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Journal of Clinical Child & Adolescent Psychology

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Interpersonal Psychotherapy for Depressed Adolescents

(IPT-A): A Case Illustration
a b
Elisabeth Baerg Hall & Laura Mufson
a
Department of Psychiatry , University of British Columbia ,
b
New York State Psychiatric Institute and Columbia University College of Physicians and
Surgeons ,
Published online: 06 Jul 2009.

To cite this article: Elisabeth Baerg Hall & Laura Mufson (2009) Interpersonal Psychotherapy for Depressed Adolescents (IPT-
A): A Case Illustration, Journal of Clinical Child & Adolescent Psychology, 38:4, 582-593, DOI: 10.1080/15374410902976338

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 Journal of Clinical Child & Adolescent Psychology, 38(4), 582–593, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 1537-4416 print=1537-4424 online
DOI: 10.1080/15374410902976338

CASE STUDIES IN EVIDENCE-BASED PRACTICE

Interpersonal Psychotherapy for Depressed

Adolescents (IPT-A): A Case Illustration
Elisabeth Baerg Hall
Department of Psychiatry, University of British Columbia

Laura Mufson
Downloaded by [Stony Brook University] at 06:58 23 October 2014

New York State Psychiatric Institute and Columbia University College of Physicians
and Surgeons

This article describes the treatment of a depressed adolescent (15 years of age) boy using
Interpersonal Psychotherapy for depressed adolescents (IPT-A). IPT-A is an empirically
supported psychosocial intervention for adolescents suffering from a depressive episode.
It is delivered as an individual psychotherapy with a minimum of parental involvement.
The following case study illustrates the principal strategies and techniques of IPT-A.

Interpersonal Psychotherapy for depressed adolescents
(IPT-A; Mufson, Dorta, Moreau, & Weissman, 2004)
is an adaptation of IPT for adults, a time-limited,
manualized psychotherapy that has been found to be
efficacious for treating adult depression in numerous
clinical trials (Weissman, Markowitz, & Klerman,
2000). IPT has its origins in the work of attachment the-
ory (Bowlby, 1978), and interpersonal theories of Henry
Stack Sullivan (Sullivan, 1953). The importance of social
supports and good relationships for mental well-being is
the foundation for the treatment focus on interpersonal
relationships. Regardless of the etiology of depression,
an IPT clinician views depression as occurring in an
interpersonal context. People experience distress when
there are disruptions in their significant relationships.
These disruptions are a consequence of or contributor
to maladaptive interpersonal communication patterns.
As a result, a person may lose his or her social support,
which in turn leaves him or her more vulnerable to life
stressors and can result in depression (Stuart, 2006).
Treatment aims to both alleviate depressive symptoms
and ameliorate interpersonal functioning within signifi-
cant relationships. The clinician helps people understand
Correspondence should be addressed to Laura Mufson, New York
State Psychiatric Institute, 1052 Riverside Drive, Unit 24, New York,
NY 10032. E-mail: mufsonL@childpsych.columbia.edu
the connection between their depressive symptoms and
their interpersonal relationships. Treatment emphasizes
improving communication and problem-solving skills
and=or changing expectations about relationships to
reduce the depression symptoms and facilitate recovery.
IPT-A is a 12-week treatment (12–15 sessions)
adaptation for depressed adolescents that has been mod-
ified to include work with schools and to address issues
such as parent involvement in treatment and the chan-
ging nature of peer relationships during adolescence.
IPT-A has demonstrated efficacy for reducing depressive
symptoms and improving the quality of interpersonal
and social functioning in adolescents with major
depression as well as other depression diagnoses includ-
ing dysthymia, depression not otherwise specified, and
adjustment disorder with depressed mood (Mufson,
Dorta, Wickramaratne et al., 2004; Mufson, Weissman,
Moreau, & Garfinkel, 1999; Rossell o & Bernal, 1999).
The treatment is divided into three phases: initial,
middle, and termination. In the initial phase, the focus
is on surveying the patient’s relationships to gain an
understanding of interpersonal patterns. At the end of
the initial phase, the clinician identifies the problem area
that will be the focus of the remainder of treatment.
The identified problem areas of IPT-A include (a) grief
reaction to an actual death, (b) interpersonal role
 INTERPERSONAL PSYCHOTHERAPY FOR DEPRESSED ADOLESCENTS
disputes such as parent–child conflicts or peer conflicts,
(c) role transitions due to difficulty adapting to life
transitions, and (d) interpersonal deficits or problems
resulting in social isolation and loneliness. The problem
area becomes the focus of treatment for the remaining
eight sessions. During the middle phase of treatment
(sessions 5–9), the clinician helps the adolescent learn
to link depressive mood to difficulties within the identi-
fied problem area and link improvement in mood to
constructive problem solving and direct, positive
communication. The clinician and adolescent collabora-
tively work to improve the targeted relationship and
associated problems by identifying specific strategies
that can help the adolescent negotiate his interpersonal
difficulties. In the termination phase the clinician assists
the patient in ending the therapeutic relationship,
reviewing skills learned, consolidating the recovery
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from the depression and assessing the need for further
treatment.
ROLE OF PARENTS
Parent involvement is integral to IPT-A, although the
week-to-week treatment sessions are primarily with
the adolescent. Parents are involved in the initial phase
to help gather diagnostic information and set appropri-
ate expectations for the course of therapy. General
issues about psychotherapy such as attendance and
payment are reviewed with parents. Within the limits
of confidentiality, parents are encouraged to share their
concerns throughout treatment. With the patient’s
knowledge and involvement, parents are apprised of
progress during therapy. This can occur in treatment
sessions with the parent or during telephone contact
in the middle phase. They are coached to be open
to the young person’s experimentation with new
problem-solving and communication styles in the
middle phase and to be supportive of efforts, however
awkward, to use these strategies at home. Parents may
be asked to attend sessions in the middle phase if it
appears their participation may be helpful to alleviate
the depression (e.g., to allow the adolescent to directly
practice new communication skills with the parent in
the presence of the clinician). In the termination phase,
parents, patient, and clinician meet again to review the
patient’s progress and make decisions about the need
for further treatment.
We offer the following case presentation to illustrate
the IPT-A approach to treating adolescent depression.
The adolescent and his parent provided informed
consent to use his treatment for educational purposes
including publication to illustrate the techniques of
IPT-A. Identifying information and details of events
have been altered to ensure anonymity. IPT-A techniques
583
are described in the initial, middle, and termination phase
discussions.
CASE PRESENTATION
Sam is a 15-year-old boy in Grade 10 referred by his
family physician to a Mood and Anxiety Disorders
Assessment Clinic at a local children’s hospital after
having a fight with a member of his soccer team. He is
the eldest of two sons and both parents are employed.
Reason for Referral
The fight prompted the parents to contact his family
physician with their concerns about other changes they
had been observing in Sam’s behavior. As captain of
the team, he was known as a leader and an even-
tempered young man, so this fight was viewed as
unusual. In addition, Sam had been irritable lately at
home and was not interacting as much with his friends.
He had lost 15 pounds over the 2 months prior to the
referral and was having trouble sleeping. His father
suffered from chronic depression and Sam spoke of his
worry to his family physician that he may be depressed
as well.
Assessment Process
A clinic psychiatrist conducted the intake assessment
and learned that 3 months prior to the referral, Sam
broke up with Lindsay, his girlfriend of 8 months. He
idealized her and was ambivalent about ending the
relationship. In addition, several days prior to the
breakup, Sam’s father was hospitalized for a major
depression. Sam felt a huge burden to provide assistance
and support at home during that time. He cancelled soc-
cer and other activities so he could be home more with
his mother and brother. He was preoccupied with these
concerns when he impulsively broke up with Lindsay
after an argument.
In the psychiatric assessment, Sam and both parents
participated in the clinical interview. He reported a
2-month history of worsening depressive symptoms
including daily irritability and sad mood for most of
the day, difficulty falling asleep (initial insomnia) with
more nights than not taking more than an hour to fall
asleep, poor concentration, loss of interest for spending
time with his friends as well as his sports activities, loss
of appetite, and weight loss without intentional dieting.
He stayed home more, turning down invitations to go
out with friends, but felt sad and lonely. He ruminated
about conversations with Lindsay and alternately
idealized and vilified her. He reported neither current
suicidal ideation nor any history of ideation or attempts
 584 HALL AND MUFSON
in the past. He used alcohol occasionally at parties but
rarely got drunk, and he had not been to a party in
several months. He denied illicit drug use. The assessing
psychiatrist had Sam complete a Beck Depression
Inventory (Beck, Steer, & Garbin, 1988) to get Sam’s
self-report of his symptoms and he scored a 23 indicat-
ing a moderate level of depression severity. The Beck
Depression Inventory has been reliably used with
adolescents (Emslie, Weinberg, Rush, Adams, &
Rintelmann, 1990; Strober, Green, & Carlson, 1981).
With Sam’s permission, the assessing psychiatrist
contacted his guidance counselor to assess for any other
changes in school and to augment the information from
his parents. His parents and the guidance counselor
corroborated that Sam was becoming more isolated
and withdrawn and specifically reported that he was
spending more time alone, participating less in class dis-
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cussions, and appearing more irritable with his teachers.
His grades had dropped from mostly As to more Bs and
B minuses. He turned down invitations to parties and to
play sports with friends when previously he was popular
and active. As a consequence, his parents perceived that
his friends were calling less frequently, which was
making him feel worse. His impairment was also evident
in his deteriorating relationships with his family. He no
longer enjoyed playing sports with his brother or father.
The parents noted increased conflict with his brother
and more arguments with his mother. She never knew
when he would storm out of the room in a rage.
Sam had no previous episodes of depression and this
was his first referral for psychological treatment. His
father was taking antidepressant medications for a
chronic, treatment-resistant depression. His father had
one previous hospitalization for depression. The most
recent episode included suicidal ideation, but Sam was
unaware of this. Sam’s younger brother was awaiting a
psychiatric assessment for anger management problems.
Case Conceptualization and Treatment Planning
Sam was diagnosed with a major depressive disorder.
The assessing psychiatrist educated Sam and his parents
about the nature of depression as a medical illness for
which there are several treatments and discussed the
availability of cognitive behavior therapy, IPT-A,
and=or medication. He recommended IPT-A because
Sam’s depression began when he was experiencing
challenges in family and romantic relationships. Antide-
pressant medication was recommended, but both Sam
and his parents preferred to try a psychotherapeutic
approach alone first. The psychiatrist referred Sam to
an experienced child psychiatrist receiving training in
IPT-A by an expert IPT-A clinician (LM). This training
was in preparation for a community clinic-based IPT-A
knowledge translation project studying methods for
long distance psychotherapy training to achieve clinician
adherence and competence in IPT-A. A first meeting
was arranged with the treating IPT-A clinician.
INITIAL PHASE
Initial Phase Tasks
There are three main tasks in the initial phase (Sessions
1–4) of treatment. First, the clinician focuses on the
depression symptoms including confirming the diagnosis
and current clinical status, providing psychoeducation
about the illness, instilling hope, assigning the ‘‘limited
sick role,’’ and evaluating the need for medications.
Second, the clinician links the depression to challenges
in relationships by exploring significant relationships
with parents, other adults, family members, and peers
through the use of the Closeness Circle and Interpersonal
Inventory (IPI), which is described further in a later sec-
tion. Third, the clinician identifies the problem area that
will be the focus of the remainder of treatment and dis-
cusses the treatment goals and contract with the patient.
IPT-A therapy sessions are typically 50 min in length.
Session 1 is an extended session, approximately 75 min,
to enable time to meet with both adolescent and
parent(s). The treating clinician hears the presenting
problem directly from the patient and reviews the
depression symptoms in detail using an evidence-based
assessment instrument, such as the Hamilton Rating
Scale for Depression (HRSD) and (Guy, 1976; Kearns
et al., 1982) as a guide. This ensures a thorough symp-
tom review while helping the IPT-A clinician to confirm
the diagnosis of depression and obtain a rating of clini-
cal severity. Assigning the limited sick role preserves the
medical model of depression to avoid blame but
encourages ongoing participation in important activities
of daily living. This involves explaining that the patient
must continue his normal activities as much as possible,
and that his interest and motivation will increase as he
begins to feel better. Parents also are advised to be less
critical of their adolescent. For example, the parent
should be understanding of a drop in grades but should
encourage and expect the adolescent to go to school
every day, and try to complete homework knowing there
will be improvements as he begins to feel better.
Thereafter, each session begins with a question about
how the past week has been and a five minute review of
the prominent depressive symptoms, always including
suicidality. During Session 2, the clinician teaches the
patient to rate his mood on scale of 1 to 10, with 10
being the worst that he could feel and 1 being the best.
This retrospective rating of his mood is assigned as an
average rating for the week, but the clinician also
queries about times when his mood would have been
 INTERPERSONAL PSYCHOTHERAPY FOR DEPRESSED ADOLESCENTS
rated higher or lower. These deviations from the average
mood rating for the week provide a lead-in for the clin-
ician to explore the events associated with the mood
fluctuations. They will use this scale on a weekly basis
to monitor the mood impact of key interpersonal events.
The clinician spends the remainder of Session 2 begin-
ning to explore the patient’s significant relationships
using the Closeness Circle and IPI.
Initial Phase Techniques
Closeness circle. The clinician explains that they
will begin IPT by learning more about the important
people in his life, the main characters in his life story.
The closeness circle is a graphic representation of this
world. The clinician draws four concentric circles and
puts the patient in the middle. She asks him to think
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of people who are very close to him for the next circle,
underscoring that these people can be important in good
or bad ways. Together they identify people in each of the
remaining circles, with less close relationships being
placed in the outer circles. The goal is to get their names
on the circle and obtain very brief descriptions (e.g.,
Rob has been my best friend since grade school) for
quick reference later.
IPI. After the closeness circle is completed, they begin
the detailed exploration of interpersonal relationships,
called the IPI. The purpose of the IPI is to identify inter-
personal patterns and themes in the patient’s relation-
ships. The clinician starts out with more superficial
questions about the relationship and then gradually asks
questions to identify the affect associated with these rela-
tionships. She looks for examples of successful as well as
problematic interactions within the important relation-
ships, and seeks information about changes that have
occurred as a result of the depression. While doing this,
the clinician is forming hypotheses about which interper-
sonal issues may be most related to the current depres-
sion. The clinician looks for clues about how the patient
deals with common emotions (e.g., when angry, does he
tell his friends? His parents? Does he show anger in other
ways?). The clinician also queries about peer and roman-
tic relationships and asks specific questions such as,
‘‘Does your friend know you have been depressed? How
does he respond? Did you tell anyone you had broken
up? How did it feel when you told them?’’ The culmina-
tion of the IPI is the problem area formulation, a discus-
sion of the interpersonal area that seems most related to
the onset and=or maintenance of the depression.
Case Presentation
Session 1. Sam’s initial session with the IPT-A clin-
ician consisted of a review of his story and symptoms
585
with him alone first and then meeting together with
Sam and his parents. The clinician administered a
clinician-rated HRSD on which he scored 25. A score
of greater than 23 is considered severe based on adult
norms (Kearns et al., 1982), which also are used for ado-
lescents. Because the HRSD severity ratings do not
address duration of symptoms as is needed for Diagnos-
tic and Statistical Manual of Mental Disorders (4th ed.
[DSM–IV]; American Psychiatric Association, 2000)
criteria, the severity may be perceived as greater than
would be assigned using DSM–IV criteria. Based on a
clinical interview with Sam and his parents and the initial
assessment with the referring psychiatrist, the clinician
confirmed the diagnosis of major depressive disorder.
The following criterion symptoms were present for
Sam: depressed mood, anhedonia, initial insomnia,
weight loss, poor concentration, and accompanying
impairment in his relationships with friends and family
and his performance in school. She assigned a Children’s
Global Assessment Score (Shaffer, Gould, Brasic,
Ambrosin, et al., 1983) of 58. The scale ranges from 1
to 100 on a hypothetical continuum of health with 100
representing the highest and a score of 61 or below repre-
senting significant impairment associated with a psychia-
tric disorder (Bird, Canino, Rubio-Stipec, & Ribera,
1987). They discussed the effects of depression on his
schoolwork and social activities to illustrate the impact
of depression on his daily functioning. This session,
Sam rated his mood as between 6 and 7 (10 ¼ worst)
most of the week. This became a baseline rating for com-
parison in later sessions.
When his parents joined the session, the clinician
provided psychoeducation about depression and an
overview of IPT-A. She emphasized the good prognosis
and instilled hope wherever possible. She introduced the
concept of the limited sick role using the analogy of a
broken leg (e.g., ‘‘When you have a broken leg, you don’t
feel well but are still able to do most of the things you
did before. You can’t run a marathon, but you can still
be out watching. As happens with a broken leg, you will
get better. To prepare for a full recovery you need to
keep your muscles strong, to keep going on with every-
thing in your life even if you don’t feel like it.’’). Sam did
not want the clinician to speak with his guidance coun-
selor about his depression at this point because the
intake psychiatrist had spoken to the counselor and let
her know that he was entering treatment. They agreed
to revisit the need for discussions with the school if they
did not see improvement in his concentration and school
performance over the next few weeks.
Session 2. In Session 2, the clinician addressed the
task of learning about the relationships in Sam’s life to
discern patterns that might be contributing to the
depression. Sam’s closeness circle represented key
 586 HALL AND MUFSON
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FIGURE 1 Sam’s Closeness Circle depicting key relationships in his life.
relationships in Sam’s life (see Figure 1), and they began
to discuss these people using the IPI techniques
previously described. They spent the next two sessions
discussing his relationship with his mother, father, girl-
friend Lindsay, brother, grandparents, several longtime
friends including Rob, and his coach. More time was
spent on his parents and girlfriend, as those relation-
ships seemed most related to his depression, and other
relationships were discussed only briefly. When it was
time to review his relationship with Lindsay, Sam
explained that she was his first serious love. He
described that she was very possessive of him and very
bossy, although he also enjoyed having her rely on
him. Both of them had a number of friends at the begin-
ning of their relationship but over their 8 months
together, they became insular and isolated. He would lis-
ten and help her with her problems to the neglect of his
other friends, though he began to realize that she did not
do the same with him. He began to feel her possessive-
ness was becoming problematic when she would not
let him socialize with anyone else. He worried that he
had neglected his other friends and felt as though they
were not there for him now that he was on his own. The
fight that precipitated the breakup was because Lindsay
was angry that Sam had spent part of Valentine’s Day
helping a female friend who was having a crisis.
Sessions 3 and 4. Over the next two sessions and
in the course of exploring key relationships, consistent
interpersonal patterns emerged. Sam appeared insightful
about relationships. Sam had not needed to take initia-
tive in forming friendships, as others often approached
him first. Therefore, he was hesitant to reach out to
friends since the breakup. Within his relationships, he
understood what makes him upset, or what is expected
of him, but he often did not address these issues even
when he may not like what was happening. Sam had a
tendency to withhold his feelings and opinions, prefer-
ring to present himself in a positive way with friends
and family, thereby avoiding conflict. He rarely chal-
lenged anyone or expressed anger. He prided himself
on his achievements and sense of responsibility in many
areas of his life (e.g., captain of the soccer team, filling
his dad’s shoes when he was in the hospital), only to
become overwhelmed and explode when the pressure
 INTERPERSONAL PSYCHOTHERAPY FOR DEPRESSED ADOLESCENTS
got to be too much. After an episode like this, he would
feel remorseful and guilty for his behavior but would
withdraw rather than address what had happened.
Problem area formulation. At the end of the fourth
session, the clinician was ready to discuss the problem
area formulation with Sam. The clinician hypothesized
that Sam was depressed as a result of difficulty negotiat-
ing the transition from childhood to adolescence, parti-
cularly in the way he was handling his first intimate
relationship and breakup—a role transition in IPT-A.
He was mourning the loss of his relationship with
Lindsay while also recognizing that there were skills he
needed to acquire to handle intimate relationships as
well as friendships differently than he did when he was
younger. He also was experiencing a transition within
his family. His need to uphold a responsible and solid
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emotional presence within his own family and his com-
munication style of little or no emotional disclosure was
contributing to his depression by preventing him from
expressing his own needs and concerns as he negotiated
these new responsibilities. As a result, he wasn’t getting
the support and responses from others that he needed.
The clinician explained this to Sam using words to
this effect: ‘‘Sam, I think your depression has something
to do with the fact that you are getting older and you are
taking on more of an adult role with the family and
friends around you. You need a new set of skills that
are different from what worked when you were younger.
You have been doing very well with understanding your
own feelings about what is going on, but it has been
hard to tell others how you feel. It is really important
to you to keep the peace with people around you—at
home, with your ex-girlfriend and with your friends.
Often you choose to keep your feelings to yourself and
this works for a while, but then you feel dissatisfied.
You weren’t able to tell Lindsay how you were feeling,
so you became resentful and eventually you exploded
and broke up with her with little warning. Then you felt
guilty about your anger towards her and you withdrew
with your feelings. This sets up a vicious cycle of holding
things in and then exploding, both of which have a nega-
tive effect on your mood. We can see from your current
sadness and anger outbursts that this isn’t working for
you anymore both in your relationship with friends
and family, especially with Lindsay, your mom, and
your brother.’’
The clinician paused to ensure that she had agree-
ment on this fundamental aspect of the formulation.
She asked questions of Sam such as ‘‘Does this make
sense to you so far? Does it seem like this is what has
been going on?’’ Sam agreed that this had been a real
problem and added that this impulsive break up was
the start of his depression. The clinician continued with
the formulation. ‘‘One of the other areas that is
587
changing for you is the level of responsibilities you are
taking on in your life and family. When you were
younger, you didn’t need to take on the worries of your
parents, but now you feel responsibilities that are con-
siderable for someone of your age. For example, your
father’s hospitalization was the first time in your life that
someone you depended on wasn’t there to take care of
you. You really felt you had to be there for your
mom. It was tough to jump into that role so quickly
when your dad was hospitalized, especially while you
had so many things going on with your soccer team
and school. It became complicated since you were reluc-
tant to speak about your feelings with your mom. The
situation in your family as well as the breakup with
Lindsay appear to be the stressors that triggered your
depression.’’
The clinician and Sam reviewed this understanding of
how he became depressed. Sam felt the clinician’s sum-
mary made sense and he was able to summarize his
own understanding of the problem. He expressed agree-
ment about focusing the treatment on these transition
and communication issues. She then outlined a general
plan to address some of the issues that had contributed
to the depression. She suggested that they use every day
situations, both with friends and family, to understand
what aspects of these new roles are difficult and to
develop skills to negotiate them more successfully. They
also agreed to focus on ways to talk to people about
feelings before they become unmanageable.
MIDDLE PHASE
Middle Phase Tasks
The Middle Phase (sessions 5–9) focuses on the identi-
fied problem area. The overall goal of this phase is to
have the adolescent work on the specific problem area
using IPT-A techniques. These techniques include affec-
tive expression, clarification of expectations for relation-
ships, communication analysis and decision analysis to
help clarify feelings, and identify improved means of
communicating and problem solving. Every effort is
made to link interpersonal events with mood to assist
with developing greater awareness of the impact of
one upon the other.
Middle Phase Techniques
Communication analysis. The objectives of a com-
munication analysis are to help the adolescent recognize
the impact of his verbal and nonverbal communications
on others and perceive how modifying his communica-
tion (what he actually says and how he says it) may
affect the response he receives from the person, the
outcome of the interaction, and associated feelings.
 588 HALL AND MUFSON
Clinician and patient dissect an interaction down to the
statements made by each person and discuss the message
sent by the words and behavior and the impact on the
feelings of both persons. They discuss how changing
the communication, even in small ways at various
points, may result in a different outcome. The adoles-
cent is asked to share ideas about what he might have
said or done differently and how the outcome could
have been different as a result. The clinician then pre-
sents various communication strategies that could be
helpful including: picking the right time to have a con-
versation, acknowledging the other person’s perspective,
using ‘‘I’’ statements, being specific and present-focused
when talking about a problem, having solutions in mind
and being willing to compromise, and not giving up
(see Mufson, Dorta, Moreau et al., 2004, for more
detailed explanation). After identifying appropriate
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techniques, they role-play these strategies while refining,
reinforcing, and reevaluating the specific strategies they
are using. When adequately prepared for a new type of
interaction, the clinician encourages the patient to set up
a specific plan to practice the new interaction at home
before the next session.
Decision analysis. Decision analysis is a technique
used in other types of psychotherapy, but the focus in
IPT-A is more specifically on addressing interpersonal
problems. The objective is to help the adolescent to iden-
tify a goal for an interaction, understand that there are
alternative solutions to the problem associated with this
interaction, and to evaluate which may be the better
solution or strategy to attempt first either within a
dyadic session or in an interaction outside of the session
(Mufson, Dorta, Moreau et al., 2004). Once the adoles-
cent has identified a possible solution or strategy, the
clinician and adolescent role play the associated interac-
tion in the session until the adolescent is ready to imple-
ment it. In ensuing sessions, they continue to evaluate
the outcome and determine if there is a need to select
an alternative strategy.
Work at home. In IPT-A, patients are encouraged
to try techniques they have learned outside of the
sessions. There are no proscribed ‘‘homework’’ assign-
ments in IPT-A. Rather, interpersonal experiments are
developed by the clinician arising out of situations and
skills that are practiced in the session. Every effort is
made to ensure successful interactions by having
coached the parents in the initial phase to note and
appreciate these efforts, practicing skills repeatedly in
sessions, and role-playing both positive and negative
responses that could occur. The emphasis is not on fail-
ure or success, but rather on experimenting with different
interpersonal skills and learning from whatever happens
when the interaction is or is not attempted. Either way it
provides more information to help improve
interpersonal relationships. The clinician reviews the
experiment’s outcome in the next session identifying
any strategies or skills that many need tweaking to be
more effective, and fostering generalization of these
skills to other situations.
Techniques for Specific Problem Areas
Each of the four IPT-A problem areas has different
goals and techniques (see Mufson, Dorta, Moreau
et al., 2004, for more detailed explanation). This case
describes a problem in role transition, which is defined
as difficulty adapting to transitions between stages in life
and=or changes in life circumstances such as parental
divorce, moving to a new town, illness of a sibling, or
transition to high school that require the person to take
on a new role or responsibilities. The treatment goal is
to help the patient take on the new role by (a) discussing
positive and negative aspects of the old and new role,
(b) relinquishing the idealized old role and mourning
the loss, (c) developing a more realistic view of old role
and new role, and (d) helping the patient develop skills
needed to succeed in the new role.
As in the initial phase, each session begins with a
check-in covering mood symptoms and how the week
has been. Every effort is made to ensure that relevant
issues from the week are dealt with during the session.
This means that, although the main focus may be on
learning new relationship skills with one individual,
those skills can be discussed and applied to other
relationships. After the adolescent gains confidence
practicing the skill in this problem area, he can learn
about generalizing the skill to other relevant areas.
Case Presentation
There were several tasks the clinician was hoping to
address with Sam in the middle phase sessions. These
included psychoeducation about normal developmental
changes in relationships (e.g., shifting from group to
dyadic romantic relationships), addressing the interper-
sonal pattern of holding back his feelings in an effort
to maintain the peace in relationships, practicing to
express his feelings in small increments before he is
overwhelmed and loses control of his emotions,
and introducing skills to help Sam initiate social
activities to decrease his passive interpersonal style.
One of the tasks for Sam was to talk about the positive
and negative aspects of being in a romantic relationship
as well as what he enjoyed about spending time with his
group of friends and what he had missed while focusing
on this romantic relationship. He needed to sort out
what were realistic expectations for an adolescent
romantic relationship and what was realistic to expect
from oneself at this age in a romantic relationship. He
 INTERPERSONAL PSYCHOTHERAPY FOR DEPRESSED ADOLESCENTS
needed to reconcile his fantasy relationship with his
reality of being an adolescent and having to balance it
with the needs of his friends and his family. Sam needed
help sorting out his ambivalent feelings toward
Lindsay. Although he appeared ambivalent, Sam’s
current stated goal was not to renew the relationship
but to learn to balance his friendships and future roman-
tic relationships.
Session 5. In this session, Sam reported a worsen-
ing of his mood, rating it 6 out of 10 when the previous
week’s average was a 3. He reported that his sleep was
better but he still didn’t have much of an appetite. He
still reported feeling tired and tearful if he thought about
Lindsay. In reviewing the week, Sam reported that his
friend Rob was angry with him for going to a BBQ with
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his school friend Katie, rather than with Rob to the
local fair. Although he never committed to going to
the fair, Sam was convinced Rob was angry. He did
not confirm this but when there were no invitations to
events later in the week, he stayed home ruminating
and did not initiate contact. Even though this was not
an issue directly related to the ending of Sam’s relation-
ship with Lindsay or his responsibilities at home, the
clinician focused on this issue for part of the session
since it may be easier to start practicing new skills with
Rob than with Lindsay. She would be able to help Sam
learn about avoidant patterns in his relationships and
link the use of these skills to more challenging situations
with Lindsay as well as his family once he had gained
some initial self-confidence.
Sam was quick to understand the link between what
was happening with his friend and his mood. They
agreed to explore ways that he could reconnect. She
reminded Sam that the communication goal was to
clarify the status of his relationship with Rob and to
keep things open in the friendship by talking about feel-
ings as they came up. They talked about what would be
comfortable to say to Rob. Sam felt that he could ask
Rob to play a casual game of basketball. He felt this
would allow him to test out his hunch that Rob was
angry with him in a casual environment where he would
not be forced to inquire directly about how Rob was
feeling. The clinician supported Sam’s choice of a
workable practice situation but also encouraged him
to consider a way to talk about his feelings. She encour-
aged Sam to go one step further, to explain why he
attended the BBQ with Katie. She explained that being
able to speak more freely about feelings would help
others understand how he was struggling to balance
his romantic relationships and friendships. She linked
this with the potential for an improved mood.
After establishing when he might be able to make the
phone call to Rob, they outlined the basketball scenario
589
in detail, reviewing how to initiate the conversation.
Sam was actively involved in the session generating
options of what to say to Rob. They began a role-play
to help Sam practice the interaction and gain confidence
in using the words and strategies they had discussed.
They talked about being casual (‘‘hey, is everything ok
with us?’’) while distracted with another activity (shoot-
ing hoops). They practiced what Sam might say if Rob
said he was not pleased about the BBQ=fair incident.
It is important to role-play several possible outcomes
so the adolescent feels prepared for different responses.
Sam and the clinician took turns playing the role of Sam
and Rob. By playing the role of Rob and seeing the
situation from Rob’s perspective, Sam began to see that
Rob might have felt hurt. He was able to come up with
an empathic response such as, ‘‘I realize I should have
talked to you about deciding to go to the BBQ with
Katie and that I might have hurt your feelings.’’ Sam
started to see that such disclosures could have a positive
effect and were unlikely to result in anger but rather
increased closeness and friendship. The clinician empha-
sized these same strategies would be useful for Sam in
other situations such as conflicts with his brother and
family, and in his next romantic relationship.
The clinician encouraged Sam to try this strategy
during the next week. She introduced it as an interper-
sonal experiment explaining that they would learn from
his attempt to have this conversation whether or not he
was able to have it at all, as well as more data about
what strategies might be most helpful for him. They
reviewed the plan and Sam felt this was something he
could try to do in the next week.
Session 6. After the check-in and review of symp-
toms (mood rating is 4, showing some improvement),
they reviewed the interpersonal experiment assigned
the previous week. In addition to improved mood, he
described decreased anhedonia, continued improve-
ments in sleep and concentration in school. He stated
that his appetite was variable depending upon whether
friends were around at mealtimes. Sam reported using
an ‘‘I statement’’ resembling, ‘‘Rob, I wanted to explain
why I went to the BBQ with Katie and not with you and
Devon to the fair. I’m worried that I might have hurt
your feelings and I wanted to be sure you are ok with
things.’’ Rob has been feeling a bit hurt, but says it is
no longer bothering him. Sam was relieved that he had
been able to raise the issue. The clinician reviewed the
success of Sam’s social interaction and how he felt less
depressed and lonely after being open and direct with
Rob. They discussed using the same skills in other social
situations where Sam felt he wanted to take more
initiative. The rest of the session was spent clarifying
his feelings about Lindsay, discussing ways he could
express these feelings to her, and the impact the
 590 HALL AND MUFSON
discussion would have on his relationship with her as
well as his mood.
Session 7. The ambivalent situation with Lindsay
continued to complicate Sam’s steadily improving
mood. In Session 7, Sam was upset about an argument
he had with Lindsay on his way to the session. He
reported, ‘‘I’m so mad at her I smashed my phone in a
thousand pieces.’’ His mood was 9 =10 (very low) at that
moment, although he had been 2 =10 for much of the
week. Sam explained that they had begun talking again
but that their interactions didn’t always make him feel
better. In fact, this last conversation made him feel much
worse. Lindsay was interrupted by another call while
they were speaking on the phone and promised to phone
him right back. When she didn’t call, he called her back
to find that she had been speaking with a new boyfriend
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and didn’t want to speak to Sam right now. Sam got so
angry that he hung up and smashed his phone on the
ground.
After Sam calmed down from telling this story, they
began a communication analysis, closely reviewing the
argument, what he felt like when she said those things
and what he had been trying to say to her. By examining
Sam’s interaction in this way, they learned that Sam was
feeling competitive and possessive at the same time as
feeling negatively about his relationship with Lindsay.
He wanted Lindsay to depend only on him even though
he was unsure whether he wanted to be her boyfriend.
They talked more about Sam’s competitive nature and
how it affected his mood when he is like this with Lind-
say. He acknowledged that he was having a problem
with the presence of another young man in Lindsay’s
life, that he felt he still needed to be the most important
one. He noticed this pattern with friends, schoolwork,
and family. He often set up these unrealistic goals or sce-
narios in which his expectations were left unmet, leaving
him feeling upset. The clinician focused on helping Sam
clarify his expectations for the relationship and whether
they were realistic. She reviewed Sam’s overall goals for
the relationship with Lindsay. Over the last few weeks,
Sam had consistently voiced his desire to end the rela-
tionship. This week, he was less clear, and seemed to
want Lindsay back. They were able to talk about his
attraction to Lindsay, and the motivation to stay in
the relationship to avoid the loneliness, awkwardness
of reconnecting with his other friends, and ultimately
having to find a new romantic relationship, rather than
positive aspects of being with Lindsay. The clinician
reflected that an experiment with reconnecting seemed
to have ended in the parking lot with a smashed cell
phone. They reviewed how his mood was worse when
he was together with Lindsay. They talked about the
previous goal of having more distance between them
and recalled how his mood had been better as a result.
Framing the issues in this way and reviewing the link
between his mood and events in the relationship helped
Sam to recognize that he would likely feel better if he
ended his relationship and contact entirely with Lindsay.
With this overall goal in mind, they turned to the
more pressing issue of what Sam would like to do when
he saw Lindsay at school the next day. Sam was con-
flicted. He wanted her to be sorry and to have her say
so. He wanted her to know how angry he was feeling.
Using a decision analysis, they discussed how his desire
to prove himself right with her apology might not help
him in his quest to separate and disconnect from her.
They considered other options he had such as walking
by her without saying ‘‘hi.’’ They also talked about what
might happen if he waited for her to approach him first.
They role-played a conversation in which the clinician
was Lindsay, pleading for more contact. They reviewed
how this felt after he had practiced a number of
responses consistent with his goal of ending communica-
tion with Lindsay. He decided that having no conversa-
tion was the best option for him at the moment since the
lure of talking could easily lead to ongoing contact,
which had repeatedly happened in the past. He remem-
bered that his phone was smashed. They laughed
together as it seemed he had literally taken matters into
his own hands and smashed the possibility of continued
contact at least by phone. They called it the ‘‘smashed
cell phone plan.’’ They reviewed other ways that Lind-
say might try to contact him and practiced possible
responses. He devised a simple statement saying that
he felt it was better if they were not in contact at all any-
more since he felt the relationship was over. He felt good
and more confident after practicing the conversation
and rehearsing strategies to have in mind should she
approach him. The clinician normalized his experience
of struggling with the ending of his first romantic rela-
tionship by reminding him that it takes a long time to
get over intense feelings. They discussed the positive
impact that his plan would likely have on his mood.
Sessions 8 and 9. In the next session, Sam
reported a successful interaction with Lindsay when
she approached him at school. This was reflected in
his continued positive mood rating of a 3 as well as
reported improvements in his appetite, energy, interest
in playing soccer, and being with friends. He felt clear
about what he wanted to say to Lindsay, was able to
say it, and was pleased with the execution of his plan.
They continued to review and apply communication
skills to his other relationships, such as I statements,
taking initiative in communications, empathizing with
the position of the other person, and speaking about
feelings in small manageable increments. He practiced
talking with friends. He had another encounter in which
he was happy to have been able to speak his mind and
 INTERPERSONAL PSYCHOTHERAPY FOR DEPRESSED ADOLESCENTS
noticed a beneficial effect on his mood. Other aspects of
Sam’s functioning were improving as well. Sam had
taken the initiative of getting a job, which proved help-
ful in increasing his social circle and getting him out of
the house. He was able to maintain his distance from
Lindsay and was spending more time with his friends.
He also had spoken with his mother and clarified what
he could do to help her around the house without feeling
overwhelmed. The effect on his mood was positive.
Improved symptoms included a return of his appetite,
improved concentration, increased social engagement,
and a decrease in depressed mood although occasional
initial insomnia remained. He was feeling more moti-
vated in terms of his schoolwork and involvement in
sports and other activities.
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TERMINATION PHASE
Termination Phase Tasks
Depression can be a chronic recurring illness so it is
important to be able to recognize another episode earlier
to get treatment sooner and prevent some of the impair-
ments from occurring. This guides all the activities of the
termination phase (sessions 10–12). The focus of the
clinician is to (a) clarify warning symptoms of future
depressive episodes, (b) identify successful strategies
used in the middle phase, (c) emphasize mastery of
new interpersonal skills, (d) foster generalization of
skills to future situations, and (e) discuss the need for
further treatment.
Case Presentation
Sessions 10 and 11. Sam continued to experience
steadily improving symptoms of depression and an
improved mood rating of 2=10 to 1=10 with experiences
of low mood being both shorter in duration and less
severe (Table 1). He reported that his sleep and appetite
were good, his energy was improved, and that although
he was still thinking of Lindsay, it was less frequent and
interfered less with his focus on schoolwork. The
smashed cell phone plan seemed to be working. Sam
understood that although he missed Lindsay in the
TABLE 1
Mood Rating Scale: 1–10
Session No.
2 3 4 5 6 7 8 9 10 11
Average Mood Rating 6–7 7 3 6 4 2a 3 2 1 2
for the Week
a
Sam’s current mood was rated as 9=10 due to the fight with his
girlfriend that happened just before the session.
591
short run, it was important to have no contact at all
as he reestablished other friendships. Sam and the
clinician reviewed skills that he had used in and outside
of sessions and how they might be helpful in other
situations.
The clinician generated a skills list that was specific to
Sam’s course of therapy as a reference sheet: (a) clarify
expectations for relationships at the start recognizing
that expectations often change as one matures and gains
additional relationship experiences; (b) talk about emo-
tions as they arise sooner and in smaller increments so
they are not so overwhelming and frightening; (c) recog-
nize the possessive role you may be playing in the rela-
tionship and how it might be a clue that you are
feeling competitive in your relationships (i.e., keep the
competition on the soccer field); (d) ‘‘smashed cell
phone’’—sometimes situations are unworkable so you
need to simply get out; (e) I statements are a good
way to communicate your feelings in a nonthreatening
ways; (f) strike while the iron is cold—save important
conversations until you have a chance to calm down
and until the person you are hoping to talk with is cal-
mer too; (g) Give to get—it’s good to practice empathy
and show that you understand the other person’s point
of view; and (h) take initiative in friendships that interest
you and don’t forget your friends.
The clinician focused the discussion on how these
skills might apply to other significant relationships.
They talked about how the strategies Sam used with
Lindsay could apply to relationships in his family.
Sam continued to work on his relationships at home.
He initiated a conversation with his father about his
concerns about how his father had dealt with his own
depression and its impact on his own mood. He spoke
to his dad using I statements and empathized with his
father’s experience. He was able to tell his dad that he
hoped he could make some changes in his life so he
won’t feel so depressed in the future and gave some
examples of what he had done for himself as motivation
for his dad to do the same. He was learning to speak to
his father in a helpful way that was more congruent with
the style of a young adult.
Sam and the clinician discussed upcoming situations
that he anticipated might be problematic and how he
could apply these strategies for greater success and as
a means of relapse prevention. For example, they dis-
cussed how Sam might approach a new romantic rela-
tionship and the accompanying intense emotions in
light of his past experience. They reviewed the impor-
12 tance of communicating early on in relationships
regarding expectations about time spent as a couple
1 and with friends. They talked about the importance of
clarifying expectations for a relationship as it progres-
ses rather than after an undesirable pattern has been
established.
 592 HALL AND MUFSON
Another important task of the termination phase is
discussing the warning signs of a recurrence or relapse
of the depression. Sam identified being irritable and
argumentative as an early indicator that something is
wrong. He also had experienced significant insomnia
and anorexia, which were atypical for him. They
reviewed what he might do should he note some of these
symptoms reemerging. They discussed the availability of
the clinician should he experience a prolonged deteriora-
tion in his mood.
Session 12. Sam’s parents joined them for part of
the session to review the course of Sam’s treatment.
Sam did not have his parents participate in any middle
phase sessions, as it did not seem necessary for the focus
of his sessions. The clinician did check in with them by
phone midway through treatment to assess whether they
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had any concerns about how the treatment was progres-
sing, and they had reported none, rather stating they
had seen improvements in his mood, sleep and appetite
and that he had been less irritable and withdrawn from
the family. Nonetheless, it was still important to involve
the parents in evaluating the outcome of treatment and
the need for further treatment. After having discussed
with Sam alone what was important for his parents to
know, they reviewed his accomplishments together.
They discussed how Sam’s improvement was a result
of his commitment to treatment evidenced in his regular
attendance at the weekly sessions and his collaborative
work with the clinician to gain insight and acquire
new strategies to improve his relationships. Both
parents reported considerable improvements in Sam’s
functioning at home, school, and with friends. They
noted he was discussing his feelings with them more
clearly and openly so that they had a better under-
standing of what his experiences were with his friends
and at home. They were pleased to see that he was
complaining less about unfairness in their parenting
style and offering more positive suggestions for rules
at home. They were relieved he had moved on in his
romantic pursuits. At the end of week 12, Sam’s HRDS
score was 3; a score of 7 or below is considered to be
within a normative range (Kearns et al., 1982). His final
Children’s Global Assessment Score was an 85, reflect-
ing a significant improvement in his overall level of
adaptive functioning.
Finally, the clinician spoke with Sam about how it
feels to stop attending weekly sessions. Sam felt confi-
dent that he had learned new ways to communicate with
people, but was a bit concerned about how things would
be later when he got busy with sports and school and felt
more stressed. They talked about the possibility of a few
booster sessions to enable him to consolidate his skills
and internalize the strategies so they would feel more
natural and automatic in their use. Sam was open to this
suggestion and a follow-up session was set for 2 months
(because of summer vacations) after his final session.
The clinician offered an opportunity to meet sooner if
necessary.
POSTTREATMENT FOLLOW-UP
Sam came for one booster session after the new school
year had begun and reported he was doing very well.
He was choosing to spend time with a group of friends
and avoid intimate relationships for a while. He was
busy on the soccer team and was preparing his applica-
tions for college so he didn’t feel the need for further
booster sessions. At last check-in contact (1 year after
completing treatment), Sam was attending a local uni-
versity and playing on the varsity soccer team. He had
a new girlfriend, but was quick to report that he still
had lots of other good friends whom he saw regularly.
Overall, the IPT-A treatment appeared to have been
an efficacious treatment for Sam both in reducing his
depression symptoms and improving his interpersonal
skills, which will be of assistance as he negotiates future
stressors.
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