Problem Areas of ITP

I. GRIEF
Normal Grief: Many of the symptoms that normally follow the death of a loved one
resemble depression. In a normal grief reaction, the person feels sad and may lose interest in
usual pleasures, have trouble sleeping, lose appetite and energy, and feel distracted even in
carrying out routine tasks. They symptoms stay for few months as one processes the loss.
This period of grief or mourning is a normal, useful, adaptive process and should be
encouraged, not pathologized.
Complicated Grief: postponing and avoidance of grief is characteristic of complicated
bereavement, a long-recognized form of major depression. Perceiving the feelings of
mourning as dangerous, too painful to contemplate, they try to “keep busy” with other
activities, numbing themselves in the hope that the feelings will subside. Avoiding the
emotions leads the person to try to go through life containing them, distancing herself from
emotional life, and consuming great emotional energy
Less commonly, you may encounter a patient who has become in essence a professional
mourner, whose entire life is devoted to the remembrance of the dead. Eg leaving the room as
it is after the death.
The IPT manuals have always used “complicated grief” or “complicated bereavement” to
define a major depressive episode associated with the death of someone close to the patient.
Even used for Normal grief if the person lacks social support.
Grief in IPT: Therapists select grief as an IPT problem area when the onset of depressive
symptoms is associated with the death of a significant other and the patient is struggling to
come to terms with that loss. in IPT, grief means complicated bereavement postmortem; life
losses that are not deaths are defined as role transition.
A complicated grief reaction may be diagnosed when grief is severe and the severe phase
lasts longer than two months, or when a loved one has died and the patient has not
experienced the normal mourning process.
Eg, guilt, suicidal ideations, not mentioning the dead, avoid circumstances (not going to
grave/funeral), preserve environment, lack of family support, not involved in family/work
even after 2-3 months.
Goals to treat grief:
- facilitate mourning
- re-establish interest and r/s
Three strategies to deal with grief
1. Educate about grief and depression.
2. Facilitate catharsis through letting the patient experience her feelings about the loss. Elicit
the feelings through detailed discussions about the deceased, the death, and the relationship.
3. Find new activities and relationships to substitute for the loss and provide a direction
forward in life
 II. ROLE DISPUTES
IPT defines an interpersonal role dispute as a situation in which the patient and an important
person in the patient’s life have differing expectations about their relationship. This leads to
either an open or a tacit struggle. The depressed individual is invariably losing out in this
conflict, which may be either a source or consequence of a depressive episode
Disputes usually become the focus of IPT when disagreements have stalled, become
repetitive, or stalemated, offering seemingly little hope of improvement. The parties often
feel they have reached an impasse. This situation may make the patient (or both parties) feel
out of control, thus threatening the relationship
The therapist’s goals are to diagnose the seriousness of the dispute and then to help the
patient to reach some resolution. A role dispute is one of the most common problem areas for
depressed patients seeking outpatient treatment
Role disputes frequently coexist with role transitions. A change in job, birth of a child, or
geographical move (role transition) may strain a marital relationship, causing a role dispute
over responsibilities at home.
Goals
the goals of treatment are to help the patient identify the disagreement, choose a plan of
action, and modify communication or expectations or both to resolve the difference of
opinion. The therapist must help the patient to consider what options exist to attempt a
renegotiation of the relationship. Patients learns better social skills and understanding of the
dynamics of the relationship.
Role disputes emerge from taking a careful history and collecting an interpersonal inventory.
Stages of Dispute
1. Renegotiation: Renegotiation means the parties are in active contact about their
differences. Are they aware or tried to change things. (therapist teaches new ways to
communicate)
2. Impasse: An impasse exists when discussion between the patient and the other person
has stopped. There is smoldering, low-level resentment and hopeless resignation but
no attempt to renegotiate the relationship. “Silent treatment”, no point talking even if
it hurts now. (bring issues out int the open)
3. Dissolution: Dissolution may be appropriate when the relationship is irretrievably
disrupted by the dispute and one or both parties actively strive to terminate it through
divorce or separation, by leaving an intolerable marriage or work situation, or by
ending a soured friendship. Could lead to loss of relationship (role transition)
Management of Role Dispute
- Elicit patient’s feelings
- Validate and normalize
- Explore options
- role play
III. ROLE TRANSITION
The IPT category of role transition is a broad and flexible one, often available to the therapist
for treating patients who have not experienced the death of a significant other and do not
report a charged role dispute. Depression associated with transitions occurs when a person
has difficulty coping with a life change that affects her mood and requires different behavior
or modifications in one or more close relationships.eg child birth, divorce, retirement, new
job, leaving home, medical disorder etc.
Two aspects of a role transition may be upsetting. One is the loss of the old, familiar role,
which may evoke a depressed nostalgia (“If only I could get back to that” or “Things were
okay then”) and reflect the disruption of social supports. The individual may also feel
depressed and anxious about the unfamiliar new role, which can appear overwhelming and
unpleasant
The aims of treating depression associated with a role transition are to understand what it
means to the patient. The therapist basically focused how to mourn the life before the loss and
see the limitation of the past “ideal” life. and further help acknowledge difficulties in new
role and advantages of new role.
Goals and strategies:
Five tasks help the patient manage transition problems:
• Giving up the old role
• Mourning the old role: expressing sadness, guilt, anger, powerlessness, and fears about
the loss
• Acquiring new skills, exploring opportunities for growth due to the change
• Developing new attachments and support groups
• Recognizing the positive aspects of the new role

IV. INTERPERSONAL DEFICITS (Social Isolation, No life events)

Interpersonal deficits, loneliness, social isolation, or a paucity of attachments may be chosen
as the focus of treatment if none of the other interpersonal problem areas exist. In a treatment
designed to address life events, this category covers those patients who present without acute
life events. The somewhat confusing term “interpersonal deficits” should be understood to
mean “none of the above”:
• No deaths (hence, no grief)
• Minimal relationships (hence, no role disputes)
• No life changes (hence, no role transitions)
• A paucity of attachments.
Patients treated for interpersonal deficits in IPT may have poorer outcomes than patients in
other categories (Elkin et al., 1989; Markowitz & Swartz, 2007; Levenson et al., 2010) and
might do better in an alternative treatment such as CBT or might require long-term treatment
(although no data exist to support this statement).
Patients who fall into this category have few of the social supports that protect against
depression, usually have impaired social skills, and feel uncomfortable in interpersonal
situations. They tend to be isolated and lonely, and chronically so.
we see interpersonal deficits as the non–life event category of IPT, only for use in the
relatively rare circumstance when the therapist can locate no life events in the patient’s
history
At least four types of patients may fall into this category:
• Individuals who are socially isolated, who lack relationships either with intimate friends or
at work, and who have longstanding problems in developing close relationships
• Individuals who have an adequate number of relationships but find them unfulfilling and
have problems sustaining them. (The quality of the relationships may be superficial. These
people may have chronic low self-esteem despite seeming popularity or work success.)
• Chronically depressed or dysthymic individuals who have lingering symptoms that have
gone untreated or been inadequately treated and whose symptoms interfere with relationships.
(If chronic depression is the issue, the adaptation of IPT for dysthymic disorder may be worth
attempting; see
• Individuals who have social anxiety disorder with social phobia may want to have, yet fear,
relationships
The interpersonal deficits focus differs from the others in lacking an acute focal life event.
Although lack of relationships can be a major life stressor, it is often a chronic, not an acute,
condition
Goals and Strategies:
The major task in this problem area is to reduce social isolation by improving the patient’s
skills in tolerating social anxiety, spending time with and talking to people; increasing the
patient’s self-confidence; strengthening the patient’s current relationships and activities; and
helping her to find new ones or even focus on past ones. Thus, help in a temporary step
toward better social functioning in outside relationships.
The three tasks are:
• To review past significant relationships, both good and bad
• how they view current friends and family
• To explore patterns of strengths and difficulties in these relationships
• To discuss the patient’s feelings—positive and negative—about any current relationships
(including possibly that with the therapist