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Clinical Child and Family PsychologyReview ISSN 1096-4037Volume 15Number 2 Clin Child Fam Psychol Rev (2012)15:93-112DOI 10.1007/s10567-012-0111-1

A Model of Therapist Competencies forthe Empirically Supported InterpersonalPsychotherapy for Adolescent Depression

Elizabeth S. Sburlati, Heidi J. Lyneham,Laura H. Mufson & CarolynA. Schniering

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A Model of Therapist Competencies for the EmpiricallySupported Interpersonal Psychotherapy for AdolescentDepression

Elizabeth S. Sburlati • Heidi J. Lyneham •

Laura H. Mufson • Carolyn A. Schniering

Published online: 7 February 2012

� Springer Science+Business Media, LLC 2012

Abstract In order to treat adolescent depression, a

number of empirically supported treatments (ESTs) have

been developed from both the cognitive behavioral therapy

(CBT) and interpersonal psychotherapy (IPT-A) frame-

works. Research has shown that in order for these treat-

ments to be implemented in routine clinical practice (RCP),

effective therapist training must be generated and provided.

However, before such training can be developed, a good

understanding of the therapist competencies needed to

implement these ESTs is required. Sburlati et al. (Clin

Child Fam Psychol Rev 14:89–109, 2011) developed a

model of therapist competencies for implementing CBT

using the well-established Delphi technique. Given that

IPT-A differs considerably to CBT, the current study aims

to develop a model of therapist competencies for the

implementation of IPT-A using a similar procedure as that

applied in Sburlati et al. (Clin Child Fam Psychol Rev

14:89–109, 2011). This method involved: (1) identifying

and reviewing an empirically supported IPT-A approach,

(2) extracting therapist competencies required for the

implementation of IPT-A, (3) consulting with a panel of

IPT-A experts to generate an overall model of therapist

competencies, and (4) validating the overall model with the

IPT-A manual author. The resultant model offers an

empirically derived set of competencies necessary for

effectively treating adolescent depression using IPT-A and

has wide implications for the development of therapist

training, competence assessment measures, and evidence-

based practice guidelines. This model, therefore, provides

an empirical framework for the development of dissemi-

nation and implementation programs aimed at ensuring that

adolescents with depression receive effective care in RCP

settings. Key similarities and differences between CBT and

IPT-A, and the therapist competencies required for

implementing these treatments, are also highlighted

throughout this article.

Keywords Interpersonal psychotherapy for adolescent

depression � Competence � Training � Dissemination

Introduction

Adolescent Depression

Depression is one of the most common psychiatric disor-

ders of adolescence, with a recent meta-analysis showing

that 5.9% of adolescent girls and 4.6% of adolescent boys

have depression at any point in time (Costello et al. 2006).

Depression can have a significant impact on an adoles-

cent’s social and academic functioning and can place the

adolescent at higher risk of developing other psychiatric

conditions including alcohol and substance abuse and sui-

cide (Angold et al. 1999; Brent 1995). Experiencing a

depressive episode in adolescence also increases the indi-

vidual’s risk of experiencing recurrent depressive episodes

into adulthood (Fombonne et al. 2001). Given such high

prevalence rates and the negative short- and long-terms

effects of adolescent depression, the development of early

and effective interventions for depressive episodes expe-

rienced during adolescence are of high priority (Kessler

et al. 2005).

E. S. Sburlati (&) � H. J. Lyneham � C. A. Schniering

Department of Psychology, Centre for Emotional Health,

Macquarie University, North Ryde, NSW 2109, Australia

e-mail: elizabeth.sburlati@mq.edu.au

L. H. Mufson

Department of Clinical Psychology, New York State Psychiatric

Institute, New York, NY 10032, USA

123

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DOI 10.1007/s10567-012-0111-1

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Empirically Supported Treatments

In response to this need, researchers from a number of

theoretical orientations including cognitive behavioral

therapy (CBT), interpersonal psychotherapy for adolescent

depression (IPT-A), family systems therapy, and nondi-

rective/supportive therapy have developed adolescent

depression treatment manuals and evaluated them in ran-

domized controlled trial (RCT) conditions. A recent review

by Ferdon and Kaslow (2008) categorized these treatment

manuals according to the empirically supported treatment

(EST) criteria set out by the American Psychological

Association (APA) Division 12 of task force on promotion

and dissemination psychological procedures (Chambless

et al. 1998; Chambless and Hollon 1998; Chambless and

Ollendick 2001; Chambless et al. 1996) and found that only

IPT-A and CBT can be considered to be well-established

and effective treatments for adolescent depression. Within

the context of Evidence-based Practice (EBP), therapists in

Routine Clinical Practice (RCP) are mandated to imple-

ment either of these ESTs with adolescents suffering from

depression (American Psychological Association 2005;

Institute of Medicine 2001; Spring 2007).

Dissemination and Uptake

Despite this mandate, research has shown that ESTs are

often underutilized by therapists in RCP (Goisman et al.

1999). Furthermore, when these ESTs are implemented in

RCP, client outcomes are typically inferior to those seen in

the RCTs in which they were initially evaluated (Stewart

and Chambless 2009; Weisz et al. 2009). Evidence sug-

gests that the reason for these inferior treatment outcomes

in RCP may be due to the fact that EST therapist training

provided in RCP is significantly inferior to that provided to

therapists in RCTs (e.g. Herschell et al. 2010; Mufson et al.

2004c; Santor and Kusumakar 2001). Given the pivotal

role of therapist training in dissemination efforts, there is

an urgent need to improve the effectiveness of the EST

training being provided to therapists in RCP (Rakovshik

and McManus 2010). However, before more effective EST

training can be developed, therapist competencies for the

implementation of ESTs for specific disorders must be

articulated (Rector and Cassin 2010).

Defining Competencies

The interest in therapist competencies has recently

increased, and according to the competencies-based

movement in psychology, therapist competence is defined

as ‘‘the habitual and judicious use of communication,

knowledge, technical skills, clinical reasoning, emotions,

values, and reflection in daily practice for the benefit of the

individual and community being served’’ (Epstein and

Hundert 2002, p. 227). Furthermore, competence is com-

prised of elements of competence, known as competencies

(Kaslow 2004; Kaslow et al. 2004). These competencies

include relevant knowledge, skills, and attitudes, and their

integration (Kaslow 2004; Kaslow et al. 2004). Drawing

upon this definition of competence, Rodolfa et al. (2005)

developed a cube model of therapist competencies in

psychology. While this model is useful for understanding

the broad range of therapist competencies required in

psychology, it does not articulate the specific competencies

required when implementing ESTs for specific disorder

populations. Roth and Pilling (2008) pioneered the articu-

lation of therapist competencies for implementing ESTs for

a specific disorder population in their development of a

model of therapist competence for the evidence-based CBT

treatment of adult anxiety and depressive disorders.

The method used to develop the Roth and Pilling (2008)

model involved a version of the Delphi technique (Linstone

and Turoff 1975). The Delphi technique is a well-estab-

lished and widely used procedure that draws together both

empirical evidence and iterative expert review to achieve

consensus regarding professional competencies (e.g. Morrison

and Barratt 2010), effective treatment approaches

(Norcross et al. 2010), and guidelines for best practice (e.g.

Garland et al. 2008; Morrison and Barratt 2010) in health

care service provision. Using such a procedure ensured that

the competencies in the model were closely related to the

empirically supported literature, and to current CBT prac-

tices (Roth and Pilling 2008). The Roth and Pilling (2008)

methodology included the following: (1) identification of

the most empirically supported CBT treatment manuals for

each of the adult anxiety and depressive disorders; (2)

intensive review of each of these treatment manuals, and

the extraction of therapist competencies necessary to

implement each manual; (3) sending these lists of compe-

tencies to the authors of the treatment manuals for review

and validation, and (4) convening an Expert Reference

Group (ERG) of experts in anxiety and/or depression-

related research, training, and/or professional practice to

generate an overall model of therapist competencies for the

empirically supported CBT treatment of adult anxiety or

depressive disorder.

The Roth and Pilling (2008) model has been used to

develop a training curriculum for therapists in RCP as part

of the UK-based, nationwide dissemination program,

Improving Access to Psychological Therapies (IAPT; Roth

and Pilling 2008). This training curriculum has been shown

to improve RCP therapist competence following training

(McManus et al. 2010), and research indicates that 76% of

depressed clients and 74% of anxious clients treated within

the IAPT program are diagnosis-free following treatment

(Clark et al. 2009; Richards and Suckling 2009). These

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impressive results are equivalent to response rates seen in

RCTs and highlight the importance of distilling compe-

tencies required for the use of ESTs for specified popula-

tions, and the use of these to inform training curriculum

development within dissemination programs.

Drawing upon the work of Roth and Pilling (2008),

Sburlati et al. (2011) generated a model of therapist com-

petencies for the effective treatment of child and adolescent

anxiety and depressive disorders using CBT. The Sburlati

et al. (2011) model lists competencies under three domains

of competence, one pertaining to general therapeutic

competencies that would be used in any psychotherapy

intervention with children and adolescents (generic thera-

peutic competencies), and two domains dealing specifically

with competencies necessary for implementing CBT with

children and adolescents (CBT competencies and specific

CBT techniques). Generic Therapeutic Competencies are

those competencies needed to relate to people and are

common to all psychological interventions (Roth and

Pilling 2008). CBT competencies are those competencies

necessary to plan, implement, and flexibly adapt specific

CBT techniques with the individual child and their parents

(Sburlati et al. 2011). Specific CBT techniques are those

cognitive behavioral techniques that have proven efficacy

for treating child and adolescent anxiety disorders and

depression (Roth and Pilling 2008). Within each domain,

competencies in the Sburlati et al. (2011) model are further

classified into categories of competence based on similarity

in process or technique.

While the Sburlati et al. (2011) model offers a clear and

comprehensive picture of therapist competencies required

for the effective treatment of adolescent depression when

using one EST for adolescent depression, CBT, it does not

extend to therapist competencies required for the imple-

mentation of the other effective EST for adolescent

depression, namely IPT-A. While CBT and IPT-A may

share some similarities, they differ considerably in their

theoretical underpinnings, processes, and techniques (e.g.

Mufson et al. 2009; Perez 1999; Stangier et al. 2010).

Similarities and Differences Between CBT and IPT-A

Similarities

Both CBT and IPT-A have been downward extensions of

effective adult treatments (e.g. Kendall et al. 1988; Klomek

and Mufson 2006; Mufson et al. 1993b; Mufson and Sills

2006). In this manner, both CBT and IPT-A have been

adapted for use with adolescents by making them more

developmentally sensitive and involving parents where

necessary or appropriate. Both CBT and IPT-A are time-

limited, goal-oriented, and present-focused treatments that

aim to instill a sense of competence in the adolescent to

deal with the difficulties faced (Mufson et al. 2009; Perez

1999). To do this, therapists in both CBT and IPT-A

generate and share a case formulation and treatment plan,

provide a treatment rationale and explanation of thera-

peutic theory and techniques, and work collaboratively

with the adolescent to agree on and achieve treatment goals

(Mufson et al. 2004a; Perez 1999). Both treatments

emphasize the importance of therapeutic techniques as well

as the therapeutic relationship in achieving treatment goals.

Further, both CBT and IPT-A make use of behavior change

strategies such as education, advice, modeling, and role

playing in order to implement the techniques used (Mufson

et al. 2009; Perez 1999).

Differences

While many similarities are present, there are many

important differences, particularly regarding the theoretical

underpinnings and specific techniques used within the

interventions. CBT draws upon both behavioral and cog-

nitive theories and research (Beck 1976; Beck et al. 1979;

Lewisohn 1974). Based on this theory and research, CBT

claims that adolescent depression is associated with nega-

tive cognitions about the self, world, and future (Kaslow

et al. 1992), withdrawal behavior leading to decreased

positive reinforcement, deficits in problem-solving and

social skills often resulting in negative environmental

feedback (Crowe et al. 2006), and a negative family

environment characterized by high parent–child conflict,

high parental expectations, and low levels of positive

reinforcement (Cole and Rehm 1986; Sheeber et al. 2007).

Based on these theoretical and empirical underpinnings, the

techniques that CBT employs aim to alter negative cog-

nitions, increase activity, improve social, and problem-

solving skills, and make positive changes to the family

environment (Brent and Poling 1997; Clarke et al. 1990;

TADS Team 2004).

By contrast, IPT-A draws upon the Interpersonal Theory

of Emotions (Kiesler 1979, 1991, 1996; Kiesler and

Watkins 1989; Meyer 1957; Sullivan 1953), Attachment

Theory (Ainsworth 1969; Bowlby 1969, 1973, 1988) and

Social Theory (Brown et al. 1977; Brown and Harris 1978,

1989) to claim that adolescent depression is associated with

interpersonal problems in the adolescent’s life. More spe-

cifically, IPT-A claims that adolescent depression is asso-

ciated with interpersonal problems possibly stemming from

a loss of attachment, poor social support, and/or unhelpful

communication patterns and poor problem-solving. IPT-A

divides these interpersonal problems into four interpersonal

problem areas, namely, Grief, Interpersonal Role Disputes,

Role Transitions, and Interpersonal Deficits (Mufson et al.

2004a). According to IPT-A, an adolescent suffering from

depression will be experiencing one or more of these

Clin Child Fam Psychol Rev (2012) 15:93–112 95

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interpersonal problem areas that can be linked to the

depressed mood’s onset or maintenance. Techniques used

in IPT-A are aimed at rectifying the interpersonal problem

area(s) identified by helping the adolescent identify their

emotions, link these emotions with interpersonal events,

and acquire new affect management, communication, and

decision-making and interpersonal problem-solving skills

to improve their interpersonal interactions and emotional

experience (Gunlicks and Mufson 2010; Mufson et al.

2004a, 2009).

The Need for IPT-A Therapist Competencies

Given the considerable differences between these two EST

approaches, it is apparent that different therapist compe-

tencies would be required for implementing CBT and IPT-A

for adolescent depression. Given that there is currently no

model of therapist competencies for the effective imple-

mentation of IPT-A, this study aims to use a similar proce-

dure and conceptual framework as the Sburlati et al. (2011)

model of therapist competencies to develop a model of

therapist competencies for the empirically supported inter-

personal psychotherapy treatment of adolescent depression.

Method

Identifying Empirically Supported IPT-A Treatments

In order to identify empirically supported IPT-A treatments

for adolescent depression, the authors first selected IPT-A

treatments identified in a review of ESTs for adolescent

depression (Ferdon and Kaslow 2008). Secondly, the

authors updated this list by performing a large-scale search

of PsycInfo, Web of Science, Pubmed, Scopus, and EB-

SCOhost from Jan 2006 to Dec 2010 using the search terms

‘‘interpersonal psychotherapy,’’ ‘‘major depressive disor-

der,’’ ‘‘depression,’’ and ‘‘adolescent’’. In an attempt to

limit the interpersonal psychotherapy ESTs to those with

the strongest evidence base, the authors selected only those

treatments that demonstrated at least probable efficacy for

treating depression (i.e. we selected those treatments

ranked as either Probably Efficacious, or Well-established).

Three different treatment programs (Mufson et al.

1993a; Mufson et al. 2004a; Rossello and Bernal 1999)

used across numerous RCTs were identified for possible

inclusion in the IPT-A competencies model (Gunlicks-

Stoessel et al. 2010; Mufson et al. 2004b; Mufson et al.

1999; Rossello and Bernal 1999; Rossello et al. 2008; Tang

et al. 2009). Since the use and citation of a treatment

manual is required within the APA Division 12 guidelines

(Chambless et al. 1998; Chambless and Hollon 1998;

Chambless and Ollendick 2001; Chambless et al. 1996) for

ESTs, and the Rossello and colleagues RCTs did not cite

the use of a treatment manual, this program was excluded

(Rossello and Bernal 1999; Rossello et al. 2008). The

remaining trials used treatment manuals; however, one of

these manuals (Mufson et al. 2004a) was a revision of the

other (Mufson et al. 1993a). Therefore, the outdated ver-

sion of the approach (Mufson et al. 1993a) was excluded,

and the most recent version only was selected to inform the

IPT-A competencies model (Mufson et al. 2004a). While it

could be argued that by excluding the Rossello and col-

leagues IPT-A treatment approach, the authors limited the

scope of the study, descriptions of this approach indicate

that it does not differ considerably from the Mufson and

colleagues IPT-A program in terms of key components. As

such it is not expected that the exclusion of this treatment

will affect the overall findings of the study.

Reviewing the Treatment Manual and Extracting

and Validating Competency Lists

A copy of the revised version of IPT-A (Mufson et al.

2004a) was obtained and reviewed intensively with the aim

of extracting a full list of therapist competencies necessary

for implementing this treatment approach. The first author

of this paper then contacted the author of IPT-A directly,

via email, inviting her to read the list of competencies that

had been extracted from the revised version of the manual,

and add any competencies that may have been omitted,

delete any competencies that were considered unnecessary,

and/or modify competencies that she considered could

have been better described. This consultation was under-

taken via two rounds of email communication, where each

round consisted of the treatment author suggesting changes

and the first author of this paper making those changes and

resending the modified model. Throughout this consulta-

tion, many additions, deletions, and modifications were

suggested by the IPT-A author, and the consultation pro-

cess was ceased when the IPT-A author felt as though the

list adequately represented the full range of therapist

competencies required to implement IPT-A.

Model Building

The first author of this paper and the IPT-A author then: (1)

generated a draft model of therapist competencies for

treating adolescent depression using IPT-A by organizing

the list of therapist competencies into the Sburlati et al.

(2011) three domain structure, (2) compiled an ERG of

eight international experts in research, training, and/or

professional practice related to IPT-A, and (3) worked in

collaboration with these experts to refine the model at a

meeting conducted over WebEx, a web conferencing

96 Clin Child Fam Psychol Rev (2012) 15:93–112

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internet platform. The topics of discussion at the ERG

meeting pertained to both the structure and the content of

the model.

After the ERG meeting, the first author compiled the

overall model of therapist competencies in accordance with

discussions at the ERG meeting. In order to ensure that this

model reflected decisions made in the ERG meeting, the

model was emailed to the ERG asking for their feedback.

Three of the ERG members replied with suggested changes

to the semantics of the model. For instance, one ERG

member suggested that more IPT-A terminology be used

within the model. Another ERG member suggested that

different phases be used to accurately explicate the

meaning of the competency in question.

Treatment Author Model Validation

To ensure that the model continued to represent the com-

petencies needed for the implementation of IPT-A and did

not diverge from the practices stipulated in the EST man-

ual, the author of the IPT-A manual was again consulted,

this time to provide feedback on the changes made at, and

following, the ERG meeting. This consultation was

undertaken via four rounds of email communication. All of

the changes made from the ERG meeting and following the

ERG meeting were confirmed by the treatment author. The

treatment author also made some additional content and

structural changes to the model. An example of a content-

related change was altering the competency regarding in-

session agenda from ‘‘Ability to collaboratively set and

adhere to session goals/agenda changes to’’ to ‘‘Ability to

collaboratively set and adhere to session goals/agenda with

regard to the identified problem area(s).’’ Structure-related

changes included the use of asterisks next to competencies

that occur in multiple phases of treatment, and the addition

of shading to several competencies in order to highlight

ones that were adolescent specific.

Results and Discussion

Review of the EST for adolescent depression, together with

feedback from the EST author, and the international ERG

resulted in the development of a model of therapist com-

petencies for the empirically supported Interpersonal Psy-

chotherapy treatment of adolescent depression. This model

is represented in Fig. 1. By way of structure, this model has

three domains of therapist competence, including Generic

Therapeutic competencies, IPT-A competencies and spe-

cific IPT-A techniques. Each domain includes multiple

competency categories, each consisting of a list of distinct

competencies. As was the case in the Sburlati et al. (2011)

model, those competencies that are found in IPT for

adolescent depression, and not IPT for adult depression, are

shaded in gray. The content of this model is described in

detail below.

The following section aims to describe each of these

competency domains in further detail, with reference to the

competency categories and individual competencies within

each domain. Note that since competency descriptions are

written in order of their appearance in the model (based on

domain and category placement), the order of descriptions

do not necessarily follow the order in which these IPT-A

practices are undertaken within the context of treatment.

The descriptions provided are not exhaustive, and the

interested reader may obtain further information on any of

the competencies in the model upon request from the first

author. Subsequently, important similarities and differ-

ences that exist between the IPT-A model and the previ-

ously published Sburlati et al. (2011) CBT model of

therapist competencies will be highlighted and implications

of the model presented.

Generic Therapeutic Competencies

Generic therapeutic competencies are those competencies

needed to relate to people and are common to all psycho-

logical interventions (Roth and Pilling 2008). These com-

petencies are, therefore, not specific to the implementation

of IPT-A or any other psychotherapy for youth. The gen-

eric therapeutic competencies that appear in this model are

largely identical to the original Sburlati et al. (2011) model

of therapist competencies, but were reviewed for their

relevance for IPT-A by the IPT-A author and experts.

These competencies include the knowledge, skills, and

attitudes related to being able to practice professionally

(e.g. knowing of and being able to operate within profes-

sional, ethical, and legal codes of conduct relevant to

working with adolescents and their families, possessing an

open attitude toward psychotherapy research, and being

capable of accessing, critically evaluating, and utilizing

this research to inform practice), understand relevant child

and adolescent characteristics that can impact on therapy

(e.g. having knowledge of developmental issues, individual

differences, environmental factors and adolescent psycho-

pathology, and comorbid presentations), build a positive

relationship with the adolescent and family (e.g. being able

to engage the adolescent through age appropriate methods

and appropriate session pacing and build a therapeutic

alliance with the adolescent and parent), and conduct a

thorough diagnostic and generic assessment (e.g. being

able to make diagnoses using an evidence-based, multi-

method multi-informant psychological assessment of the

disorder presentation, undertake a generic assessment of

the adolescent’s current functioning and suitability for the

intervention, assess for and manage risk of self-harm and

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Fig

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suicide, and make appropriate use of referral when a client

is unsuitable for treatment or requires medication).

Several minor changes were made to the Generic

Therapeutic Competencies from Sburlati et al. (2011) to be

suitable for IPT-A implementation. Since the IPT-A model

is designed for the treatment of adolescents only, not

children and adolescents, child-specific examples for

engagement methods (e.g. games) included in the CBT

model were not included in the IPT-A model (Sburlati et al.

2011). In addition, the ERG in this study considered it

important to include a competency regarding making

appropriate use of referral when a client is unsuitable for

treatment or requires medication. This was added to the

assessment-related competency category in the generic

therapeutic competencies section of the IPT-A model.

However, it could be argued that inclusion of this generic

therapeutic competency is equally relevant to the CBT

model. All other aspects of the generic therapeutic com-

petencies are the same in both the CBT and IPT-A alter-

ations, and the reader can find more detail on the generic

therapeutic competencies in Sburlati et al. (2011).

IPT-A Competencies

IPT-A competencies are those competencies necessary to

plan, implement, and adapt specific IPT-A techniques to

the individual adolescent and his or her parents. IPT-A

competencies are divided into four categories, one relating

to knowledge of IPT-A theory and research, and three

relating to the skills necessary to undertake the three phases

of IPT-A. As seen in Fig. 1, IPT-A competencies that occur

across multiple phases of therapy appear with an asterisk in

the model. The four IPT-A competency categories and the

individual competencies are described below. Within the

categories, individual competencies are underlined.

Understanding Relevant IPT-A Theory and Research

Similar to the corresponding competency in the CBT

model, a therapist who is competent at implementing IPT-

A should have a solid knowledge of the theoretical

underpinnings of IPT (i.e. interpersonal theory of emo-

tions, attachment theory, and social theory) and the ability

to apply IPT-A practices in line with these theoretical

underpinnings. All three theories underpinning IPT-A

suggest negative emotional states (such as depression) are

the result of, and/or are maintained by, the use of poor

interaction styles in current relationships (Bowlby 1969,

1973, 1988; Brown et al. 1977; Brown and Harris 1978,

1989; Kiesler 1979; Meyer 1957; Sullivan 1953). Further,

there is significant empirical evidence to support this the-

oretical claim (Altmann and Gotlib 1988; Garber et al.

1988; Hammen 1999; Marx and Schulze 1991; Puig-Antich

et al. 1993; Reynolds et al. 2010; Speckens and Hawton

2005; Stader and Hokason 1998). Therefore, a therapist

who is delivering IPT-A in line with these theoretical

underpinnings would aim to examine and modify the

negative communication styles that are contributing to the

negative emotional state of the adolescent.

When working specifically with adolescent depression,

the IPT-A therapist should have a strong knowledge of the

principles of, and rationale for, using IPT-A with adoles-

cent depression. This involves possessing knowledge that

IPT-A, in general, is a time-limited, present-focused psy-

chotherapy that aims to provide the adolescent with skills

that improve present (not past) social and interpersonal

functioning, which are deemed to contribute to the onset

and/or maintenance of depressive symptoms. In addition, a

therapist should also understand the rationale for including

parents as either supports for the treatment, or to be

involved in direct interventions on patterns of interactions

in the home environment.

Furthermore, a competent IPT-A therapist must have a

good knowledge of the nature of the IPT-A interpersonal

problem areas that are targeted in this intervention, and

how these problems present in, and relate to, adolescent

depression. These interpersonal problem areas include

Grief, Interpersonal Role Disputes, Role Transitions, and

Interpersonal Deficits and are described below.

Grief is understood to be a normal process that occurs in

adults and youth following a significant loss. It is charac-

terized by symptoms such as sadness and/or anger about

the loss, guilt, or regret about deeds done or not done with

the deceased, excessive responsibility over the events

surrounding the loss, anxiety over the same thing happen-

ing to the self, increased tearfulness, and disturbances in

sleep, appetite, and daily functioning (Horowitz 1976;

McGoldrick and Walsh 1991).

In IPT for adult depression, grief is considered to be an

interpersonal problem area when it is distorted, delayed, or

chronic, but not when it is normal (Middleton et al. 1993;

Raphael 1983). Unlike the adult model, IPT-A does con-

sider normal grief reactions to be appropriate interpersonal

problem area if the adolescent experiences significant

depressive symptoms. Grief can appear differently in

adolescents, when compared with adults since the devel-

opmental tasks associated with adolescence can interact

with and complicate the mourning process (Balk and Corr

2001). Specifically, adolescents may experience their Grief

as episodic rather than pervasive and may continue with

their usual activities, appearing to have dealt with the loss.

Meanwhile, their grief is expressed in other symptoms such

as psychosomatic complaints, anger, or academic failure

(Schoeman and Kreitzman 1997). Grief reactions also

appear to differ between male and female adolescents.

While males evidence social withdrawal or externalizing

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behaviors such as stealing and drug taking, females tend to

seek increased closeness with others, which can lead to the

over sexualization of peer relationships (Osterweis et al.

1984).

In IPT-A, an Interpersonal Role Dispute is considered to

be a situation where the adolescent and at least one sig-

nificant other have nonreciprocal role expectations of each

other’s behavior in a relationship, which cannot be resolved

(Klerman et al. 1984). An example of an Interpersonal Role

Dispute with a parent may be one where the parent expects

the adolescent to behave in a manner that is in line with

family values, whereas the adolescent expects that he or

she should be able to act in line with peer norms (Mufson

et al. 2004a). Such unresolved Interpersonal Role Disputes

continue to be repeated and leave the adolescent feeling

helpless and more likely to withdraw from the relationship

or use poor communication styles, further exacerbating the

problem. There is substantial empirical evidence that sup-

ports the claim that unresolved interpersonal role disputes

with family members or friends precipitate adolescent

depression (Fergusson et al. 1995; Schocket and Dadds

1997).

There are three stages of Interpersonal Role Dispute that

an adolescent could present with: the renegotiation,

impasse, and dissolution stages (Klerman et al. 1984).

Renegotiation is the stage of an Interpersonal Role Dispute

is where the adolescent and the significant other continue to

communicate with one another, attempting to resolve the

dispute, but have been unsuccessful in doing so. The

impasse stage of an Interpersonal Role Dispute is where the

adolescent and the other are no longer communicating or

trying to resolve the dispute. The dissolution of an Inter-

personal Role Dispute is where the adolescent and other

person involved have decided to terminate the relationship

due to an agreement that the dispute cannot be resolved.

Role Transitions are the turning points that lie between

the major stages of life and can become an interpersonal

problem area when the individual experiences difficulty

relinquishing an old role and/or taking on a new role

(Klerman et al. 1984; Weissman et al. 2000). A number of

major Role Transitions occur in adolescence, including the

onset of puberty, the separation from parents and family to

achieve greater independence, the shift from group rela-

tionships to close intimate dyadic relationships, the

beginning of romantic and/or sexual relationships, and

entry into the workforce and/or making future career

decisions such as college enrollment (Erikson 1968; Mufson

et al. 2004a). An adolescent can experience problems in

making these Role Transitions when there are difficulties in

the adolescent–parent relationship, impairments or imma-

turity in the adolescent’s own social or psychological

functioning, or when Role Transitions occur unexpectedly

or are non-normative for the adolescent stage of life

(Mufson et al. 2004a). Such difficulties can lead to a loss of

self-esteem or confidence in the adolescent’s own abilities

to meet role expectations, making the Role Transition

difficult for the adolescent, resulting in depression. In

addition, Role Transitions can be a focus of treatment when

a parent appears to have difficulty accepting a develop-

mental shift in the adolescent and has not made his or her

own transition to parent more appropriately to the new

situation or developmental stage.

Transitions Due to Family Structural Change is a type of

Role Transition that is not seen in IPT for adult depression

(Mufson et al. 2004a). Transitions Due to Family Structural

Change occur when there is a change in the structure of the

family (e.g. through divorce, separation, the inclusion of a

step-family, grandparents moving in) and a subsequent

change in the role of the adolescent (Mufson et al. 2004a).

Often the individuals in the family hold differing role

expectations for the adolescent’s behavior, and as such the

adolescent can also experience Role Disputes within the

family (Mufson et al. 2004a). In this manner, the Transi-

tions Due to Family Structural Change problem area can be

a combination of the Interpersonal Role Transitions and

Role Disputes problem areas (Mufson et al. 2004a).

Interpersonal Deficits is an interpersonal problem area

that is characterized by a lack of communication skills (e.g.

inability to initiate or maintain relationships, inability to

express one’s feelings or difficulty eliciting information

from others to maintain communication) that interferes

with interpersonal relationships (Klerman et al. 1984;

Weissman et al. 2000). Such problems can occur in the

adolescent’s development of close friendships, romantic

relationships, or involvement in peer groups (Mufson et al.

2004a). When this occurs, the adolescent can feel a sense

of inadequacy, which can lead to problems with identity

formation and depression (Erikson 1968; Mufson et al.

2004a). It can also lead to further social withdrawal that

exacerbates the lag in social skills and the depressed mood.

It is important to note, however, that these adolescents

differ from those with Asperger’s disorder in that their

history indicates normal social development; rather some-

thing usually has happened in their adolescence that caused

them to withdraw socially and contributed to interpersonal

skills deficits, which in turn exacerbate and/or maintain

their depression.

Devising, Implementing, and Revising an IPT-A Case

Formulation and Treatment Plan (Initial Phase)

An IPT-A therapist ought to have the ability to conduct an

interpersonal inventory. The interpersonal inventory is a

detailed and systematic review of the adolescent’s signifi-

cant relationships in the present and in the immediate past

(Mufson et al. 2004a). While the emphasis is on current

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relationships, knowledge of recent past social relationships

and interpersonal functioning can be useful when

attempting to understand the adolescent’s patterns of

communication and interaction in relationships (Mufson

et al. 2004a). The interpersonal inventory is completed

following the diagnostic assessment and can be considered

an assessment of the specific interpersonal problems with

which the individual presents (Mufson et al. 2004a). The

first step in conducting an interpersonal inventory in IPT-

A, but not IPT, is to complete the closeness circle with the

adolescent (Mufson et al. 2004a). The closeness circle is a

sequence of circles, one inside of the next. In the middle of

the circles, there is an X that represents the adolescent

(Mufson et al. 2004a). The therapist and adolescent work

together to identify and place all of the people with whom

the adolescent has a relationship into the circles depending

on the degree of closeness that the adolescent feels with the

other person (Mufson et al. 2004a).

Following this, the therapist assesses for important

interpersonal life events associated with the onset or

maintenance of depression and the adolescent’s typical

response to, and difficulties with adjusting to, these events.

Within this assessment, the therapist conducts a thorough

assessment of the communication and problem-solving

skills that the adolescent displays in extant relationships.

The therapist’s role is to then hypothesize about the pos-

sible role of these interpersonal events/difficulties in the

current depression episode. The therapist should then

assess for, identify, and formulate the interpersonal prob-

lem area(s) associated with the individual adolescent’s

depression presentation. If more than one problem area is

present, the therapist would work with the adolescent to

identify the most salient interpersonal problem area (and

focus for treatment). This is considered to be the IPT-A

case formulation, which guides the subsequent IPT-A

treatment plan.

Treatment planning in IPT-A involves being able to

devise, implement, and flexibly revise an IPT-A treatment

plan by selecting, sequencing, and applying the most

appropriate specific IPT-A techniques (seen in Fig. 1) for

the interpersonal problem area, its goals and strategies,

and the adolescent’s individual style. Selecting the most

appropriate specific IPT-A techniques for the interpersonal

problem area depends on the interpersonal problem area

that is most salient in the adolescent’s presentation. Each

interpersonal problem area has its own goals for treatment

and strategies for achieving these goals. The specific IPT-A

techniques are used within these strategies. To be capable

of devising a treatment plan for the adolescent, the thera-

pist must understand the goals and strategies for each of the

interpersonal problem areas, and be able to make use of the

specific IPT-A techniques to implement the strategies to

achieve the appropriate treatment goals. Below is a

description of the strategies and techniques used for each

problem area. See Table 1 for a list of the specific IPT-A

techniques typically used within each interpersonal prob-

lem area.

In the case of Grief as an interpersonal problem area, the

goal is to facilitate the mourning process (Mufson et al.

2004a). This involves a series of seven strategies, which

make use of specific IPT-A techniques (described in detail

in Tables 2 and 3) to achieve the treatment goal. These

strategies include the following: (1) Helping the adolescent

to see the link between their depressed mood and the loss

experienced (using the linking mood to interpersonal

problem area specific IPT-A technique), (2) reviewing in

detail the adolescent’s relationship with the deceased

(using the specific IPT-A techniques of encouragement,

exploration, and expression of affect), (3) providing reas-

surance regarding feelings and the grieving process using

psycho education, (4) connecting current behaviors to

feelings surrounding the death, (5) improving communi-

cation skills (using the specific IPT-A techniques including

communication analysis, and communication skills), (6)

developing other supportive relationships by conducting

‘‘work at home’’ tasks aimed at applying new social skills

Table 1 Summary of specific IPT-A techniques typically used in

each interpersonal problem area

Interpersonal

problem area

Specific IPT-A techniques

Grief Linking mood to interpersonal problem area

Encouragement, exploration, and expression of

affect

Communication analysis

Communication skills

Interpersonal role

disputes

Linking mood to interpersonal problem area

Clarification of feelings, expectations, and

roles in relationships

Communication analysis

Decision analysis

Communication skills

Managing affect in relationships

Role transitions Linking mood to interpersonal problem area

Encouragement, exploration, and expression of

affect

Clarification of feelings, expectations, and

roles in relationships

Decision analysis

Interpersonal problem-solving skills

Managing affect in relationships

Communication skills

Interpersonal

deficits

Linking mood to interpersonal problems

Communication analysis

Communication skills

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to other relationships that could provide support, and (7)

reintegration into the social milieu with further application

of communication skills.

In the case of interpersonal role disputes, the goals of

treatment differ based upon the stage of the dispute (i.e.

renegotiation, impasse, or dissolution). While the goal for

working with disputes at the renegotiation and impasse

stages is to help the adolescent define and resolve the

dispute, the goal for the dissolution stage is to help the

adolescent identify the best way to end the relationship

and to mourn the loss of the relationship (Mufson et al.

2004a). It is important to note it is infrequent that work is

done in the dissolution phase, and if it is done, it is typ-

ically with regard to peer, not family, relationships. The

strategies and specific IPT-A techniques (described in

Tables 2 and 3) used to achieve these goals include

helping the adolescent to see the link between their

depressed mood and the interpersonal role dispute (using

the linking mood to interpersonal problem area specific

IPT-A technique) and identifying and exploring the

Interpersonal Role Dispute. Such discussion should focus

on the expectations for the relationship (using the specific

IPT-A techniques of clarification of feelings, expectations,

and roles in relationships) and communication patterns

that may be contributing to the dispute (using the specific

IPT-A technique of communication analysis). Following

this, the therapist and adolescent work together to make

decisions regarding potential solutions to the Interpersonal

Role Dispute (using the decision analysis specific IPT-A

technique). Such solutions may be to continue to attempt

to resolve the Interpersonal Role Dispute or to end the

relationship.

If the decision is to continue to attempt to resolve the

Interpersonal Role Dispute, then the therapist aims to assist

the adolescent to improve communication skills in the

target relationship (using specific IPT-A techniques such as

communication analysis, communication skills, and man-

aging affect in relationships). If the decision is to terminate

the relationship, communication skills are aimed at assist-

ing the adolescent to communicate this with the significant

other. The final strategy in the Interpersonal Role Disputes

problem area is to increase the social support in the ado-

lescent’s life by having the adolescent apply his or her new

skills to external relationships.

The goals for the role transitions interpersonal problem

area include relinquishing the old role and accepting/

developing a sense of mastery over the new role (Mufson

et al. 2004a). The first strategy used is to help the adoles-

cent see the link between the Role Transition and their

depressed mood (using the specific IPT-A technique of

linking mood to interpersonal problem area). Once the link

between the Role Transition and depression has been made,

the therapist should educate adolescents and parents about

the transition and explore the adolescent and parent feel-

ings about the role transition using the specific IPT-A

techniques of encouragement, exploration, and expression

of affect. In the case of transitions due to family structural

change, therapists should aim to include all involved,

including custodial, noncustodial, biological, and steppar-

ents if the therapist feels it would be beneficial.

The therapist should then work with those involved to

review old and new roles (using the specific IPT-A tech-

niques of clarification of feelings, expectations, and roles in

relationships). In the case of transitions due to family

structural change, the therapist should be aware that there

are multiple levels of role expectations for the adolescent

from different people involved. As such, the therapist

should be able to identify all of the adults who hold

expectations for the adolescent and the adolescent’s

expectations for each relationship, assess the ability and

willingness of each of the key adults to work together to

come to an agreement regarding expectations for the ado-

lescent, and facilitate this agreement by involving these

individuals in a therapy session or helping the adolescent to

negotiate these conversations at home between sessions.

The therapist should also explore and resolve the adoles-

cent’s feelings about any lost relationships or significantly

changed relationships in the family (using the specific IPT-

A technique of clarification of feelings, expectations, and

roles in relationships). Any misconceptions about the

assignment of blame for the departure of the other person

(if appropriate) should be identified and clarified.

When the adolescent has not made the decision to

relinquish the old role and accept the new role, the specific

IPT-A technique of decision analysis should be applied to

assist the adolescent to problem-solve the issue. In the case

of transitions due to family structural change, this will

require the adolescents to use the specific IPT-A technique

of interpersonal problem-solving skills aimed at working

with the family members to generate solutions to the

problems that they face as a family. The specific IPT-A

technique of managing affect in relationships should also

be implemented, such that emotions are regulated during

these interactions. After the decision is made to accept the

new role, the therapist and the adolescent should work

together to develop the social skills needed for the new role

(using the specific IPT-A technique of communication

skills). Finally, additional social support to aid in the pro-

cess of making such transitions should be achieved by

helping the adolescent to apply the new skills to other

relationships.

The goals for the Interpersonal Deficits problem area are

to reduce social isolation and improve the relationships the

adolescent currently has and encourage the development of

new relationships (Mufson et al. 2004a). The therapist can

meet these goals by implementing the following strategies

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and techniques: (1) assisting the adolescent to make the

association between interpersonal deficits and depression

(using the specific IPT-A technique of linking mood to

interpersonal problems), (2) extending the interpersonal

inventory to further review current and past relationships

and interactions, (3) exploring interactions with the thera-

pist in order to help the adolescent see parallels between

the therapeutic relationship and significant relationships in

his or her life, and (4) highlighting the interpersonal

strengths and skills that the adolescent possesses and

building upon them (using the specific IPT-A techniques of

communication analysis and communication skills).

Finally, the IPT-A treatment plan should not only be

based on the interpersonal problem area, but also the

adolescent’s own individual style (e.g. his or her ability to

manage emotions, level of organization and insight, and/or

level of communication and problem-solving skills). While

the original devising of the treatment plan occurs in the

initial phase of IPT-A, implementing, and revising, it

occurs in the middle phase of IPT-A.

The therapist ought to be capable of collaboratively

communicating appropriate psycho education about the

nature of the disorder and the treatment plan to both the

adolescent and the parent, and the interpersonal problem

area to the adolescent only. When providing psycho edu-

cation to the parent and the adolescent, depression is

framed as a known disorder that is linked to the adoles-

cent’s current interpersonal context and functioning

(Mufson et al. 2004a). IPT-A is described as a time-limited,

three phase psychotherapy that aims to bring about changes

in the adolescent’s interpersonal context and functioning

and depressive symptoms. Both the parent and the ado-

lescent should be engaged in discussions around their

reactions to the diagnosis and IPT-A as an intervention.

When providing psycho education about the interper-

sonal problem area to the adolescent, the therapist ought to

describe the formulation to the adolescent and facilitate

feedback from the adolescent regarding his or her opinions

about the formulation (Mufson et al. 2004a). The therapist

should take an open stance in such discussions and work

with the adolescent to come to an agreement on the for-

mulation. If appropriate, the therapist can facilitate the

adolescent’s sharing of the interpersonal problem area with

the parent (Mufson et al. 2004a).

The therapist should have the ability to assign a limited

sick role to the adolescent, to collaboratively negotiate and

agree on treatment goals, and generate a treatment con-

tract, and determine and explain the role of the adolescent,

parent, and therapist throughout therapy. Treatment goals

should then be negotiated, along with the role of the ado-

lescent, therapist, and parent. In IPT-A, the adolescent is

assigned the limited ‘‘sick role’’ that acknowledges the

adolescents’ illness, but balances this with an expectation

that the adolescent will take an active stance in and

between therapy sessions (Mufson et al. 2004a). The pur-

pose of the limited sick role is to acknowledge that

depression affects the adolescent’s functioning, to remove

the blame from the adolescent to the illness, but at the same

time to encourage him or her to participate in normal

activities with the knowledge that performance and moti-

vation will improve with recovery. This is important for the

parents as well so that they shift their blaming to the illness

and become more supportive and less critical as they

motivate their adolescent to go to school and do the other

normal activities. The therapist should describe the thera-

peutic relationship between the adolescent and therapist as

a ‘‘team,’’ where both parties are working together to

understand the conflict precipitating the depression, and

to find ways to resolve it (Mufson et al. 2004a). The degree

to which parents are involved in the middle phase of IPT-A

will depend on the therapists clinical judgment regarding

the therapeutic usefulness of their involvement, as well as

the parents’ own ability and willingness to be involved.

When parents are involved, the therapist should possess the

ability to frame and facilitate parent involvement as a

‘‘collaborative therapist’’—the therapist carrying the work

out at home (Mufson et al. 2004a). Once treatment goals

are established, and the role of each individual involved

has been negotiated, a treatment contract should be written

up (Mufson et al. 2004a).

Throughout the course of therapy, the therapist should

use measures and adolescent self-monitoring to track

depression levels and interpersonal functioning. This can

be used to inform the therapeutic intervention and to

assess the adolescent’s progress and outcome. Finally, the

therapist ought to be able to identify and manage special

clinical situations, clinical issues, and crises in IPT-A

(Mufson et al. 2004a). Special clinical situations might

include the presence of sexual abuse, or substance abuse,

aggression, school refusal, or sexuality confusion in the

adolescent. Clinical issues might include excessive

dependence on the therapist, frequent cancellation and

lateness to sessions, resistance to treatment, and non-

compliance with therapeutic tasks or early termination.

Crises might include suicidality, running away, pregnancy,

illness in the adolescent or family, or involvement with the

law.

Collaboratively Conducting IPT-A Sessions

(Middle Phase)

When conducting IPT-A sessions with depressed adoles-

cents, a collaborative stance should be taken. One way in

which collaboration with the adolescent can be fostered is

by collaboratively setting and adhering to a session agenda

or session goals with regard to the identified problem

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area(s). In this manner, the therapist enables the adolescent

to elaborate on interpersonal events and his or her feelings

rather than dictating the session, clarifies the problem with

the adolescent, and ensuring it relates to the identified

problem area and discusses ways to improve the situation

or the adolescents’ approach to the situation. Throughout

sessions, an IPT-A therapist’s task is to elicit and respond

to feedback about the adolescent’s understanding or

engagement in the therapeutic process and provide reflec-

tions about, and positive feedback for, changes in inter-

personal functioning and/or depressive symptoms. While

such collaboration is promoted, an IPT-A therapist should

also aim to keep the sessions focused on the identified

problem area and to maintain the time-limited framework.

During middle phase sessions, treatment is focused on

the implementation of specific IPT-A techniques and

strategies. Such specific IPT-A techniques and strategies

should be implemented with flexibility for the client dis-

order presentation, needs or preferences, cultural back-

ground, and current mood (Chu and Kendall 2009; Kendall

et al. 2008). Flexibility for the disorder presentation in this

context might involve knowledge of depression-related

symptoms that can impact on the implementation of spe-

cific IPT-A techniques and strategies and the ability to

adapt IPT accordingly. For example, hopelessness (the

sense that whatever one does, nothing will change) can

impact on the usefulness of decision analysis (described in

Table 3), since adolescents will believe that none of the

options will lead to any change. The therapist should be

able to highlight that although some of the bigger concerns

that the adolescent has may not be possible to change at

this time, small changes are always possible (Mufson et al.

2004a).

Flexibility for the adolescent’s needs or preferences

involves identifying the adolescent’s own needs or pref-

erences in regard to treatment focus and goals and

addresses the concerns within the IPT-A framework and

identified problem area. Implementing specific IPT-A

techniques or strategies flexibly for the adolescent’s cul-

tural background might involve being aware that some

interpersonal role disputes can be due to cultural expecta-

tions of the parents for their adolescent’s behavior. A

therapist should be capable of being sensitive to these

cultural beliefs and respectful of the familial and cultural

differences among families while also enabling a com-

promise between the adolescent and parents. In this case,

the therapist must be able to help the parents see the ado-

lescent’s point of view and, in many cases, help the ado-

lescent better understand his parent’s perspective and work

within culturally appropriate norms for communication and

behavior. Finally, flexibility for the adolescents involves

being able to identify and acknowledge the adolescent’s in

session focus, identify whether that mood and focus can be

used to illustrate a point in therapy, and if not, refocus the

adolescent on more therapeutically relevant interpersonal

events (Mufson et al. 2004a).

When implementing specific IPT-A techniques, it is

important that the therapist is able to make use of behavior

change methods such as education, advising, role play,

modeling, corrective feedback and use of the therapeutic

relationship to help the adolescent practice the use of

specific IPT-A techniques. Education in IPT-A is aimed at

building the adolescent’s own knowledge, abilities, and

skills in interpersonal problem areas and subsequently

promoting independence rather than dependence on the

therapist.

Advising, as a behavior change method in IPT-A,

involves giving more direct suggestions to the adolescent

regarding their behavior and is sparingly used in IPT-A.

Modeling is a process where the therapist shows the ado-

lescent how to engage in a new behavior, and role playing

is when the adolescent and therapist practice these new

behaviors together. Role playing can be used to explore the

adolescent’s typical style of communicating with others,

and rehearse new ways of interacting and communicating

with others where constructive feedback is available in a

safe environment.

In IPT-A the therapeutic relationship functions as a

mini-laboratory and provides both an example of the ado-

lescent’s relationships and a forum in which skills can be

practiced and feedback can be given. To make use of the

therapeutic relationship, the therapist identifies and sensi-

tively comments on their own experiences within the

relationship (particularly those related to the problem area),

points out how these difficulties may manifest in other

relationships, provides constructive advice for improve-

ment in interactions based on the client’s pre-existing

strengths and good qualities, and asks the adolescent to

examine his or her own negative feelings toward the

therapist in this supportive atmosphere (if relevant). This

communication serves several purposes. It helps to link

what happens in the session to similar patterns that occur

with other relationships and models direct communication

between two people about their feelings and can show the

adolescent that expressing negative feelings within a rela-

tionship (e.g. hurt, anger, or disappointment) will not be

catastrophic, but can improve the quality of the relationship

for both individuals involved (Mufson et al. 2004a). This

use of the therapeutic relationship in IPT-A can also pre-

vent misunderstandings between the therapist and adoles-

cent that could lead to premature termination (Mufson et al.

2004a).

Sessions in all phases of IPT-A should be conducted

with developmental sensitivity. In the middle phase of IPT-

A, this refers to adapting IPT-A techniques and strategies

for the adolescent stage of social, emotional, and cognitive

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development. With regard to social development, this

might mean adapting IPT-A techniques and strategies for

the social developmental tasks of adolescence (e.g. indi-

viduation, establishment of autonomy, development of

close interpersonal relationships with peers, members of

the opposite sex and potential romantic partners). The way

that techniques are presented may need to be altered for the

adolescent’s stage of emotional development, and ability to

identify emotions. For instance, when implementing the

specific IPT-A technique of linking mood to interpersonal

problems (described in Table 2), the therapist might need

to engage in some preliminary affective training, aimed at

teaching the adolescent how to identify feelings and how

these might impact on relationships (Mufson et al. 2004a).

Finally, specific IPT-A techniques can be adapted to suit

the adolescent’s stage of cognitive development by making

use of concrete representations for abstract concepts (e.g.

using an affect rating scale when conducting mood rating)

and making IPT-A techniques less cognitively demanding

(e.g. avoiding cognitive overload in the younger adolescent

by offering fewer options when implementing the specific

IPT-A technique of decision analysis).

With reference to parent involvement, the therapist who

has planned for parents to be extensively involved in

therapy ought to be capable of engaging parents in a

number of sessions, where appropriate. This involves: (1)

engaging the parent in the session, (2) facilitating the

appropriate form of parent involvement for the adoles-

cent’s problem area, (3) ensuring that the session remains

focused on the identified problem area and/or particular

specific IPT-A technique being discussed, (4) ensuring that

interactions between the parent and adolescent are con-

structive rather than destructive, and (5) assisting both the

parent and adolescent to manage high levels of emotion in

session (Mufson et al. 2004a).

When conducting IPT-A, a therapist ought to assess

whether setting ‘‘work at home’’ tasks or interpersonal

experiments will be beneficial for the adolescent in general.

If it is decided that ‘‘work at home’’ tasks will be useful for

the adolescent, the therapist should determine whether the

content of the specific session being conducted requires an

experiment to be assigned for that week (Mufson et al.

2004a). If so, then the therapist should set, plan, and review

personally meaningful ‘‘work at home’’ tasks. Such ‘‘work

at home’’ tasks should be presented to the adolescent as

interpersonal experiments that do not involve failure or

success, but rather provide more data for determining out

how to improve the identified relationship and problem

area. Following this, the IPT-A therapist should work with

the adolescent to identify ‘‘work at home’’ tasks that are

aimed at producing changes in the identified problem area,

communication and/or problem-solving skills and that are

manageable by the adolescent at their particular stage or

skill level. It is important for the therapist to start small and

work toward more challenging interpersonal experiments.

Once the task has been set, the therapist and adolescent can

identify obstacles to task completion, and work together to

problem-solve these. The IPT-A therapist then reviews the

‘‘work at home’’ task in the following session and discusses

lessons learned.

Another important part of between session planning in

IPT-A is the degree to which parents are involved in

assisting the adolescent with ‘‘work at home’’ tasks

(Mufson et al. 2004a). The therapist ought to be capable of

facilitating parents to take an appropriate role between

sessions as needed (i.e. as support person). This involves

teaching the parent the skills that the adolescent should be

practicing at home and how to be receptive to, encourage,

and praise these behaviors when they occur. If parents have

been involved in the session (e.g. the session focused on

the specific IPT-A technique of interpersonal problem-

solving skills), then parents may also be set ‘‘work at

home’’ tasks aimed at helping them practice the therapeutic

tasks of the session.

Finally, an important aspect of conducting IPT-A ses-

sions is ending sessions in a planned manner. This means

ending each session by summarizing the content covered in

an attempt to reinforce thematic continuity (i.e. focus on

interpersonal issues) and also reminding the adolescent as

to how many sessions remain to serve as motivation for

continuing to work on the strategies outside of sessions.

Ending Therapy and Planning for Maintenance

of Gains (Termination Phase)

When terminating IPT-A with an adolescent, the adoles-

cent should be informed of the cessation of treatment with

three sessions remaining, and the therapist is required to

elicit feelings about ending treatment from the adolescent

(Mufson et al. 2004a). The therapist might need to engage

the adolescent in discussions around the notion that while

they may feel sad about termination of treatment, this

feeling is different from depression and does not indicate

the onset of relapse (Mufson et al. 2004a). Warning

symptoms of depression are then reviewed, and the ado-

lescent is engaged in conversation about how they might

use such warning symptoms of depression as signs of a set

back or relapse.

Following this, the therapist should work with the ado-

lescent to review progress in the identified problem area

and help the adolescent to recognize the interpersonal

competencies developed throughout treatment and those

interpersonal strategies and techniques that were most

useful (Mufson et al. 2004a). In order to foster general-

ization of skills and enhance relapse prevention, the

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therapist should engage the adolescent in identifying how

those useful strategies could be applied to future events.

This involves working with the adolescent to identify

future situations where these skills can be applied and

discuss how the adolescent might apply these strategies in

future circumstances (Mufson et al. 2004a). This might

also include engaging the adolescent in identifying people

in his or her life that can remind them of the identified

strategies and support him or her in their use. This would

be discussed with the parents (or other significant figures)

in the termination phase (Mufson et al. 2004a).

Finally, the therapist must evaluate the adolescent’s

need for further treatment. The decision to recommend

further treatment may be due to residual depressive

symptoms, limited social support, and/or the presence of

comorbid disorders. If the adolescent does require further

treatment, the therapist should review the reasons for this

with the adolescent and discuss treatment options with the

Table 2 Descriptions of specific IPT-A techniques from the linking affect to interpersonal relationships category

Specific IPT-A technique Description

Encouragement, exploration, and

expression of affect

Encouragement and exploration of affect refers to a range of techniques used to help the patient

express, explore, and understand the nature of their emotions (Mufson et al. 2004c). The therapist can

facilitate this by normalizing the experience of negative emotions, helping the adolescent identify,

acknowledge, and accept painful affective states, and develop new, desirable affects that may

facilitate growth and change. Encouragement and Exploration of Affect also involves learning how to

express affect more effectively in order to feel more heard and elicit desired responses more

frequently (Mufson et al. 2004a, b, c). While some adolescents may need only minimal training in

identifying their emotional states, others may need substantial therapist support (Mufson et al. 2004a,

b, c). In such instances, affect training may be required. Affect training involves teaching the

adolescent to identify feelings using strategies like feeling cards that depict a variety of feeling states

and discussing when people might experience such feelings, whether the adolescent has experienced

it and how he or she behaves when feeling this affective state (Mufson et al. 2004a, b, c). This is

aimed at helping the adolescent identify both negative and positive emotions

Mood rating Mood rating is a technique that involves the adolescent rating their moods on a scale of 1-10 on a daily

basis (Mufson et al. 2004a, b, c)

Linking mood to interpersonal

problems

Linking mood to interpersonal problems involves helping the adolescent to link interpersonal events

related to the interpersonal problem area with the onset or maintenance of depression (Mufson et al.

2004a, b, c). The therapist can facilitate the connection between the onset of depression and

interpersonal problems by establishing a timeframe and plotting interpersonal events, and the onset

and variation of depressive symptoms on this timeframe (Mufson et al. 2004a, b, c). The therapist can

facilitate the connection between the maintenance of depression and interpersonal problems by

having the adolescent use Mood Rating to rate their mood on a daily basis, monitor the interpersonal

events that occur and determine whether changes in mood correlate with interpersonal problems/

events (Mufson et al. 2004a, b, c). The therapist might also make use of the ‘‘depression circle’’ to

help the adolescent link interpersonal events with mood. The depression circle is a concrete

representation of the relationship between the adolescents affect (particularly depressed mood) and

events in interpersonal relationships (Mufson et al. 2004a, b, c). This circle helps to illustrate

repetitions in the pattern, identify areas for change/places to break the depression cycle and to

document changes made in therapy when alterations are made in the cycle. The depression circle is

developed by the adolescent and the therapist at the end of the initial stage of therapy, and used as a

reference point throughout the middle phase of therapy and termination phase (Mufson et al. 2004a, b,

c)

Clarification of feelings, expectations,

and roles in relationships

Clarification of feelings in relationships is aimed at helping the adolescent understand and accept the

experience of both positive and negative emotions toward another person (Mufson et al. 2004a, b, c).

Clarification of expectations in relationships is aimed at helping the adolescent (and parent if involved

in therapy) to understand the expectations that both parties have of the other in the relationship and

whether or not those expectations need to be revised to alleviate depression (Mufson et al. 2004a, b,

c). Clarification of roles in relationships is aimed at helping the adolescent to understand the roles in

relationships and their contribution to the depression (Mufson et al. 2004a, b, c). It may also lead the

adolescent to consider relinquishing old roles, accepting new roles, renegotiating aspects of the role,

and developing a sense of mastery over new role (Mufson et al. 2004a, b, c)

Managing affect in relationships Managing affect in relationships is aimed at helping the adolescent to recognize that while emotions do

need to be expressed in relationships, they need to be managed, tolerated, contained, and expressed

incrementally to be most effective. Ways that this might be done include being aware of voice tone,

timing, calming down, and waiting to discuss matters rather than engaging in an argument in

‘‘the heat of the moment,’’ communicating feelings rather than ‘‘bottling them up’’ (Mufson et al.

2004a, b, c)

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adolescent and parent. Wherever appropriate, parents

should be included in the termination phase.

Specific IPT-A Techniques

Specific IPT-A techniques are those Interpersonal Psy-

chotherapy techniques that are used to perform strategies

aimed at achieving IPT-A goals relevant to the interper-

sonal problem area. As seen in Fig. 1, these techniques are

divided into two categories, based on whether they aim to

link affect to interpersonal relationships (linking affect to

interpersonal relationships) or build the adolescents inter-

personal skills (interpersonal skills building). The tech-

niques found in the linking affect to interpersonal

relationships category are described in Table 2, and the

techniques found in the Interpersonal skills building cate-

gory are described in Table 3. These specific IPT-A tech-

nique descriptions should be read in conjunction with

earlier sections relating to IPT-A competencies. Below is a

discussion on the similarities and differences between the

IPT-A model of therapist competencies outlined in this

article and the CBT model of therapist competencies from

Sburlati, et al. (2011).

Similarities and Differences Between the IPT-A

and CBT Competencies Models

The three domain structure of the CBT model and the use

of shading to reflect differences between adult and youth

treatments were retained in the IPT-A model; however, the

content within the model differed considerably, in line with

the substantial differences between CBT and IPT (as dis-

cussed in the introduction to this article). In addition, while

the CBT model included reference to children and ado-

lescents and anxiety and depression, this model only refers

to adolescents and depression only. As highlighted earlier,

the Generic Therapeutic Competencies in both models are

nearly identical. The following section describes the sim-

ilarities and differences between the IPT-A and CBT for

the therapeutic orientation competencies and the specific

technique competencies.

Table 3 Descriptions of specific CBT techniques from the interpersonal skills building category

Specific IPT-A technique Description

Communication analysis Communication analysis is aimed at identifying ways in which the patient’s communication is ineffective and

fails to achieve the goal of the communication (Mufson et al. 2004c). The goal of this technique is to teach the

patient to communicate in a more effective manner by increasing his clarity and directness (Mufson et al. 2004a,

b, c). The therapist can conduct communication analysis by performing a thorough analysis of a specific

argument and reporting on all dimensions of the interaction (e.g. verbal and nonverbal communications, feelings

generated, and responses given) and goals of the communication. During this process, the therapist can also

educate the adolescent about the nature of ineffective communication styles (e.g. using unnecessarily indirect

verbal communication, using hostile communication, which leads to either hostile or passive responses from

those with whom they are interacting) so that he or she is more aware of these in the future

Communication skills Communication skills are aimed at developing the adolescent’s communication abilities in interpersonal

relationships (Mufson et al. 2004a, b, c). The therapist can teach adolescents more effective means of

communicating by teaching alternative communication strategies, including communicating feelings,

expectations, and opinions directly and clearly and without blame, clarifying misperceptions made by the other

communication partner, seeing the other person’s point of view and use empathy appropriately, communicating

when calm rather than when angry, and making use of ‘‘I’’ statements to express feelings (Mufson et al. 2004a,

b, c)

Decision analysis Decision analysis is aimed at assisting an adolescent with making decisions that are in some way related to the

interpersonal problem area (Mufson et al. 2004a, b, c). The therapist’s role is to help the patient consider a range

of alternative actions that he can take and to assess the possible consequences associated with each of those

actions. The general steps involved in decision analysis are to: (1) identify the decision that needs to be made,

(2) determine a goal, (3) generate a list of alternative actions, (4) highlight missing options and patterns in the

patient’s decision-making, (5) evaluate the options by thinking through the consequences, (6) select and

implement the ‘‘best’’ option, and (7) evaluate the outcome and potential need to select a second option (Mufson

et al. 2004a, b, c)

Interpersonal problem-

solving skills

Interpersonal problem-solving skills are aimed at assisting the adolescent to engage in effective problem-solving

skills in relation to interpersonal problems that they experience with another person (e.g. parents, friends).

Interpersonal Problem-solving Skills can be thought of as an interpersonal adaptation of the Decision Analysis

technique. Within Interpersonal Problem-solving, the therapist can teach the adolescent (and parent if involved)

how to: (1) identify and define the interpersonal problem, (2) generate and evaluate various solutions to

identified problems in the family and /or peer relationships, (3) discuss the proposed solutions with the other

party involved (in session if the other party is involved in therapy, or out of session if they are not), (4) evaluate

the pros and cons of the different solutions and select one to try first, and (5) evaluate the outcome and the

potential need to select a second option (Mufson et al. 2004a, b, c)

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Similarities and Differences in the CBT Competencies

and IPT-A Competencies

The CBT competencies and IPT-A competencies share

several fundamental processes. These shared processes

include the therapist having an understanding of theory

and research relevant to the therapeutic orientation, being

able to develop and communicate a case formulation and

treatment plan that reflects the therapeutic orientation,

ability to collaboratively implement treatment sessions,

and to apply therapeutic techniques flexibly, with devel-

opmental sensitivity and using behavior change strategies.

However, the theoretical underpinnings of IPT-A and

CBT differ substantially (as mentioned in the introduction

to this article), meaning that the knowledge and skills that

a therapist must possess to implement these IPT-A pro-

cesses differs considerably from CBT at a theoretical

level.

Similarities and Differences in the Specific CBT

Techniques and the Specific IPT-A Techniques

In line with the differing theories underlying CBT and IPT-

A, the specific techniques used in these therapeutic orien-

tations are somewhat different. For instance, while CBT

includes techniques that aim to alter the adolescent’s dis-

torted cognitions and inactivity, IPT-A does not. On the

other hand, while IPT-A includes techniques that aim to

link mood with interpersonal events and clarify feelings,

expectations, and roles in relationships, CBT does not.

However, there is significant overlap between CBT and

IPT-A techniques that aim to alter social, interpersonal, and

familial interactions. For example, in both CBT and IPT-A,

depressed adolescents are taught to problem-solve,

improve their interpersonal communication skills, and

family communication and conflict resolution skills. Hav-

ing said this, the ways in which these similar techniques are

taught and the relative emphasis on these skills differs

between the two approaches. The similarities between both

of these effective therapeutic orientations for adolescent

depression may hold some insight into the mechanisms of

change at play in the treatment of depression in

adolescents.

Implications of the Model

In summary, this work provides a comprehensive set of

operationalized and measureable therapist competencies

for the interpersonal psychotherapy treatment of adolescent

depression. This model can inform the development and

improvement of therapist training and the development of

EBP guidelines for treating adolescent depression.

Training

This competency model provides a framework for the

development of a training curriculum for treating adoles-

cent depression using IPT-A. A training program based on

this model would provide therapists with the knowledge,

skills, and attitudes relevant for treating adolescent

depression using IPT-A and would provide goals and

measurable objectives to assess therapist outcomes post-

training within the context of expert supervision, feedback,

and evaluation. Subsequently, this model forms the foun-

dation for a dissemination training curriculum, which could

be used within the context of a large-scale dissemination

project similar to the highly successful IAPT project in the

UK.

While this competencies-based framework adequately

provides the content for the development of a training

curriculum, recent evidence suggests that in order to

develop effective therapist training, consideration must be

given to effective training delivery methods as well as

training content (Rakovshik and McManus 2010). It is

suggested that training methods be developed based on a

solid understanding of adult learning theory and research as

well as well-developed training methods in other health

professions such as nursing and medicine (Lyon et al.

2011; Rakovshik and McManus 2010). This might include

a combination of several training delivery methods, such as

didactic instruction (e.g. lectures), problem-based learning

(e.g. case examples), experiential learning (e.g. role plays),

and supervision from expert clinicians (Herschell et al.

2010; Rakovshik and McManus 2010). Out of these

training delivery methods, supervision has received the

most research attention (Accurso et al. 2011; Milne et al.

2011).

In light of the fact that access to training is a significant

barrier to the uptake of ESTs in RCP (Nelson and Steele

2007), competence-based training resources need to be

made readily available. One method for overcoming this

access to training barrier has been to make training mate-

rials available online (Dimeff et al. 2009; Granpeesheh

et al. 2010; Sholomskas and Carroll 2006; Sholomskas

et al. 2005; Weingardt et al. 2009). It is unknown whether

these online training resources should be used alone or as

an adjunct to face-to-face training; however, it is clear that

they may prove useful within the context of large-scale

dissemination projects (Godley et al. 2011; Martino et al.

2011; McCloskey 2011).

It is important to note here that there are a number of

other therapist, client and organizational barriers to the

uptake of ESTs, and it is strongly recommended that these

be taken into account when disseminating training (Beidas

and Kendall 2010; Schoenwald et al. 2010). Furthermore,

consideration of the continued use of ESTs following

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training and initial uptake must also be considered and

evaluated within dissemination projects (Forgatch and

DeGarmo 2011; Massatti et al. 2008). For reviews

and recommendations on the development, implementation

and evaluation of EST dissemination projects see the recent

updates on this endeavor (e.g. Becker and Stirman 2011;

Fixsen et al. 2005; Godley et al. 2011; Higa-McMillan

et al. 2011; Landsverk et al. 2011; Meredith et al. 2011;

Mufson 2010; Mufson et al. 2004b; Nakamura et al. 2011;

Palinkas et al. 2011; Proctor et al. 2011).

This therapist competencies model could not only

inform training curriculums for dissemination programs,

but also could assist with the revision of pre-existing

clinical psychology and psychiatry training programs in

educational institutions (Weissman et al. 2006). Certainly,

if the field of professionals were provided with adequate

competencies training prior to certification, the problem of

EST dissemination would be reduced.

Evidence-based Practice Guidelines

Given that this model outlines best practice when using

IPT-A, this model could be used to generate EBP guide-

lines for regulators, accreditation boards, and policy mak-

ers. Such guidelines are becoming imperative within the

field of clinical psychology and psychiatry, in light of the

ethical requirement that professional psychologists practice

competent EBP (American Psychological Association

2002). When seen together, the IPT-A and the CBT models

of therapist competence offer a comprehensive picture of

those therapist competencies required to make use of either

EST for adolescent depression within the context of EBP.

Further research is needed in order to extend this model

framework to the evidence-based treatment of other dis-

orders in children (e.g. externalizing disorders). By

including ESTs for each common psychiatric disturbance

of childhood and adolescence, standard practice guidelines

of EBP with children and adolescents could be developed

to inform more comprehensive training, assessment and

accreditation of mental health care providers.

Limitations and Summary

A limitation of this model exists in the efficacy of the

treatments used to inform the model development. While

ESTs are the best treatments available, they are not

effective in all clients seen (e.g. Harrington et al. 1998;

Mufson et al. 2004c). Thus, any work that reflects these

treatments must also share this vice. This means that even

therapists who would be considered competent using this

model will have clients that are unresponsive to treatment.

Furthermore, little research has been done into which

elements of ESTs are the mechanisms of change, meaning

that some of the treatment techniques and processes

included in this model may be inert. As the field advances

and identifies which treatment elements are responsible for

change, this model of therapist competencies should be

updated to give greater weight to those therapist compe-

tencies corresponding to mechanisms of change, and

eliminate inert elements.

In summary, this model represents those competencies

required by a therapist in order to implement empirically

supported IPT-A. This model can be used to develop dis-

semination and clinical training programs EBP guidelines,

thus offering a variety of potential ways of ensuring

competent therapist practice when treating adolescent

depression.

Acknowledgments The authors would like to extend the utmost

gratitude to all of those individuals who so kindly offered their expert

opinion in the development of this model. In particular, we would like

to thank Jami Young, Anat Brunstein Klomek, Helena Verdeli, Laura

Dietz, Elizabeth Baerg-Hall, Ulla Lith-Hobson and Catherine Carr.

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