What is IPT? (Stuart, 2008)

1. ORIGINAL PAPER
What is IPT? The Basic Principles and the Inevitability of Change
Scott Stuart
Published online: 25 September 2007
Springer Science+Business Media, LLC 2007
AbstractInterpersonal Psychotherapy (IPT) is an
empirically validated treatment for a number of psychiatric
disorders. Like all psychotherapies, IPT can be described
by its theoretical foundations and its primary targets, tac-
tics, and techniques. The need for continued creativity in
IPT and other treatments is reviewed, and several specific
proposals for change in IPT based on clinical observations
and theoretical considerations are discussed. A paradigm
for collaboration between academic research and clinical
observation required for continued creativity is offered.
Change is inevitable, and the empirically validated thera-
pies such as IPT will be even more effective as they
incorporate and test new and creative elements.
KeywordsInterpersonalTherapy
Introduction
‘‘Even if you’re on the right track, you’ll get run over
if you just sit there.’’—Will Rogers
The development and evaluation of Interpersonal Psy-
chotherapy (IPT) (Stuart and Robertson2003; Klerman
et al.1984; Klerman and Weissman1993; Weissman et al.
2000) is a fascinating case-study. Based on the research
conducted by Klerman, Weissman, and others in the 1970s
(Klerman et al.1974; Weissman et al.1981; Paykel et al.
1976), IPT was manualized by Klerman et al. (Klerman
et al.1984) in 1984 for use within the National Institute of
Mental Health Treatment of Depression Collaborative
Research Program (TDCRP) (Elkin et al.1989). In this
study, both IPT and Cognitive Behavior Therapy (CBT)
(Beck et al.1979) compared favorably to imipramine for
the treatment of major depression. Since that time, IPT has
been adapted to a wide variety of psychiatric disorders and
a great deal of empirical evidence has accumulated
supporting its efficacy. Within research settings, IPT has
been an unmitigated success.
Statements such as ‘‘an unmitigated success within a
research setting,’’ of course, imply less favorable compar-
isons in other settings. Such is the case with IPT. The
consequences of its inclusion in the TDCRP and other
research programs have been dichotomous. On the one
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
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
have focused on symptom change within specific DSM-IV
diagnoses as opposed to focusing treatment on individual
patients and the unique formulations that are developed for
each of them. In such protocols, the length of treatment is
artificially determined by research requirements as opposed
to clinical indications. More importantly, techniques that
might otherwise be effective are constrained by the pro-
tocol, rather than allowing therapists to utilize their clinical
experience and judgment to adapt the approach to indi-
vidual patients.
Because IPT has been codified in research settings, a
critical balance between clinical development and
research-based evaluation has been lost. Rather than uti-
lizing clinical observations to inform potential innovations
and then incorporating and validating these new elements,
S. Stuart (&)
Department of Psychiatry, University of Iowa,
1-293 Medical Education Building, Iowa City, IA 52242, USA
e-mail: [email protected]
123
J Contemp Psychother (2008) 38:1–10
DOI 10.1007/s10879-007-9063-z

2. adaptations (as opposed to innovations) have been limited
to the testing of IPT with diagnostic subgroups, such as
dysthymic disorders, or for specific patient populations
such as depressed perinatal women, depressed geriatric
patients, and depressed adolescents. These applications of
IPT for subgroups are neither new nor ‘‘novel’’ treatments.
While they provide more specific evidence-based treat-
ment, this conservative academic approach to adapting IPT
hinders creativity. Innovations resulting from ‘‘outside the
box’’ thinking that might radically change the IPT
approach are not compatible with this academic research
paradigm. To paraphrase Mark Twain, ‘‘an academician is
a person who does things because they have been done
before; a clinician is a person who does things because the
things that have been done before don’t work.’’
Of course IPT is not unique in having conflict between
rigid adherence to the original version of a treatment and
the innovations which inevitably arise. This type of conflict
led to Freud’s excommunication of many of his disciples,
and has occurred within the schools of behavior therapy,
cognitive therapy, and specific approaches such as Rational
Emotive Therapy (Ellis1970) and Dialectical Behavior
Therapy (Linehan1987). In many cases, the more specific
the psychotherapeutic treatment the more the resistance to
change. Psychotherapies ought to be developed through
constructive dialogue rather than defined by those whose
arguments are loudest and most vehement.
The history of psychotherapy might well by character-
ized as a history of charismatic figures in psychiatry and
psychology. The degree of innovation permitted, tolerated,
or encouraged in a specific therapeutic approach depends
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 essence of this process. One might argue that the
diverging paths of CBT and RET, for example, have hin-
ged largely on the generativity of their charismatic
founders.
There are other factors that have influence the degree to
which current treatments are rigidly constrained. The first
is that many are now supported by empirical evidence, and
the argument is easily made that the therapy should be
rigidly applied because ‘‘the evidence supports the man-
ual.’’ This reductionistic argument is a great hindrance to
innovation and dissemination, for it ignores the chasm that
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
past, we might be reading those manuals on parchment by
candlelight!
In addition, although there are no pharmaceutical com-
panies influencing psychotherapy development, there are
nonetheless fortunes to be made and academic glories to be
won by individuals who are able to maintain a franchise on
a particular psychotherapy. Many institutes, training sem-
inars, and textbook/manual sales depend on maintaining
fidelity to the franchise, and on presenting a therapy as
unique and obtainable only through specific training. Even
more insidious are the riches of research funding—
obtaining such funding depends in large part on developing
and maintaining a reputation as an expert in a particular
treatment.
These factors have often conspired to create psycho-
therapy ‘‘guilds’’ in which proper training and lineage must
be demonstrated for entry. The guild model of psycho-
therapy implies that there is ‘‘ownership’’ of the therapy.
By extension, it also implies that there are guild masters
who have the power to decide ‘‘what the therapy is,’’ to
determine who gets ‘‘credit’’ for the therapy, and who
decide who is branded an ‘‘iconoclast or heretic.’’ Guilds
are effective for propagation and maintenance of franchise,
but discourage innovation. As Confucius said, ‘‘The cau-
tious seldom err (Confucious1893).’’ A new model is
sorely needed.
In this paper, the starting point for discussing a new
model is a review of the fundamental principles of IPT as
they are currently conceptualized. Potential innovations are
then discussed, as well as their implications for treatment.
A new paradigm is proposed, in which the interaction
between clinical practice and research is renewed and
serves as the genesis for creative innovations and
improvements in IPT. Though the examples are specific to
IPT, the model can potentially be applied to all psycho-
therapeutic approaches.
The Defining Elements of IPT
As houses are best built by starting with the foundation and
frame, IPT can best be understood by first describing its
theoretical foundation and the framework for its delivery.
1
This framework can be divided into thetheoriessupporting
IPT; thetargetsof IPT; thetacticsof IPT (i.e., the concepts
applied in the treatment); and thetechniquesof IPT (i.e.,
what the therapist says or does in the treatment). Though
individual elements in each of these categories may be
shared with other psychotherapeutic approaches, it is their
unique combination which defines IPT (Table1).
1
Additional details regarding IPT can be found in: Interpersonal
Psychotherapy: A Clinician’s Guide by Scott Stuart and Michael
Robertson, Basic Books,2003. The text includes information about
the practical conduct of IPT and a review of the empirical data
supporting its use. Unfortunately the scope of this paper precludes a
detailed discussion of IPT techniques; the reader is referred to the text
for additional information in this regard.
2 J Contemp Psychother (2008) 38:1–10
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3. The Interpersonal Triad: A Model for Psychological
Distress
IPT is based on the premise that interpersonal distress is
intimately connected with psychological symptoms. An
acute interpersonal crisis (stressor) begins the process. The
ability of the patient to manage the crisis psychologically
and biologically is heavily influenced by the patient’s
biopsychosocial vulnerabilities (diatheses) such as genetic
vulnerability to illness, temperament, attachment style, and
personality, which may modulate or exacerbate the crisis.
Social factors such as a patient’s current significant rela-
tionships and general social support provide the context in
which the stress-diathesis interaction occurs, and further
modify the individual’s ability to cope with his or her
distress. Together, these elements form the Interpersonal
Triad (Fig.1), which models the basic IPT conceptualiza-
tion of the development of psychological distress.
Theory Supporting IPT
In their 2003 Clinician’s Guide (Stuart and Robertson
2003) Stuart and Robertson described a detailed tripartite
theoretical foundation for IPT which included attachment
theory, communication theory, and social theory. Each was
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
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
‘‘good supportive therapy.’’ It was only after IPT was
found to be efficacious that theory was appended to it—the
process by which theory has been appended to IPT has
been a bit like building the house and then digging the
foundation. Fortunately, the empirical structure of IPT has
been strong enough to sustain the excavation.
Within the last several years, attachment theory has been
increasingly recognized as the primary theoretical pillar of
IPT, with communication and social theory relegated to a
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
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
(Ainsworth1969; Ainsworth et al.1978; Bowlby1969,
1977a,b,1988). Simply put, attachment forms the basis for
an enduring pattern of interpersonal behavior through
which individuals seek care and reassurance in character-
istic ways. Bowlby stated that, ‘‘The desire to be loved and
cared for is an integral part of human nature throughout
adult life as well as earlier, and the expression of such
desires is to be expected in every grown-up, especially in
times of sickness or calamity (Bowlby1977a, p. 428).’’ It is
a concept which is easy to understand, but one which has
proven difficult to measure.
Attachment theory posits that individuals become dis-
tressed when they experience disruptions in their
relationships with others. Insecurely attached individuals
are more vulnerable to losses, to interpersonal conflicts,
and to role transitions, both because of their tenuous pri-
mary relationships and because of their poor social support
networks (Parkes1965,1971; Bowlby1973). 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,
whether it be plaintive, distancing, or productively enlist-
ing of support, is highly dependent upon his or her
Table 1The defining elements of IPT
Theory: Attachment theory
Supported by communication theory and social theory
Targets: Interpersonal relationships, social support
Secondarily impacts psychiatric symptoms
Tactics: Interpersonal Triad
Biopsychosocial model
Interpersonal inventory
Interpersonal problem areas
Interpersonal Formulation
IPT structure
Non-transferential focus of interventions
Present focus
Collaboration and goal consensus
Positive regard for the patient
Techniques:
Interpersonal incidents
Communication analysis
Use of content and process affect
Role playing
‘‘Common’’ techniques
Acute Interpersonal Crisis (stressor)
Social Support (context)
Biopsychosocial
Vulnerability
(diathesis)
DISTRESS
Fig. 1The Interpersonal Triad
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4. attachment style. Likewise attachment influences the
patient’s ability to generate social support—more securely
attached individuals have larger social networks and many
more people on whom they can call for support. Con-
versely, those with insecure attachment style have a
paucity of social support and few adaptive interpersonal
relationships. Both the trees of specific interpersonal
communication and the forest of social support depend on
the roots of attachment.
Therefore, while both Communication Theory (Kiesler
and Watkins1989; Kiesler1991,1992,1996; Benjamin
1996a,b) and Social Theory (Henderson et al.1982;
Brown1998; Weissman and Paykel1974) remain impor-
tant theoretical elements in IPT, they are conceptualized as
derivatives of attachment. Patients with more maladaptive
attachment styles burn their social bridges and alienate
others when they ask for support. Maladaptive attachment
styles also lead to inappropriate or inadequate interpersonal
communications which prevent individuals’ attachment
needs from being met (Stuart and Noyes1999). Attachment
is the template upon which specific communication occurs;
communication reflects attachment style. The social milieu
in which a patient develops interpersonal relationships
strongly influences the way in which he or she is able to
cope with interpersonal stress. That social milieu, or social
support network, is directly influenced by the patient’s
attachment style.
In sum, IPT is firmly grounded in attachment theory.
Communication theory and social theory are important, but
explain phenomena that are derivative from attachment. In
the IPT model, biopsychosocial diatheses render a patient
vulnerable to an acute interpersonal crisis. If intense
enough, the crisis will trigger care-seeking behavior driven
by attachment needs. If sufficient social support is avail-
able, the crisis may be diffused at this point. Insufficient
social support, however, will push the care-seeking
behavior even further. Patients with the ability to con-
structively communicate their distress and need for care
may avoid overwhelming distress by enlisting additional
support, but those whose attachments are maladaptive will
likely communicate their need for care in ways which will
drive potential care-providers away. Faced with crises in
which social support is not immediately available and
cannot be obtained, such patients experience psychological
distress. If the distress is severe enough, they may even
lapse into DSM-IV disorder which qualifies them for a
research protocol.
The Targets of IPT
IPT is based on aBiopsychosocial Modelof psychological
functioning (Engel1980), which asserts that biological,
psychological and social factors coalesce within an indi-
vidual to produce a unique diathesis and response to stress.
Given this causative model (Fig.1), the targets of IPT are
twofold.The conflicts, transitions, and losses in the
patient’s interpersonal relationships are the first target.
The second is the patient’s social support.
The formulation clearly identifies biopsychosocial fac-
tors as one of the three legs of the Interpersonal Triad
predisposing a patient to distress. There is no evidence to
date that IPT has a direct effect upon biological diatheses,
so biological factors are not a primary target. Ongoing
research may produce such evidence (Brody et al.2001;
Martin et al.2001), in which case the target of biological
functioning can be added to IPT in the future.
In addition, though there are compelling clinical and
theoretical reasons to believe that IPT is likely to have an
impact on personality and attachment, there is no empirical
evidence to date that IPT directly impacts the psycholog-
ical diatheses that predispose patients to distress. These
include such factors as personality and attachment style.
Both have been implicated as moderators of response to
IPT (Stuart and Noyes1999; McBride et al.2006) (see also
Ravitz et al this issue), but it is not yet known whether
treatment with IPT produces change in these factors.
Therefore, IPT (at present) is targeted at the acute
interpersonal stressors and lack of social support that cause
distress. It is critical to note that psychiatric symptoms,
described as a primary target in the original iteration of
IPT, are now regarded as a secondary target. In other
words, it is through changes in interpersonal functioning
and social support that symptoms are reduced—symptom
reduction results from interpersonal and social changes.
IPT is therefore conceptually distinct from treatments
such as CBT (Beck et al.1979) and behavior therapy. In
contrast to CBT, in which the primary focus is the patient’s
internal cognitions, IPT’s primary targets are the patient’s
interpersonal relationships and social support. Though IPT
may address cognitions, they are not primary targets.
Similarly, though CBT and other approaches deal with
interpersonal issues, they are not primary targets.
In contrast to IPT, the primary targets of behavioral
interventions, such as behavioral activation and exposure
therapy, are literally the symptoms of psychopathology.
Anhedonia, for instance, is targeted by tasking the patient
to schedule and engage in pleasurable activities. Phobic
avoidance is targeted through graded exposure. Needless to
say, the theoretical bases for IPT, CBT, and behavioral
therapy are all different as well.
In contrast to analytically oriented treatments, in which
the focus is the contribution of early life experiences to
psychological functioning, IPT focuses on helping the
patient to improve his or her interpersonal relationships and
social support in the present. Neither the psychic
4 J Contemp Psychother (2008) 38:1–10
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5. determinism nor unconscious mental processes that char-
acterize psychoanalytic psychotherapy (Brenner1973) are
invoked in IPT. The fundamental basis of IPT is that
current interpersonal stressors in the context of biopsy-
chosocial diatheses lead to psychological distress—there is
no reliance on unconscious processes to explain psycho-
logical dysfunction.
IPT Tactics
Psychotherapy ‘‘tactics’’ can be defined as ‘‘a plan, strat-
egy, or concept used to attain a particular goal,’’ and IPT is
characterized by a combination of them. Several, such as
the Interpersonal Triad (discussed above), the Interpersonal
Inventory, the Interpersonal Formulation, and the Inter-
personal Problem Areas, are specific to IPT. Others, such
as the Biopsychosocial Model, the Structure of IPT, the
Non-Transferential Focus of Intervention, and the Present
Focus of Intervention, are not unique but are necessary
ingredients. Collaboration and Positive Regard are among
many that are non-specific. A brief review of IPT-specific
tactics follows.
IPT Tactics: The Interpersonal Inventory
The Interpersonal Inventory (Klerman et al.1984)isa
unique feature of IPT that structures the process of history
gathering and formulation of interpersonal problem areas
as well as providing a reference point for conducting IPT.
The Interpersonal Inventory focuses on: 1) the patient’s
contemporary relationships; 2) the history of the patient’s
current interpersonal problems; and 3) information that is
relevant to resolving the interpersonal problem—e.g., the
patient’s attachment style, communication style, and social
support. The Interpersonal Inventory is typically compiled
during the first several sessions; however it is best con-
sidered a ‘‘work in progress’’ as most therapists and
patients find that their understanding of the patient’s rela-
tionships and the problems associated with them evolve
during the course of IPT.
IPT Tactics: The Interpersonal Formulation
The IPT Formulation (Stuart and Robertson2003) syn-
thesizes information from the Interpersonal Inventory and
psychiatric history, creating a plausible hypothesis
explaining the patient’s psychological symptoms (Fig.2).
In essence, the ‘‘formulation’’ is nothing more than a the-
oretically grounded understanding of the unique individual
in therapy. It is a critical bridge between attachment theory
and the patient’s specific problems.
The Interpersonal Formulation provides a grounded
hypothesisexplaining the patient’s problems and their
onset, clinical manifestation, and course. That hypothesis
should address the following questions:1) How did the
patient come to be the way he or she is? 2) What factors
are maintaining the patient’s problems? and 3) What can
be done about them?It should also provide avalidationof
the patient’s experience, amutually determined focusfor
intervention based on the threeproblem areas, and a
plausible rationale for treatmentwith IPT.
IPT Tactics: Interpersonal Problem Areas
The IPT Problem Areas include Interpersonal Disputes,
Role Transitions, and Grief and Loss. Interpersonal
Disputes are simply conflicts between individuals that are
causing distress. The process of change within relation-
ships which occurs as a consequence of contextual changes
within the patient’s life is conceptualized as a Role
Transition. Grief and Loss can be broadly understood. This
problem area includes reactions to an actual death, antici-
patory grief, and loss of physical health or of relationships.
All of the problem areas are tactics used to maintain the
interpersonal focus of treatment; they are not ‘‘diagnostic
labels.’’
IPT Tactics: Time Limit for Acute Treatment with IPT
IPT has historically been defined as a time-limited treat-
ment. In general, a course of 10–20 weekly sessions has
been used for acute efficacy trials. Clinical experience,
however, has been that tapering sessions over time is
generally more effective. In the community, weekly
Biological Factors
Genetics
Substance Use
Medical Illnesses
Medical Treatments
Social Factors
Intimate
Relationships
Social Support
Psychological Factors
Attachment Style
Temperament
Cognitive Style
Defense Mechanisms
Unique Individual
Interpersonal Crises
Grief and Loss
Interpersonal Disputes
Role Transitions
Psychological Distress
Fig. 2The Interpersonal Formulation
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6. therapy may be provided for 6–10 weeks, followed by a
gradual increase in the time between sessions as the patient
improves, such that weekly sessions are followed by
biweekly and monthly meetings.
Both empirical research and clinical experience with
IPT have demonstrated that maintenance treatment, par-
ticularly for patients with recurrent disorders such as
depression, should be provided to reduce relapse risk
(Frank et al.1990). IPT is therefore currently conceptual-
ized as a two-phase treatment, in which an intense acute
phase focuses on resolution of symptoms, and a mainte-
nance phase follows to prevent relapse and maintain
interpersonal functioning. There is no theoretical or prac-
tical need in IPT to ‘‘terminate’’ at the end of acute
treatment; it is clearly not in the interest of many patients to
do so.
IPT Tactics: Non-Transferential Focus of IPT
IPT has historically been characterized by the relative
absence of interventions which directly address the thera-
peutic relationship. Though it shares this characteristic with
CBT and other therapies, IPT clearly differs in this way
from the dynamically oriented psychotherapies.
Clinical experience with IPT has supported the premise
that focusing on the transference changes the focus of
treatment from more immediate work on the patient’s
current interpersonal problems and social relationships to
an intense experience with, and analysis of, the relationship
with the therapist (Stuart and Robertson2003). Addressing
the patent-therapist relationship directly also shifts the
therapy from one that is oriented towards improvement in
social support and immediate interpersonal functioning to
one that is oriented towards intrapsychic insight. This shift
is a departure from the current targets of IPT.
For this reason, IPT is structured at present in a way that
transference issues are less likely to emerge. The IPT
therapist generally takes a supportive stance, rather than
being neutral or opaque. The therapy is generally of short
duration, which diminishes the intensity of the therapeutic
relationship. Provision of maintenance treatment when
necessary rather than abruptly terminating treatment also
reduces the likelihood that transference will become a
focus in IPT.
Proposed Changes to IPT
IPT has often been very imprecisely described as a time-
limited, dynamically-informed psychotherapy (Klerman
et al.1984; Weissman et al.2000; Stuart and Robertson
2003). Largely unspecified in these historical descriptions
of IPT are the terms ‘‘time-limited’’ and ‘‘psychodynami-
cally informed.’’ In reality, the time-limited nature of IPT
has had more to do with the requirements imposed by
research protocols than a theoretical advantage; as noted
above, both IPT and CBT were artificially constrained by
their inclusion in the TDCRP (Elkin et al.1985). In that
study, a 16-week treatment trial was conducted because it
was believed to be the time required to determine if
medication treatment of depression was efficacious. The
tradition established by that study has remained largely
unchallenged in academia, though in clinical practice,
treatments of much longer duration and longer intervals
between sessions are often used; research is now beginning
to support the effectiveness of this clinical observation (see
Talbot et al. Grote et al. and Stuart et al. this issue).
The theoretical premise that limiting the number of
psychotherapy sessions improves psychotherapy outcome
has never been demonstrated (Reynolds et al.1996), and
there are no data suggesting that short-term therapy (i.e.,
12–20 sessions) is more effective than longer treatment. In
fact, psychotherapy studies typically show that though the
degree of improvement per session diminishes over time,
longer treatment leads to better outcomes (Howard et al.
1986). While the evidence certainly indicates that
12–16 weekly sessions is efficacious, there have been no
IPT dose-response studies. Thus it is impossible to say with
any certainty whether the proposed time limit, weekly
sessions,
2
or hour-long sessions are optimal, or whether
lengthening (or shortening) the treatment might be more
effective.
The ‘‘dynamically-informed’’ description of IPT is a nod
to its historical roots, particularly to Harry Stack Sullivan
and Adolf Meyer. As noted above, John Bowlby is a more
recent addition to the list of historical luminaries who were
unaware that their work would later be co-opted by IPT.
Given the early division of psychotherapy into behavioral
and psychoanalytic branches and that behavior therapy and
CBT have laid claim to the behavioral roots, it is little
surprise that IPT has attempted to distinguish itself by
claiming a psychodynamic lineage. This despite the fact
that it bears little resemblance to time-limited psychoana-
lytic precursors such as those described by Davanloo
(Davanloo1980) and Sifneos (Sifneos1987), in which
explicit discussion of the transference plays a major role.
2
The only study to address dosing in any fashion was recently
published by Frank et al. (2007) Randomized Trial of Weekly,
Twice-Monthly, and Monthly Interpersonal Psychotherapy as Main-
tenance Treatment for Women With Recurrent Depression. American
Journal of Psychiatry, 164, 761–767. in which women with recurrent
depression were assigned after remission to one of 3 maintenance
treatments: once-weekly IPT, bi-weekly IPT, or once-monthly IPT.
There was no difference in recurrence rates between groups.
6 J Contemp Psychother (2008) 38:1–10
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7. ‘‘Dynamically-informed’’ might be more accurately
understood as a recognition in IPT that the nuances of
interpersonal relationships are important. And in this
obvious statement, IPT does point to the lineage of Sulli-
van and Bowlby, who both described approaches to
treatment based on that observation. However, there has
historically in IPT been direct discouragement, if not out-
right prohibition, of techniques directed towards examining
transference and the patient-therapist relationship, which is
still understood as the basis of psychodynamic
psychotherapy.
This historical imprecision points to several of the
elements in IPT that merit creative attention. There is now
sufficient reason to consider attachment as a potential
target of IPT, particularly given its theoretical foundation.
As attachment becomes a focus, the artificial time-limit in
IPT will need to be addressed, and the current lack of
interventions directly addressing the patient-therapist
relationship should be reconsidered and tested as well. The
focus on attachment as a target rather than a moderator also
prompts a re-examination of the Interpersonal Problem
Areas (Table2).
IPT could easily be targeted towards attachment style.
Since maladaptive attachment is hypothesized to be at the
core of the distress experienced by many individuals,
modifying attachment may be a factor in acute response,
and may have profound preventive effects as well. The
development of a more adaptive and flexible attachment
style as a result of therapy would have a significant impact
on reducing vulnerability to stress, as well as the ripple
effects of improving communication and increasing social
support.
It is critical to note, however, that the attachment-based
model of IPT does not presupposed that all patients have
maladaptive attachment styles, and by extension, that
modification of attachment should or need be the focus of
treatment for all. Clinical experience is replete with
examples of crises of sufficient intensity to trigger distress
even in the most securely attached individuals: natural
disasters, severe and chronic illnesses, or the death of one’s
child are among many. Thus the distinction must be made
between those patients for whom maladaptive attachment
is a diathesis for distress, and those who are simply over-
whelmed with tragic circumstances.
Several characteristics of IPT would need to be radically
modified in cases in which it was targeted towards
changing attachment style, personality, or even insight
(another potential byproduct of the current approach which
has not been examined). As time-limited therapies, (which
in their primary iteration may be very different), become
longer in duration and as they focus more on relatively
enduring traits such as personality, they begin to bear
similarity to one another. Among other things, clinical
discussion frequently shifts to past events and relation-
ships, and the therapeutic relationship becomes more
intense and more subject to influence by the patient’s (and
therapist’s) unique characteristics. Would changing the
treatment focus and lengthening the treatment still be IPT?
If not, why not? How should this be determined?
Attachment theory and clinical experience both support
the observation that given enough time, a patient will
display behavior towards his or her therapist which is
reflective of his or her working model of attachment
(Bowlby1988; Sullivan1953). This is in essence the basis
for transference as conceptualized in IPT. Both Sullivan
and Bowlby believed that one of the most powerful ways to
work on correcting these distorted models of attachment
ions was to examine in detail the relationship between
therapist and patient. This was done overtly and explicitly,
using techniques such as interpretation in which the
transference was directly discussed, and clarification, in
which the therapist would directly ask the patient for his or
her reactions to the therapist.
At present, the patient-therapist relationship, and partic-
ularly the information provided by the transference, are
recognized as extremely important in IPT, but are not
addressed directly in therapy (Stuart and Robertson2003). A
careful review of the evidence, an examination of the
accumulated clinical experience, and a review of the theo-
retical reasons for addressing transference directly make a
very compelling case that techniques which allow a direct
examination of the patient-therapist relationship might be
very helpful additions to the IPT therapist’s armamentarium.
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
develops and maintains relationships, because the therapist
is in a relationship in which he or she is the person upon
whom the working models of attachment are imposed. In
some, but not all cases, direct discussion of the therapeutic
relationship might be very beneficial. This explicit dis-
cussion would likely be of most benefit to those patients
with more maladaptive attachment styles.
There is little explanation in the early IPT literature
regarding the absence of interventions directed towards
Table 2Potential revisions to IPT
Targets: Add attachment style as a primary target
Tactics: Extend the duration of IPT
Include a focus on the patient–therapist relationship
Eliminate the interpersonal deficits/sensitivity problem area
Staging of patients
Techniques:
Include direct discussion of treatment alliance
J Contemp Psychother (2008) 38:1–10 7
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8. transference. The prominence of biological psychiatry in
the 1970s and 1980s, when IPT was developed, undoubt-
edly played a role. It is likely, given the emphasis on
empirical validation, that the absence of data at the time
which supported transference-based therapies diminished
enthusiasm for them. A desire to distinguish IPT from
psychoanalytic schools may have been an issue, and cer-
tainly the research protocol emphasis on therapies which
were easily described and reliably delivered was a factor.
The continuing lack of research in IPT in this area is due
largely to two issues. The first is that there has been little
interest in examining the effects of treatment on personality
or other constructs presumed to be more stable; instead the
primary focus of outcome, consistent with the pharmaco-
logic model, has been change in symptomatic status.
Second, the time limit which has been an integral part of
IPT has led to the assertion, clearly stated, that it is not
designed to effect change in personality or ego functioning
(and by implication is not likely to do so). Adding
attachment style as a therapeutic target and extending the
duration of treatment would change this equation.
What would make IPT distinct from longer-term
psychodynamic psychotherapies if attention were drawn
directly to the patient-therapist relationship? First, the
primary emphasis in IPT would continue to be helping the
patient to build greater social support in his or her world
outside of therapy. While therapists are wonderful tools
when used for their specific purposes, they are no substitute
for real people. The primary focus in IPT would remain on
building social support outside of therapy and improving
interpersonal relationships, with explicit discussion of the
patient-therapist relationship being a tactic to foster these
goals—a means to an end.
The Interpersonal Problem Areas utilized in IPT also
require reconsideration. In the first iteration of IPT (Kler-
man et al.1984) there were four: Grief, Interpersonal
Disputes, Role Transitions, and Interpersonal Deficits.
They have undergone slight modifications: the term
‘‘Interpersonal Sensitivity’’ (Stuart and Robertson2003)
has been substituted in some cases for Interpersonal Defi-
cit, and the Grief Problem Area has been reframed to
encompass all grief and loss issues, rather than restricting it
to situations in which a death has occurred (Stuart and
Robertson2003). Nonetheless, the basic problem areas
have remained largely unchanged.
Accumulated clinical experience and theoretical devel-
opments now indicate that the ‘‘Interpersonal Deficit/
Sensitivity’’ domain is better conceptualized as an attach-
ment style or a character trait and should be discarded as an
acute problem area. As originally described, Interpersonal
Deficit was used to designate the problems experienced by
patients with a longstanding paucity of relationships who
tended to be avoidant and lacked confidence or skill in
social interactions. This contrasts greatly with the other
three problem areas, which are acute interpersonal stress-
ors. Nearly all clinicians agree that the Deficits/Sensitivity
problem area is different in quality from the others; some
research also suggests that patients presenting with prob-
lems in this ‘‘area’’ are more difficult to work with and
have poorer outcomes (Barber and Muenz1996; Wolfson
et al.1997; Luty et al.1998; Reay et al.2003) (see also
Grote et al and Talbot et al. this issue).
Another way in which IPT might be revised involves
patient and therapist selection. A staging concept would be
helpful in this regard. Using such a system, more difficult
patients might receive IPT of longer duration which targets
attachment, while those who are easier to treat might
receive shorter-term treatment without need to address the
patient-therapist relationship directly. Both clinical expe-
rience and theoretical considerations suggest that assessing
patient ‘‘difficulty’’ on the basis of diagnosis or symp-
tomatic status is quite likely barking up the wrong tree.
Instead, prognosis is much more likely to be correlated
with security of attachment and strength of social support.
A similar system of therapist staging would contribute
even more. A greater reliance on therapist judgment would
be expected from those with greater experience and
expertise. Therapists with less training might be advised to
steer clear of transference issues and to focus more on the
supportive elements of IPT. Such a system for both patients
and therapists would allow delivery of those elements of
IPT that are likely to be maximally beneficial, and allow
for the flexibility that is critical for any therapy delivered to
real people. In psychotherapy, one size clearly does not fit
all.
Conclusion
What is IPT? For the present, the framework presented in
Table1is an accurate description. The outline of theory,
targets, tactics, and techniques can be used as a framework
to describe other therapies or combination of therapies as
well.
There are two critical questions that must be addressed
in order for IPT to continue to develop: ‘‘What should IPT
be?’’ and ‘‘What is the process by which changes should be
incorporated?’’ The glib answer to these questions is sim-
ple: IPT should be whatever maximizes the benefit to
patients, and the process should facilitate this. All would
agree that this is our final goal. The devil, of course, is in
the details.
Those details should be addressed in at least two ways.
First, strong consideration should be given to modifying,
adding, or eliminating the elements of IPT as it is currently
conceptualized, and the effects of those changes should be
8 J Contemp Psychother (2008) 38:1–10
123

9. studied. There are several obvious candidates. The attach-
ment theory supporting IPT makes it clear that attachment
style should be tested as a target for treatment with some
patients. In turn, this leads to consideration of additional
techniques which address the patient-therapist relationship
directly. And for more difficult patients, a tactical shift to
extend the duration of treatment is a natural adaptation.
Second, more ‘‘outside the box’’ ideas must be devel-
oped and tested. Many of these will emerge from continued
clinical observation and from the questions generated from
quality research. It is critical that IPT be considered as a
work in progress; to do otherwise and insist on rigid
application or strict adherence to manuals will quash
creativity. To paraphrase Mark Twain, ‘‘be careful of
definitive psychotherapy manuals: you might die of a
misprint.’’
The process by which creativity can be reinvigorated
must be collaborative. Academics should do what they do
best: engage in spirited discourse and test their assump-
tions. Clinicians should do what they do best: closely and
critically observe what works with the individuals they
treat. And both groups must engage in a dialogue which
informs and inspires the other. The synthesis is the process
which will determine what IPT should be and how it should
continue to change.
Change is not only inevitable but necessary. The gen-
erativity we embody will be reflected to our colleagues and
our patients, and will be of inestimable benefit to both.
AcknowledgementThis work was supported by the following
grants: 5K24MH72757-02 (NIMH- Stuart).
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