J Contemp Psychother (2008) 38:1–10
What is IPT? The Basic Principles and the Inevitability of Change
Published online: 25 September 2007
Ó Springer Science+Business Media, LLC 2007
Abstract Interpersonal Psychotherapy (IPT) is an Mental Health Treatment of Depression Collaborative
empirically validated treatment for a number of psychiatric Research Program (TDCRP) (Elkin et al. 1989). In this
disorders. Like all psychotherapies, IPT can be described study, both IPT and Cognitive Behavior Therapy (CBT)
by its theoretical foundations and its primary targets, tac- (Beck et al. 1979) compared favorably to imipramine for
tics, and techniques. The need for continued creativity in the treatment of major depression. Since that time, IPT has
IPT and other treatments is reviewed, and several speciﬁc been adapted to a wide variety of psychiatric disorders and
proposals for change in IPT based on clinical observations a great deal of empirical evidence has accumulated
and theoretical considerations are discussed. A paradigm supporting its efﬁcacy. Within research settings, IPT has
for collaboration between academic research and clinical been an unmitigated success.
observation required for continued creativity is offered. Statements such as ‘‘an unmitigated success within a
Change is inevitable, and the empirically validated thera- research setting,’’ of course, imply less favorable compar-
pies such as IPT will be even more effective as they isons in other settings. Such is the case with IPT. The
incorporate and test new and creative elements. consequences of its inclusion in the TDCRP and other
research programs have been dichotomous. On the one
Keywords Interpersonal Á Therapy hand, IPT has been widely adopted and adapted by aca-
demicians for a number of psychiatric disorders and
diagnostic subgroups. On the other hand, the application
Introduction and further development of IPT has been constrained by
research protocols and has led to rather rigid manualized
descriptions of its use. For instance, research protocols
‘‘Even if you’re on the right track, you’ll get run over
have focused on symptom change within speciﬁc DSM-IV
if you just sit there.’’—Will Rogers
diagnoses as opposed to focusing treatment on individual
The development and evaluation of Interpersonal Psy- patients and the unique formulations that are developed for
chotherapy (IPT) (Stuart and Robertson 2003; Klerman each of them. In such protocols, the length of treatment is
et al. 1984; Klerman and Weissman 1993; Weissman et al. artiﬁcially determined by research requirements as opposed
2000) is a fascinating case-study. Based on the research to clinical indications. More importantly, techniques that
conducted by Klerman, Weissman, and others in the 1970s might otherwise be effective are constrained by the pro-
(Klerman et al. 1974; Weissman et al. 1981; Paykel et al. tocol, rather than allowing therapists to utilize their clinical
1976), IPT was manualized by Klerman et al. (Klerman experience and judgment to adapt the approach to indi-
et al. 1984) in 1984 for use within the National Institute of vidual patients.
Because IPT has been codiﬁed in research settings, a
critical balance between clinical development and
S. Stuart (&)
research-based evaluation has been lost. Rather than uti-
Department of Psychiatry, University of Iowa,
1-293 Medical Education Building, Iowa City, IA 52242, USA lizing clinical observations to inform potential innovations
e-mail: email@example.com and then incorporating and validating these new elements,
2 J Contemp Psychother (2008) 38:1–10
adaptations (as opposed to innovations) have been limited won by individuals who are able to maintain a franchise on
to the testing of IPT with diagnostic subgroups, such as a particular psychotherapy. Many institutes, training sem-
dysthymic disorders, or for speciﬁc patient populations inars, and textbook/manual sales depend on maintaining
such as depressed perinatal women, depressed geriatric ﬁdelity to the franchise, and on presenting a therapy as
patients, and depressed adolescents. These applications of unique and obtainable only through speciﬁc training. Even
IPT for subgroups are neither new nor ‘‘novel’’ treatments. more insidious are the riches of research funding—
While they provide more speciﬁc evidence-based treat- obtaining such funding depends in large part on developing
ment, this conservative academic approach to adapting IPT and maintaining a reputation as an expert in a particular
hinders creativity. Innovations resulting from ‘‘outside the treatment.
box’’ thinking that might radically change the IPT These factors have often conspired to create psycho-
approach are not compatible with this academic research therapy ‘‘guilds’’ in which proper training and lineage must
paradigm. To paraphrase Mark Twain, ‘‘an academician is be demonstrated for entry. The guild model of psycho-
a person who does things because they have been done therapy implies that there is ‘‘ownership’’ of the therapy.
before; a clinician is a person who does things because the By extension, it also implies that there are guild masters
things that have been done before don’t work.’’ who have the power to decide ‘‘what the therapy is,’’ to
Of course IPT is not unique in having conﬂict between determine who gets ‘‘credit’’ for the therapy, and who
rigid adherence to the original version of a treatment and decide who is branded an ‘‘iconoclast or heretic.’’ Guilds
the innovations which inevitably arise. This type of conﬂict are effective for propagation and maintenance of franchise,
led to Freud’s excommunication of many of his disciples, but discourage innovation. As Confucius said, ‘‘The cau-
and has occurred within the schools of behavior therapy, tious seldom err (Confucious 1893).’’ A new model is
cognitive therapy, and speciﬁc approaches such as Rational sorely needed.
Emotive Therapy (Ellis 1970) and Dialectical Behavior In this paper, the starting point for discussing a new
Therapy (Linehan 1987). In many cases, the more speciﬁc model is a review of the fundamental principles of IPT as
the psychotherapeutic treatment the more the resistance to they are currently conceptualized. Potential innovations are
change. Psychotherapies ought to be developed through then discussed, as well as their implications for treatment.
constructive dialogue rather than deﬁned by those whose A new paradigm is proposed, in which the interaction
arguments are loudest and most vehement. between clinical practice and research is renewed and
The history of psychotherapy might well by character- serves as the genesis for creative innovations and
ized as a history of charismatic ﬁgures in psychiatry and improvements in IPT. Though the examples are speciﬁc to
psychology. The degree of innovation permitted, tolerated, IPT, the model can potentially be applied to all psycho-
or encouraged in a speciﬁc therapeutic approach depends therapeutic approaches.
on the degree to which the speciﬁcs of that approach are
considered dogma by its originators. Erikson’s (Erikson
1998) concept of ‘‘generativity versus stagnation’’ captures The Deﬁning Elements of IPT
the essence of this process. One might argue that the
diverging paths of CBT and RET, for example, have hin- As houses are best built by starting with the foundation and
ged largely on the generativity of their charismatic frame, IPT can best be understood by ﬁrst describing its
founders. theoretical foundation and the framework for its delivery.1
There are other factors that have inﬂuence the degree to This framework can be divided into the theories supporting
which current treatments are rigidly constrained. The ﬁrst IPT; the targets of IPT; the tactics of IPT (i.e., the concepts
is that many are now supported by empirical evidence, and applied in the treatment); and the techniques of IPT (i.e.,
the argument is easily made that the therapy should be what the therapist says or does in the treatment). Though
rigidly applied because ‘‘the evidence supports the man- individual elements in each of these categories may be
ual.’’ This reductionistic argument is a great hindrance to shared with other psychotherapeutic approaches, it is their
innovation and dissemination, for it ignores the chasm that unique combination which deﬁnes IPT (Table 1).
exists between the worlds of research and clinical practice
(Nathan et al. 2000). Had there been this insistence on rigid
adherence to manuals supported by efﬁcacy data in the 1
Additional details regarding IPT can be found in: Interpersonal
past, we might be reading those manuals on parchment by Psychotherapy: A Clinician’s Guide by Scott Stuart and Michael
candlelight! Robertson, Basic Books, 2003. The text includes information about
the practical conduct of IPT and a review of the empirical data
In addition, although there are no pharmaceutical com-
supporting its use. Unfortunately the scope of this paper precludes a
panies inﬂuencing psychotherapy development, there are detailed discussion of IPT techniques; the reader is referred to the text
nonetheless fortunes to be made and academic glories to be for additional information in this regard.
J Contemp Psychother (2008) 38:1–10 3
Table 1 The deﬁning elements of IPT Theory Supporting IPT
Theory: Attachment theory
Supported by communication theory and social theory
In their 2003 Clinician’s Guide (Stuart and Robertson
2003) Stuart and Robertson described a detailed tripartite
Targets: Interpersonal relationships, social support
theoretical foundation for IPT which included attachment
Secondarily impacts psychiatric symptoms
theory, communication theory, and social theory. Each was
Tactics: Interpersonal Triad
given equal credence, and all were supported by research.
None of the research, however, was speciﬁc to IPT.
Prior to that, the emphasis in IPT had been much more
Interpersonal problem areas
on the empirical evidence of its efﬁcacy than on its theo-
retical foundation. In fact, IPT was largely atheoretical in
its early iterations, and was originally designed to reﬂect
Non-transferential focus of interventions
‘‘good supportive therapy.’’ It was only after IPT was
found to be efﬁcacious that theory was appended to it—the
Collaboration and goal consensus process by which theory has been appended to IPT has
Positive regard for the patient been a bit like building the house and then digging the
Techniques: foundation. Fortunately, the empirical structure of IPT has
Interpersonal incidents been strong enough to sustain the excavation.
Communication analysis Within the last several years, attachment theory has been
Use of content and process affect increasingly recognized as the primary theoretical pillar of
Role playing IPT, with communication and social theory relegated to a
‘‘Common’’ techniques secondary role. IPT speciﬁc research on attachment has
also supported this position (McBride et al. 2006) (see also
Ravitz this issue). Attachment theory describes the way in
The Interpersonal Triad: A Model for Psychological
which individuals form, maintain, and end relationships,
and is based on the premise that humans have an intrinsic
drive to form interpersonal relationships with others
IPT is based on the premise that interpersonal distress is
(Ainsworth 1969; Ainsworth et al. 1978; Bowlby 1969,
intimately connected with psychological symptoms. An
1977a, b, 1988). Simply put, attachment forms the basis for
acute interpersonal crisis (stressor) begins the process. The
an enduring pattern of interpersonal behavior through
ability of the patient to manage the crisis psychologically
which individuals seek care and reassurance in character-
and biologically is heavily inﬂuenced by the patient’s
istic ways. Bowlby stated that, ‘‘The desire to be loved and
biopsychosocial vulnerabilities (diatheses) such as genetic
cared for is an integral part of human nature throughout
vulnerability to illness, temperament, attachment style, and
adult life as well as earlier, and the expression of such
personality, which may modulate or exacerbate the crisis.
desires is to be expected in every grown-up, especially in
Social factors such as a patient’s current signiﬁcant rela-
times of sickness or calamity (Bowlby 1977a, p. 428).’’ It is
tionships and general social support provide the context in
a concept which is easy to understand, but one which has
which the stress-diathesis interaction occurs, and further
proven difﬁcult to measure.
modify the individual’s ability to cope with his or her
Attachment theory posits that individuals become dis-
distress. Together, these elements form the Interpersonal
tressed when they experience disruptions in their
Triad (Fig. 1), which models the basic IPT conceptualiza-
relationships with others. Insecurely attached individuals
tion of the development of psychological distress.
are more vulnerable to losses, to interpersonal conﬂicts,
and to role transitions, both because of their tenuous pri-
Acute Interpersonal Crisis (stressor) mary relationships and because of their poor social support
networks (Parkes 1965, 1971; Bowlby 1973). These
issues—Grief and Loss, Interpersonal Disputes, and Role
Transitions—are speciﬁc Interpersonal Problem Areas
addressed in IPT.
Two key derivatives of the patient’s attachment style are
his or her communication style and social support network.
The patient’s interpersonal communication of distress,
Social Support (context)
whether it be plaintive, distancing, or productively enlist-
Fig. 1 The Interpersonal Triad ing of support, is highly dependent upon his or her
4 J Contemp Psychother (2008) 38:1–10
attachment style. Likewise attachment inﬂuences the psychological and social factors coalesce within an indi-
patient’s ability to generate social support—more securely vidual to produce a unique diathesis and response to stress.
attached individuals have larger social networks and many Given this causative model (Fig. 1), the targets of IPT are
more people on whom they can call for support. Con- twofold. The conﬂicts, transitions, and losses in the
versely, those with insecure attachment style have a patient’s interpersonal relationships are the ﬁrst target.
paucity of social support and few adaptive interpersonal The second is the patient’s social support.
relationships. Both the trees of speciﬁc interpersonal The formulation clearly identiﬁes biopsychosocial fac-
communication and the forest of social support depend on tors as one of the three legs of the Interpersonal Triad
the roots of attachment. predisposing a patient to distress. There is no evidence to
Therefore, while both Communication Theory (Kiesler date that IPT has a direct effect upon biological diatheses,
and Watkins 1989; Kiesler 1991, 1992, 1996; Benjamin so biological factors are not a primary target. Ongoing
1996a, b) and Social Theory (Henderson et al. 1982; research may produce such evidence (Brody et al. 2001;
Brown 1998; Weissman and Paykel 1974) remain impor- Martin et al. 2001), in which case the target of biological
tant theoretical elements in IPT, they are conceptualized as functioning can be added to IPT in the future.
derivatives of attachment. Patients with more maladaptive In addition, though there are compelling clinical and
attachment styles burn their social bridges and alienate theoretical reasons to believe that IPT is likely to have an
others when they ask for support. Maladaptive attachment impact on personality and attachment, there is no empirical
styles also lead to inappropriate or inadequate interpersonal evidence to date that IPT directly impacts the psycholog-
communications which prevent individuals’ attachment ical diatheses that predispose patients to distress. These
needs from being met (Stuart and Noyes 1999). Attachment include such factors as personality and attachment style.
is the template upon which speciﬁc communication occurs; Both have been implicated as moderators of response to
communication reﬂects attachment style. The social milieu IPT (Stuart and Noyes 1999; McBride et al. 2006) (see also
in which a patient develops interpersonal relationships Ravitz et al this issue), but it is not yet known whether
strongly inﬂuences the way in which he or she is able to treatment with IPT produces change in these factors.
cope with interpersonal stress. That social milieu, or social Therefore, IPT (at present) is targeted at the acute
support network, is directly inﬂuenced by the patient’s interpersonal stressors and lack of social support that cause
attachment style. distress. It is critical to note that psychiatric symptoms,
In sum, IPT is ﬁrmly grounded in attachment theory. described as a primary target in the original iteration of
Communication theory and social theory are important, but IPT, are now regarded as a secondary target. In other
explain phenomena that are derivative from attachment. In words, it is through changes in interpersonal functioning
the IPT model, biopsychosocial diatheses render a patient and social support that symptoms are reduced—symptom
vulnerable to an acute interpersonal crisis. If intense reduction results from interpersonal and social changes.
enough, the crisis will trigger care-seeking behavior driven IPT is therefore conceptually distinct from treatments
by attachment needs. If sufﬁcient social support is avail- such as CBT (Beck et al. 1979) and behavior therapy. In
able, the crisis may be diffused at this point. Insufﬁcient contrast to CBT, in which the primary focus is the patient’s
social support, however, will push the care-seeking internal cognitions, IPT’s primary targets are the patient’s
behavior even further. Patients with the ability to con- interpersonal relationships and social support. Though IPT
structively communicate their distress and need for care may address cognitions, they are not primary targets.
may avoid overwhelming distress by enlisting additional Similarly, though CBT and other approaches deal with
support, but those whose attachments are maladaptive will interpersonal issues, they are not primary targets.
likely communicate their need for care in ways which will In contrast to IPT, the primary targets of behavioral
drive potential care-providers away. Faced with crises in interventions, such as behavioral activation and exposure
which social support is not immediately available and therapy, are literally the symptoms of psychopathology.
cannot be obtained, such patients experience psychological Anhedonia, for instance, is targeted by tasking the patient
distress. If the distress is severe enough, they may even to schedule and engage in pleasurable activities. Phobic
lapse into DSM-IV disorder which qualiﬁes them for a avoidance is targeted through graded exposure. Needless to
research protocol. say, the theoretical bases for IPT, CBT, and behavioral
therapy are all different as well.
In contrast to analytically oriented treatments, in which
The Targets of IPT the focus is the contribution of early life experiences to
psychological functioning, IPT focuses on helping the
IPT is based on a Biopsychosocial Model of psychological patient to improve his or her interpersonal relationships and
functioning (Engel 1980), which asserts that biological, social support in the present. Neither the psychic
J Contemp Psychother (2008) 38:1–10 5
determinism nor unconscious mental processes that char- Biological Factors Social Factors Psychological Factors
acterize psychoanalytic psychotherapy (Brenner 1973) are Genetics Intimate Attachment Style
Substance Use Relationships Temperament
invoked in IPT. The fundamental basis of IPT is that Medical Illnesses Social Support Cognitive Style
Medical Treatments Defense Mechanisms
current interpersonal stressors in the context of biopsy-
chosocial diatheses lead to psychological distress—there is
no reliance on unconscious processes to explain psycho-
Grief and Loss
IPT Tactics Role Transitions
Psychotherapy ‘‘tactics’’ can be deﬁned as ‘‘a plan, strat- Psychological Distress
egy, or concept used to attain a particular goal,’’ and IPT is
characterized by a combination of them. Several, such as Fig. 2 The Interpersonal Formulation
the Interpersonal Triad (discussed above), the Interpersonal
Inventory, the Interpersonal Formulation, and the Inter- in therapy. It is a critical bridge between attachment theory
personal Problem Areas, are speciﬁc to IPT. Others, such and the patient’s speciﬁc problems.
as the Biopsychosocial Model, the Structure of IPT, the The Interpersonal Formulation provides a grounded
Non-Transferential Focus of Intervention, and the Present hypothesis explaining the patient’s problems and their
Focus of Intervention, are not unique but are necessary onset, clinical manifestation, and course. That hypothesis
ingredients. Collaboration and Positive Regard are among should address the following questions: 1) How did the
many that are non-speciﬁc. A brief review of IPT-speciﬁc patient come to be the way he or she is? 2) What factors
tactics follows. are maintaining the patient’s problems? and 3) What can
be done about them? It should also provide a validation of
the patient’s experience, a mutually determined focus for
IPT Tactics: The Interpersonal Inventory intervention based on the three problem areas, and a
plausible rationale for treatment with IPT.
The Interpersonal Inventory (Klerman et al. 1984) is a
unique feature of IPT that structures the process of history
gathering and formulation of interpersonal problem areas IPT Tactics: Interpersonal Problem Areas
as well as providing a reference point for conducting IPT.
The Interpersonal Inventory focuses on: 1) the patient’s The IPT Problem Areas include Interpersonal Disputes,
contemporary relationships; 2) the history of the patient’s Role Transitions, and Grief and Loss. Interpersonal
current interpersonal problems; and 3) information that is Disputes are simply conﬂicts between individuals that are
relevant to resolving the interpersonal problem—e.g., the causing distress. The process of change within relation-
patient’s attachment style, communication style, and social ships which occurs as a consequence of contextual changes
support. The Interpersonal Inventory is typically compiled within the patient’s life is conceptualized as a Role
during the ﬁrst several sessions; however it is best con- Transition. Grief and Loss can be broadly understood. This
sidered a ‘‘work in progress’’ as most therapists and problem area includes reactions to an actual death, antici-
patients ﬁnd that their understanding of the patient’s rela- patory grief, and loss of physical health or of relationships.
tionships and the problems associated with them evolve All of the problem areas are tactics used to maintain the
during the course of IPT. interpersonal focus of treatment; they are not ‘‘diagnostic
IPT Tactics: The Interpersonal Formulation
IPT Tactics: Time Limit for Acute Treatment with IPT
The IPT Formulation (Stuart and Robertson 2003) syn-
thesizes information from the Interpersonal Inventory and IPT has historically been deﬁned as a time-limited treat-
psychiatric history, creating a plausible hypothesis ment. In general, a course of 10–20 weekly sessions has
explaining the patient’s psychological symptoms (Fig. 2). been used for acute efﬁcacy trials. Clinical experience,
In essence, the ‘‘formulation’’ is nothing more than a the- however, has been that tapering sessions over time is
oretically grounded understanding of the unique individual generally more effective. In the community, weekly
6 J Contemp Psychother (2008) 38:1–10
therapy may be provided for 6–10 weeks, followed by a of IPT are the terms ‘‘time-limited’’ and ‘‘psychodynami-
gradual increase in the time between sessions as the patient cally informed.’’ In reality, the time-limited nature of IPT
improves, such that weekly sessions are followed by has had more to do with the requirements imposed by
biweekly and monthly meetings. research protocols than a theoretical advantage; as noted
Both empirical research and clinical experience with above, both IPT and CBT were artiﬁcially constrained by
IPT have demonstrated that maintenance treatment, par- their inclusion in the TDCRP (Elkin et al. 1985). In that
ticularly for patients with recurrent disorders such as study, a 16-week treatment trial was conducted because it
depression, should be provided to reduce relapse risk was believed to be the time required to determine if
(Frank et al. 1990). IPT is therefore currently conceptual- medication treatment of depression was efﬁcacious. The
ized as a two-phase treatment, in which an intense acute tradition established by that study has remained largely
phase focuses on resolution of symptoms, and a mainte- unchallenged in academia, though in clinical practice,
nance phase follows to prevent relapse and maintain treatments of much longer duration and longer intervals
interpersonal functioning. There is no theoretical or prac- between sessions are often used; research is now beginning
tical need in IPT to ‘‘terminate’’ at the end of acute to support the effectiveness of this clinical observation (see
treatment; it is clearly not in the interest of many patients to Talbot et al. Grote et al. and Stuart et al. this issue).
do so. The theoretical premise that limiting the number of
psychotherapy sessions improves psychotherapy outcome
has never been demonstrated (Reynolds et al. 1996), and
IPT Tactics: Non-Transferential Focus of IPT there are no data suggesting that short-term therapy (i.e.,
12–20 sessions) is more effective than longer treatment. In
IPT has historically been characterized by the relative fact, psychotherapy studies typically show that though the
absence of interventions which directly address the thera- degree of improvement per session diminishes over time,
peutic relationship. Though it shares this characteristic with longer treatment leads to better outcomes (Howard et al.
CBT and other therapies, IPT clearly differs in this way 1986). While the evidence certainly indicates that
from the dynamically oriented psychotherapies. 12–16 weekly sessions is efﬁcacious, there have been no
Clinical experience with IPT has supported the premise IPT dose-response studies. Thus it is impossible to say with
that focusing on the transference changes the focus of any certainty whether the proposed time limit, weekly
treatment from more immediate work on the patient’s sessions,2 or hour-long sessions are optimal, or whether
current interpersonal problems and social relationships to lengthening (or shortening) the treatment might be more
an intense experience with, and analysis of, the relationship effective.
with the therapist (Stuart and Robertson 2003). Addressing The ‘‘dynamically-informed’’ description of IPT is a nod
the patent-therapist relationship directly also shifts the to its historical roots, particularly to Harry Stack Sullivan
therapy from one that is oriented towards improvement in and Adolf Meyer. As noted above, John Bowlby is a more
social support and immediate interpersonal functioning to recent addition to the list of historical luminaries who were
one that is oriented towards intrapsychic insight. This shift unaware that their work would later be co-opted by IPT.
is a departure from the current targets of IPT. Given the early division of psychotherapy into behavioral
For this reason, IPT is structured at present in a way that and psychoanalytic branches and that behavior therapy and
transference issues are less likely to emerge. The IPT CBT have laid claim to the behavioral roots, it is little
therapist generally takes a supportive stance, rather than surprise that IPT has attempted to distinguish itself by
being neutral or opaque. The therapy is generally of short claiming a psychodynamic lineage. This despite the fact
duration, which diminishes the intensity of the therapeutic that it bears little resemblance to time-limited psychoana-
relationship. Provision of maintenance treatment when lytic precursors such as those described by Davanloo
necessary rather than abruptly terminating treatment also (Davanloo 1980) and Sifneos (Sifneos 1987), in which
reduces the likelihood that transference will become a explicit discussion of the transference plays a major role.
focus in IPT.
The only study to address dosing in any fashion was recently
Proposed Changes to IPT published by Frank et al. (2007) Randomized Trial of Weekly,
Twice-Monthly, and Monthly Interpersonal Psychotherapy as Main-
IPT has often been very imprecisely described as a time- tenance Treatment for Women With Recurrent Depression. American
Journal of Psychiatry, 164, 761–767. in which women with recurrent
limited, dynamically-informed psychotherapy (Klerman
depression were assigned after remission to one of 3 maintenance
et al. 1984; Weissman et al. 2000; Stuart and Robertson treatments: once-weekly IPT, bi-weekly IPT, or once-monthly IPT.
2003). Largely unspeciﬁed in these historical descriptions There was no difference in recurrence rates between groups.
J Contemp Psychother (2008) 38:1–10 7
‘‘Dynamically-informed’’ might be more accurately is a diathesis for distress, and those who are simply over-
understood as a recognition in IPT that the nuances of whelmed with tragic circumstances.
interpersonal relationships are important. And in this Several characteristics of IPT would need to be radically
obvious statement, IPT does point to the lineage of Sulli- modiﬁed in cases in which it was targeted towards
van and Bowlby, who both described approaches to changing attachment style, personality, or even insight
treatment based on that observation. However, there has (another potential byproduct of the current approach which
historically in IPT been direct discouragement, if not out- has not been examined). As time-limited therapies, (which
right prohibition, of techniques directed towards examining in their primary iteration may be very different), become
transference and the patient-therapist relationship, which is longer in duration and as they focus more on relatively
still understood as the basis of psychodynamic enduring traits such as personality, they begin to bear
psychotherapy. similarity to one another. Among other things, clinical
This historical imprecision points to several of the discussion frequently shifts to past events and relation-
elements in IPT that merit creative attention. There is now ships, and the therapeutic relationship becomes more
sufﬁcient reason to consider attachment as a potential intense and more subject to inﬂuence by the patient’s (and
target of IPT, particularly given its theoretical foundation. therapist’s) unique characteristics. Would changing the
As attachment becomes a focus, the artiﬁcial time-limit in treatment focus and lengthening the treatment still be IPT?
IPT will need to be addressed, and the current lack of If not, why not? How should this be determined?
interventions directly addressing the patient-therapist Attachment theory and clinical experience both support
relationship should be reconsidered and tested as well. The the observation that given enough time, a patient will
focus on attachment as a target rather than a moderator also display behavior towards his or her therapist which is
prompts a re-examination of the Interpersonal Problem reﬂective of his or her working model of attachment
Areas (Table 2). (Bowlby 1988; Sullivan 1953). This is in essence the basis
IPT could easily be targeted towards attachment style. for transference as conceptualized in IPT. Both Sullivan
Since maladaptive attachment is hypothesized to be at the and Bowlby believed that one of the most powerful ways to
core of the distress experienced by many individuals, work on correcting these distorted models of attachment
modifying attachment may be a factor in acute response, ions was to examine in detail the relationship between
and may have profound preventive effects as well. The therapist and patient. This was done overtly and explicitly,
development of a more adaptive and ﬂexible attachment using techniques such as interpretation in which the
style as a result of therapy would have a signiﬁcant impact transference was directly discussed, and clariﬁcation, in
on reducing vulnerability to stress, as well as the ripple which the therapist would directly ask the patient for his or
effects of improving communication and increasing social her reactions to the therapist.
support. At present, the patient-therapist relationship, and partic-
It is critical to note, however, that the attachment-based ularly the information provided by the transference, are
model of IPT does not presupposed that all patients have recognized as extremely important in IPT, but are not
maladaptive attachment styles, and by extension, that addressed directly in therapy (Stuart and Robertson 2003). A
modiﬁcation of attachment should or need be the focus of careful review of the evidence, an examination of the
treatment for all. Clinical experience is replete with accumulated clinical experience, and a review of the theo-
examples of crises of sufﬁcient intensity to trigger distress retical reasons for addressing transference directly make a
even in the most securely attached individuals: natural very compelling case that techniques which allow a direct
disasters, severe and chronic illnesses, or the death of one’s examination of the patient-therapist relationship might be
child are among many. Thus the distinction must be made very helpful additions to the IPT therapist’s armamentarium.
between those patients for whom maladaptive attachment Particularly in a course of IPT in which the treatment
duration is extended, the therapist is in a unique position to
experience and examine the way in which a patient
Table 2 Potential revisions to IPT develops and maintains relationships, because the therapist
Targets: Add attachment style as a primary target is in a relationship in which he or she is the person upon
Tactics: Extend the duration of IPT whom the working models of attachment are imposed. In
Include a focus on the patient–therapist relationship some, but not all cases, direct discussion of the therapeutic
Eliminate the interpersonal deﬁcits/sensitivity problem area relationship might be very beneﬁcial. This explicit dis-
Staging of patients cussion would likely be of most beneﬁt to those patients
Techniques: with more maladaptive attachment styles.
Include direct discussion of treatment alliance
There is little explanation in the early IPT literature
regarding the absence of interventions directed towards
8 J Contemp Psychother (2008) 38:1–10
transference. The prominence of biological psychiatry in social interactions. This contrasts greatly with the other
the 1970s and 1980s, when IPT was developed, undoubt- three problem areas, which are acute interpersonal stress-
edly played a role. It is likely, given the emphasis on ors. Nearly all clinicians agree that the Deﬁcits/Sensitivity
empirical validation, that the absence of data at the time problem area is different in quality from the others; some
which supported transference-based therapies diminished research also suggests that patients presenting with prob-
enthusiasm for them. A desire to distinguish IPT from lems in this ‘‘area’’ are more difﬁcult to work with and
psychoanalytic schools may have been an issue, and cer- have poorer outcomes (Barber and Muenz 1996; Wolfson
tainly the research protocol emphasis on therapies which et al. 1997; Luty et al. 1998; Reay et al. 2003) (see also
were easily described and reliably delivered was a factor. Grote et al and Talbot et al. this issue).
The continuing lack of research in IPT in this area is due Another way in which IPT might be revised involves
largely to two issues. The ﬁrst is that there has been little patient and therapist selection. A staging concept would be
interest in examining the effects of treatment on personality helpful in this regard. Using such a system, more difﬁcult
or other constructs presumed to be more stable; instead the patients might receive IPT of longer duration which targets
primary focus of outcome, consistent with the pharmaco- attachment, while those who are easier to treat might
logic model, has been change in symptomatic status. receive shorter-term treatment without need to address the
Second, the time limit which has been an integral part of patient-therapist relationship directly. Both clinical expe-
IPT has led to the assertion, clearly stated, that it is not rience and theoretical considerations suggest that assessing
designed to effect change in personality or ego functioning patient ‘‘difﬁculty’’ on the basis of diagnosis or symp-
(and by implication is not likely to do so). Adding tomatic status is quite likely barking up the wrong tree.
attachment style as a therapeutic target and extending the Instead, prognosis is much more likely to be correlated
duration of treatment would change this equation. with security of attachment and strength of social support.
What would make IPT distinct from longer-term A similar system of therapist staging would contribute
psychodynamic psychotherapies if attention were drawn even more. A greater reliance on therapist judgment would
directly to the patient-therapist relationship? First, the be expected from those with greater experience and
primary emphasis in IPT would continue to be helping the expertise. Therapists with less training might be advised to
patient to build greater social support in his or her world steer clear of transference issues and to focus more on the
outside of therapy. While therapists are wonderful tools supportive elements of IPT. Such a system for both patients
when used for their speciﬁc purposes, they are no substitute and therapists would allow delivery of those elements of
for real people. The primary focus in IPT would remain on IPT that are likely to be maximally beneﬁcial, and allow
building social support outside of therapy and improving for the ﬂexibility that is critical for any therapy delivered to
interpersonal relationships, with explicit discussion of the real people. In psychotherapy, one size clearly does not ﬁt
patient-therapist relationship being a tactic to foster these all.
goals—a means to an end.
The Interpersonal Problem Areas utilized in IPT also
require reconsideration. In the ﬁrst iteration of IPT (Kler- Conclusion
man et al. 1984) there were four: Grief, Interpersonal
Disputes, Role Transitions, and Interpersonal Deﬁcits. What is IPT? For the present, the framework presented in
They have undergone slight modiﬁcations: the term Table 1 is an accurate description. The outline of theory,
‘‘Interpersonal Sensitivity’’ (Stuart and Robertson 2003) targets, tactics, and techniques can be used as a framework
has been substituted in some cases for Interpersonal Deﬁ- to describe other therapies or combination of therapies as
cit, and the Grief Problem Area has been reframed to well.
encompass all grief and loss issues, rather than restricting it There are two critical questions that must be addressed
to situations in which a death has occurred (Stuart and in order for IPT to continue to develop: ‘‘What should IPT
Robertson 2003). Nonetheless, the basic problem areas be?’’ and ‘‘What is the process by which changes should be
have remained largely unchanged. incorporated?’’ The glib answer to these questions is sim-
Accumulated clinical experience and theoretical devel- ple: IPT should be whatever maximizes the beneﬁt to
opments now indicate that the ‘‘Interpersonal Deﬁcit/ patients, and the process should facilitate this. All would
Sensitivity’’ domain is better conceptualized as an attach- agree that this is our ﬁnal goal. The devil, of course, is in
ment style or a character trait and should be discarded as an the details.
acute problem area. As originally described, Interpersonal Those details should be addressed in at least two ways.
Deﬁcit was used to designate the problems experienced by First, strong consideration should be given to modifying,
patients with a longstanding paucity of relationships who adding, or eliminating the elements of IPT as it is currently
tended to be avoidant and lacked conﬁdence or skill in conceptualized, and the effects of those changes should be
J Contemp Psychother (2008) 38:1–10 9
studied. There are several obvious candidates. The attach- Bowlby, J. (1977b). The making and breaking of affectional bonds:
ment theory supporting IPT makes it clear that attachment Etiology and psychopathology in the light of attachment theory.
British Journal of Psychiatry, 130, 201–210.
style should be tested as a target for treatment with some Bowlby, J. (1988). Developmental psychiatry comes of age. American
patients. In turn, this leads to consideration of additional Journal of Psychiatry, 145, 1–10.
techniques which address the patient-therapist relationship Brenner, C. (1973). An elementary textbook of psychoanalysis. New
directly. And for more difﬁcult patients, a tactical shift to York: Anchor Press.
Brody, A. L., Saxena, S., Stoessel, P., et al. (2001). Regional brain
extend the duration of treatment is a natural adaptation. metabolic changes in patients with major depression treated with
Second, more ‘‘outside the box’’ ideas must be devel- either paroxetine or interpersonal therapy: Preliminary ﬁndings.
oped and tested. Many of these will emerge from continued Archives of General Psychiatry, 58, 631–640.
clinical observation and from the questions generated from Brown, G. W. (1998). Genetic and population perspectives on life
events and depression. Social Psychiatry and Psychiatric
quality research. It is critical that IPT be considered as a Epidemiology, 33, 363–372.
work in progress; to do otherwise and insist on rigid Confucious (1893). Confucian analects, the great learning, and the
application or strict adherence to manuals will quash doctrine of the mean (trans. J. Legge). New York: Dover
creativity. To paraphrase Mark Twain, ‘‘be careful of Publications, Inc.
Davanloo, H. (1980). Short-term dynamic psychotherapy. Northvale:
deﬁnitive psychotherapy manuals: you might die of a Aronson.
misprint.’’ Elkin, I., Parloff, M. B., Hadley, S. W., & Autry, J. H. (1985). NIMH
The process by which creativity can be reinvigorated treatment of depression collaborative research program. Back-
must be collaborative. Academics should do what they do ground and research plan. Arch Gen Psychiatry, 42, 305–316.
Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotcky, S.
best: engage in spirited discourse and test their assump- M.,Collins, F. L., Glass, D. R., Pilkonis, P. A., Leber, W. R.,
tions. Clinicians should do what they do best: closely and Doherty, J. P, Fiester, S. J., & Parloff, M. B. (1989). NIMH
critically observe what works with the individuals they treatment of depression collaborative research program: I.
treat. And both groups must engage in a dialogue which General effectiveness of treatments. Archives of General
Psychiatry, 46, 971–982.
informs and inspires the other. The synthesis is the process Ellis, A. (1970). The essence of rational psychotherapy: A compre-
which will determine what IPT should be and how it should hensive approach to treatment. New York: Institute for Rational
continue to change. Living.
Change is not only inevitable but necessary. The gen- Engel, G. L. (1980). The clinical application of biopsychosocial
models. American Journal of Psychiatry, 137, 535–544.
erativity we embody will be reﬂected to our colleagues and Erikson, E. H. (1998). The life cycle completed: A review (1985,
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Acknowledgement This work was supported by the following of weekly, twice-monthly, and monthly interpersonal psycho-
grants: 5K24MH72757-02 (NIMH- Stuart). therapy as maintenance treatment for women with recurrent
depression. American Journal of Psychiatry, 164, 761–767.
Frank, E., Kupfer, D. J., Perel, J. M., et al. (1990). Three-year
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