Interpersonal psychotherapy

1. Introduction

Version followed: individual IPT for adult major depression as set out in Weissman, Markowitz & Klerman, The Guide to Interpersonal Psychotherapy (updated and expanded ed., Oxford University Press, 2018): 12–16 weekly sessions in three phases. The 2018 Guide is not drawn on directly. Detail attributed to it comes from the authors' standard published account and is tagged [uncertain] where it could not be checked. Sources include the ISIPT site, an open-access article co-authored by Markowitz, and Mufson's IPT-A training slides. [source: ISIPT; Markowitz, Milrod, Luyten & Holmqvist; Oxford Academic chapter page]

Interpersonal psychotherapy (IPT) is a time-limited, diagnosis-focused, manualised therapy. Klerman, Weissman and colleagues developed it in the 1970s, and its first manual appeared in 1984. Its core idea is that, whatever causes depression, the illness begins and persists within the patient's current relationships. Mood and life events affect each other in both directions. Change happens in three ways. First, the therapist defines depression as a treatable medical illness that is not the patient's fault, which lifts self-blame. Second, therapist and patient agree on one current interpersonal problem area linked to the episode: grief, role dispute, role transition, or interpersonal deficits. Third, the patient resolves that problem by mourning, renegotiating, adapting or building connections, which brings both better social support and better mood. The work stays on present relationships outside the office. It does not dwell on childhood or interpret the therapy relationship. [source: ISIPT "What is IPT"; Markowitz et al. AJP; Klerman et al. 1984; Weissman et al. 2018 [uncertain]]

2. Framework

Format. The standard format is individual, weekly, 45–50-minute sessions, 12–16 in total. An 8-session brief format has also been tested. The number of sessions can vary, but the therapist sets a "discrete time frame" at the start and keeps to it. IPT can be combined with antidepressant medication. [source: ISIPT]

Phase 1: Initial (about sessions 1–3)

Goals:
- Diagnose the depression and review its symptoms with a rating instrument. The Guide uses the Hamilton scale; any validated scale such as the PHQ-9 is a [synthesis] substitute.
- Give the diagnosis and psychoeducation, assign the sick role, and evaluate the need for medication.
- Take the interpersonal inventory and date the onset of symptoms against life events.
- Pick the problem area, offer the interpersonal formulation, get the patient's explicit agreement, and set the contract: number of sessions, focus, and practical arrangements. [source: ISIPT; Mufson 2015 (IPT-A version); Weissman et al. 2018 [uncertain]]
Moving to the middle phase: the patient has a diagnosis, has accepted the sick role, the inventory is done, and both of you agree on the focus and the end date. If no focus has been agreed by session 3, extend this phase by at most one session [synthesis]. Mufson's IPT-A model uses sessions 1–4 for this phase. [source: Mufson 2015]

Phase 2: Middle (about sessions 4 to 3 sessions before the end)

Goals: work on the chosen problem area with its specific goals and strategies (section 4). Open every session by linking mood to recent interpersonal events, and track symptoms regularly.
Moving to termination: the calendar decides, not the patient's readiness. The therapist reminds the patient of the time remaining throughout. [source: ISIPT; Weissman et al. 2018 [uncertain]]

Phase 3: Termination (last 2–4 sessions)

Goals:
- Say openly that treatment is ending, frame the ending as a role transition and a "good goodbye", and review gains.
- Credit improvement to the patient's own competence.
- Name early warning signs of relapse.
- Address any remaining symptoms by recommending further or added treatment.
- Decide on continuation or maintenance IPT (IPT-M, usually monthly) for patients at risk of recurrence. [source: ISIPT; Weissman et al. 2018 [uncertain]]
If the patient has not responded, the treatment has failed, not the patient. Offer an alternative. [source: Weissman et al. 2018 [uncertain]]

Named adaptations (not covered here):

IPT-A, for depressed adolescents (Mufson)
Group IPT, including the WHO 8-session Group IPT
IPSRT, interpersonal and social rhythm therapy for bipolar disorder (Frank)
IPT-M, maintenance IPT
Brief IPT (IPT-B)
Interpersonal counselling (IPC)
IPT for dysthymia
IPT for PTSD
Conjoint IPT for marital disputes
Telephone IPT

Training. The International Society of IPT (ISIPT) certifies therapists. Requirements:

At least 16 hours of introductory IPT training
Reading an ISIPT-recommended manual
At least 3 supervised cases of 8 or more sessions each, covering early, middle and late treatment
Supervision by an ISIPT-endorsed supervisor, at least 1 hour per 2 therapy sessions

[source: ISIPT therapist certification page]

3. Guiding principles

Time limit. Name the number of sessions in session 1 and count down aloud. The deadline drives the work and discourages dependence. [source: ISIPT]
Medical model and diagnosis focus. Name the disorder, rate its symptoms each session or at set intervals, and judge success by symptom change. [source: Markowitz et al. AJP; Weissman et al. 2018 [uncertain]]
Sick role. Depression is an illness "that is not the patient's fault" (Markowitz et al.). The patient is temporarily excused from some duties but is responsible for working on recovery. [source: Markowitz et al. AJP; Mufson 2015]
Here and now. Ask about current relationships and recent events. Bring up the past only to clarify a present pattern or a loss. [source: Weissman et al. 2018 [uncertain]]
Mood and events are linked both ways. In every session, connect a change in mood to something that happened between people, and connect what happened to how it felt. [source: ISIPT; Mufson 2015]
One focus. Work on one problem area, or at most two. Keep coming back to it when sessions drift. [source: Weissman et al. 2018 [uncertain]]
Shared formulation. Propose the focus as a hypothesis in the patient's own words. Do not start the middle phase until the patient agrees. [source: Mufson 2015; Weissman et al. 2018 [uncertain]]
Active, non-neutral, supportive therapist. Act as the patient's ally: validate, encourage, and suggest options when exploring stalls. Markowitz et al. say therapists "openly validate" feelings. [source: Markowitz et al. AJP]
Therapeutic optimism. Say that depression is treatable and that the patient has options. This counters depressive hopelessness. [source: Markowitz et al. AJP]
No transference work. IPT "does not interpret or work within the transference" (Markowitz et al.). Raise feelings about the therapist only when they block treatment or mirror the patient's outside patterns. [source: Markowitz et al. AJP]
Affect is information about relationships. Help the patient name, tolerate and normalise feelings, then use them to decide what to say or do with others. [source: Markowitz et al. AJP]
Change happens outside the office. Sessions prepare the patient. Real conversations and decisions happen between sessions and are reviewed the next week. [source: Mufson 2015; ISIPT]
Credit and blame. Improvement is credited to the patient's efforts. Non-response is blamed on the illness or the treatment. [source: Weissman et al. 2018 [uncertain]]
Fidelity. Follow the manual and avoid eclectic mixing of frameworks. [source: Markowitz et al. AJP]
Safety first. Assess suicide risk at intake and whenever symptoms worsen, using standard risk assessment. IPT does not replace crisis management. [source: Mufson 2015; synthesis]

4. Intervention inventory

All example language is the author's own (illustrative) unless it is quoted and cited. The interventions are grouped as initial-phase tasks (4.1–4.9), the middle-phase session frame (4.10), problem-area strategies (4.11–4.14), general techniques (4.15–4.24) and termination (4.25–4.26). [source for list structure: Weissman et al. 2018 [uncertain]; Indian J Psychiatry guideline summary (technique list); Mufson 2015]

4.1 Diagnostic assessment and symptom rating

Purpose / when: Session 1, then at regular intervals (every session in the IPT-A protocol). It confirms the target disorder, sets a baseline and tracks response. [source: Mufson 2015; Weissman et al. 2018 [uncertain]]
Steps:
1. Take the psychiatric history and assess against DSM-5 criteria.
2. Give a rating scale. The Guide uses the HAM-D; a self-report scale such as the PHQ-9 is a [synthesis] option.
3. Run a standard suicide risk assessment.
4. Screen for exclusions and conditions that need treating first: psychosis, active substance use disorder, or a different primary disorder. [source: Mufson 2015 (adolescent contraindications); synthesis for adults]
5. Show the patient the score and name each symptom as part of the illness.
Example language (illustrative): "Your answers add up to a moderate-to-severe depression. The sleep problems, low energy and guilt are all part of the same illness."
Watch for: Scores going down over the middle phase. Any rise in suicidality means a fresh risk assessment.

4.2 Psychoeducation: naming the illness

Purpose / when: Sessions 1–2. It turns vague self-blame into a named, treatable condition and builds hope. [source: Markowitz et al. AJP; Mufson 2015]
Steps:
1. State the diagnosis clearly.
2. Explain that depression is common and treatable.
3. Link the specific symptoms to the illness rather than to the patient's character.
4. Give a realistic expectation of improvement within the time limit.
5. Invite questions.
Example language (illustrative): "What you have is called major depression. It's a medical illness, like diabetes or pneumonia. It isn't a weakness, and it responds well to treatment."
Watch for: The patient starts describing symptoms as "the depression" instead of "me being lazy". Guilt drops.

4.3 Assigning the sick role

Purpose / when: Session 1 or 2. It excuses the patient from impossible demands while making recovery the patient's job. [source: Markowitz et al. AJP; Mufson 2015]
Steps:
1. Tie the sick role to the diagnosis.
2. Name which duties can temporarily be done at a reduced level.
3. State the obligation to attend sessions and work toward recovery.
4. Stress that the role is temporary.
5. In IPT-A, coach parents to criticise less and support more. [source: Mufson 2015]
6. If relatives blame the patient, consider explaining the illness to them as well [synthesis].
Example language (illustrative): "While you're ill, it's reasonable to do less at work and at home, as you would with a bad flu. Your job right now is to come here and work with me on getting better."
Watch for: The patient using the sick role to withdraw completely. In IPT-A, Mufson's "limited sick role" asks the patient to keep up normal activities as far as possible. Relief from self-criticism is the sign it's working.

4.4 Medication evaluation

Purpose / when: Initial phase, and again if the patient isn't responding. IPT is compatible with antidepressants. [source: Weissman et al. 2018 [uncertain]; Indian J Psychiatry summary]
Steps:
1. Assess severity and the patient's history and preference.
2. Refer for a pharmacotherapy consultation when indicated (no dosing guidance here).
3. Agree on how the two treatments will be coordinated.
Example language (illustrative): "Given how severe this is, I'd like a psychiatrist to see you about medication alongside our work."
Watch for: Side effects being misread as depressive symptoms, and divided adherence.

4.5 Interpersonal inventory

Purpose / when: Sessions 1–3. It maps the patient's important relationships to find the problem area and the available support. [source: ISIPT; Mufson 2015]
Steps:
1. List the important people in the patient's life. In IPT-A this is done visually with a "closeness circle"; note who is missing. [source: Mufson 2015]
2. For each person, cover:
  - how often you have contact, what about, and in what setting
  - what each of you expects from the relationship, and whether those expectations are met
  - what is satisfying and what is unsatisfying
  - how you communicate, and how you argue
  - who you can confide in
  - what has changed since the depression began [source: Mufson 2015; ISIPT]
3. Ask what the patient would like to change in each relationship.
4. Note recurring patterns and gaps in support.
Example language (illustrative): "Tell me about your wife. How often do you really talk? What do you each expect from the other? What's good between you, and what isn't? Has that changed since you got depressed?"
Watch for: A vague, global description such as "everyone's fine" needs gentle direct questions about specific recent contacts. Very few people listed points toward interpersonal deficits.

4.6 Timeline: linking onset to life events

Purpose / when: During the inventory. It finds the interpersonal event that started or is keeping up the episode. [source: Mufson 2015 (relate depression to current problems); Weissman et al. 2018 [uncertain]]
Steps:
1. Date when symptoms began, and any earlier episodes.
2. Ask what was happening in the patient's relationships and roles just before and during onset: deaths, conflicts, moves, job changes, births, illness.
3. Ask about the reverse direction too: how the depression has affected those relationships.
Example language (illustrative): "You said the low mood started around March. What was going on in your life then? Who was around you?"
Watch for: Patients often don't make the connection themselves. Several events at once suggests a primary and a secondary problem area.

4.7 Choosing the problem area

Purpose / when: End of the initial phase. It picks one focus (at most two) for the middle phase. [source: ISIPT; Weissman et al. 2018 [uncertain]]
Steps:
1. Match the timeline to the four areas:
  - Grief: depression linked to the death of someone important
  - Role dispute: conflict with an important person over mismatched expectations
  - Role transition: a life change such as a job, relationship, move, illness or new parenthood
  - Interpersonal deficits: no recent trigger and a long-standing pattern of thin or unsatisfying relationships [source: ISIPT]
2. When more than one fits, prefer the one most closely tied to onset that the patient can realistically work on.
3. Use deficits only when no other area applies; ISIPT notes these patients tend to do less well. [source: ISIPT]
Example language (illustrative): "Of everything we've covered, the fights with your mother since the move seem most tied to how bad you feel. Would it make sense to focus there?"
Watch for: Deciding without the patient. Choosing a focus the patient experiences as blaming them.

4.8 Interpersonal formulation

Purpose / when: Session 2 or 3. It gives the patient a brief, shared explanation that links the diagnosis, the sick role, the problem area and the plan. It also forms the treatment contract. [source: Mufson 2015; Weissman et al. 2018 [uncertain]]
Steps:
1. Restate the diagnosis and the sick role.
2. Name the problem area, using IPT's label and the patient's own facts.
3. Link the problem area to the depression.
4. State the plan and the number of sessions.
5. Ask explicitly whether the patient agrees, and revise it if not.
Example language (illustrative): "You're suffering from depression, which is an illness and not your fault. It seems to have started when your marriage got into a stand-off over money and your career. IPT calls that a role dispute. Over the next 12 weeks I suggest we work on how you and your husband handle this. As that improves, the depression should too. Does that fit how you see it?"
Watch for: Polite agreement without real buy-in. Check by asking the patient to say the focus back in their own words.

4.9 Treatment contract and time limit

Purpose / when: End of the initial phase. It makes the frame explicit. This is listed among the Guide's "adjunctive" techniques. [source: Mufson 2015; ISIPT; Weissman et al. 2018 [uncertain]]
Steps:
1. Agree the number of sessions, the end date, session length, and the policy on missed sessions.
2. In IPT-A, agree the parents' role. [source: Mufson 2015]
3. From then on, mention the sessions remaining every few weeks.
Example language (illustrative): "We'll meet weekly for 14 sessions, finishing around mid-December. If you need to cancel, let me know in advance and we'll reschedule within the same week if we can."
Watch for: Requests to leave the end date open. Keep it fixed (see section 5).

4.10 Session opening: linking mood and events

Purpose / when: The start of every middle-phase session. It keeps the session on the problem area and shows the patient, week after week, that mood and relationships are connected. [source: ISIPT; Mufson 2015]
Steps:
1. Open with a general question about the time since the last session.
2. Get a mood rating. In IPT-A, average, best and worst mood on a 1–10 scale. [source: Mufson 2015]
3. Find the interpersonal event behind the best and worst moments.
4. If mood improved, ask what the patient did and credit them. If it worsened, look at what happened.
5. Tie the event to the problem area and move to the relevant strategy.
Example language (illustrative): "How have things been since we last met?" Then: "When did you feel worst this week? What was happening, and who was involved?" (The opener is the wording commonly attributed to the Guide [uncertain].)
Watch for: Mufson distinguishes "feeling" patients, who need the week reviewed in detail to find the triggering event, from "event" patients, who need the feelings behind the event drawn out. [source: Mufson 2015]

4.11 Problem-area strategy: Grief

Purpose / when: The depression is linked to the death of a significant person. Since DSM-5, the 2018 Guide uses this area only for death, not other losses, which count as role transitions [uncertain]. The goals are (a) to help the patient mourn and (b) to help the patient rebuild interests and relationships that can partly take the place of what was lost. [source: ISIPT; Mufson 2015; Weissman et al. 2018 [uncertain]]
Steps:
1. Link the onset of symptoms to the death and its aftermath.
2. Reconstruct the relationship with the deceased in detail: how they met, shared activities, good times, and disappointments.
3. Go through the sequence of events before, during and after the death: the illness, last contact, the funeral, and what changed afterwards.
4. Explore the feelings involved, both positive and negative. Explicitly allow anger, guilt and relief alongside sadness.
5. Correct the idealised or one-sided picture so that both sides of the relationship can be held at once.
6. Once mourning is under way, move to re-engagement: who else is around, which old interests could return, and what new contacts are possible. [source: Mufson 2015 (review relationship and events around the death, facilitate mourning, new supports); Weissman et al. 2018 [uncertain] for the sequence]
Example language (illustrative): "Tell me about your father. What was he like?" Later: "You've told me what you miss. Were there things about him that were hard, or that you resented?" Later still: "Who in your life now could you spend a Sunday with?"
Watch for:
- Mourning is under way when the patient can cry, tell the story in a less fragmented way, and speak of the deceased in a more balanced way.
- Re-engagement is under way when the patient takes steps toward other people.
- Watch for avoidance (changing the subject, saying "I'm over it") and for suicidal thoughts about joining the deceased, which call for a risk assessment.

4.12 Problem-area strategy: Role disputes

Purpose / when: The patient and a significant other have non-reciprocal (mismatched) expectations about their relationship, and the conflict is linked to the depression. The goals are to identify the dispute, choose a plan, and change expectations and/or faulty communication so the dispute is settled satisfactorily. [source: ISIPT; Mufson 2015; Oxford Academic chapter stub; Weissman et al. 2018 [uncertain]]
Stage assessment: decide which of three stages the dispute is in. [source: Mufson 2015]
- Renegotiation: the two people are still talking and trying, but failing.
- Impasse: discussion has stopped and resentment simmers.
- Dissolution: one or both want to end the relationship.
Steps:
1. Link the onset of symptoms to the overt or covert dispute.
2. Determine the stage.
3. Clarify the issues: what each person expects, where the expectations and values differ, what the patient wants, what options exist, and what resources are available for change.
4. Look at how the dispute is kept going (communication analysis, 4.18) and at parallels in other relationships.
5. Work according to the stage:
  - Renegotiation: calm things down and improve communication. Prepare specific requests and rehearse them (role play, 4.20).
  - Impasse: help the patient reopen negotiation. This may first bring more open conflict, which is a sign of movement. Warn the patient in advance [uncertain].
  - Dissolution: help the patient decide (decision analysis, 4.19). If the patient chooses to end the relationship, treat the separation as a role transition and help them mourn.
6. Review each real-world attempt in the next session. [source: Mufson 2015 (explore expectations, modify communication, teach negotiation); Weissman et al. 2018 [uncertain]]
Example language (illustrative): "What do you want from him on this? What do you think he expects from you? Where do those two pictures not match?"
Watch for:
- Progress shows as concrete exchanges that went better, expectations stated directly, and mood improving after them.
- Screen for intimate-partner violence before encouraging confrontation (see section 5) [synthesis].
- Seeing the other party in a joint session is possible; see 4.24.

4.13 Problem-area strategy: Role transitions

Purpose / when: The depression is linked to difficulty adapting to a life change: a new or lost job, retirement, a move, a relationship beginning or ending, new parenthood, a diagnosis, or a developmental stage. The goals are (a) to mourn and accept the loss of the old role, (b) to see the new role more positively, and (c) to restore self-esteem by building mastery of the new role's demands. [source: ISIPT; Mufson 2015; Weissman et al. 2018 [uncertain]]
Steps:
1. Link the onset of symptoms to the transition.
2. Review the old role: what was good and what was bad about it. Depressed patients tend to remember the old role as all good.
3. Explore the feelings about what was lost and about the change itself, including anger at how it happened.
4. Review the new role: realistic downsides and real opportunities.
5. Identify the skills the new role needs and practise them.
6. Build new sources of support that fit the new role. [source: Mufson 2015 (meaning of change, gains and losses, skills); Weissman et al. 2018 [uncertain]]
Example language (illustrative): "What did you lose when you left the firm? Was there anything about that job you don't miss? Now that you're at home with the baby, what's harder than you expected, and is there anything you're starting to like?"
Watch for: Movement from an all-good old role and an all-bad new role toward a balanced view of both, the first experiences of competence in the new role, and new relationships forming.

4.14 Problem-area strategy: Interpersonal deficits (sensitivity / social isolation)

Purpose / when: Use this only when there is no recent life event to work on and the patient has a history of impoverished, few or unsatisfying relationships. The label varies across texts: "interpersonal deficits", "interpersonal sensitivity", or, in Markowitz et al., "social isolation". The goals are to reduce isolation and encourage new relationships. [source: ISIPT; Markowitz et al. AJP; Mufson 2015; Weissman et al. 2018 [uncertain] for naming and goals]
Steps:
1. Link the symptoms to isolation or unmet needs.
2. Review past important relationships, both positive and negative, to find what has worked before.
3. Identify repeating patterns: how relationships start, stall and end.
4. Because outside relationships are thin, use the therapy relationship as a sample. Ask about the patient's positive and negative feelings toward the therapist and look for parallels with other relationships (4.21).
5. Build skills (communication analysis, role play) and set graded social steps between sessions. [source: Mufson 2015; Weissman et al. 2018 [uncertain]]
Example language (illustrative): "Think of a friendship that went fairly well, even for a while. What made it work? What usually happens when someone at work invites you somewhere?"
Watch for:
- Expect slower, more modest gains; ISIPT notes poorer outcomes in this group.
- For chronic depression, Markowitz's IPT for dysthymia instead frames treatment as a deliberate ("iatrogenic") role transition out of the depressed state [uncertain: named from Markowitz's dysthymia adaptation].
- Any new contact, or any initiative the patient takes, counts as progress.

4.15 Exploratory techniques (non-directive and directive)

Purpose / when: Gathering material throughout treatment. Mufson recommends a balance of non-directive and directive questioning. [source: Indian J Psychiatry summary (non-directive exploration, elicitation); Mufson 2015]
Steps:
1. Non-directive: ask open questions, acknowledge supportively ("go on", nodding), and stay on a topic the patient brings up.
2. Directive elicitation: ask targeted questions about specific people, dates and exchanges when the material stays vague.
3. Switch to directive questions when sessions drift away from the focus.
Example language (illustrative): "Say more about that." Then: "What exactly happened on Tuesday evening, and who said what first?"
Watch for: Too much open exploration lets the session drift. Too much questioning feels like an interrogation.

4.16 Encouragement of affect

Purpose / when: Throughout, and especially in grief and transitions. The aim is to help the patient name, accept and tolerate painful feelings, and use them to guide what they do with other people. [source: Markowitz et al. AJP (elicit, normalise, name, tolerate, link to circumstances); Indian J Psychiatry summary]
Steps:
1. Notice feelings the patient shows or hints at, and name them.
2. Normalise them as understandable reactions to the situation.
3. Link each feeling to the interpersonal event that set it off.
4. Ask what the feeling says about what the patient wants from the other person.
5. When feelings have been suppressed, invite them gently (for example, anger at the deceased).
Example language (illustrative): "You look angry as you tell me this. That makes sense, since she promised and didn't follow through. What does the anger tell you that you need from her?"
Watch for: The patient can stay with the feeling without being flooded. If they are overwhelmed, slow down (see section 5). Markowitz et al. note that some patients first need help simply getting access to feelings.

4.17 Clarification

Purpose / when: When the account is contradictory, vague, or full of unexamined assumptions. [source: Markowitz et al. AJP; Indian J Psychiatry summary]
Steps:
1. Rephrase what the patient said and check it.
2. Point out contradictions gently, for example between what the patient says and how they say it, or between two accounts.
3. Ask the patient to say it again more specifically.
Example language (illustrative): "You said it didn't bother you, but you've brought it up three times today. What do you make of that?"
Watch for: Clarification should feel curious, not accusatory. It is working when the patient reaches a fresh, more specific statement of what they want.

4.18 Communication analysis

Purpose / when: In any problem area, whenever an important exchange went badly. It shows the gap between what the patient meant to send and what the other person received. [source: ISIPT; Mufson 2015; Markowitz et al. AJP]
Steps:
1. Pick a specific recent exchange connected to a mood change.
2. Get a word-for-word account: what was said, in what tone, and what happened next. ISIPT calls this a "movie script".
3. At each turn, ask how the patient felt and what they intended.
4. Ask how the other person probably felt and what they heard.
5. Ask whether that was the message the patient wanted to send.
6. Generate other ways it could have been said and how each might have landed.
7. Move into role play (4.20) to practise the alternative. [source: Mufson 2015 (question sequence); ISIPT]
Example language (illustrative): "Take me through it line by line. What did you say, and how did you say it? What did she say back? How do you think that sounded to her? Is that what you wanted her to hear?"
Watch for:
- Common errors include indirect or non-verbal hints, assuming the other person knows what you want, silence that ends contact, sarcasm, and giving in before the patient's own wish is stated. This list is [synthesis], consistent with Weissman et al. 2018 [uncertain].
- It is working when the patient spots their own part in the sequence and proposes a more direct version.

4.19 Decision analysis / exploring options

Purpose / when: When the patient faces a choice or feels stuck: in disputes, especially at dissolution; in transitions; when building a social life. [source: ISIPT; Mufson 2015]
Steps:
1. Define the situation and ask what the patient wants.
2. Generate as many options as possible. Let the patient lead, and add suggestions only if they run dry.
3. Weigh the pros, cons and feasibility of each.
4. Choose one to try first.
5. Rehearse it (4.20).
6. Review the outcome the next week: what worked, what didn't, and why.
7. If the outcome the patient wants cannot be reached, help them mourn it. [source: Mufson 2015 (steps 1–6); ISIPT (step 7)]
Example language (illustrative): "What would you ideally like to happen? Let's list every option, even ones that sound unrealistic. Which seems most doable this week?"
Watch for: Hopelessness that rules out every option. Name it as a depressive symptom and go on generating options anyway. It is working when the patient chooses an action and carries it out.

4.20 Role play

Purpose / when: After communication or decision analysis, before a real conversation. It rehearses wording and tone, builds confidence, and shows the patient how the other person might react. [source: Markowitz et al. AJP; Mufson 2015]
Steps:
1. Talk through the goal of the conversation and what the patient wants to say.
2. Set the scene: who, where, when.
3. Let the patient choose the more comfortable role first. Often the therapist plays the patient and the patient plays the other person.
4. Switch roles and act it out. Do not just discuss it.
5. Give specific feedback on wording, tone and timing. Mufson's tips include "I" statements, opening with understanding of the other person, and having several options ready.
6. Repeat with variations, including a difficult response from the other person.
7. Agree when the real conversation will happen. [source: Mufson 2015]
Example language (illustrative): "Let's try it. I'll be your boss. Start the way you'd actually start on Monday." Later: "Now swap: you be her, and I'll say it the new way."
Watch for: Embarrassment or refusal, which needs a gradual approach (see section 5). It is working when the patient's statements become more direct and calm and the real exchange goes ahead.

4.21 Use of the therapeutic relationship

Purpose / when: Mainly in interpersonal deficits, or when the patient's behaviour toward the therapist threatens treatment or clearly mirrors an outside pattern. It is not transference interpretation. [source: Markowitz et al. AJP; Mufson 2015; Weissman et al. 2018 [uncertain]]
Steps:
1. Notice the in-session pattern, for example apologising, withholding, or anger at the therapist.
2. Ask about it directly and in the present.
3. Link it to the same pattern outside the office.
4. Use the therapy relationship as a safe place to practise a different response.
Example language (illustrative): "You seemed hesitant to tell me you disagreed just now. Is that like what happens with your colleagues?"
Watch for: Getting drawn into exploring the relationship for its own sake. Bring the discussion back to outside relationships.

4.22 Directive and behaviour-change techniques: education, advice, modelling

Purpose / when: When the patient lacks information or a skill, or exploration has stalled. Listed among the Guide's behaviour-change techniques alongside decision analysis and role play [uncertain]. [source: Weissman et al. 2018 [uncertain]; Mufson 2015 (psychoeducation, skills)]
Steps:
1. Give information, for example about grief, typical reactions to parenthood, or how to state a request.
2. Make suggestions offered as options, not orders.
3. Model the skill in role play.
Example language (illustrative): "Many people find it helps to raise money matters at a calm time rather than in the middle of a row. Would that be worth trying?"
Watch for: Over-directing, which undermines the patient's sense of competence.

4.23 Between-session practice

Purpose / when: The middle phase. The patient tries new skills in real relationships. IPT-A formally calls this "work at home". In adult IPT it is framed less formally as encouraging the patient to act and reviewing the result next session [uncertain]. [source: Mufson 2015; ISIPT]
Steps:
1. Draw the task from the session's role play or decision.
2. Make it specific: who, when, and what words.
3. Predict the possible responses.
4. Review it at the next session's opening (4.10).
Example language (illustrative): "So the plan is to ask your sister on Sunday whether she'll share the visits to your mum. Next time, let's see how it went."
Watch for: Tasks that are too big, and failure being read as personal inadequacy. Frame every attempt as information.

4.24 Joint session with the significant other

Purpose / when: Optional, mostly in role disputes, or to explain the illness to a relative. In IPT-A, parent sessions are routine. A conjoint marital IPT adaptation exists. [source: Mufson 2015; Weissman et al. 2018 [uncertain] for adult use]
Steps:
1. Get the patient's agreement and agree goals in advance.
2. In the session, keep the focus on communication and expectations rather than settling every issue.
3. Debrief with the patient individually afterwards.
Example language (illustrative): "I've asked you both here so we can understand what each of you expects around the household, and practise talking about it."
Watch for: Siding with one person, safety risks, and the patient being silenced. If there is any concern about abuse, do not hold a joint session [synthesis].

4.25 Termination work

Purpose / when: The last 2–4 sessions. Mention the ending earlier as the sessions count down. The aim is to treat the ending as a role transition, consolidate gains and prepare for the future. [source: ISIPT; Mufson 2015; Weissman et al. 2018 [uncertain]]
Steps:
1. State explicitly that the ending is near.
2. Invite feelings about ending and distinguish normal sadness from depression returning.
3. Review the symptom course using scores.
4. List what the patient did that helped, crediting their competence.
5. Identify personal early-warning signs and plan what to do if they appear.
6. Apply the skills to expected future situations.
7. Note interpersonal issues that are still open.
8. Say a clear, warm goodbye. [source: ISIPT; Mufson 2015]
Example language (illustrative): "We have three sessions left. It's natural to feel sad about ending, and that's different from being depressed. Your scores have gone from 24 to 8. What did you do that made the difference?"
Watch for: Last-minute crises and requests to extend (see section 5). It is working when the patient can describe the improvement as their own achievement.

4.26 Continuation, maintenance, and handling non-response at the end

Purpose / when: At the end of acute treatment. [source: ISIPT; Weissman et al. 2018 [uncertain]]
Steps:
1. If the patient responded but has a history of recurrence, offer continuation or maintenance IPT (IPT-M, often monthly) with the same problem-area focus.
2. If the patient responded partially or not at all, say clearly that the treatment, not the patient, fell short. Then discuss alternatives: medication, a different psychotherapy, or a combination.
3. Make the referral before the last session.
Example language (illustrative): "This treatment hasn't helped as much as we hoped. That's a limit of the treatment, not a failing in you. There are other good options, and I'd like to set one up before we finish."
Watch for: The patient taking non-response as further proof of personal failure.

5. Handling problems

The sources say little about difficulties. The Guide has material on common patient and therapist problems that could not be checked here [uncertain]. Items tagged [synthesis] are the author's own guidance, built to fit IPT's principles.

No clear problem area, or several. Levenson et al., cited in Miniati et al., found that clinicians sometimes could not identify a focus in the first two sessions. [source: Miniati et al. 2021]
- Re-run the timeline with direct questions about the months before onset.
- Pick the area most closely tied to onset as primary and keep a second in reserve.
- Use interpersonal deficits only as a last resort. [source: ISIPT; synthesis]
The patient rejects the formulation. Ask what feels wrong, use the patient's words, and revise. Agreement matters more than the label. If the patient insists the problem is purely biological, keep the illness model and add: "and illnesses affect, and are affected by, what's going on around us." [synthesis]
The patient rejects the sick role ("I'm just weak"). Treat the self-blame as a symptom. Go through the diagnostic criteria together and compare with a physical illness that saps energy. Repeat in later sessions. [synthesis consistent with Markowitz et al. AJP]
The sick role becomes total withdrawal. Set limits: name which activities continue, and point out that the role is temporary and carries the duty to work on recovery. [source: Mufson 2015 (limited sick role); synthesis for adults]
Sessions drift to the past, to symptoms, or to unrelated topics. Acknowledge the material briefly, then use a directive question that links back to the focus. Remind the patient how many sessions remain. [synthesis on ISIPT time-limit principle]
"Nothing happened this week." Go through the week day by day and find the best and worst moments, then the people involved (Mufson's "feeling" patients). [source: Mufson 2015]
Patients who describe events without feelings, or are emotionally detached. Slow down, name likely feelings tentatively, and normalise them. Markowitz et al. describe chronic PTSD patients who needed half the treatment just to regain access to feelings. [source: Markowitz et al. AJP]
Overwhelm or flooding (acute grief, rage):
- Lower the intensity. Move from emotional detail to factual sequence, ground the patient in the present, and finish the session with a contained summary.
- Plan pacing with the patient.
- Consider closer support or medication review if symptoms are worsening. [synthesis]
Suicidal ideation or worsening. Do a standard structured risk assessment and safety planning. Escalate care (psychiatric review, more frequent contact, crisis services) according to local protocols. IPT goes on only within a safe frame. [source: Mufson 2015 (monitor suicidality each session); synthesis]
Missed sessions or lateness. Raise it directly and without judgment. Ask whether depression (low energy, hopelessness) or a relationship pattern is behind it, and reschedule within the time frame. Repeated absence that endangers the contract needs explicit renegotiation. [synthesis; Mufson 2015 (attendance policy in contract)]
Not trying the agreed action. Do communication or decision analysis on what got in the way. Shrink the step, rehearse more, and treat the avoidance as information about the dispute or transition rather than as failure. [synthesis]
Reluctance to role-play. Start by discussing the wording, then have the therapist play the patient first. Keep it short and joke about the awkwardness. Mufson advises coaxing anxious patients gradually. [source: Mufson 2015; synthesis]
Alliance rupture: anger at the therapist, feeling misunderstood, "this isn't working."
- Name it in the present, take responsibility for your part, and validate.
- Check whether the focus is wrong.
- If it mirrors an outside pattern (especially in deficits), link it carefully (4.21).
- Do not interpret it as transference. [source: Markowitz et al. AJP (non-transference stance); synthesis]
The patient wants the therapist as a friend, or asks personal questions. Answer briefly and warmly, then turn to who in the patient's life could meet that need. The therapist is an ally, not a substitute relationship. [synthesis; Weissman et al. 2018 [uncertain]]
Requests to extend near the end. Explore the fear behind the request and point to the patient's own gains. Keep the end date. If symptoms remain, offer a separately contracted continuation or maintenance phase, or a referral, rather than an open-ended extension. [source: ISIPT (discrete time frame); synthesis]
Early improvement and wanting to stop. Credit the gains, explain the risk of relapse, and agree to finish the contract or taper to continuation sessions. [synthesis]
No improvement by mid-treatment (for example, scores flat at session 6–8). Check the focus, adherence and comorbidity. Add a medication consultation. Plan for an alternative if the patient has still not responded at the end (4.26). [synthesis; Weissman et al. 2018 [uncertain]]
Role dispute with an abusive partner. Screen for violence before any communication-based intervention. Safety planning comes first. Never set up a confrontation or joint session where there is a risk of harm. Decision analysis can then address safety and leaving. [synthesis]
Dissolution: the patient can't decide whether to leave. Use decision analysis over several sessions. Remind the patient that IPT's aim is not to keep or end the relationship but to resolve the depression-linked stalemate. If they leave, move to mourning. [source: Mufson 2015; synthesis]
Chronic depression with no recent trigger. Consider treating the work as a role transition out of the depressed state, as in Markowitz's dysthymia adaptation [uncertain], rather than as interpersonal deficits. [synthesis]
Substance use, psychosis, or another primary disorder. These are outside the core model. Treat them first or refer. [source: Mufson 2015 (contraindications, adolescents); synthesis for adults]
Therapist drift into CBT homework or psychodynamic interpretation. Use supervision and session recordings to check fidelity. Markowitz et al. warn against eclectic mixing. [source: Markowitz et al. AJP; ISIPT supervision requirements]
Cultural mismatch (for example, family hierarchy makes direct requests unacceptable). Adjust the wording and the target of negotiation, for instance going through an intermediary. Keep the problem-area logic. [synthesis]

Sources

Sources:

Books cited ([uncertain] where relied on):

Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2018). The Guide to Interpersonal Psychotherapy (updated and expanded ed.). Oxford University Press.
Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive Guide to Interpersonal Psychotherapy. Basic Books.
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal Psychotherapy of Depression. Basic Books.
Mufson, L., Dorta, K. P., Moreau, D., & Weissman, M. M. (2004). Interpersonal Psychotherapy for Depressed Adolescents (2nd ed.). Guilford Press.
Weissman, M. M. (Ed.) (2024). Interpersonal Psychotherapy: A Global Reach. Oxford University Press.

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