Interpersonal Psychotherapy and Mentalizing—Synergies in Clinical Practice

Interpersonal psychotherapy (IPT) is an evidence-supported, relationally focused psychological treatment for people living with symptoms of psychiatric disorders and interpersonal difficulties (1–3). IPT focuses on ameliorating interpersonal problems, whereas mentalizing seeks to understand what processes can prevent or facilitate interpersonal problem resolution. The capacity to mentalize and remain open to social learning is linked to the central proposition of IPT for depression—that in understanding oneself and others in relation to one another, interpersonal effectiveness is strengthened for resilience and illness recovery. We review the therapeutic goals and strategies of IPT for depression and the theory and principles of mentalizing and then highlight the clinical synergies of these treatments through a case example.

IPT

The efficacy of IPT has been well established globally, with diverse clinical populations across the lifespan, including in low-income countries. A transdiagnostic meta-analysis of IPT (2) (90 randomized controlled trials, N=11,434) found this therapy had a moderate to large effect size compared with control treatments, was equal in efficacy to cognitive-behavioral therapy or medication, and had sustained effects in reducing relapse. The goals of IPT are to reduce symptoms and to improve functioning by enhancing interpersonal effectiveness. IPT strategies guide affect-focused exploration to understand, resolve, or adapt to current stressful relational experiences and life events that are associated with symptom onset or worsening (see Table 1). These life events are reflected in four focal areas, which frame depression in an interpersonal context (1). When worsening symptoms are linked to the death of a significant person, the grief focus is chosen; when linked to life changes, the role transition focus is chosen; and when linked to conflicts in a close relationship, the role dispute focus is chosen. The interpersonal sensitivities focus is chosen for the treatment of individuals who struggle to form or maintain relationships and “when none of the other interpersonal problem areas exist” (1). Patients with interpersonal sensitivities are assisted to reduce their social isolation and the interpersonal estrangement associated with their current symptoms and to encourage the formation of new relationships. This assistance involves affectively guided exploration of past relationships to identify repetitive interpersonal problems and positive and negative feelings in relationships. Difficulties with perspective-taking and understanding others are targeted to promote resilience and recovery. IPT focuses primarily on relationships outside of therapy, differentiating it from psychodynamic and psychoanalytic models, where transferences within therapy play a central role (4). However, when the focal area is interpersonal sensitivities, how the therapist is experienced by the individual in treatment is also explored (1). It is in this IPT focal area that mentalizing is especially salient to the therapeutic process.

Mentalizing

Mentalizing describes the distinctly human capacity to imagine the motivations and perspectives in our own and others’ minds that underly overt behavior. It is the work of a lifetime, emerging in infancy as the advantageous outcome of a secure attachment and practiced across the life span. At the heart of human relatedness and the social systems in which we live, effective mentalizing is argued to be central to mental health and a basis of all forms of effective psychotherapy (5). Mentalizing theory offers an explanatory model for the evolutionary advantage of making accurate inferences about others’ motivations. The experience of being accurately understood and reflected back confers the “capacity to learn from social experience [social learning] that enables people to respond effectively to adversity and challenge” and to be resilient in the face of stress (6). Insecure attachment patterns of relating (7, 8) can result in mentalizing impairments and poor reflective functioning and are postulated as key features of depressive psychopathology (9). Difficulties in identifying and interpreting one’s own and others’ mental states may underlie an inability to recruit or use social support in a state of depression (10). Attention to social learning and mentalizing in the wider interpersonal network are thus relevant to the key objectives in IPT practice (11, 12).

In mentalization-based treatment, the therapeutic context is used as a vehicle through which mentalization and social learning are promoted. Lapses in mentalizing in the individual and the therapist alike are used to explore the blind spots that may undermine moments of relational effectiveness and satisfaction. Mentalizing theory aids this recognition by highlighting the impacts of an unhelpful dominance of either pole within four dimensions: automatic versus deliberate processing, feelings versus cognitions, self versus others, and internal experiences versus external actions (see Table 1). Connection with supportive others in times of need relies on our ability to process social information and to move fluidly along each of these mentalizing dimensions. Examples of ineffective mentalizing include unwarranted certainty, unsubstantiated presumptions about feelings and beliefs, or insistence on actions to demonstrate intention.

IPT and Mentalizing Synergies in Clinical Practice

The resolution of interpersonal problems and a felt security in close relationships both require and promote mentalizing, which is hypothesized as a mechanism of change in IPT and other therapeutic models (11–16). Individuals in IPT treatment with interpersonal sensitivities may, from a mentalizing perspective, be understood to occupy a state of epistemic mistrust, compounded by current depressive symptoms. Epistemic trust is a concept that describes optimal conditions for social learning, in which the recipient can discern when the other is reliable, trustworthy, and helpful (5, 17). Put simply, when an individual feels safe in a relationship, the individual might think, “you understand me, I trust you, and I am interested in what you have to say and will bring my understanding in line.” The IPT therapist works with the person in treatment to collaboratively discover interpersonal patterns that arise inside and outside the therapy room. Where these patterns relate to epistemic mistrust, they can contribute to worsening depression, perpetuating isolation and interpersonal problems.

Fonagy et al.’s 2014 collaborative framework of social learning in psychotherapy process highlights therapist activities that include provision of a convincing model to understand experience, fostering the emergence of mentalizing in the therapeutic relationship and attention to social learning in the wider interpersonal network (17). Clinical synergies of IPT and mentalizing are summarized in Table 1 and are illustrated within a social learning framework through the following case example of an individual with depression and interpersonal sensitivities.

Case Illustration of Synergies of Mentalizing and IPT

Ethyl, a 53-year-old single, socially isolated, White woman, had symptoms that met DSM-5 criteria for major depressive disorder. She described low mood, anhedonia, decreased energy, poor concentration, and feelings of worthlessness. She was not suicidal nor did she misuse substances. She was referred to IPT for treatment of depression that had worsened after the death of her dog 6 months prior. She conveyed the significance of this loss and her epistemic mistrust by saying, “I am a dog person and not a people person.” Her dismissing attachment style presumed that relationships with others, including the therapist, were not necessarily worth pursuing. She entered therapy reluctantly, unsure how it could help her.

Beginning Phase of IPT and Provision of a Convincing Model to Understand Experience

Early in IPT and following detailed discussion of Ethyl’s current symptoms, the therapist offered psychoeducation and a no-blame diagnosis of depression as understood in its interpersonal context. The therapist approached this discussion gently with Ethyl, recognizing that she prided herself on her pragmatic self-sufficiency and was likely inclined to see depression as a weakness. However, Ethyl also revealed that she struggled to find a way through the isolation and depressive symptoms that had worsened her day-to-day experience since her pet dog and main companion, Brandy, died. She expressed her discomfort with tearful frustration during the first meeting, “Here I go, it’s ridiculous. I have to get over this, and I’m just not.” The therapist recognized that Ethyl did not know how to think about her situation. He invited her to reconsider her symptoms as a treatable mood disorder, closely linked to heightened isolation dating to the loss of her cherished companion.

Ethyl’s reticence toward human interaction became evident when the relational focus of IPT was introduced. Ethyl was not practiced at reaching out to others and reacted, “You ask me to talk about my relationships. I told you, I don’t really have any. I am a dog person, not a people person.” By recognizing the patient’s dilemma when embarking on an interpersonally focused therapy, the therapist had an opportunity to empathically acknowledge Ethyl’s underlying distress, which she found difficult to share openly. Rather than directly challenging her stance of certainty, the therapist focused on the depth of her distress—for many years she had invested in a relationship with her pet, which had provided her with an uncomplicated source of affection and emotional support.

The therapist’s compassionate reflection of Ethyl’s experience invited Ethyl’s deliberate revision of her self-view. However, the emotional intimacy of this experience risked activating dismissing automatic self-reliance, seen in her rebuttal that she did not need to be “mollycoddled.” The dimensions of mentalizing illuminate the knife’s edge on which explicitly reflective practice operates in IPT. Ethyl’s inability to imagine her therapist’s intention creates a roadblock to epistemic trust. Attuned to Ethyl’s internal state and emotions, the therapist wondered aloud whether Ethyl’s current sense of worthlessness and shame might be heightened in the uncomfortable, unfamiliar position of seeking support, which was unnecessary when she had Brandy. The loss Ethyl recognized was used as a platform to tentatively draw attention to her struggle to engage others without her pet companion by her side.

The therapist learned about Ethyl through a historical timeline of relational stressors associated with evolving symptoms and conducted an interpersonal inventory during the beginning IPT phase. The symptom story was populated and contextualized, and it was this integrated narrative that began to shed light on a previously unspoken sense of collapse. Feeling slightly more understood, Ethyl revealed more and reflected that after losing Brandy, “it’s hard to get out without him,” expressing the difficulty in facing life alone. With continued interpersonal inquiry, Ethyl revealed her experience of being routinely rejected, “I am under no illusions. I am not the world’s most pleasant, sunshiny person. I don’t blame people for not wanting to be around me.” Ethyl’s sweeping conclusion exemplifies ineffective mentalizing. Her sense of being rejected was felt with such certainty that she was convinced it was a fact that was in the mind of even casual acquaintances and her therapist. The therapist validated her emotions and encouraged more reflection to counterbalance the automatic and cognitive biases of Ethyl’s view. The intention was to help Ethyl connect to her feelings and to gently shake her conviction that everyone has the same experience of her. In keeping with an IPT interpersonal sensitivities focus, exploring past relationships, the therapist asked, “How did it feel to turn up at the park each day and stand with the other dog owners while Brandy ran off and played? What was it that they did that gave you clues about how they felt about you?” Ethyl reflected that she did not feel altogether uncomfortable or unwelcomed and did not have the sense that others did not want to be around her at the park.

Ethyl described having had few opportunities to develop relationships during her life. Her mother lived with untreated depression and was a passive background presence. Her father struggled to cope with the responsibility of parenting and retreated into his work life and alcohol, making him an inconsistent and sometimes volatile presence. The IPT therapist commented that while Ethyl was growing up, her parents were not able to be as present or responsive as she needed. Ethyl accepted this observation and added that she spent much of her childhood on her own in a lonely and unpredictable household. The uncertainty of her home environment made her reluctant to foster friendships, and this instinct was reinforced when she was victimized by peers at school for being a loner. This early bullying experience compounded her view of others as threatening and unreliable, which in combination with childhood neglect and adversity conferred significant vulnerability for depression. On reflection, Ethyl wondered if some of the feelings she was currently experiencing may first have been evident during her adolescence, although her feelings as a teen were never discussed or acknowledged.

The therapist developed a formulation with Ethyl to place depression in an interpersonal context and to help her understand why she had become depressed, how she might recover, and the relevance of an interpersonal approach for achieving that. In suggesting the interpersonal sensitivities focus, the therapist looked further into Ethyl’s experience of losing her dog, in an effort to understand why that loss meant so much. Although the grief problem area was also considered as a possible IPT focus given the recent loss of Ethyl’s beloved dog, the therapist opted to choose the interpersonal sensitivities problem area because of the salience of Ethyl’s life-long pattern of impoverished interpersonal relationships. In so doing, long-standing relational isolation was understood to amplify the impact of the loss of her canine companion.

Mentalizing theory can guide an understanding of the cost of Ethyl’s isolation. She could not make the imaginative leap required to consider how her actions might make others think and feel. Her persistent withdrawal may be off-putting to others and deprive her of the closeness needed to learn from and sustain relationships. Mentalizing effectively needs to be reinforced by daily practice through collaborative social interactions; however, she was unable to do this on her own. In the absence of frequent social contact with others, unbalanced mentalizing had taken hold in Ethyl, and beliefs about herself and others had come to be taken as facts. The therapist wondered aloud how Ethyl’s early relational experiences may have contributed to her difficulty experiencing others, including her therapist, as worthy of her trust. With this lived experience of being mentalized within the therapeutic alliance, Ethyl began to reflect more deeply about how she may be inadvertently keeping others at a distance.

Middle Phase of IPT for Interpersonal Sensitivities and the Emergence of Mentalizing

For people with interpersonal sensitivities and a paucity of present relationships, the IPT middle-phase strategies include a collaborative review of past relationships to identify recurring patterns. In mentalizing terms, this was an invitation to Ethyl to become curious about her own thoughts, feelings, intentions, motivations, and impacts within relationships, including those to which her mind had been closed. Ethyl and her therapist recognized that she routinely saw herself as a target for others, imagining others as rejecting. Consequently, she maintained her distance, and when Brandy was around, she concealed herself behind him. This behavior often resulted in her being ignored or overlooked, feeling safe but lonely. If others were more persistent, Ethyl would try to dissuade them with irritable or minimal responses, which either led people to back off or elicited a critical response, reinforcing her view of others as rejecting or threatening, and the cycle would repeat. This interpersonally distancing manner of relating, which originated early in life, continued into the present and was compounded by the instinctive withdrawal that exacerbates depression. It is this understanding of the patient’s here-and-now presentation, enriched by awareness of its origins, that serves as a foundation for IPT interpersonal sensitivities work. Ethyl began to consider her self-protective motivation and how its assumed necessity could obscure others’ intentions. The IPT therapist’s careful and emotionally attuned navigation of this previously unconsidered territory helped Ethyl to reconsider the social capital surrounding her. When Ethyl and the therapist became mutually open to the possibility that Ethyl’s emotional experience could cut short her capacity to consider what she and others think and intend, the therapeutic relationship became a vehicle for new learning and the potential for epistemic trust beyond the relationship with the therapist.

In a subsequent session, the therapist offered positive feedback to Ethyl on being more open with him, and she retorted that he was listening to her only because he was being paid. The historical weight of Ethyl’s experience thus overwhelmed her capacity to be present in the moment as she reverted to an internalized model of purely transactional human interaction. The therapist drew on the work they had done in identifying repeating patterns to create an opportunity to apply this new learning in the moment. This pause-and-rewind in the session allowed them to transition from an automatic and externally focused assumption about the other, to deliberately explore feelings provoked in Ethyl in the here and now. The therapist invited Ethyl’s consideration of both her own and the therapist’s perspectives and the possibility of personal emotional investment that may exist within this and other transactions.

This shared understanding of repeating patterns is used in IPT to navigate. In this case, it highlighted how Ethyl was easily triggered into habitually spiky responses that concealed vulnerabilities she might feel. The work within the therapeutic relationship was used to cast light on current examples outside of therapy, a core strategy for interpersonal sensitivities work in IPT. This exploration supported Ethyl to be curious about the alternatives available for new experiences of connection in relationships. In the therapeutic frame of IPT, experiences of mentalizing, with near misses and recoveries, unfold. The impact of these small incremental missteps and realignments opened Ethyl to the communications of others. With such engagement, epistemic trust begins to be restored and the capacity to mentalize inside, and crucially for IPT, outside of therapy is promoted.

Encouraging Social Learning in the Wider Interpersonal Network and Ending Phase of IPT

In IPT, understanding and noticing problematic interpersonal patterns associated with low mood aid in connecting with supportive others. This noticing and understanding creates a platform for social learning, to collaboratively examine and recover when mentalizing with others or self falters, to more effectively engage in a wider interpersonal network. For example, Ethyl experienced feelings of sadness and excitement in an online chatroom conversation, which prompted her to consider getting another dog. Her feelings remained unexpressed at the time, fearful that others would criticize her. Highlighting the similarity of her unexpressed feelings early in therapy offered a perspective to aid reflection. The IPT strategies of communication analysis and role-playing were then used to reconstruct the chatroom discussion step by step, and the therapist worked with Ethyl to consider alternative responses. These strategies, congruent with mentalizing, slow the pace by micro-slicing interactions, during which emotions can be better regulated, and the overwhelming fear of rejection can be held at bay. In a subsequent session Ethyl described the surprise and comfort she felt on hearing other dog owners describe pain reminiscent of her own when they lost a pet. At this point in therapy, both Ethyl and her therapist were able to acknowledge the reduction in the intensity of her depressive symptoms that occurred with the opening of her social communication, bypassing a retreat into an earlier strategy of self-sufficiency.

Mentalizing theory suggests that Ethyl’s avoidance was maintained not only by her symptoms of depression but by her poorly mentalized understanding of the attitudes this affect state generates among others. Epistemic hypervigilance is maintained by automatic application of prior learning, unencumbered by awareness of novel experience and leading to a revised perspective. Reciprocal emotional attunement in IPT helped Ethyl to disrupt this vicious cycle and begin to open herself to learning from current relational experience. As mentalizing is more reliably, albeit not necessarily consistently, established, interpersonal sensitivities work can focus primarily on relationships beyond the therapeutic relationship.

Ethyl’s interpersonal inventory was revisited to explore previously unimagined opportunities for social connection, such as resuming her daily walks in the park, although now pausing to share a coffee with the people previously known to her only by their pets’ names. The incremental interpersonal changes achieved in interpersonal sensitivities work often appear objectively small. Although incremental, they reflect a significant relational reorientation to aid recovery from depression and continue beyond therapy’s conclusion. Ethyl’s depressive symptoms resolved as she was able to feel more safe in connecting and engaging with both her therapist and others in her social universe.

Conclusions

IPT targets depression by helping people connect to social support and resolve interpersonal problems, whereas mentalizing targets lapses in the accuracy with which people understand the motivations underlying their own and others’ actions. IPT may assume implicitly that mentalizing is operating in the IPT guidelines for exploring and resolving interpersonal problems and life events associated with depression onset or perpetuation (Box 1). It is especially in the focal area of interpersonal sensitivities that IPT and mentalizing circle each other’s orbits.

Mentalizing theory can provide IPT therapists with an enhanced road map to reveal and work within the fluctuations of the therapeutic alliance and maladaptive patterns of relating (18). Learning to attend accurately to the mental states of oneself and others fosters social learning for people in whom this ability has been eroded by social isolation, interpersonal estrangement, and depressive states. Crucially for IPT depression treatment with a focus on interpersonal sensitivities, an activation of self-correcting interpersonal learning has the potential to generalize from the therapeutic alliance to relationships outside of therapy (19, 20). Through understanding oneself and others in relationships, resilience can be strengthened for interpersonal problem resolution and illness recovery.