Diagnostic Interview and Interpersonal Inventory
The first portion of the pre-group meeting is used to assess the patient’s interpersonal history through standard diagnostic interview and administration of the interpersonal inventory (Weissman et al., 2000). The interview establishes a DSM-IV diagnosis, along with a general formulation that pulls together past development, current stress, and relevant psychological issues. The therapist may then decide whether the patient is suitable for the group being planned.
Patients should be informed if a disorder has been diagnosed, with the intention of assigning to the patient a “sick role.” The therapist should review symptoms, explain them as part of the disorder, and describe the relevant course of treatment. As with individual IPT, the “sick role” temporarily relieves each group member of responsibility for his or her current state, placing the blame, instead, on the diagnosed disorder. Furthermore, assignment of the “sick role” allows each member to receive compensatory (if time-limited) care that has not been adequately received, or felt as received, from others, and informs the patient of the obligation to cooperate with treatment.
The interpersonal inventory allows the therapist to identify targeted interpersonal problem(s) (i.e., interpersonal deficits, role disputes, role transitions, or grief) and to formulate prescriptions for change. In individual IPT, the first few sessions involve a
detailed examination of the patient’s interpersonal history via the interpersonal inventory, and the formulation of problem areas and goals that will guide the therapeutic work. Because this luxury of time is not available in the group IPT format, the therapist must rapidly discern and evaluate patients’ interpersonal problem areas during the pre-group meeting and develop target goals that will become the focus of each patient’s group work. Target goals should refer to specific persons, specific events, and specific interpersonal themes. This ensures particularizing the target goals in language that maximizes personal meaning for the patient. Having identified a goal, the therapist will want to match concrete ideas for change, collaboratively identifying the specific steps the patient will take to improve relationships and socialization. The therapist should provide these goals to the patient in writing and address them with the patient throughout the course of group treatment.
Here are case examples for each of the four problem areas:
Grief. The death of your wife four years ago was a very difficult time. Her lengthy illness with cancer occupied a great deal of your time and energy, and her demanding nature complicated your caring for her. From your description, it appears that you never really addressed the actual event of her death: you looked after all the funeral arrangements, and then returned directly to work. You have acted responsibly in caring for your three young children since then, though perhaps this focus also diverted you from dealing with both the grief and the anger you describe experiencing.
Goal: Unresolved grief is a common trigger for depression. You will need to let yourself go back in time to re-experience all that was happening around the time of your wife’s death. This will be a complicated but important task. On the one hand, you adored your wife; on the other hand, her rather forceful personality became increasingly demanding during her illness. You may help this process of working through the grief by going through pictures or letters you have from your wife and also talking to good friends who were involved at the time. You might also think of reconnecting with her by visiting her grave, something you’ve been avoiding. The group will provide an opportunity to talk about your wife from both the positive and not-so-positive perspectives and give you an opportunity to let yourself grieve.
Interpersonal Disputes. You describe your current depression as being directly connected to a lengthy intimate relationship about which you feel quite ambivalent. On the one hand, you question whether James will allow it to progress from its present state into a full and committed relationship; on the other, you find yourself quite dependent on the relationship to fulfill your legitimate emotional needs for a close bond with someone. You feel that this impasse affects your feelings about yourself and your future.
Goal: No one can make this decision for you, but it is important that you resolve it, by either negotiating a commitment for a future with him or resolving that the relationship must end. It is important to break out of the stuck position in which you have felt yourself trapped for several years. The group will provide an opportunity to explore this relationship and especially the emotions it evokes for you. Talking about the implications of the alternatives and getting ideas from others in the group may help you in your decision.
Role Transition. You see yourself as somewhat sheltered and naive and feel very much under parental supervision, even though your parents live abroad. You are acutely aware of your parents’ admonitions, which are always in your mind, and you describe these negative messages as continually reinforcing your depression. Although you do wish to maintain connections with your parents, you feel that the current ways of interacting are damaging to you. You want to move on to make your own decisions in your life.
Goal: Your goal is to begin setting clear boundaries with your parents. This will entail standing up for yourself and setting limits on your parents’ influence so that you are not as enmeshed in their expectations (or at least your ideas of their expectations). Part of this task is to come to terms with just how emotional you feel about this situation, while maintaining control of your feelings. The group will provide an opportunity to talk about these issues, including your emotions as you experience them in the group, and to develop strategies that allow you to react less to your parents and increase your social network to include more peer relationships.
Interpersonal Deficits. You describe yourself as quite socially isolated, even though you have a variety of potential creative interests that you could share in social groups. From your descriptions, you can be quite open and friendly in the workplace, but this changes immediately when you leave work. Depression generally responds to an increase in interpersonal contact and support.
Goal: It would be helpful to become more actively involved in social organizations associated with your interests. Your membership would be an opportunity to talk to others and perhaps develop some ongoing friendships. You would also have an opportunity to lower your anxiety about how people might see you and whether that corresponds to your view that you are ugly. It will be important to discuss this goal with the group and use the group sessions to monitor efforts to become more involved and self-disclosing.
Finally, before the patient begins the group sessions, the therapist must prepare each patient for group treatment by linking each patient’s individual goals to those of the group as a whole. We encourage patients to think of the group as an “interpersonal laboratory” where they can develop ties to others, examine naturally occurring “impasses” in the formation of intimate relationships in detail, and experiment with new approaches to handling interpersonal problems. We stress to patients that they should not use the group as a substitute for a social network, but use it instead to work on modifying their current interpersonal situations or intensifying important existing relationships.