What is Interpersonal Psychotherapy (IPT): A Case History

What is Interpersonal Psychotherapy (IPT): A Case History

The discovery of Interpersonal Psychotherapy is a great example of scientific serendipity, in that, it was discovered by accident.

The story goes that in 1969 the U.S. National Institute of Mental Health began a new policy of evaluating mental health treatments in the same way other medical treatments are tested.

Large-scale outcome studies were conducted to evaluate the efficacy of anti-depressant treatments including medications and psychotherapies. Interpersonal Psychotherapy (IPT) was included, but only as a control group.

The results found that IPT punched above its weight proving to be as effective as tricyclic medication and Cognitive Behavioural Therapy. And so a new, evidence-based therapy was born.

What is Interpersonal Psychotherapy?

When Chris Peterson said, ‘other people matter,’ he was referring to the impact our interactions with others have on our wellbeing. Conversely, when Sartre said, ‘hell is other people’ he was also right. Although this seems like a contradiction, it’s more an example of how two things can be true at once.

If you feel positive about your life, it’s likely your interactions with other people are positive and fulfilling. But if you are unhappy or depressed, your interactions with others may be more complicated. This is the basic thinking that underlies IPT.

 

Theory of IPT

The theory behind IPT draws on the principles of attachment theory and the personality theory of Harry Stack Sullivan (Klerman, Weissman, Rounsaville, & Chevron, 1994). Sullivan first noted that personality is shaped by our interactions with other people and encouraged therapists to explore the tensions clients experience in key relationships (Chapman, 1976).

Two key tenets underlie this branch of therapy. Both draw upon the practice’s primary application, which is the treatment of depression.

  • The first tenet is that depression is a medical illness, rather than a personal defect, meaning that a person experiencing it should not blame him/herself.

  • The second underlying assumption is that mood and life situation are closely related. Therefore, IPT helps to uncover links between a patient’s mood and events in their environment that may be triggering or worsening the symptoms of mood disorders (Markowitz & Weissman, 2004).

 

Focus of Interpersonal Psychotherapy

The two tenets are based on observations in research that depression often follows disturbances in a person’s interpersonal environment (e.g., bereavement, role dispute with a partner), which are the focus of IPT (Markowitz & Weissman, 2004).

Therefore, IPT helps clients to analyze their current social interactions and explore interpersonal tensions and conflicts. From this, patients can be empowered to change the dynamics of their relationships and eliminate or reduce the drivers of their experienced mood disorder.

In IPT, the therapist understands people are often reluctant to acknowledge mixed feelings about others, especially loved ones. For example, a patient may describe feeling stressed about their financial situation.

But in IPT, the issue that a patient presents with is often symptomatic of something deeper and more relational in nature. When we explore a little further, the patient may reveal that the worst part about their situation is the arguments with their partner over money.

Another example is if a patient were to describe work as stressful – only to later reveal that the main source of stress is bullying at the office.

 

Main Goals of IPT

While IPT is a short-term form of therapy typically lasting 8-16 weeks (Markowitz & Weissman, 2004), 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 identify and make adjustments to their social relationships, enabling them to do so independently to avoid the onset of depressive symptoms stemming from interpersonal interactions in the future (Rafaeli & Markowitz, 2011).

 

Pros and Cons

When clients are choosing a form of therapy, it is important that they understand the strengths and weaknesses of each. The same goes for IPT.

There are a few important pros and cons for clients to consider when deciding whether IPT is the best form of therapy to meet their needs.

 

The Pros of IPT

  • Useful for strengthening interactions and relationships with others.
  • Can help patients learn new skills to manage their current and future relationships and interactions.
  • Can help patients recognize and unlearn unhealthy patterns of interaction, communication, etc.
  • Serves as a useful outlet for those who are grieving the loss of a relationship (e.g., death, separation, abandonment).
  • Can help with mood regulation.
  • Teaches useful and productive modes of emotion expression.
  • Can be conducted in group settings (Markowitz & Weissmann, 2012).

 

The Cons of IPT

On the whole, research suggests that IPT has very few downsides (Van Hees, Rotter, Ellermann, & Evers, 2013). However, there are some situations where it may not be the most appropriate therapy for a client.

  • A person undertaking IPT must want to change. A client who is only undergoing IPT because someone else in their life wants them to is unlikely to benefit. Likewise, a client must be willing and self-aware enough to reflect on their contribution to particular problems in their relationships (GoodTherapy, 2020).

  • IPT relies on a client completing 10-16 weeks of therapy. If a client drops out partway through treatment, they may not see its desired benefits.

  • Because the focus of IPT is on current interpersonal relationships, clients whose relational dynamics are heavily influenced by experiences in their past (e.g., early developmental experiences) may find that this form of therapy fails to address the core issue.

 

2 Examples of Effective IPT

Interpersonal psychotherapy case historyTo understand how clients may benefit from the practice of IPT, let’s look at three case studies illustrating how a series of sessions may play out.

The first case study is a description of a real patient (with names changed to protect anonymity).

The second case study is a summary of a 14-week research program, which novelly employed IPT as an approach to helping a client experiencing interpersonal problems stemming from PTSD (Rafaeli & Markowitz, 2011).

 

Joanne

Joanne is a 26-year-old recently married woman referred by her doctor for counseling and stress management. Joanne had been diagnosed with mild depression and had been experiencing frequent headaches.

As we explored the pattern and frequency of Joanne’s headaches they mostly occurred later in the week. This raised some obvious questions… “what else is happening towards the end of the week?” and “what happens at the end of the week that doesn’t happen at other times?

Joanne couldn’t think of anything specific, except that on Friday evenings her in-laws often visited and sometimes stayed for dinner. As we explored how Joanne experienced these visits she provided a slightly ‘glossy’ description of family bliss and harmony.

However, as we discussed specific examples of these interactions she agreed her mother-in-law, who she insisted was well-meaning, did offer occasional ‘constructive criticisms’ of Joanne’s cooking. She also liked to remind her son how he always enjoyed his favorite meals back when he lived at home.

On other occasions, she would make passive-aggressive remarks about Joanne’s housekeeping, for example suggesting Joanne must have had a very busy week judging from the state of the house.

Moreover, as if to make matters worse, during these condescending exchanges Joanne’s husband would sit back, apparently enjoying both women competing for his attention. No wonder she gets a headache.

Joanne’s IPT Sessions

One of the ‘moves’ of IPT is to help the client recognize how the way they are being treated is unacceptable, or even abusive. This realization can liberate an emotional ‘how dare they’ epiphany. The therapeutic value of such cathartic release cuts across several therapeutic traditions.

For example, Freud believed ‘anger turned inward’ was a cause of depression. Also, stress experts have long believed repressed anger is a cause of somatic problems, especially headaches and other tensions in the body. Or as Woody Allen once said. “I don’t get angry, I get a tumor!

To help Joanne explore such possible, deeper feelings I asked her what advice she would have for a best friend, or her sister if they were in a similar situation. This technique creates a few degrees of separation making it easier (and safer) to say “No one should have to put up with that!”… “You deserve better!

Joanne is then prompted to consider why she isn’t as protective of her own boundaries as she is of those she cares about.

At this point, it’s helpful to understand when we repress a particular emotion we tend to do it absolutely. The door is shut tight. We are not even a tiny bit angry. Nothing to see here. So it’s a significant development to open the door just a little bit. Over time, once the door is cracked open it continues opening further by itself.

Fritz Perls, the legendary founder of Gestalt therapy, explained this phenomenon with the unlikely metaphor of a roast dinner. When the roast is removed from the oven and placed on top of the stove it continues to simmer and cook a while longer.

Likewise, during the gap between weekly sessions, clients process the insights gained from the session and return a week later with a more robust view of their situation, and more determined to make changes.

Not surprisingly, as Joanne explored how she felt about ‘everyone putting me down’ her anger focussed increasingly on her unsupportive husband. Despite her attempts to gain more support from him he continued to dismiss her concerns and insisted she was overreacting. He refused to accept that his mother meant any harm and would not consider relationship counseling.

It is a cornerstone of most therapeutic models that we cannot change other people, but we can work on ourselves. So as Joanne worked on Joanne, she began to place more importance on her own wishes and explored what putting her foot down might look like. We rehearsed some assertive ‘I’ statements and she asserted the following position…

I know you don’t agree, but I need a break from your parents’ visits. If you insist on having them over that’s fine, but I’ll be at my sister’s house.

Over the following months, Joanne did, in fact, spend some Friday evenings out shopping with her sister. Just enough to break the cycle of playing hostess to her ungracious visitors. Whether her in-laws got the message doesn’t matter.

The goal is not to change other people and they most likely continue to lack boundaries and basic manners. The point is Joanne was now placing more value on her own wishes. She harnessed (sublimated) her anger into positive action and took steps to protect herself. She was less depressed and enjoyed a better sense of control over her life. And her headaches stopped!

 

Mr. A. (Rafaeli & Markowitz, 2011)

Mr. A. is a 48-year-old male. He requested IPT after experiencing “irritability, sleep disturbance, and interpersonal conflicts” (Rafaeli & Markowitz, 2011, p. 208), stemming from a recent history of traumas and PTSD. While Mr. A. tried to accept and move on from the pain of his past experiences, he reported feeling resentment and difficulty forgiving those who wronged him.

Mr. A.’s primary interpersonal struggles played out in his relationship with his girlfriend, Diane. As is often the case in IPT, Mr. A expressed mixed feelings about his relationship with Diane and the idea of long-term commitment in general.

On the one hand, he was extremely loyal and devoted to Diane and described her warmly, sometimes referring to her as his fiancée. However, he also noted their lack of sexual intimacy and struggled to imagine her as his future wife or mother to his children.

He also described interactions in his home life as tense and sometimes explosive and described feeling uncomfortable with any form of “intense feelings”. He enjoyed working in complete solitude and had thus crafted a working life that was almost entirely void of social interaction.

He described himself as being extremely disturbed when interrupted by Diane and was also distrustful of her.

Mr. A. also had an adult daughter with whom he wished to develop a stronger connection, but struggled.

Mr. A.’s IPT Sessions

Mr. A. underwent 14 weekly sessions of Interpersonal Psychotherapy (Markowitz et al., 2009), which comprised three phases.

In Phase One (sessions 1-3), the researchers aimed to identify problems with Mr. A’s interpersonal function based on his current and past relationships. This is referred to as an “interpersonal inventory”.

The researchers also identified the recurrent theme of betrayal in his past relational traumas. These negative past experiences were highlighted as barriers to closeness in his present relationships.

Following these initial sessions, the researcher formulated a written statement outlining the focus for the remainder of the 14 weeks, based on Mr. A’s desired interpersonal goals. These involved a wish to grow closer with his daughter, reduce disputes with Diane, and become clear about whether he’d like to stay with Diane.

In outlining these goals, and as per one of the primary tenets of IPT, the therapist reassured Mr. A. that his experiences were symptomatic of a treatable illness, not reflective of a personal failing, and could be improved upon with treatment.

In Phase Two (sessions 4-10), each session began with the therapist asking a simple question: “How have things been since we last met?

This question allows a therapist to surface current interpersonal events or conflicts. From there, the therapist can anchor the session in these examples.

For Mr. A. this question revealed a tendency to intellectualize his emotions. When asked to recall his emotional reactions to the experiences of his recent week, he would initially do so using detached language (e.g., referring to the responses he believed the left and right hemispheres of his brain were experiencing, rather than his own subjective experiences).

Indeed, Mr. A. had a tendency to parry emotional vulnerability in conversation by lecturing or intellectualizing feelings in his interactions with Diane and his daughter.

However, by Session six, Mr. A. had learned strategies to identify and become comfortable feeling and expressing both his positive and negative emotions, thereby strengthening his ability to connect emotionally to others. Consequently, he began having more open conversations with his daughter.

Using roleplay, the therapist also helped Mr. A. learn more productive ways to express frustration with Diane and avoid emotional outbursts. This was achieved by helping Mr. A. recognize the utility of sitting with his negative emotions and treating them as informative, rather than something to be avoided.

Mr. A. also practiced using “I” statements to facilitate productive dialogue with Diane (e.g., When X happens, I feel hurt).

Another important feature of the therapy was the therapist’s insistence that Mr. A.’s interpersonal difficulties were not unchangeable features of his personality.

For years, Mr. A. had accepted that the symptoms of his PTSD (e.g., irritability, avoidance) were simply his character. However, by reminding Mr. A. that these challenges were symptoms of a sickness that could be treated, he began to take steps to improve his relationships and communication

By Phase Three (sessions 11-14), the symptoms of Mr. A.’s PTSD had reduced dramatically. Mr. A. expressed some concern about whether he would continue to function so well upon the ending of the sessions, but this was treated as an opportunity to anticipate and prepare for any possible difficulties that could surface post-treatment.

Overall, Mr. A. had grown more affectionate with Diane and improved his relationship with his daughter. He came away from the treatment feeling committed to improving his social skills and broadening his social circle.

 

Similarities and Differences with other Therapies

A traditional psychoanalytic approach might have explored Joanne and Mr. A.’s childhood memories including those of the mothering relationship. Their progress might have been credited to the new insights (from the id to the ego) and the cathartic release of repressed anger.

Sublimating repressed anger into increased assertiveness would be considered a healthier defense mechanism -compared with previous denial and repression.

A CBT approach would emphasize the role of dysfunctional beliefs in causing her initial symptoms. In Joanne’s situation, this may translate to beliefs such as, “I am a bad housewife.” For Mr. A., this might have been beliefs like “I am a bad parent.”

Progress for both patients would have been credited to changes in those beliefs “I’m a good person, even if my in-laws lack manners,” or “I deserve emotional connection, never though it can be frightening.

Relationship counseling might focus on the poor communication between partners, help them to express themselves better, and build more understanding and negotiate clearer rules for a better relationship.

In this current example of Interpersonal Psychotherapy Joanne was helped to see how her symptoms were linked to her current (not childhood) relationships. She came to realize her treatment was unacceptable and gave herself permission to acknowledge her resentment at such treatment. She then harnessed that anger towards empowering herself and asserting a better deal for herself at home.

Likewise, Mr. A. discovered that the success of his present relationships needn’t be dictated by his past experiences of trauma. Rather, he could employ strategies to become comfortable with his emotions and strengthen his emotional connections with those he loved.

The consequence was that Mr. A. became clearer about his goals for those relationships (e.g., he knew he wanted to continue working on his relationship with Diane) and rectified some of his initial ambivalence.

 

8 Training and Certification Opportunities

There are a range of institutions around the world and 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, both in-person and online.

The IPT Institute’s four-day basic course 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.

Four other courses offered by the Institute range from between two days and eight weeks and focus on a range of IPT substreams:

  • IPT Booster Course (advanced IPT techniques)
  • Perinatal IPT for Depression and Anxiety
  • IPT for Groups
  • IPT for Adolescents (IPT-A)

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.

I saw a quote on a T-shirt once that summarized this latter feature of IPT rather neatly:

Stress is the confusion created when one’s mind overrides the body’s basic desire to choke the crap out of someone who desperately deserves it…

Now I’m not saying this crass utterance captures any of the subtleties of IPT… but it’s not entirely wrong either.

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.

  • Chapman, A. H. (1976). Harry Stack Sullivan: His life and his work. New York, NY: Putnam.
  • Frank E, Levenson JC. Interpersonal Psychotherapy. Washington DC, American Psychological Association, 2010.
  • GoodTherapy. (2018, March 14). Interpersonal psychotherapy (IPT). Retrieved from https://www.goodtherapy.org/learn-about-therapy/types/interpersonal-psychotherapy
  • ISIPT. (2020). Overview of IPT. Retrieved from https://interpersonalpsychotherapy.org/ipt-basics/overview-of-ipt/
  • Klerman, G.L., Weissman, M.M., Rounsaville, B., & Chevron, E.S. (1994), Interpersonal Psychotherapy of Depression, New York: Basic Books.
  • Markowitz, J. C., Milrod, B., Bleiberg, K., & Marshall, R. D. (2009). Interpersonal factors in understanding and treating posttraumatic stress disorder. Journal of Psychiatric Practice, 15(2), 133-140.
  • Markowitz J.C, Weissman, M.M. (2004) Interpersonal psychotherapy: principles and applications. World Psychiatry. Oct; 3(3): 136–139.
  • Markowitz J.C., Weissman, M.M. (2012) Interpersonal Psychotherapy: Past, Present, and Future. Clinical Psych Psychotherapy. Mar-Apr; 19(2): 99–105.
  • Rafaeli, A. K., & Markowitz, J. C. (2011). Interpersonal psychotherapy (IPT) for PTSD: A case study. American Journal of Psychotherapy, 65(3), 205-223.
  • Robertson, M. et.al. (2008) Interpersonal Psychotherapy: An overview. Psychotherapy in Australia. Vol. 14. No 3.
  • Van Hees, M. L., Rotter, T., Ellermann, T., & Evers, S. M. (2013). The effectiveness of individual interpersonal psychotherapy as a treatment for major depressive disorder in adult outpatients: a systematic review. BMC Psychiatry, 13(1), 22-32.
  • Weissman MM, Markowitz JC, Klerman GL: (2000) Comprehensive Guide to Interpersonal Psychotherapy. New York: Basic Books.

About the Author

Brad Desmond is an award-winning psychologist with additional post-graduate qualifications in education and training. He is a frequent presenter at national and international conferences and a twenty-year member of the Australian Psychological Society.

Comments

  1. Tracey Doss

    I am working on my PhD in Clinical Psychology and only recently learned of IPT, and have to say that I love this. I find that it helps all facets of an individual and couldn’t be more excited about this.

    Reply
  2. Priyamvada

    An effective therapeutic model

    Reply
  3. Pimlico Psychotherapist

    IPT, something I’ve been meaning to look into more,
    Thanks for this
    Natalija Psychotherapist

    Reply
  4. Robert Matek

    Brad, great article here. Thanks.

    Reply
    • Brad Desmond

      Thanks for the comments. Even if you don’t embrace IPT completely, you can always probe for hidden ‘mixed feelings’ about loved ones (or others) while remaining predominantly in your preferred therapeutic model. I find IPT fits very well with about half of referred clients. Best wishes.

      Reply

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