Interpersonal Psychotherapy Group (IPT-G) for Depression

Abstract

A case study of a time-limited interpersonal psychotherapy group (IPT-G) is presented to illustrate the use of interpersonal therapy (IPT) to treat patients with major depression in a group psychotherapy format. The use of individual outcome measures as a helpful adjunct to clinical psychotherapeutic practice is demonstrated. Because IPT-G has only a few exclusion criteria (active suicidality and significant borderline personality features), it can be used in a broad range of clinical settings. This clinical example demonstrates IPT-G to be a useful modality for addressing a common and difficult patient population.

This case study of a time-limited interpersonal group (IPT-G) is presented to illustrate the application of the IPT model to patients with major depression in a group psychotherapy format. Interpersonal psychotherapy (IPT) was developed originally as an individual psychotherapy model in the 1970s by Klerman et al.¹ for the treatment of major depression and dysthymia, and it has since been adapted for the treatment of a range of other conditions. The use of IPT-G has been reported in the treatment of bulimia by Wilfley et al.² and others,³ with efficacy similar to that of individual IPT. These findings are congruent with the results from two recent meta-analytic studies,^4,5 which indicate that individual psychotherapy and group psychotherapy have equal effectiveness across a range of diagnostic populations. IPT in a group psychotherapy format for the treatment of depression has been informally reported, but there are no empirical studies. The recent availability of a treatment manual for IPT-G by Wilfley and colleagues⁶ may encourage the further exploration of this model for diverse patient populations.

As well as illustrating the use of IPT-G, the case report presented here also demonstrates the routine use of formal questionnaires in a clinical setting and shows that the use of such measures can be of clinical interest. There is an increasing expectation that service programs will administer change measures.⁷

IPT-G FORMAT

The 8 members of the group were referred through the Mood Disorders Clinic at a tertiary care university hospital and met DSM-IV criteria for major depressive disorder.⁸ All had an extensive history of depression and had had several adequate trials of antidepressants. Most had an early onset of depression with fluctuating dysthymia. The group was led by a psychiatrist experienced in the use of IPT in both individual and group settings and a psychiatry resident in the fourth postgraduate year. Assessment for each group member involved two sessions and included, in addition to a standard psychiatric assessment interview, the completion of several change measure questionnaires.

Patients were accepted into the group if they were not actively suicidal and did not have significant features of borderline personality disorder. Patients were prepared for the group experience through the discussion of a handout, which outlined the effectiveness of group treatment; how to benefit most from the group experience; expectations regarding confidentiality, attendance, and substance use; and common myths about groups.⁹ The goals of this preparation were to foster cohesion, reduce early dropouts, and establish a bond to the therapist that would provide motivation in the early sessions of treatment.

In the IPT model, patient difficulties are classified into one or more of four problem areas: Grief, Role Disputes, Role Transition, and Interpersonal Deficits. As a second step, up to three specific target goals related to the problem area were developed in collaboration with the patient. The decision to add this step of developing target goals to the IPT format was based on the difficulty of maintaining a clear focus on the individual in the complexity of group interaction as compared with the individual psychotherapy format. During the group sessions, depressive symptoms are consistently related to both the identified problem areas and the target goals.¹⁰

The group met for 14 weekly 90-minute sessions. Several formal group structural components were implemented in the early sessions. Member introductions in the first session were centered on target goals. A detailed review of DSM-IV depressive symptoms and, in particular, a discussion of their effects on each member's life filled the second session. A more detailed review of each member's target goals, including a written Target Goals Form for each member, provided more depth over the next two sessions. Thus, using a number of perspectives, the first four sessions focused on the issues that needed to be addressed during the group experience. A formal target goal review was repeated midway through treatment.

The 21-item Beck Depression Inventory (BDI)¹¹ was the primary change measure. It was completed at assessment, at the midpoint of the group, at the end of therapy, and again at 4-month follow-up (Figure 1). At the beginning of therapy, 6 members had scores in the severe range (BDI>30), and 2 members in the upper portion of the moderate range (BDI between 17 and 29).¹² At 4-month follow-up, 5 patients had scores in the minimal to mild range (BDI<16), of whom 3 had originally scored in the severe level. All of these 5 members had begun to show improvement with the midpoint BDI score rated at the seventh session. The 3 members who met criteria for a personality disorder (2 with avoidant personality disorder and 1 with schizotypal personality disorder) did not improve.

FIGURE 1.

Beck Depression Inventory scores

Group members also completed the Inventory of Interpersonal Problems.¹³ The IIP is a brief 32-item circumplex scale structured around two dimensions, Affiliation and Dominance. The circumplex is filled in with intermediate positions, giving a total of 8 interpersonal styles (Figure 2). The relationship between these interpersonal measures and the patient's experience in the group will be discussed with this figure as a guide.

FIGURE 2.

Inventory of Interpersonal Problems Report Form (IIP-modified)

At the end of treatment, group members were encouraged to maintain a treatment-free period to consolidate and apply gains. The follow-up interview at 4 months provided an opportunity to assess clinical status and the possible need for further treatment.

GROUP MANAGEMENT ISSUES

The interpersonal group model uses the group primarily for its supportive, challenging, and motivational properties. Prolonged discussion of symptoms is discouraged after the full review of symptoms in session two. The group environment is used to promote and explore behavioral and affective responses to interpersonal relationships. Negative relational themes between members are addressed with a problem-solving approach rather than through the use of psychodynamic interpretations. Past relationship patterns, including those in the family of origin, are used to develop an understanding of current patterns. The main focus is on modifying key relationships and socialization patterns in current circumstances.

A major challenge in adapting IPT for the group format is to ensure a continuing focus on interpersonal phenomena. The structure of the first four sessions ensures that all members are aware not only of the issues they must address, but also the other members' issues. This mutual awareness helps to develop a working atmosphere from the very beginning and promotes rapid group cohesion because many members will share the problems being addressed. It is helpful for the group leaders to regularly review the target goals sheets to alert themselves to issues that are being avoided. At the midpoint of the group, each member reviews his or her target goals and discusses progress on each.

IPT is a psychodynamically informed but supportive treatment model. The focus is primarily oriented to current external relationships or situations. Tensions in the group are addressed at an early point in a problem- solving fashion. Extended exploration of process meaning is not pursued. This approach requires restraint on the part of therapists who have been trained in a psychodynamic or Yalom-influenced style of group psychotherapy. One advantage of the IPT approach lies in its constant concern with applying changes to present outside circumstances, using the group as a reflecting arena to report on these efforts and the personal issues that are raised. It also works against the group becoming enmeshed in process issues that detract from the application task. This is an important issue in a time-limited group model.

A description of the group experience of a member from each of the IPT problem areas follows. These vignettes will demonstrate how IPT principal strategies are enacted in a group environment. The Inventory of Interpersonal Problems scores obtained at assessment from each member will be used to demonstrate the emergence in the group of patterns common in outside relationships. Management of these patterns within the IPT-G model will be demonstrated. These phenomena are familiar to any group therapist, and the recognition of them is not solely dependent on the use of the IIP results. However, the use of self-report information has a powerful impact because it alerts the individual members to salient issues that they themselves have identified in this way.

CASE REPORTS

Problem Area: Grief

Member 6 was a single professional man in his early forties with a history of chronic dysthymia and depression in spite of multiple medication trials with augmentation. Clinical assessment revealed a self-doubting, subtly controlling style that made it difficult for him to share his emotional state with others. There was a professional veneer that carried with it a lack of authenticity. These characteristics complicated his grieving of the death of a close family member 3 years ago and the ending of an intimate relationship 6 months ago. During the group, he initially was a sympathetic, supportive and understanding figure for other members. At the same time, he was rather flat and guarded regarding his own relationships. He was leading a very isolated existence and was on a leave of absence from his work.

As the group progressed, there was less need for his supportive role and he became quieter and more withdrawn. He was, however, clearly involved in the group discussion and well accepted by the other members. The therapists made a number of comments linking the themes of loss that were being addressed by other members to his grief reaction, but he did not actively respond. A post-session review of his IIP scores revealed that he had described himself as Too Caring, but also as Non-Assertive and Hard to be Sociable. This combination of segments almost opposite each other on the circumplex suggests the presence of conflictual tension around socializing that might make it difficult for him to address his issues in the group, just as it had been difficult over the preceding 3 years to address his grief. His Non-Assertive style made it difficult for him to initiate important personal material, while his Too Caring pattern caused him to fear that he might upset others if he were to vent his grief. He had volunteered these observations at various points during the first half of the group.

As the group was nearing the midpoint, it became increasingly urgent that his issues be addressed if he were to benefit from the treatment. In a time-limited therapy such as IPT-G, the therapist has a responsibility to ensure that identified problem areas not be avoided. In the seventh session, the therapist took a firm stance and invited the support of the group members in helping Member 6 discuss the events surrounding the death of his family member. A major portion of that session was devoted to the task. His full descriptions of the details of the death and his role in the situation were accompanied by powerful crying. Other group members spoke to him of their own experiences with death. This work continued over the next several sessions as the theme of loss triggered parallel issues for other members. At the recommendation of the therapist, the patient visited the grave and put up pictures of the deceased in his home. He became an active member again, but with a shift in style. He continued to be a helpful agent for other members, but with less emphasis on bland sympathy and more capacity to become engaged in the issues they were addressing. His depression clearly began to lift, and he was freed up to become more engaged with his former friendship circle. At this point, he announced that he would be absent for the next session because he was going to a Club Med resort with a friend. There he had a brief relationship with a woman and some follow-up correspondence. At the end of the group, he mentioned that he had started dating again. As noted in Figure 1, his BDI continued to decrease, and at 4-month follow-up it was in the mild range. He was no longer preoccupied with the death. This phenomenon of continuing improvement for some months after termination is described in the IPT empirical literature.¹⁴

In the group context it is not as straightforward to implement the central IPT Grief strategy of eliciting full details around the death and the nature of the relationship that had existed. In this case, Member 6 did review the basic information. His grieving process was greatly assisted by parallel experiences of several other members who discussed their losses. The group environment therefore helped to promote a cathartic experience through the mechanism of universality and acceptance of the grief. This seemed particularly valuable for this man who feared he would distress others by speaking of his grief.

Problem Area: Role Transition

Member 5 was a woman in her late twenties currently unemployed after completion of a graduate degree and in the process of negotiating a possible relocation with her fiancé to forward her career. A secondary problem area of Interpersonal Disputes was identified in regard to her relationship with her partner. She had had a diagnosis of dysthymia ever since her teenage years, and she had continued to have depression since her diagnosis 3 years ago despite full treatment trials of selective serotonin reuptake inhibitor (SSRI) therapy with augmentation. She described a series of romantic relationships during her university years in which she felt that she had capitulated to her partners and had been used by them. She was currently engaged to a man who had significant drug abuse problems. In the early sessions of the group she described in an angry, complaining tone her efforts to make him stop using drugs. She also spoke of frustration at repeatedly rescuing him from embarrassing social situations or financial stresses. It was clear that she was experiencing difficulties in setting appropriate limits, much as she described her mother dealing with her alcoholic husband. The group members were quite active in challenging her role in the relationship. During the course of the group she made several major decisions that involved taking a firm stand with her fiancé. She became more assertive regarding her unwillingness to tolerate his behavior and the need for it to change. This culminated in her telling her fiancé that she was going to her new job in a distant city and that he would have to choose if he was going to accompany her or not. This appeared to have been an important shift in her predominantly nurturing but self-effacing style.

She played a supportive role in the group but was not overly intrusive or controlling. She displayed early affect in the group regarding her situation that provided a model for other members to emulate, and overall she was competent in her level of interpersonal functioning.

At the time of assessment, it had been determined that Member 5 was primarily dealing with issues concerning Role Transition from dependent student to independent professional. However, initially she brought into the group the distress she was experiencing with her fiancé. As in any beginning psychotherapy, it is important to go with the direction the patient believes is most central. This proved most effective because it allowed her to be more assertive with her fiancé with the help of the group, which expressed in no uncertain terms that the situation was intolerable and needed to be addressed. It also addressed her own self-description on the IIP that pointed strongly to the Too Easily Influenced segment, sometimes termed the exploitable pole. This process of externalizing the issues allowed her to move from her uncertainty about what she could do to stop her fiancé's problems to a consideration of what she needed to do to forward her own ambitions and plans. It appeared that her preoccupation with her partner masked her apprehension about the challenges of moving into a work role in a different city. Treatment allowed her to proceed in addressing these normal transitional challenges.

The therapists were clear in insisting that she be certain that any decisions were truly hers and not those proposed by others. This was not a major concern with this patient but could be one in less competent individuals. Because of the importance of external application in IPT, it is tempting for members to adopt superficial solutions that avoid addressing internal ambivalence.

Problem Area: Interpersonal Disputes

Member 7, a divorced professional woman who lived with her 11-year-old daughter, had had a chronic psychiatric condition since childhood. She had experienced major depressions since her teens, and these became more intense after the birth of her daughter. Over the last 5 years she had had numerous medication trials, with limited response despite augmentation strategies. Although she had devoted a great deal of time and effort to her daughter, she described considerable guilt over her mothering skills. She regularly went through periods of feeling totally overwhelmed, during which she had little energy and strong feelings of hopelessness.

Early in the group, her behavior was of considerable concern to the therapists. Her emotional states were intense and rapidly fluctuating. She would shift from tears regarding her daughter to forceful directive advice to other members. She reported extensive searching of archives regarding what she considered inappropriate treatment when she was a teenager, an event that had not been revealed in several detailed psychiatric assessments. These searches appeared to be an attempt to master painful memories of her early environment. At times, her rapid shifts of focus were destabilizing for the group. The therapists began discussing borderline phenomena and how to contain potential volatility and reconsidered their initial judgment that she had “difficulty in identifying her feelings.”

Entering the middle phase of the group, however, her affective state seemed to settle and become more contained, while her helpful involvement with other members gained positive appreciation. She received considerable support regarding her dedication to her child and her efforts at managing. She actively and vigorously addressed a series of difficult decisions involving the care of her daughter. This effort addressed the degree of enmeshment that existed between them, which had led to a severe restriction on her own personal life and had also been enacted in her overly intense concern for others in early group sessions. She was able to transfer some of this load to other caregivers. In a parallel fashion, she also set firmer limits on a tenant who hosted wild parties in her house and reconsidered her involvement with a boyfriend who could not commit to the relationship. This work appeared to improve her sense of mastery in regard to managing herself and her desired life direction.

The IIP profile of Member 7 revealed some interesting shifts in scores over the course of the group. Her initial IIP profile was in the lower right quadrant. Problems in this quadrant often involve a struggle to contain resentment at being taken advantage of. On follow-up, she rated herself as having fewer problems in the Too Caring area. This had been a major focus during her treatment. However, she also rated herself as experiencing more problems with being Too Revengeful/Hard to Trust Others, segments she had rated quite low at the beginning. It would be reasonable to consider this woman as having addressed her area of initial vulnerability (lower right) followed by a period of adaptation to others' responses to her new style (upper left). It appeared to the therapists that she was overrating her anger and was in no danger of becoming excessively negativistic.

Problem Area: Interpersonal Deficits

Member 3 was a widowed woman in her fifties who lived alone, had a very limited social circle, and worked as an administrator in a small business. She had experienced multiple losses, including a sense of estrangement from her children and the unexpected death of her second husband several years previously. In addition to depression, she met criteria for avoidant personality disorder. Her descriptions of all relationships—family and friends—were replete with negative features. Predominant themes in the assessment interview were inferiority and being blocked from achieving a meaningful future. This interpersonal pattern of defended distancing, coupled with a distrust of the value of self-disclosure, clearly made it difficult for her to engage productively in the group. Interestingly, the other group members appeared to see through this defensive veneer and offered understanding and support that she clearly appreciated but could not acknowledge. She repeatedly stated that she couldn't express herself satisfactorily, despite clear expertise in doing so. She was able to address neither the theme of multiple losses nor her sense of not being understood or nurtured throughout her life, although these were common themes in the group. Though not able to put the thoughts into words, she indirectly expressed her positive feelings to the group with elaborately created personal mementos at the end. She expressed surprise and confusion over the positive comments she received from other members at termination.

DISCUSSION

This case study of a time-limited interpersonal group for depression illustrates the use of IPT in the group setting. In this group, 5 of the 8 members were able to achieve a marked reduction in their depressive symptoms in the course of the 14-week group experience and maintain this improvement for 4 months. All of these responders had an extensive history of major depression, often combined with dysthymia, with poor response to multiple trials of pharmacotherapy. The relatively limited response from the 3 members meeting criteria for personality disorder is in keeping with the individual IPT literature indicating the low response to time-limited intervention by individuals with a comorbid diagnosis of personality disorder. The 4-month follow-up is inadequate to address the question of how much this model might have an impact on recurrence rates. This case study suggests IPT-G to be a promising, cost-effective treatment modality for patients suffering from depression.

Acknowledgments

The authors thank Dr. S. Perkins for her contributions. This paper was presented at the annual conference of the Society for Psychotherapy Research, Portugal, June 1999.