This case illustrates how IPT can provide a supportive framework in treating bereavement-related depression. The introduction of the diagnosis appeared a key intervention in this case, as in many grief cases. This did not dismiss or override the understandable and predictable sadness of bereavement, but rather clarified that Ellen was struggling with the added burden of depression. This manoeuvre helped her understand the enormity of her distress and to start to confront the necessary and unnecessary losses she faced. This distinction was a crucial point that she had not been able to consider before, having felt all was lost in her unrecognized depressed state. Considering the differences as well as the similarities between bereavement and depression helped her to allow herself relief from some of the burden.
IPT has an explicit interpersonal focus that evidently contrasted with Ellen’s initial response. This can be a challenge in grief work, when anger and resentment can be directed towards others simply because they are still alive. The fact of existence can become a point of contention, over and above individual relationship issues and expectations. The slow, careful inventory of relationships aimed to engage Ellen in remembering the other people in her life rather than just gathering information. The discussion deliberately focused on both the experience of relationships in the context of the depressive episode and her memories of earlier periods. We thus made a connection with Ellen outside of her depression, in areas of competence and relationships she had temporarily forgotten. This piqued her curiosity and motivation to re-engage with others and resume her own life again.
One distinctive feature of the grief focal area in IPT is the intensity of the affect in and between sessions. Affect is a routine focus in IPT but often appears to be felt more deeply by both patients and therapists in grief focal work. It is crucial that therapists allow time and space for patients to express this, and that the therapist and perhaps even other people in the patient’s life demonstrate their capacity to stay with the patient despite sadness, anger, and fear (Markowitz & Milrod, 2011). This demands a slow, confident pace to the work at times, but without it attempts to reengage with the routines and activities of everyday life may be unavailing.
Affect is often related to unspoken fears or unresolved issues in the relationship with the deceased, as in Ellen’s suspicions of suicide, guilt at not having supported her father, and anger at her mother’s apparent rejection of her father in her own grief. These issues are often difficult to express openly and require gentle but persistent therapist attention. The IPT model provides an tolerant, constructive, and effective framework for working with bereavement-related depression, helping patients to understand and manage the impact of one of the most difficult interpersonal events any of us can face, and to explicitly and deliberately engage with the network who remain while remembering, in full richness and diversity, the person and relationship that has been lost.