours)
have been carved in stone and carried down from Mount Horeb.
A flexible approach is needed as manual-based psychotherapies are disseminated
from tightly controlled academic settings into the field. Terms such as ‘empirically based’
or ‘empirically supported’ treatments are now being used to describe clinical applications,
denoting not only that flexibility is important with complex patients,a but that rigid
adherence to manuals often results in outcomes that are not as good as those obtained when
manuals are used as guides and combined with clinical judgment and common sense. Our
use of the term ‘guide’ is intended to convey that IPT is best conceptualized as a treatment
which is theoretically grounded, empirical, and clinically validated, and applied with a
healthy measure of clinical judgment. We recognize that randomized controlled trials,
though critically important, are only one means of obtaining empirical data. The experience
of clinicians is also a wealth of qualitative data which should inform clinical practice.
Our primary goal is to assist therapists in their endeavors with the unique individuals
with whom they work, with the conviction that IPT is an extremely useful framework for
both clinicians and their patients to accomplish the goals that they have mutually set forth.
Our objective aim is to provide a guide to the conduct of IPT, but our subjective aim is to help
therapists better understand their patients. This mirrors the process of IPT: helping patients
alleviate their suffering requires that therapists understand their individual patients, all the
while working to help those patients better understand themselves.
Since we last wrote, there have been many changes to IPT which have been disseminated
worldwide. Among these are major modifications in the structure of IPT. Acute treatment
with IPT is now concluded rather than terminated, with provision made for Maintenance
Treatment for most patients. This practice of shifting to maintenance therapy rather than
‘terminating’ IPT has been the norm in clinical practice for many years. The range of sessions
which may be used in IPT has expanded, and is now conceptualized as a flexible dosing
range rather than a fixed number. The Problem Areas have been reduced from four to three
(eliminating Interpersonal Sensitivity). Each of these changes is grounded in empirical
research and clinical experience with IPT.
We have also greatly expanded the application of Attachment and Interpersonal Theory
to IPT. A structured IPT Formulation, which has proven to be extremely valuable for
clinicians and patients, incorporates this new emphasis. Several specific techniques, such
We have, for convenience sake, chosen to use the term patient throughout the text. In many ways, the term ‘patient’,
a  

which originally meant ‘one who suffers’, is a very accurate description of the people with whom we work – they are
suffering, and are in need of help. In other ways, neither the term ‘patient’ nor ‘client’ captures what we would most
like to convey; as an alternative, we encourage you to think of the people with whom we work as unique individu-
als, whose diagnoses, disorders, and distress are but a few of their many human qualities.
 Preface

as communication analysis, have also been modified. Also new to this edition are some
additional clinical tools which have been tested in the field and are now widely disseminated.
These include a structured Interpersonal Inventory, a Timeline for Role Transitions, and an
Interpersonal Conflict Graph for Interpersonal Disputes. Each is a simple tool designed to
help clinicians better understand their patients.
Most importantly, this second edition takes a much broader view of the problems that
are amenable to treatment with IPT. Over the past decade there have been a multitude
of treatment trials using IPT for many different disorders, and clinical experience has
also supported its use transdiagnostically. Given the upcoming shift to Diagnostic and
Statistical Manual of Mental Disorders (DSM)-V as well as the completely new Research
Domain Criteria (RDoC),1,2 which are under development by the US National Institute of
Mental Health, this transdiagnostic approach is both timely and empirically supported.
Consequently, we have chosen to use the term ‘distress’ to encompass these concepts broadly
as well as to describe their formulation within IPT.
Since our first edition in 2003, there have been many exemplary studies of IPT for a
number of disorders and populations.b However, it continues to be the case that, while IPT
enjoys even more empirical support for its efficacy, there is still limited research evaluating
its effectiveness in typical clinical settings. As we noted a decade ago, this is the case for all of
the empirically validated psychotherapies. In other words, IPT (and other evidence-based
practices) have been empirically demonstrated to be of benefit when used:
●● In academic settings with therapists specifically devoted to their application

●● With subjects (as opposed to patients) who meet carefully selected diagnostic criteria and

do not have comorbid diagnoses

●● With subjects who agree to be involved in randomized clinical trials

●● With subjects who are not required to pay for treatment

●● With tightly controlled protocols which dictate strict adherence to a manual.

In contrast, most clinicians work in settings in which it would be nearly inconceivable to

meet weekly with a patient for 12, 16, or any arbitrary number of consecutive weeks as
research protocols require. Most clinicians are paid for direct patients services rather than
being paid by a research grant. Most clinicians do not have the luxury of working with
patients with major depression without any comorbid diagnoses – many ‘real-life’ patients
have combinations of depression, anxiety, dysfunctional personality traits, substance abuse,
and many other problems. Most patients who seek treatment in community clinics do so
with a preconceived idea about the kind of treatment they want, whether it is medication,
therapy, or something else. They are different from subjects in research studies who agree to
be randomly assigned to treatment. There are no distressed patients who come to community
clinics and ask to be treated by being randomized to a placebo.
While empirical research regarding the efficacy of a treatment is essential (e.g. its benefit
when applied in a strict research setting in a randomized, controlled study), the effectiveness
of a treatment (e.g. its benefit when applied in clinical settings) is the ultimate measure of its
clinical utility.3,4 Though population-based empirical research regarding the effectiveness of
IPT is not well-developed at present, there is a great deal of clinical wisdom and experience
which does address its use in the community. This clinical experience is also a form of
research: the careful observation of the application of IPT and the responses of patients to
adaptations and changes is qualitative data. We believe that the practice of IPT should be

b   
See Chapters 19 and 20.

v
Preface

based on both empirical data gathered from randomized trials and from the qualitative data
derived from clinical experience.c
This conviction leads to a fundamental conclusion about manualized forms of IPT
and manualized treatments in general. Requiring strict adherence to a manual outside
of a research protocol is likely to diminish the effectiveness of the treatment because
it discourages therapists from utilizing their clinical experience. This assertion is now
supported by evidence: experienced therapists have been shown to have better outcomes
when they more flexibly deliver empirically validated treatments.5,6
The data – observable and inferential data – that a therapist obtains from a patient
during therapy, such as the kind of insight the patient is developing, the degree to which she
is motivated to change, the effect of the transference on the therapeutic interaction, and the
quality of the therapeutic alliance, should assist the therapist to decide whether the patient
might benefit from a homework assignment, might develop more insight with a well-timed
therapist self-disclosure, or might have greater improvement with 20 as opposed to 16
sessions of therapy. These decisions should be mutually determined within each therapeutic
dyad, not dictated ‘a priori’ by a manual.7–9 Thus this book is a guide rather than a manual – it
provides a set of principles which serve as a framework for the conduct of IPT rather than a
set of rules which constrain it.
This is reflected in our description of the structure of IPT in this second edition. For
instance, we originally noted that clinical experience had made clear that conducting
consecutive weekly sessions of IPT, then terminating treatment abruptly after 12 or 16 sessions,
was not the best way to conduct IPT most effectively in a clinical setting. Since then, several
well-controlled efficacy trials have been conducted in which Acute Treatment with IPT was
concluded, often with sessions tapering in frequency over time, and Maintenance Treatment
was then provided.10–12 Outcomes using this approach have been superior in reducing relapse,
as experienced clinicians have known for some time. Since there are data which demonstrate
that many disorders such as depression recur,13,14 and since Maintenance IPT reduces the risk
of recurrence,10,11 it is literally malpractice not to provide it if patients are at high risk.
The provision of Maintenance Treatment means that IPT should not be terminated. It is
much more effective to negotiate the scheduling of sessions with each patient, to meet for several
biweekly or monthly sessions prior to concluding Acute Treatment, and to provide Maintenance
Treatment as indicated. Acute Treatment with IPT should be concluded, not terminated. Clinical
experience with IPT as well as empirical data also support a Biopsychosocial formulation for IPT.
The Biopsychosocial model is used universally in psychiatry, psychology, and medicine.15–19 More
recent clinical experience suggests that expanding this model to include cultural and spiritual
factors is likely to be of even more benefit.d Human psychological functioning is complex,
multifactorial, and far beyond characterization as a simple medical ‘disorder’. We are more than
the sum of our genes or our ‘medical’ selves.
It is our belief that strict adherence to a medical model of psychopathology dehumanizes both
the therapist and the person with whom she is working. The medical model requires that patients,
not people, must be diagnosed with a specific medical disorder, usually as defined by DSM20 or
the International Classification of Diseases (ICD)21 criteria. This approach not only categorizes
and defines the people with whom we work by their ‘symptoms’ or ‘diagnoses’, it limits our ability
to understand them as unique individuals, and to work creatively with them to develop solutions
to the problems they are experiencing. Since the primary goal of therapy in general, and IPT

This same principle applies to all other empirically validated treatments, whether they are psychotherapeutic or
c    

psychopharmacologic.
d   
We are indebted to our colleagues Rob McAlpine and Anthony Hillin for this improvement in IPT.

vi
 Preface

specifically, is to understand the person seeking treatment, using only strict medical diagnoses to
develop that understanding and reflect it to the patient is simply poor clinical practice. IPT should
be based on a comprehensive Biopsychosocial/Cultural/Spiritual formulation.
Therefore, although a symptom-based diagnostic system is an important way to
understand patients, it should not be used as the primary basis for conceptualizing
patients’ distress, nor as a requirement for treatment with IPT. IPT can be used clinically
with patients who present with interpersonal problems. Some will be depressed, some will
be anxious, some will have personality issues, and many will have combinations of these
factors. Some will be old, some adolescents; some will be male, some female; some will
be from cultural backgrounds different from their therapists’; some will be poor, some
wealthy; but all will be individuals who can be understood in part as social beings who
are intimately involved in a social network, and are therefore potential candidates for IPT.
The question of whether the treatment should be applied in a clinical setting if the patient
does not meet strict diagnostic criteria is not relevant; it is the individual’s unique problems
and distress and social context that should be used to make a determination regarding her
suitability for IPT.
In sum, the empirical evidence of efficacy should form the foundation for the clinical
delivery of IPT, should be built upon by clinical experience, and should be supplemented by
clinical judgment.

The History of IPT

The early developmental trajectory of IPT was different from most of the other ‘brands’
of empirically supported psychotherapy currently practiced. Most have been derived
from clinical observations which gradually coalesced into theories explaining how
the treatments ‘worked’. In many cases, such as that exemplified by behavioral therapy,
these theoretical hypotheses about the mechanisms of change led to specific therapeutic
techniques.
Over the past four decades, the movement towards the delivery of evidence-based
medicine has required that psychotherapeutic treatments also be empirically validated.
Largely influenced by psychopharmacologic trials, randomized and well-controlled
efficacy treatment trials have been the ‘sine qua non’ method for ‘proving’ that a particular
psychotherapy works.22 Empirically supported treatments (ESTs) are defined as ‘clearly
specified psychological treatments shown to be efficacious in controlled research with a
delineated population’,23 and specific criteria have been established to define what an EST
is24 (Box 0.1). At the time of this writing, the American Psychological Association (APA)
Division 1225 lists 60 psychotherapies that meet these criteria (Box 0.1).
Thus the progression of most recently developed psychotherapies, epitomized by
cognitive behavioral therapy (CBT), has moved from clinical observation to theory to
randomized treatment trials. Efficacy testing is critical: it is becoming increasingly common
around the world that reimbursement and licensure are tied to provision of ESTs. Because
of this, there is a lot at stake in ensuring that one’s favorite therapy, especially if one is the
developer, is on the EST list. This has compounded the rigidity of manualized therapies –
once on the list and recognized as empirically validated or supported, there is every reason
to insist that one’s favored therapy be delivered exactly as described. Manuals become dogma
rather than a set of guiding principles.
This same process occurs when pharmaceutical companies market their US Food and
Drug Administration (FDA)-approved psychopharmacologic medications. It is in the
vii
Preface

Box 0.1 Criteria for well-established empirically validated psychotherapy

I. At least two good between-group design experiments demonstrating efficacy in one
or more of the following ways:
A. Superior (statistically significantly so) to pill or psychological placebo or to another
treatment
B. Equivalent to an already established treatment in experiments with adequate
sample sizes
or
II. A large series of single case design experiments (n >9) demonstrating efficacy. These
experiments must have:
A. Used good experimental designs
B. Compared the intervention to another treatment as in IA

Further criteria for both I and II:

C. Experiments must be conducted with treatment manuals
D. Characteristics of the client samples must be clearly specified
E.  Effects must have been demonstrated by at least two different investigators or teams

developer’s interest to make every possible distinction between his medication or therapy and
all of the others, and to argue for the superiority and universality of his treatment. A treatment
that is advertised as better than others increases sales. It is not in the developer’s interest to
make any adaptations or changes to the treatment because adaptations or changes put the
FDA approval or APA approval at risk. This contrasts with the ideal bidirectional collaboration
which should occur when empirically validated treatments are disseminated. Ideally, as
experience is gained and additional clinical observations accumulate, both theory and
techniques should be modified and then tested for efficacy once again. This bidirectional or
circular approach to psychotherapy development recognizes that data also come from clinical
practice. The best evidence-based practices recognize practice-based evidence (Figure 0.1).
Clinical observations lead to a theoretical understanding of psychopathology and
mechanisms of change. These are then translated into clinical strategies and techniques
which are refined during pilot testing. A manual or guide is then developed and the
treatment empirically tested; those that are efficacious are disseminated clinically. Often,
the process stops at this point. Ideally, once the treatment is disseminated, additional
clinical observations are collected and used to further refine the theory and improve clinical
interventions. These are then pilot tested, added to a revised manual, and empirically tested
and disseminated once again. The process is dynamic and evolving, and leads to therapies
that are both efficacious and effective.
IPT evolved in a strikingly different fashion than most ESTs. Rather than beginning
as a set of clinical observations that were used as the basis for a coherent theory of
psychopathology and led to specific techniques to bring about change, IPT began as a
manualized treatment developed for a research protocol. In fact, IPT was initially developed
not as a clinical treatment, but for the express purpose of serving as a manualized ‘placebo
condition’ for a psychopharmacologic treatment trial for depression.26–29 It was largely
accidental that IPT was discovered to be of benefit.
In order to understand the original IPT model, it is important to note that it was
developed in the 1970s,26 during which time the medical model of psychopathology reigned
supreme. At that time, there was an increasing emphasis on medical treatments, particularly
psychotropic medications, fueled both by the pharmaceutical industry and the desire of
many psychiatrists to be seen as legitimate, empirically based ‘medical’ specialists.30,31 It was
viii
 Preface

Clinical observations Clinical dissemination

Theory Empirical testing

Clinical strategies and techniques Manual/guide development

Clinical refinement/Pilot
testing

Figure 0.1 Psychotherapy development: an ideal approach

widely held within this model that psychotherapy was not particularly effective, and that it
should largely be subsumed by psychopharmacologic treatments.
Nonetheless, some early studies investigating the treatment of depression with
medication included psychotherapy as a treatment component, as the trials were designed
to mirror the clinical practice of the time, which generally included some form of
psychodynamic psychotherapy along with medication.e Klerman, Weissman, and their
colleagues incorporated a manualized form of psychotherapy in their medication trials for
depression for this reason. This manualized treatment, which later became IPT, was initially
called a ‘high contact’ condition,32 the presumption being that there might be some benefit
from the non-specific effects of contact with a therapist, but none that would be attributable
to any specific techniques.29
Explicitly following the model established by pharmacologic treatment trials, a codified
manual describing the procedures and techniques to be used in the psychotherapy condition
was developed, so that fidelity to treatment could be preserved. The primary concern
of the investigators was that the therapeutic treatment was reproducible – the specific
techniques to be used and the theoretical basis for the psychotherapeutic interventions were
of secondary importance.29 In contrast to the investigators’ expectations, the early studies
of IPT demonstrated that it had a therapeutic effect.26,28 As IPT was largely conceived of as
a ‘social work’ or ‘social support’ intervention, it was hypothesized that changes in social
circumstances and social relationships were largely the driving force behind improvement.
The investigators’ enthusiasm to continue to empirically test IPT in rigorously controlled
trials led to the use of IPT in many research settings.
In short, IPT was initially constructed in ‘retrograde’ fashion rather than being derived
from clinical observations which were used to develop a theory of psychopathology and
to develop specific techniques. IPT began as a manualized therapy which was believed to
be an inert treatment, or at most was simply thought to be a codification of ‘non-specific’
therapeutic factors common to all psychotherapies. The original purpose of IPT was to serve
as a credible and reproducible placebo psychotherapy. It was not originally developed from

Some have suggested that psychotherapies were included in these medication treatment trials with the intent of
e   

demonstrating that they were not effective, thus reinforcing the primacy of biological psychiatry.

ix
Preface

clinical observations, and it has only been over the past decade that close attention has been
paid to its theoretical foundations.
This developmental process had two effects on the dissemination of IPT in the 1980s and
1990s. First, ‘manualized’ IPT was constructed to meet the demands of an empirical research
protocol; it was not designed for clinical use. Consequently, for nearly two decades, IPT was
largely restricted to academic settings and efficacy studies, with clinical dissemination lagging far
behind empirical research. Second, the historical emphasis on the reproducibility of IPT in efficacy
research studies led to an insistence by many investigators that IPT had to precisely follow the
dictates of the research manual, rather than being flexible when it was adapted to clinical settings.
Adherence to the manual was primary; flexibility and quality were distant seconds.
These two effects were magnified by the inclusion of IPT as one of the two
psychotherapeutic treatments investigated in the National Institute of Mental Health
Treatment of Depression Collaborative Research Program (NIMH-TDCRP).33 The
NIMH-TDCRP, which utilized what is still considered the gold-standard methodology
for psychotherapy efficacy studies, was designed to definitively answer how efficacious
psychotherapy (IPT and CBT specifically) and medication were as acute treatments
for depression. The rigorous design dictated that IPT be adapted to the research
protocol, rather than adapting the protocol design to reflect good clinical use of IPT.33
For instance, the description of the NIMH-TDCRP protocol specifically states that the
length of the treatments selected for the trial were based on the requirements of the
psychopharmacologists, not on the needs of the psychotherapists. To quote Elkin et al.:33
All treatment conditions are 16 weeks long. This treatment length was based
primarily on pharmacotherapy practice current at the time this program was initi-
ated; the two experimental psychotherapies are frequently only 12 weeks long.

The rigorous NIMH-TDCRP design further entrenched IPT as a ‘research’ therapy following
a medical model. The emphasis on reproducibility and adherence to the IPT manual led to an
insistence that it continue to be conducted exactly as specified in the NIMH-TDCRP protocol.
Rather than being conceptualized as a dynamically developing treatment which should
incorporate new clinical observations and clinical experience, the way IPT was manualized
in the NIMH-TDCRP became for many years the singular and ‘correct’ way to conduct it. For
nearly two decades this 16-week protocol was used inflexibly by many IPT clinicians.
Ironically, the flexibility that was included in the NIMH-TDCRP protocol was ignored by
those advocating rigid adherence to the manual. In fact, clinical judgment was permitted, and
flexibility was explicit. To quote the investigators once again:33
There are, however, some slight differences in the total number and frequency
of treatment sessions. These differences are consistent with usual practice for
each of the approaches. The patients in CB therapy receive 12 sessions over
the course of the first eight weeks, followed by eight sessions once a week, for
a total of 20 sessions. The patients in IPT receive 16 weekly sessions with the
therapist having the option of scheduling up to four additional sessions, for a total
of 16 to 20 sessions.
There was also a wide range of psychotherapy delivery in the NIMH-TDCRP. Though the
treatments were planned to be 16 weeks in length, the average number of sessions actually
delivered was only 13.0.
The NIMH-TDCRP was structured with the intentional inclusion of therapeutic
judgment. Therapists were allowed to schedule up to four additional sessions at their
discretion. A reasonable interpretation of the data is that there should be flexibility in the

x
 Preface

structure of IPT, and that a dosing range should be used for individual patients. This was not
the way that IPT was disseminated for nearly two decades. The early manuals became a set of
rigid rules rather than clinical guidelines, and dissemination was hindered.
Another ramification of the inclusion of IPT in the NIMH-TDCRP was that some of the
components in the original IPT research manual were included (or excluded) primarily as
a means of distinguishing it from CBT. By intent, the two psychotherapies to be compared
were to be as different as possible in hypothesized effects, therapeutic stance, and specific
interventions.33 Some techniques which are intrinsic to CBT, such as the assignment of
homework, were intentionally excluded from IPT. IPT was described as relying largely on
‘non-specific’ techniques such as non-directive exploration and clarification in order to
distinguish it from the behavioral components of CBT. Thus the exclusion of homework
specified in the early IPT manuals, for example, was the result of research expedience rather
than being supported by a specific theoretical rationale or by clinical experience. The lack
of techniques specific to IPT, and the lack of techniques derived from a theoretical base,
led some critics to describe IPT as nothing more than a ‘time-limited psychodynamic
psychotherapy’, or a sophisticated means of encouraging social support.34
Another major influence of the NIMH-TDCRP on the development of IPT was that the
major outcome measures used were focused on symptom reduction. Because medications
for depression are targeted specifically at DSM symptoms, the efficacy of IPT as a comparison
treatment was measured by the reduction it brought about in depressive symptoms. This reduced
IPT (and CBT) to simplistic analogs of antidepressant medication.35 The implication was that
the ‘value’ of IPT was restricted to the narrow focus of relieving a predefined cluster of symptoms
rather than recognizing the benefit of IPT for more broadly defined psychological distress.
While there is no doubt that symptom relief is a highly desirable goal, and no doubt that
a multitude of efficacy studies demonstrate that IPT does lead to reduction in symptoms, this
narrow focus has displaced attention from the other benefits of IPT. These include potential
changes in insight, improvement in social relationships, general life satisfaction and well-
being, and an acceptance of life circumstances which is more congruent with the patient’s
condition. Though these concepts are very difficult to quantify and to measure, neglecting
them as changes in IPT, and focusing narrowly on symptomatic outcome alone, runs the risk
of missing some of the most powerful and beneficial aspects of the therapy – changes that
would be unique to psychotherapy as opposed to the use of medication.
Though the more comprehensive Biopsychosocial/Cultural/Spiritual model is
now widely used in IPT, most IPT research still continues to be focused narrowly
on symptomatic relief. Most research in IPT continues to examine its application to
well-circumscribed DSM psychiatric disorders, rather than examining its impact on
interpersonal problems in general. There is a great need for effectiveness studies of IPT in
the community with complex patients that focus on presenting problems rather than strict
diagnoses, as well as a need for investigation of changes in interpersonal functioning, social
functioning, and general distress.
Fortunately, over the past decade, adaptations to IPT have occurred, driven both by
clinical experience and research. The application of IPT to more complex populations and to
non-affective disorders has led to changes such as the modification of frequency and duration
of treatment, development of maintenance treatment, and the combination of IPT with other
modalities. These have been implemented in training as well. IPT is now disseminated and
practiced as a flexible principle-guided treatment, reflecting what is universally recognized
as the most appropriate and effective means of delivering ESTs. To quote the American
Psychological Association:36

xi
Preface

The APA has identified ‘best research evidence’ as a major component of

evidence-based practice. This research evidence for psychological treatments
will necessarily be combined with clinician expertise and patient values and
characteristics in determining optimum approaches to treatment. (emphasis
added)
These changes and the flexible approach to IPT that is now used are emphasized in this text.
These include a shift to Conclusion of Acute Treatment followed by Maintenance Treatment,
a flexible approach to scheduling sessions, and flexibility in utilizing the three Problem Areas.
These changes also reflect the further development of the theoretical basis of IPT, from the
original description of the use of Attachment and Interpersonal Theory in IPT in our first
edition to current data supporting the impact of attachment in the clinical delivery of IPT.37–39
These changes are of critical importance in fostering the dissemination of IPT. A new
paradigm of clinical practice is emerging. Driven by insurer and governmental demands
that therapists deliver evidence-based treatments, IPT and many of the other ESTs are being
rolled out across the globe. This trend hearkens a profound change: community-based
clinicians will be expected to be trained in IPT and other ESTs in order to be reimbursed or
employed in mental health systems. It is our responsibility to ensure that these therapists
are well-trained, can utilize a variety of ESTs, and that they can deliver high-quality ESTs
combined with clinician expertise and patient values and characteristics to provide the optimum
approach to treatment for the specific individuals with whom they work.

A Metaphor for IPT and Other Empirically

Supported Therapies
Learning psychotherapy is like learning to play chess. If you want to learn how to play chess
well, you need to do two things: read books which explain how to play, and play a lot of games
against the best competition you can find.
Nearly all chess textbooks divide games into opening, middle, and endgame phases.
There are always detailed discussions about how to begin the game, ranging from simple
descriptions of the movements of the various pieces to elaborate opening defenses such as
the Italian Game or the Vienna Game. Chess manuals also have detailed descriptions of
the conclusions of games. As with the opening phases, elaborate descriptions and analyses
are offered for the few moves which conclude a game. In contrast, there isn’t much
information about what happens in the middle of games. This is particularly striking
considering how much of the game actually takes place in this ‘middle’ phase. The middle
of the game is shrouded in mystery, a black box which connects the input of the opening
phase to the endgame output.
Psychotherapy manuals are like chess textbooks. Most provide detailed information
about selecting patients for the specific therapy being described, beginning treatment, and
introducing the treatment model to the patient. This is usually followed by a brief review
of techniques that might be used (a simple description of how the pieces move outside
of the context of an actual game), and then a detailed description of the end of therapy is
given. There is good reason to be critical of this approach, which neglects the importance
of understanding techniques in the context of the whole treatment. However, much of
the reason that disproportionate time is spent on the opening phases of chess games and
psychotherapy treatments, and the reason that so much effort is expended on the end of
the games/treatments, is that these are the only two times in the process when things can be

xii
 Preface

described with any precision. There are too many permutations and too many possibilities to
even begin to describe what happens in the middle of the game or the middle of therapy. In
contrast, the limited possibilities of move and countermove, statement and response, during
the opening phase make it more amenable to precise description. When only a few pieces are
left at the end, or when only a session or two is left, it again becomes possible to offer more
precise descriptions – there aren’t so many moves that they defy analysis.
Textbooks which give an ordered list of sequential moves to make in a chess game are
of little value. Manuals which prescribe what a therapist is to do each and every session are
of little value. Patients are different. Some don’t want to do homework; some don’t want to
set an agenda. Some will follow the lead of the therapist; some won’t. In each and every case,
adaptations have to be made. There are too many ways the middle of the game can be played
to script every move.
This is where playing a lot of games with the best competition and working with the most
challenging patients comes into the picture. Experience is the best way to learn to conduct
the Middle Phase – more so if there is a chess master or psychotherapy supervisor to offer
further insights and tips along the way. Experience and skill come from practice. Learning
what to do in the Middle Phase, developing a repertoire of moves and strategies and knowing
what tactics to use, depends not on rigidly following a manual but on refining intuition and
judgment. Master chess players and master therapists develop an intuitive sense of what will
work best in a particular session with a particular client, and have the experience to decide
when and how to do it. Master chess players and therapists are artisans, not technicians. As
one devotes a lifetime to mastering chess, expert clinicians do the same with continual study,
self-reflection, and constant practice.
After studying the ‘how-to’ manuals and getting some experience playing games, chess
players move on to the ‘case-study’ books that describe the great games of the masters. Rather
than providing technical information, these case studies are read to hone the chess player’s
sense of judgment, timing, and intuition – to get inside the mind of the great chess masters.
Similarly, at a high level of development, therapists also learn from case studies describing
individual cases from which general principles can be gleaned.
Master psychotherapists are those who work to understand the craft of psychotherapy as
well as specific techniques. While opening chess defenses and various forms of psychotherapy
are important tools to have at one’s disposal, they do not constitute the whole of the
experience or the process of therapy. Just as chess masters intimately understand a variety
of opening strategies, psychotherapy masters should understand and practice a variety
of approaches. The art of chess and psychotherapy is making well-informed judgments
about when to use which specific strategies and having the ability to carry them out. Master
clinicians, like master chess players, recognize that textbooks and manuals are limited.
Though helpful in providing a framework for treatment, clinical practice demands that
therapists be flexible and that they use clinical judgment in applying the therapy to individual
patients. The psychotherapy texts, like the chess books, should be used as guides to treatment.
The ability to combine experience and judgment and a willingness to practice diligently is
what makes a clinician an expert.

Conclusion
This text is designed to guide clinicians who wish to practice IPT. Our primary goal is to
make IPT available and applicable – to encourage the dissemination of what we believe
to be an extraordinary treatment for a variety of interpersonal problems and psychiatric

xiii
Preface

syndromes. We offer a paradigm universally accepted by clinicians and researchers alike: IPT
is an EST that can be used as a foundation for therapists using their clinical experience within
each unique clinical relationship. IPT is grounded in theory, empirical research, and clinical
experience, and should always incorporate clinical judgment.

IPT: An Established Paradigm

1. The practice of IPT should be based on theory, empirical data, and clinical experience.
2. Incorporating new empirical data and clinical experience into the IPT model will
continue to improve treatment.
3. IPT therapists should utilize IPT as an EST, meaning that adaptations to individual
patients and circumstances will enhance outcome.
4. Utilizing clinical judgment within an IPT framework will improve outcome.
5. IPT need not be restricted to specific diagnostic entities, but can be applied to a variety of
interpersonal problems.

References
1. Cuthbert BN and Insel TR. Toward new approaches to psychotic disorders: the NIMH
Research Domain Criteria project. Schizophrenia Bulletin, 2010, 36(6): 1061–1062.
2. Insel T, et al. Research domain criteria (RDoC): toward a new classification framework
for research on mental disorders. American Journal of Psychiatry, 2010, 167(7): 748–751.
3. Nathan PE, Stuart S and Dolan S. Research on psychotherapy efficacy and effectiveness:
between Scylla and Charybdis? Psychological Bulletin, 2000, 126: 964–981.
4. Barlow DH. Health care policy, psychotherapy research, and the future of psychotherapy.
American Psychologist, 1996, 51: 1050–1058.
5. Barber J, et al. The role of therapist adherence, therapist competence, and the alliance in
predicting outcome of individual drug counseling: results from the NIDA collaborative
cocaine treatment study. Psychotherapy Research, 2006, 16: 229–240.
6. Castonguay L, et al. Predicting the effect of cognitive therapy for depression: a study of unique
and common factors. Journal of Consulting and Clinical Psychology, 1996, 64: 497–504.
7. Edelson M. Can psychotherapy research answer this psychotherapist’s questions?, in
Talley PF, Strupp HH and Butler SF (eds) Psychotherapy Research and Practice: Bridging
the Gap. 1994, New York: Basic Books.
8. Garfield SL. Some problems associated with ‘validated’ forms of psychotherapy. Clinical
Psychology: Science and Practice, 1996, 3: 218–229.
9. Strauss BM and Kaechele H. The writing on the wall: comments on the current
discussion about empirically validated treatments in Germany. Psychotherapy Research,
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10. Frank E, et al. Interpersonal psychotherapy and antidepressant medication: evaluation
of a sequential treatment strategy in women with recurrent major depression. Journal of
Clinical Psychiatry, 2000, 61: 51–57.
11. Frank E, et al. randomized trial of weekly, twice-monthly, and monthly interpersonal
psychotherapy as maintenance treatment for women with recurrent depression.
American Journal of Psychiatry, 2007, 164: 761–767.

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12. Talbot N, et al. A randomized effectiveness trial of interpersonal psychotherapy for

depressed women with sexual abuse histories. Psychiatric Services, 2011, 62: 374–380.
13. Kessler RC, et al. The epidemiology of major depressive disorder: results from the
National Comorbidity Survey Replication (NCS-R). Journal of the American Medical
Association, 2003, 289: 3095–3105.
14. Kessler RC, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV
disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry,
2005, 62: 593–602.
15. Engel GL. The clinical application of biopsychosocial models. American Journal of
Psychiatry, 1980, 137: 535–544.
16. Engel GL. The biopsychosocial model and medical education: who are to be the teachers?
New England Journal of Medicine, 1982, 306: 802–805.
17. Sadler JZ and Hulgus YF. Clinical problem solving and the biopsychosocial model.
American Journal of Psychiatry, 1992, 149: 1315–1323.
18. Hartmann L. Presidential address: reflections on humane values and biopsychosocial
integration. American Journal of Psychiatry, 1992, 149: 1135–1141.
19. Fava G and Sonino N. The biopsychosocial model 30 years later. Psychotherapy and
Psychosomatics, 2008, 77: 1–2.
20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
4th edn. 1994, Washington, DC: American Psychiatric Association.
21. World Health Organization. International Statistical Classification of Diseases and Related
Health Problems: ICD-10, 10th edn. 1992, Geneva: World Health Organization.
22. Parloff MB. Placebo controls in psychotherapy research a sine qua non or a placebo
for research problems? Journal of Consulting and Clinical Psychology, 1986, 54:
79–87.
23. Chambless DL and Hollon S. Defining empirically supported therapies. Journal of
Consulting and Clinical Psychology, 1998, 66: 7–18.
24. Chambless DL, et al. Update on empirically validated therapies, II. Clinical Psychologist,
1998, 51(1): 3–16.
25. Society of Clinical Psychology APA Division 12. Psychological Treatments. 2011.
Available at: www.psychology.sunysb.edu/eklonsky-/division12/treatments.html.
26. Klerman GL, et al. Treatment of depression by drugs and psychotherapy. American
Journal of Psychiatry, 1974, 131: 186–191.
27. Weissman MM. The psychological treatment of depression. Evidence for the efficacy of
psychotherapy alone, in comparison with, and in combination with pharmacotherapy.
Archives of General Psychiatry, 1979, 36: 1261–1269.
28. Weissman MM, et al. The efficacy of drugs and psychotherapy in the treatment of acute
depressive episodes. American Journal of Psychiatry, 1979, 136(4B): 555–558.
29. Weissman MM. A brief history of interpersonal psychotherapy. Psychiatric Annals, 2006,
36(8): 553–557.
30. Detre T. The future of psychiatry. American Journal of Psychiatry, 1987, 144: 621–625.
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General Psychiatry, 1997, 54: 201–204.

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32. DiMascio A, Weissman MM and Prusoff BA. Differential symptom reduction by drugs and
psychotherapy in acute depression. Archives of General Psychiatry, 1979, 36: 1450–1456.
33. Elkin I, et al. NIMH Treatment of Depression Collaborative Treatment Program:
background and research plan. Archives of General Psychiatry, 1985, 42: 305–316.
34. Markowitz JC, Svartberg M and Swartz HA. Is IPT time-limited psychodynamic
psychotherapy? Journal of Psychotherapy Research and Practice, 1998, 7: 185–195.
35. Stiles WB and Shapiro DA. Abuse of the drug metaphor in psychotherapy process-
outcome research. Clinical Psychology Review, 1989, 9: 521–544.
36. APA Presidential Task Force on Evidence-Based Practice. Evidence-based practice in
psychology. American Psychologist, 2006, 61: 271–285.
37. Ravitz P, Maunder R and McBride C. Attachment, contemporary interpersonal theory
and IPT: an integration of theoretical, clinical, and empirical perspectives. Journal of
Contemporary Psychotherapy, 2008, 38(1): 11–22.
38. McBride C, et al. Attachment as a moderator of treatment outcome in major depression:
a randomized control trial of interpersonal psychotherapy versus cognitive behavior
therapy. Journal of Consulting and Clinical Psychology, 2006, 74: 1041–1054.
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Psychosomatics, 1999, 40(1): 34–43.

Acknowledgments
We are indebted to many for their help with this project. We are particularly grateful to Mike
O’Hara and the staff of the Iowa Depression and Research Center, the participants in the IPT
Institute, and the many clinicians and colleagues we have had the privilege of working with
over the years.
A personal and heartfelt thanks as well to the many patients we have had the privilege of
working with. We are grateful for all we have learned from you, and for the graciousness with
which you have shared your life stories with us.
Finally we are grateful to our families: Shana, Kaela, Ryson, Darra, and Logan, and to
Anna and Lucas.
Scott Stuart – Iowa City, USA
Michael Robertson – Sydney, Australia

xvi
 Section 1
Introduction

Chapter 1. Introduction
Chapter 2. Theory and Clinical Applications
This page intentionally left blank
 1
Introduction
Characteristics of IPT 4
A Metaphor for IPT 14
Conclusion 15
References 15

Interpersonal Psychotherapy (IPT) is a short-term, attachment-based psychotherapy which

aims to alleviate patients’ suffering and improve their interpersonal functioning. IPT focuses
specifically on interpersonal relationships as a means of bringing about interpersonal change
and symptomatic recovery, with the goal of helping patients to improve their interpersonal
relationships and to learn to ask more graciously for the emotional and practical support they
need. In addition, IPT also aims to assist patients to improve their social support so that they
can better manage their current interpersonal distress.
IPT was originally developed in a research context as a treatment for major depression
and was codified in a research manual by Klerman et al. in 1984.1 Since that time, as clinical
experience and empirical evidence supporting IPT has accumulated, its use has broadened
to include not only the treatment of patients with a variety of well-specified diagnoses as
described in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV,2 but also
the treatment of patients presenting with a variety of interpersonal problems and those with
psychological ‘distress’ broadly conceptualized.
IPT reflects the best of both empirical research and clinical experience, incorporating
changes as additional data (both quantitative and qualitative) and clinical experience
continue to grow. IPT is not static or fixed; clinical experience and research have (and
will continue) to inform modifications to IPT. Since the publication of Interpersonal
Psychotherapy: A Clinician’s Guide in 2003, the modified and flexible structure of IPT has
fostered its dissemination and utilization in general clinical settings, moving beyond its
previously exclusive use in randomized treatment trials in academic research settings.
Moreover, this flexible structure, which allows and encourages therapists to apply their
clinical judgment when providing IPT, has also increased its effectiveness and allowed it to be
applied to a more diverse group of patients.
As was the case with our first edition, this updated guide is written to reflect the current
‘state of the art’ of IPT, recognizing that future research and clinical experience will lead
to further refinements in the treatment, and that IPT will continue to evolve and improve
over time. It is our conviction that this should and must be the case in order to maximize its
effectiveness. We are grateful to have the opportunity to publish this revision, but our hope is
that there will continue to be subsequent revisions as new clinicians and investigators develop
even better techniques and tactics within the IPT framework. Both empirical data and
clinical experience have contributed, and should continue to contribute, to the IPT model
and its clinical application.

3
Introduction

Characteristics of IPT
IPT is characterized by four primary elements. First, as is clear from the name, it focuses
specifically on interpersonal relationships and social support as points of intervention.
Second, IPT is based on a Biopsychosocial/Cultural/Spiritual model of psychological
functioning. Third, IPT is short-term in the Acute Phase of Treatment. Fourth, the
interventions used in IPT typically do not directly address the patient–therapist relationship
as it develops in therapy (Box 1.1).
Box 1.1 Characteristics of IPT

●● IPT focuses specifically on interpersonal relationships and social support as points of

intervention
●● IPT is based on a Biopsychosocial/Cultural/Spiritual model of psychological

­functioning
●● IPT is short-term in the Acute Phase of treatment

●● IPT interventions typically do not directly address the patient–therapist relationship

IPT Is Interpersonally Oriented

IPT is based on the premise that interpersonal distress is intimately connected with
psychiatric symptoms and psychological distress generally. Thus the foci of IPT are twofold.
The first is the conflicts, transitions, and losses in the patient’s relationship: the aim is to help the
patient to either improve communication within those relationships, or to develop more
realistic expectations about them. The second focus is helping the patient to build or better
utilize her extended social support network so that she is better able to muster the interpersonal
support needed to deal with the crises which precipitated the distress.
This approach is extremely well-suited, for instance, to the treatment of women who may be
experiencing postpartum depression.3 Many women in these circumstances describe that their
distress is linked to conflicts in their relationships with their partners. In addition, many also report
that they have difficulty making the transition from ‘working woman’ to ‘mother’, and that this
change in social circumstances and social support contributes to their problems. An IPT therapist
would help her to resolve the conflicts with her partner over issues such as division of childcare
labor, and would also assist the woman to garner more support from her social network. This
might include connecting with and asking for support from other friends who have had children,
extended family members, or colleagues at work. It could also include encouraging her to get
involved in a new mothers’ support group. Resolution of the particular interpersonal conflict,
along with improved interpersonal support while the Role Transition is being negotiated, leads to
symptomatic improvement and improvement in interpersonal functioning.
This is a clear distinction between IPT and treatments such as Cognitive Behavior
Therapy (CBT)4 and psychoanalytically oriented psychotherapy. In contrast to CBT, in
which the primary focus of treatment is the patient’s internally based cognitions and
schema, IPT focuses first and foremost on the patient’s interpersonal communications
with others in her interpersonal sphere and on her social support. In contrast to
analytically oriented treatments, in which the primary focus of treatment is on
understanding the contribution of early life experiences to psychological functioning,
IPT focuses primarily on helping the patient to improve her communication and social
support in the present. Past experiences, while clearly influencing current functioning,
are not a major focus of intervention.

4
 Characteristics of IPT

This critical distinction between IPT and other psychotherapies merits further emphasis
because it is often missed or glossed over by proponents of other approaches. There is no
doubt that all psychotherapies address interpersonal functioning to some degree – it is the
bread and butter of the problems that lead people to seek counseling. The difference is in the
emphasis. In IPT, these interpersonal issues – Grief and Loss, Interpersonal Disputes, and
Role Transitions – are the primary foci of treatment. In CBT, psychodynamic psychotherapy,
Problem Solving Therapy, Acceptance and Commitment Therapy, Behavioral Activation,
and even new-wave ‘stand on your head in the corner with crystals’ therapies, interpersonal
issues are not the primary focus. Cognitions, schema, values, or upside-down crystals are.
Interpersonal issues are discussed in other treatments, but they are not the primary focus.
This is why these therapies are not called ‘Interpersonal CBT’ or ‘Interpersonal Crystal
Therapy’.
To be fair and balanced, there is also no doubt that IPT also addresses issues inherent
in other therapies. For instance, one could make a compelling Socratic argument that
what are called ‘expectations’ about relationships in IPT are very similar to what are called
cognitions in CBT, or that IPT therapists are suppressing the concept that motivations in
communication may be driven by psychological factors outside of the patient’s awareness.
These are valid points. But these issues are not the primary foci of IPT, just as interpersonal
issues are not the primary foci of these other therapies. While there is overlap between the
empirically validated therapies, there are also very clear distinctions.
It is this primary focus on interpersonal issues, however, that is part of the reason why
IPT is so effective. IPT directly addresses the here-and-now interpersonal problems that
people bring to therapy without having to invoke some kind of sophisticated psychological
mechanisms or theories. In IPT, the therapist can state simply and directly that the
interpersonal issues which drove the patient to seek help, such as grief, will be talked about
in therapy – there’s no need to describe hypothetical concepts such as schema or ids or
crystalline magnetism.
A corollary of these differences is that by virtue of IPT’s primary focus on here-and-
now interpersonal functioning, it is designed to resolve psychiatric symptoms and improve
interpersonal functioning rather than to change underlying psychodynamic structures.
While ego strength, defense mechanisms, and personality characteristics are all important
in assessing suitability for treatment, change in these constructs is not presumed to occur in
IPT because it is short-term. There’s not enough time. Rather, ego strength, personality, and
attachment are taken as givens for a particular patient, and the question that drives the IPT
therapist’s interventions is:
Given this patient’s personality style, ego strength, defense mechanisms, and
early life experiences, and the time frame I am working within, how can I help
her to improve her here-and-now interpersonal relationships and build a more
effective social support network?

IPT Is Based on a Biopsychosocial/Cultural/Spiritual Model

IPT is based on a Biopsychosocial/Cultural/Spiritual model of psychological functioning.
Rather than viewing psychological distress or psychiatric problems narrowly as medical
diseases, the IPT approach is to conceptualize the patient’s functioning in broad terms as a
product of her temperament, personality, and attachment style, placed upon a foundation
of biological factors such as genetics and physiological functioning, in the context of social
relationships and general social support. Cultural and spiritual elements are also major

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