iii

The Guide to Interpersonal

Psychotherapy
Updated and Expanded Edition

MYRNA M. WEISSMAN

JOHN C. MARKOWITZ

GERALD L. KLERMAN

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10

IPT Techniques and

the Therapist’s Role

The strategies used in IPT, described in the preceding chapters, are distinctive.
The techniques used to facilitate these strategies are neither unique nor new, how-
ever; most will be familiar to any experienced psychotherapist, particularly those
familiar with affect-​focused psychotherapies (Markowitz & Milrod, 2011). These
aspects of the therapy constitute some of the “common factors” shared by many
or all psychotherapies (Frank, 1971; Wampold, 2001). Our patient handbook
(Weissman, 2005) explicitly states some of these methods from a patient’s point
of view. The time spent in IPT focuses on discussing feelings, normalizing them
as responses to interpersonal interactions and as useful interpersonal informa-
tion, and using them to take action to change the patient’s interactions in order
to resolve the identified problem area. You can use the following techniques to
accomplish this.

NONDIRECTIVE EXPLORATION

Nondirective exploration uses open-​ended questions to facilitate free discussion

in order to gain information and identify problem areas. Some sample questions
include “Who are the important people in your life?” and “How have you been since
we last met?”
With a supportive acknowledgment, encourage the patient to continue: “Please
go on,” “I understand,” or, to deepen or extend the topic, “Can you tell me more
about the friend you mentioned earlier?”
Nondirective exploration is useful with a verbal patient to focus the treatment,
but it can make a less verbal patient anxious. As the therapeutic goal is to develop
a comfortable alliance, more directed, active techniques are indicated for less ver-
bal patients. The therapist must always weigh whether to intervene, providing
structure and honing the direction of the therapy, or to wait, listening for the
development and allowing the deepening of the patient’s feeling state.
 
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DIRECT ELICITATION

Use direct elicitation of material to obtain specific information, such as to develop

the interpersonal inventory, to obtain symptoms in order to make a diagnosis, or
where specific information is needed to demonstrate a point, such as defining a
patient’s role in a dispute or an unexpressed affect. For example: “Can you tell me
what you said before your wife accused you?” or “How did you feel when clearing
out your husband’s clothes after the funeral?”

ENCOURAGEMENT OF AFFECT

Encouraging affect helps the patient to express, understand, and manage affect.
The expression of affect may help her to decide what is important and make emo-
tionally meaningful changes. Choosing options and making changes are more
difficult if the patient does not recognize the range and intensity of her feelings
about key interpersonal situations. Awareness of a sense of guilt, anger, or sad-
ness, and reflecting on it, may help to clarify and point the patient in an interper-
sonal direction.
Further, tolerating strong affects, while not the primary goal of IPT, is an impor-
tant byproduct of treatment. Many patients consider their strong negative emo-
tions evidence of their defectiveness: many patients with depression view strong
anger or hatred as indicating how “bad” they are; patients with posttraumatic
stress disorder (PTSD) see anger as evidence of their dangerousness. For patients,
learning that these feelings are normal—​powerful, but not dangerous—​and inter-
personally informative (anger tells you someone is bothering you) can be trans-
formative (Markowitz & Milrod, 2011). The IPT therapist encourages the patient
to see strong emotions as human, as good rather than bad. Strong emotions can
be converted into words that can lead to more adaptive interpersonal encounters,
with benefits for overall mood and symptoms.
One way to help the patient deal with and accept painful affect, especially in
grief reactions, is to elicit details of her interactions with others or to explore top-
ics to which she has shown an emotional response. In the case example of Mitzi’s
grief in Chapter 5, she had idealized her husband but became able in therapy to
express some of her disappointment and the burden she experienced following
his sudden death. In the case of Phil in Chapter 7, direct exploration of his inter-
actions at work allowed him to begin to make the transition into the retirement he
had unexpectedly found so difficult. Patients who often feel guilty about express-
ing negative feelings may benefit from your direct reassurance, such as, “Most
people would feel like that,” or “Of course you’re angry! It makes sense to feel angry.”
This conveys your acceptance of the patient’s feelings.
Although patients with many psychiatric disorders constrict their feelings and
can be encouraged to express their emotions within the therapy, how they should
act in close interpersonal relationships outside of the office varies by culture and
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situation (Markowitz et al., 2009; Verdeli et al., 2008). In some instances, strong
expression of anger and resentment might damage already fragile relationships.
The first steps are to elicit the feelings in the therapeutic situation, to normalize
them where possible (but defining suicidal feelings, for example, as symptoms),
and then to discuss the pros and cons of expressing them or how best to express
them in existing relationships. When possible, the therapist can also encourage
the patient to use social supports to express feelings. How best to do so, to whom,
and what reactions can be anticipated are options to explore and to role play in
IPT before the patient tries them out at home or work. Listen for emotionally
important statements, and encourage their expansion by discussing them.
Yet constant repetition of angry, hostile, and sad outbursts can be counterpro-
ductive. When this occurs, you can help the patient to explore other options to
break a maladaptive pattern of emotional expression. For example:

You seem to get into this pattern that doesn’t really help you to feel better. Do
you agree? . . . What other options might you have to express these feelings?
How else might you communicate how you feel to your friend?

Alternatively, an excessively affective display may be tempered by inquiring about

the patient’s thoughts about these strong feelings and exploring how she may
delay acting on an impulse, allowing time to consider the consequences. If some
behaviors or circumstances of the troubling problem change, this may reduce
some of the patient’s angry affect. Nor need the IPT therapist stop at encourag-
ing angry and resentful feelings; many patients have difficulty expressing affec-
tion, gratitude, or caring, and can work on this in therapy sessions and in outside
relationships.

CLARIFICATION

Clarifying a theme a patient has raised is a useful technique to increase the

patient’s awareness of how she is interacting or communicating. Patients can be
asked to repeat or rephrase what they said. You may then rephrase this by say-
ing, “You were angry with her?” You may call attention to the logical extension of
a statement the patient has made: “Do you mean to say that you would like your
daughter to move out of the house?”
The therapist can bring contradictions and contrasts to the patient’s attention.
For example:

• You just described your husband’s affair without showing any emotion.
How do you feel about it?
• You were smiling when you told me about the angry exchange between you
and your friend, but it hardly seems a happy matter.
• I noticed that you said X when you had previously said something else.
 
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Chapter 10  IPT Techniques & Therapist’s Role91

• Before, when you told me about this, you were sad, and now you seem to
be calm.

Such maneuvers help patients to reflect on their feelings and behaviors, a general
benefit of psychotherapy that is a crucial element of IPT as a prelude to interper-
sonal action.

COMMUNICATION ANALYSIS

Communication analysis is a central IPT technique for examining and identifying

problems in communication. It helps both therapist and patient to understand
how the patient is interacting and to consider more adaptive alternatives when
appropriate. The therapist elicits a detailed account of an important conversation
or argument that the patient has had with a significant other in order to under-
stand (1) the patient’s feeling state and behavioral patterns, (2) the meaning of the
transaction, and (3) the pair’s methods of communication. The therapist listens
to the communication in detail, stopping to understand the patient’s feelings and
intents at critical points:

Then what did (s)he say? . . . Then how did you feel? . . . Then what did you say?

Listen for a dissonance between what the patient feels and what she actually says,
a discrepancy that may reflect how symptoms are interfering with interpersonal
functioning. For example, a depressed patient may feel angered by an insult but
say nothing, feeling that her reaction is inappropriate or might shatter the rela-
tionship if expressed. Ambiguous, indirect, nonverbal communication can be
identified as less-​than-​satisfactory alternatives to verbal confrontation (e.g., the
patient who sulks when angry). Patients are often not aware of how they commu-
nicate or how their depression may distort other people’s messages and their own
response to these.
Communication analysis provides a valuable interpersonal focus that may
help patients detect these difficulties in communication, come up with alterna-
tives (“What other options do you have?”), role play these, and ultimately improve
the encounters. This interpersonal improvement leads to a greater sense of per-
sonal and environmental control, and an improvement in symptoms (Lipsitz &
Markowitz, 2013).
At the same time, when treating patients from other cultures, it is important
to take into account which forms of communication are accepted and which are
proscribed in the patients’ culture. Although therapists may be tempted to use
their own culture as a referent, adopting the therapist’s modes of communication
might not always be in the patient’s best interest (Chapter 24).
Another technique is to help the patient communicate directly her needs and
feelings. Many patients assume that others will anticipate their wants or read their
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minds, the failure of which can result in anger, frustration, silence, and unex-
pressed affect that can destabilize a relationship.
Incorrect assumptions that one has been understood also need clarification. For
example, was a friend’s comment about the patient’s hair meant as a criticism or a
compliment? To identify faulty communication, listen for assumptions that patients
make about others’ thoughts or feelings. Rather than giving immediate feedback,
encourage patients to draw their own conclusions. Follow through a particular
conversation, again checking the patient’s feelings as you progress. After she has
offered her interpretation of events, you can elicit and suggest alternatives to poor
communication and use role play (see below) to help improve communication.

DECISION ANALYSIS

Decision analysis helps the patient to consider alternative courses of action and
their consequences in order to solve a given problem. Like most IPT techniques,
the patient can learn to use it not only within the treatment but as a general inter-
personal skill. Helpful questions may include:

• What would you want to happen?

• What solution to this would make you happiest?
• What are the alternatives?
• What are the tradeoffs?
• Have you considered all the choices?

ROLE PLAY

Role play has uses across the four IPT problem areas. You as the therapist can
generally take the role of the other person, giving the patient needed practice in
developing skills in self-​assertion, confrontation, self-​disclosure, and so on. For
patients in the interpersonal deficits focus, it can sometimes be useful for them
to take the role of someone in their life with whom they would like to develop a
relationship. Role play can help prepare the patient to interact with others in dif-
ferent ways, particularly in acting more assertively or expressing anger. It clarifies
for the patient and therapist how the patient reacts to others. In other cases (e.g.,
role disputes or role transitions), role play may helpfully rehearse the patient’s
handling of new situations or new ways to handle old situations. In instances of
grief, it is often useful to role play an imaginary conversation between the patient
and the deceased.
To avoid the role play feeling like artificial playacting, it is often helpful to just
jump in, taking the role of the other person and implicitly inviting the patient to
respond:

But Deborah, I wanted to go to this movie!

 
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At the end of a role play, review with the patient:

• Did you say what you wanted to say? (That is, is the patient satisfied with
the content of the message delivered?)
• How did you feel about your tone of voice? (Is the patient satisfied with
the delivery of that content?)

Repeat the role play until the patient feels reasonably confident with the mes-
sage and the medium. Consider contingencies: What might go wrong in the inter-
change, and how can the patient anticipate or respond to that?

THE THERAPEUTIC RELATIONSHIP

A large literature indicates the necessity of a therapeutic relationship as the basis

for treatment outcome. A good relationship between therapist and patient does
not guarantee the patient’s improvement, but it is a sine qua non for that improve-
ment. Without a good alliance, patients will not take medication (Krupnick et al.,
1996); without a good alliance, the most elaborate psychotherapeutic approach
will not matter. A good therapist helps a patient feel understood, listened to, and
reasonably hopeful about prognosis, elicits affect, encourages success experiences,
and so on. (Frank, 1971).
Common factors of psychotherapy are listed in Box 10-​1, and implicit in that
list are therapeutic authenticity, empathy, and warmth. IPT does not exploit or
interpret the transference as in psychodynamic psychotherapy, where a trans-
ferential focus is an essential part of the treatment (Markowitz et  al., 1998).
However, IPT therapists do pay attention to the therapeutic relationship, rec-
ognizing that this may reflect how the patient thinks and acts in other close
relationships. Although the focus of IPT treatment remains squarely outside

Box 10-​1.
Common Factors of Psychotherapy

• Affective arousal (Response)

• Feeling understood by therapist (Relationship)
• Framework for understanding (Rationale)
• Expertise (Reassurance)
• Therapeutic procedure (Ritual)
• Optimism for improvement (Realistic)
• Success experiences (Remoralization)

Note: Adapted from Frank, 1971.

   
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the office, rather than on the therapeutic dyad, the therapist can ask the patient
to express negative feelings about both the therapy and the therapist, as well
as to voice complaints, apprehensions, anger, and aversive feelings that may
arise in the course of the treatment. (Psychiatric patients are notoriously averse
to criticizing their therapists, even when the therapists make mistakes. IPT
encourages patients to raise their interpersonal dislikes about therapist and
therapy.)
These exchanges focus on the here-​and-​now interpersonal issues, not on child-
hood antecedents or other remote historical material. They allow the therapist to
correct distortions or acknowledge genuine deficiencies or problems in the treat-
ment. (IPT therapists need not hesitate to apologize for mistakes they may make.
If you are late to a session or make a mistake, acknowledge it; apologize. If you
sense the patient dislikes something in your style, ask about it in nonjudgmental
fashion.) This approach helps patients to feel understood by the therapist (a “com-
mon factor” associated with better treatment outcome) and to see themselves as a
partner in the treatment process.
The therapeutic relationship can be used in role disputes to give feedback
on how the patient comes across to others and to help her understand mal-
adaptive approaches to interactions. In interpersonal deficits, the patient’s
relationship with the therapist may provide a model for interacting in other
relationships. Directive techniques include educating, advising, modeling, or
directly helping the patient solve relatively simple, practical problems such as
referrals for social services, housing, public assistance, medical insurance, or
educational opportunities for family members. Advice, suggestions, limit set-
ting, education, direct help, and modeling are elements of the therapeutic rela-
tionship but not necessarily major parts of it. They are best employed in early
sessions to create an atmosphere in which the therapist is perceived as helpful.
It is always preferable to encourage the patient’s own sense of agency rather
than to do something for her. Advice should ideally take the form of helping
the patient to consider options not previously entertained (rather than direct
suggestion).

THE THERAPIST’S ROLE

The therapist takes the stance of a friendly, helpful, hopeful, encouraging ally,
evoking what would be expected of any physician, nurse, psychologist, social
worker, or other health professional. This does not mean acting chipper and sac-
charine: it is important to sit with the patient’s painful feelings rather than cutting
them off, and before indicating that however difficult a situation may be, there
is hope. As the therapist, you of course need to draw boundaries when neces-
sary:  being warm and friendly does not mean having a social friendship. Self-​
disclosure can be effective in rare circumstances but is generally discouraged. The
focus should be on the patient, not on indulging the therapist’s needs. IPT is an
active therapy, and you should not allow long, painful silences. On the other hand,
 
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too much therapist activity can fragment patient affect, keeping sessions from
building the depth of emotion that can make therapy effective. It takes practice
to balance activity and reflective listening. Keeping interventions pithy—​using a
minimum of words—​tends to maximize effectiveness. Patients with poor concen-
tration can get lost in long speeches, which tend in any case to intellectualize the
treatment.
In summary:

• The therapist is the patient’s advocate and does not attempt a neutral
stance. If the patient is self-​deprecating, IPT therapists attribute such
remarks to being depressed. Depressed patients are likely to take
the therapist’s silence after such self-​criticism as agreement that the
patient is worthless or as a withholding behavior on the therapist’s
part. Being the patient’s advocate does not mean doing things for
her. Rather, it means trying to understand things from the patient’s
point of view and validating her feelings (aside from the depressive
outlook), siding with her against a sometimes hostile environment,
and encouraging her to do things that she is capable of doing to
change that environment.
• The therapist attempts to be nonjudgmental. Yet encouraging change
in behaviors you believe are wrong, such as antisocial behavior, is a
judgment that you should acknowledge as such.
• The IPT therapist does not view the therapeutic relationship through
the lens of transference nor as the focus of treatment, but as an
interpersonal relationship in which the patient may have feelings.
The patient’s expectations of assistance and understanding from the
therapist are realistic and are not to be interpreted as a reenactment
of the patient’s previous relationships with others. The assistance that
IPT therapists offer is limited to helping patients to learn and test new
ways of thinking about their feelings, themselves, and their social
roles and in solving interpersonal problems. When difficulties arise
in the therapeutic relationship (e.g., the patient becomes angry at or
feels criticized by the therapist), these are addressed in here-​and-​now,
interpersonal fashion:

Let’s talk about what’s going on between us. It’s good that you’re telling me
you’re upset—​this is the sort of interpersonal communication we’re work-
ing on, and with your feedback I can stop doing what’s bothering you.

• Limits are set in the same way they would be in relationships with other
medical clinicians.
• The therapist is active, not passive. As the therapist, you actively help to
focus on improving the patient’s current situation.
• The therapist encourages the patient to think of solutions to
interpersonal problems. If the patient is unable to come up with new
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approaches, despite your probing or leading questions, then you may

suggest alternatives. The goal, however, is always to emphasize the
patient’s potential agency and autonomy, recognizing that the depressed
patient has capacities she may not be recognizing or using while feeling
hopeless and helpless.