The Development and Content of an Interpersonal Psychotherapy ...

INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 62 (2) 2012

The Development and Content of an Interpersonal Psychotherapy Group for Postnatal Depression REBECCA E. REAY, PH.D. RIANNON MULCAHY, PH.D. ROSS B. WILKINSON, PH.D. CATHY OWEN, M.D. BRUCE SHADBOLT, PH.D. BEVERLEY RAPHAEL, M.D.

ABSTRACT

Postnatal depression (PND) usually causes distressing symptoms for sufferers and significant impairments in relationships. Group Interpersonal Psychotherapy (IPT-G) provides the experienced therapist with a brief, focused, and manualized approach to helping women recover from the debilitating effects of PND. This paper describes the background and development of IPT-G for PND. The evidence for the effectiveness of individual and group IPT formats with this population is summarized. The triad of theories underpinning IPT are discussed with an emphasis on the important role of attachment styles during the transition to parenthood. Its strengths, which include its unique package of targets, tactics, and techniques, are highlighted. The benefits and challenges of IPT-G are also explored, and the results of a randomized controlled trial are summarized. Finally, a case study illustrates how IPT-G specifically addresses the social role transitions, conflicts, losses, and social isolation that mothers commonly experience. Rebecca E. Reay is a research officer at the Academic Unit of Psychological Medicine, Australian National University (ANU) Medical School, Canberra. Rhiannon Mulcahy is a clinical psychologist at the Perinatal Mental Health Department, Mercy Hospital for Women, Melbourne. Ross B. Wilkinson is a senior lecturer in the Department of Psychology, Australian National University, Canberra. Cathy Owen is a professor at the Rural Clinical School, ANU Medical School, Canberra. Bruce Shadbolt is Director of the Centre for Advances in Epidemiology and Information Technology, The Canberra Hospital, Canberra. Beverley Raphael is Professor and Head of Psychological Medicine at the Academic Unit of Psychological & Addiction Medicine, ANU Medical School, Canberra.

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aving a child is a life-changing event that can involve significant changes in roles and responsibilities within families and relationships. For women, it is a time of increased vulnerability to a range of mental health problems and disorders, including postnatal depression (PND), the most frequent form of maternal morbidity after delivery (Stocky & Lynch, 2000). A systematic review of prevalence studies concluded that as many as 7.1% of mothers experience a major depressive episode in the first three months postpartum (Gavin et al., 2005). When minor depression was included in the analysis, the prevalence rate increased to 19.2%. This condition has well-documented impacts on the mother, the child (Cogill, Caplan, Alexandra, Robson, & Kumar, 1986; Cooper & Murray, 1997, 1998; Josefsson & Sydsjo, 2007), her partner, and family (Cox, Connor, & Kendell, 1982; Dennis & Letourneau, 2007). Further, mothers affected by PND report lower levels of partner support (Cooper, Campbell, Day, Kennerley, & Bond, 1988) and poorer social support (Dennis & Letourneau, 2007) compared with other families. Partners of women with PND generally find it a negative, bewildering experience (Gruen, 1990; Morgan, Matthey, Barnett, & Richardson, 1997), and PND is associated with greater rates of marital conflict, separation, and divorce (Boyce & Stubbs, 1994; Holden, 1991). The strong evidence that PND can set in motion detrimental, far-reaching impacts on women and families has made this condition a significant public health priority. THE TREATMENT OF POSTNATAL DEPRESSION

Despite the high prevalence and negative impacts of PND, several reviews of the evidence have generally concluded that the quality and quantity of treatment research is very limited (Boath & Henshaw, 2001; Craig & Howard, 2009; Cuijpers, Brannmark, & Van Straten, 2008; Dennis, 2004; Dennis & Stewart, 2004; Pope, 2000). For instance, there has been an absence of large, placebocontrolled randomized controlled trials (RCT) of antidepressants that include breastfeeding women. Furthermore, antidepressant studies generally suffer from high attrition and refusal rates (Appleby, Warner, Whitton, & Faragher, 1997; Wisner et al., 2006;

GROUP FOR POSTNATAL DEPRESSION

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Yonkers, Lin, Howell, Heath, & Cohen, 2008), in part due to women’s concerns about unpleasant side effects and unknown effects on breastfed infants (Dennis & Chung-Lee, 2006; Pearlstein et al., 2006). While non-directive counseling (NDC) appears to be effective for mild to moderate depression, a significant proportion of women do not appear to benefit (Holden, Sagovsky, & Cox, 1989; Wickberg & Hwang, 1996). Although cognitive behavioral therapy (CBT) is a well-established, efficacious treatment for general depression, CBT (individual or group) has consistently been found to be no more effective than NDC, ideal primary care, individual counseling, or medication with this population (Cooper, Murray, Wilson & Romaniuk, 2003; Meager & Milgrom, 1996; Milgrom, Negri, Gemmill, McNeil, & Martin, 2005; Prendergast & Austin, 2001). Only psychodynamic psychotherapy has been found to be more effective than NDC and CBT, but only in the short term (Cooper et al., 2003). Other studies have suggested that peer support (Dennis, 2003; Dennis et al., 2009), Relational-Developmental group therapy (Kurzweil, 2008), exercise (Armstrong & Edwards, 2003, 2004), mother infant massage (O’Higgins, St. James Roberts, & Glover, 2008), and oestrodial, a hormone treatment, (Gregoire, Kumar, Everitt, Henderson, & Studd, 1996) may be beneficial in the treatment of PND although further research is required. Interpersonal Psychotherapy for Postnatal Depression

According to Pearlstein (2008), Interpersonal Psychotherapy (IPT) is the most extensively studied psychosocial treatment for PND. Stuart and O’Hara adapted IPT to the issues of postpartum women in an open clinical trial with positive results for treated mothers (Stuart & O’Hara, 1995) and established its efficacy in a larger randomized controlled trial (O’Hara, Stuart, Gorman, & Wenzel, 2000). Clark and colleagues reported that individual IPT was as effective as a mother-infant group, and both were more effective than a wait list control condition (Clark, Wenzel, & Tluczek, 2003). The first study to test the potential effectiveness of group IPT adapted to the postpartum was conducted in Austria by Klier and colleagues (Klier, Muzik, Rosenblum, & Lenz, 2001). Twelve sessions of IPT-G was associated with significant reductions

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in depressive symptoms, a result that was maintained at the sixmonth follow-up. However, partners were not directly involved and there was no measureable improvement in partner relationships at the end of treatment. In Australia, a 10-session IPT-G intervention was piloted which included a partners-only session (Reay et al., 2006). Mean depression scores significantly decreased from pre- to post-treatment and were maintained at the three-month follow-up. Further, there was a significant improvement in the partner relationship, although not in overall social support. These two studies provided some evidence for the potential effectiveness of IPT-G as a treatment for PND, although both were limited by small sample sizes and the absence of a control group. The rationale for an interpersonally focused intervention is based on extensive evidence of a clear link between women’s relationships and postnatal depression. Having healthy, supportive relationships and adequate social support has been shown to protect individuals against the development of mental health problems (Henderson, 1977; Henderson, Byrne, & Duncan-Jones, 1982). Conversely, relationship changes, conflicts, and losses can increase women’s vulnerability to depression (Cox et al., 1982; Dennis & Ross, 2006; Gotlib, Whiffen, Wallace, & Mount, 1991; Kumar & Robson, 1984; O’Hara, Rehm, & Campbell, 1983; O’Hara & Swain, 1996). Interpersonal Psychotherapy (IPT) was developed in the 1970s by Klerman, Weissman, and Rounsaville (1984) as a treatment for individuals with major depressive disorder. IPT has since accumulated strong empirical evidence supporting its efficacy as a treatment for general depression (Churchill et al., 2001; Cuijupers, van Straten, Warmerdam, & Andersson, 2009) and a wide variety of psychiatric disorders (see Markowitz, 2006, for an overview). IPT is now recognized as an efficacious treatment in various treatment guidelines (American Psychiatric Association, 1993; Depression Guideline Panel: Clinical Practice Guideline, 1993; National Institute for Health and Clinical Excellence, 2007). Pilot studies have demonstrated its potential effectiveness with major depression (Levkovitz et al., 2000; MacKenzie & Grabovac, 2001) and posttraumatic stress disorder (PTSD; Ray & Webster, 2010; Robertson, Rushton, Bartrum, & Ray, 2004). A simplified version of group IPT, trialled with Ugandan villagers experiencing


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high rates of poverty, HIV, and depression was shown to be more effective than treatment as usual (Bolton et al., 2003). Overview of the Defining Elements of IPT

Several influential textbooks have been published which include the updated manual (Weissman, Markowitz, & Klerman, 2000); group IPT manual for bulimia (Wilfley, Mackenzie, Welch, Ayres, & Weissman, 2000); and two more recent clinical guides (Stuart & Robertson, 2003; Weissman, Markowitz, & Klerman, 2007). These key manuals have further articulated the underlying theories, empirical research, and the evolving practice of IPT. As with all therapies, some of the components of IPT are not exclusive to this treatment. However, it is the unique combination of theory, targets, tactics, and techniques that define it as original (Stuart, 2006b). IPT theory. In their clinician’s guide, Stuart and Robertson (2003) describe a biopsychosocial model for understanding patients’ mental health problems that is underpinned by three theories of human behavior: attachment theory, communication theory, and social theory. Attachment theory (Bowlby, 1969, 1973, 1979) provides one of the most important foundations for IPT. According to Bowlby, the desire to form attachments or emotional bonds to other human beings is an intrinsic need that is critical for survival. Stemming from psychological, evolutionary, and ethological research, attachment theory hypothesizes that the early bond between infant and primary attachment figure is fundamental to the development of the infant’s sense of security. The parents’ responses to the child’s bids for security lead to the development of patterns of attachment which can generally be described as either secure or insecure. These early attachment “styles” (Ainsworth, Blehar, Waters, & Wall, 1978) represent cognitive “internal working models” that guide the individual’s thoughts, emotions, behaviors, and expectations about the self and others and can influence relationship interactions across the lifespan (Bowlby, 1979). A series of landmark studies demonstrated that attachment styles could also be identified in adult attitudes to a range of significant others (Bartholomew & Horowitz, 1991; Hazan & Shaver, 1987; Main, Kaplan, & Cassidy, 1985).

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Alexander, Feeney, Hohaus, and Noller (2001) proposed that adult attachment theory is uniquely suited to the study of the transition to parenthood. An attachment theory perspective would suggest that when couples experience anxiety and stress they seek each other out for support and reassurance. If both partners are securely attached, then they typically respond by offering either emotional or instrumental support (Simpson, Rholes, & Nelligan, 1992). Based on their early, positive parental experiences, these individuals have come to expect that the people in their lives can be trusted and will largely respond to their needs. They also tend to have extensive social networks which buffer against many of life’s stressors. Insecurely attached individuals, on the other hand, are more vulnerable to mental health disorders (Dozier, Stovall, & Albus, 1999; Main, 1995). Their early experiences are often characterized by parental misattunement, neglect, or abuse. Individuals with an anxious attachment style are preoccupied with getting their attachment needs met. They desire a high level of closeness and are often fearful that others will not reciprocate. As a result, they constantly seek support and reassurance and have a tendency to exhaust the people in their lives with their overwhelming needs. Those with an avoidant attachment style expect their attachment needs will never be met and they adapt to their distress by minimizing the importance of relationships, emphasising autonomy and self-reliance. For couples in which one or both partners are insecurely attached, the demands and changes brought about by having a baby may activate insecure working models. Mothers with insecure attachment styles are more likely to report high levels of marital dissatisfaction and discord and are considerably more vulnerable to developing postnatal depression (Wilkinson & Mulcahy, 2010). Further, marital dissatisfaction (at four months postpartum) and insecure attachment styles have both been shown to predict persistent depression (McMahon, Barnett, Kowalenko, Tennant, & Don, 2005; McMahon, Trapolini & Barnett, 2008). The findings from these studies lend support to the applicability of interventions, such as IPT, that are informed by attachment theory and aimed at improving the interpersonal functioning of vulnerable mothers. Communication theory provides the basis for understanding how individuals with insecure attachments styles employ maladaptive


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communication styles. These communication patterns are thought to inadvertently elicit unhelpful responses from their relationships (Kiesler, 1996; Kiesler & Watkins, 1989). Exploring and modifying the patient’s unique pattern of communication is the intention of treatment with IPT. Social theory provides the basis for understanding how problems in the patient’s social networks impact on their mental health and functioning (Henderson et al., 1982). In contrast to other psychotherapies that emphasize the influence of unconscious processes and early life experiences, social theory views current social network difficulties as a casual factor in the development of psychological problems. Support for this assertion rests on the abundant evidence that inadequate social support is a risk factor for postnatal depression and other mental health problems (Brugha et al., 1998; Honey, Bennett, & Morgan, 2003; Milgrom et al., 2008; O’Hara & Swain, 1996). Social theory suggests that treatments which have an impact on a patient’s current social environment are likely to lead to improved functioning and well-being. Targets. While IPT recognizes the important role of biological, psychological, and early life experiences in the development and maintenance of psychiatric difficulties, treatment focuses on the patient’s key interpersonal relationships and social support network. It does not target or attempt to alter an individual’s attachment style, personality, or defenses, although an awareness of these characteristics is used to enrich the therapist’s understanding of the patient, his or her functioning in relationships (including the therapeutic relationship), and the selection of appropriate techniques and strategies. Figure 1 illustrates the IPT model of postnatal depression representing the influence of biological, psychological, social, and interpersonal factors in its genesis. Tactics. The tactics of IPT include the structure of therapy, Interpersonal Inventory, Interpersonal Formulation, and specific IPT problem areas. The acute phase of treatment is structured into the initial, middle, and concluding stages, with specific tasks to be achieved by the patient and therapist. During the initial phase, the Interpersonal Inventory—which is essentially a detailed description of the patient’s key relationships, the history of current problems, and communication patterns—is obtained. It is used to establish treatment goals and guide therapy, serving as a monitor for progress.

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Biological factors Genetics History of depression Family history Medical illness and treatments Substance use

Psychological factors Attachment style Temperament Cognitive style Coping mechanisms

Social factors Intimate relationships Social networks

Personality

Unique individual

Interpersonal precipitants Role transitions Interpersonal disputes Grief and loss Interpersonal Sensitivity

Postnatal depression

Figure 1. The IPT Model of Postnatal Depression (Adapted from Stuart & Robertson, 2003)

Once this is established, the therapist collaborates with the patient to establish an Interpersonal Formulation of their difficulties. In essence, this is a concise and plausible working understanding of how the patient’s distress has developed. The Interpersonal Formulation enables a focus on the IPT problem areas of role transitions, disputes, grief, and interpersonal sensitivity. Each specific problem area, described below, is associated with a number of strategies for assisting patients to resolve their unique difficulties. IPT problem areas. The IPT problem areas are considered to be highly applicable to mothers affected by PND as they specifically address the social role transitions, conflicts, losses, and social isolation that mothers commonly experience (Grigoriadis & Ravitz, 2007; Stuart & Robertson, 2003). The arrival of a baby can alter important social roles and relationships central to a woman’s identity, creating anxiety and confusion. The strategies associated with


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role transitions assist mothers to mourn their lost roles, better adapt to the changes, and develop some of the skills required in the new role. Familiar social networks may need to be modified, old relationships renegotiated, and new ones established. Disputes become the focus of therapy when there is evidence of misaligned or non-reciprocal role expectations. This problem area is designed to help patients understand their expectations and ways to communicate them more effectively. Grief is addressed as a problem area when the onset of depression is associated with a death or perinatal loss, either past or recent. Mothers are assisted to work through the loss, enhance their key relationships, and construct a more supportive social network. Interpersonal sensitivity is chosen when individuals experience difficulties forming or sustaining relationships. The therapeutic relationship is often used to provide necessary feedback and build social skills. Techniques. Resolution of the patient’s interpersonal difficulties is achieved by working through each problem area, using a variety of techniques. The effectiveness of these techniques relies on the quality and strength of the therapeutic relationship. The therapist establishes this relationship through warmth, genuine concern, empathy, and understanding, without which the techniques are of little use (Stuart, 2006a). The techniques of IPT may assist a woman to articulate her needs and expectations (clarification), to acknowledge her accompanying feelings (use of affect), to explore specific incidents (interpersonal incidents), with general communication patterns (communication analysis), and to devise and implement helpful ways of dealing with her problems (brainstorming, problem solving, role playing). The therapist takes into account the patient’s unique characteristics, attachment style, and the strength of the therapeutic relationship when selecting appropriate techniques. THE DEVELOPMENT OF IPT-G FOR PND

Given the strong evidence for the effectiveness of individual IPT and similar efficacy between individual and group IPT, we embarked on the development of a group intervention for this population. The first application of IPT-G for postpartum depression was published by Klier and her colleagues in an open, pilot trial (2001). The authors described the protocols for a 12-session

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intervention based on a modified version of the manualized IPT-G for bulimia (Wilfley et al., 2000). The design of our intervention is also informed by the pioneering work of Wilfley and colleagues (2000), along with IPT-G applications for major depression (MacKenzie & Grabovac, 2001) and PTSD (Robertson et al., 2004). We endeavored to create a feasible and viable group intervention taking into account the unique issues and barriers to care experienced by postpartum mothers. Protocols were modified to address the challenges, losses, and changes in relationships associated with becoming a parent (Stuart & O’Hara, 1995). In terms of the IPT problem areas, our experience from the pilot study highlighted that mothers suffering from PND generally present with role transitions, disputes, and/or social isolation. As a result, the treatment manual specifies structured sessions that focus on these issues. Grief as an IPT problem area is rarer, although it can be incorporated into the group sessions using the therapist’s clinical judgement. We agree with Stuart and Robertson (2003) that the fourth IPT problem area described in the original manual, interpersonal sensitivity, is best viewed as an insecure attachment style which gives rise to the other three problem areas. Therefore, we have not directly addressed it in the session plans, although careful assessment and attention to the therapeutic stance, alliance, and pacing of the change process are required for these mothers. Taking these multiple factors into consideration, an eight-week group intervention for postnatal depression was developed and manualized (available from the corresponding author). The Benefits and Challenges of an Interpersonal Psychotherapy Group

Groups have a valuable set of unique therapeutic characteristics that make them an appealing treatment option (see Yalom & Leszcz, 2005 for a review). They can provide women with a supportive network of peers who often share similar feelings, thoughts, and problems. Within the safe environment created by the group, mothers experience a sense of cohesiveness and belonging, enabling them to focus on their relationship issues. Women become aware of the universality of their problems, and this helps to normalize their experiences. Group participants can encourage each other to express their needs and wishes, which are, arguably, more


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powerfully reinforced when validated by peers. An “interpersonal laboratory” is created in which women can work through interpersonal problems, observe, and learn from others. Role plays in individual therapy are often limited to the woman playing the role of herself or another person in her life. In group therapy, women can play the role of another participant, enabling them to experience other perspectives. Likewise, communication analysis and brainstorming of solutions involve all participants. These additional aspects of group IPT help women to share coping strategies, gain insights, and expand their knowledge and skills through vicarious learning and feedback. Helping others to solve problems can enhance women’s self-esteem and restore a sense of competence. When women embark on the challenging process of transferring these skills to their lives, their peers can act as cheerleaders, reinforcing their endeavors. Witnessing the success of others at solving problems can instill a sense of hope and optimism in the whole group. In addition, mothers can potentially continue to meet and assist each other at the conclusion of the therapy sessions. This ongoing social support, reinforcement, and encouragement can be invaluable in easing women through the transition from the highly structured, weekly therapy to working autonomously. It should also be noted that groups pose some challenges for therapists and group participants. IPT-G therapists need a sound understanding of group stages, group dynamics, and their mechanisms of action as well as the skills to establish a well-functioning group (Bernard et al., 2008). Disturbances can be magnified in the group setting compared to individual therapy. For example, dropouts can be more problematic than in individual treatment, as the loss of a group member can affect the group size, relationships, and dynamics. The inclusion of infants in a group setting is more disruptive than in individual therapy, and therefore, childcare is usually provided on site by experienced carers, thus allowing easy access for breastfeeding. However, some mothers are reluctant to be separated from their babies for any length of time and may perceive this aspect of treatment as an obstacle. Further, not all peer support is positive. Potential negative factors of peer support reported in the literature include conflicts, criticism, and minimizing others’ problems (Dennis, 2010). Therapists also

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need to be mindful that women are prone to unfavorably comparing themselves to others, which can diminish their confidence (Fleming, Klein, & Corter, 1992). The following case vignette, using pseudonyms for the patients, highlights some of the challenges of conducting IPT-G with mothers affected by PND. Imelda was a first-time, married mother who had moved to Australia during her pregnancy. Her nine-month-old infant was very unsettled and had difficulties sleeping. Further, Imelda’s family lived overseas and she had few supports in Australia. Imelda was assessed as having moderate to severe postnatal depression on the background of an anxious, insecure attachment style. At the initial group sessions, the co-therapists observed that Imelda was experiencing significant separation anxiety and needed additional support and reassurance in order to leave her daughter in childcare. Without extra support it was likely that Imelda would have dropped out of the group. During the first group psychoeducation session, Imelda commented that “all mothers should stay at home with their babies for at least the first year.” Her comment, delivered in a lecturing manner, lacked empathy and elicited a negative reaction from some group members, many of whom worked or used childcare. Sandra, a full-time working mother, was observed to disengage from the group following Imelda’s comments. The therapists observed the maladaptive communication patterns of both parties, considered their insecure attachment styles but elected to delay dealing directly with the conflict until sufficient group trust and cohesion had developed. The next week Sandra called to say she couldn’t attend the next group due to work commitments. With the therapist’s encouragement, Sandra acknowledged her hurt feelings at the perceived criticism from Imelda, saying she was considering dropping out all together. The therapist expressed understanding and encouraged Sandra to communicate her concerns at the next group session, as this was a recurrent problem in her other relationships. One of the group facilitators commenced the group by encouraging the women to raise any issues related to the group agreements. Sandra spoke about her perception of being criticized by Imelda


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and thoughts of leaving the group. The therapist commented, “Imelda, you came to the group to broaden and strengthen your social supports, to improve the way you communicate with others. Sandra, one of your goals is being able to resolve conflicts with people you perceive are criticizing you. This seems like an opportunity to address those issues more directly right here and now. I wonder, Imelda and Sandra, if you would be willing to look in more detail at that interaction to see if we can try to resolve what happened between you.” The therapist carefully encouraged both parties to better express their conflicted thoughts and feelings about separating from their children. Other group members empathized with the tension created by conflicting desires: to nurture their children and yet have time to themselves. The discussion enabled a richer understanding of this very common difficulty for many mothers. Over the successive groups, the group therapists invited Imelda and Sandra to “give each other some feedback on what you are finding more helpful or effective with each other.” Over time and with support and encouragement from other members, Imelda was more easily able to separate from her daughter and fully participate in the groups, while Sandra reported she was speaking up more about her needs and feelings with the important people in her life.

Although there is little empirical evidence to guide therapists, clinical experience suggests that some women may not be suited to IPT-G. For example, women who are experiencing current domestic violence, child neglect or abuse, suicidality, severe personality disorder, or serious substance abuse problems are likely to be less suited. These complex problems can monopolize the therapy time and cause distress to other participants, making it difficult for them to focus on their own issues. According to Grigoriadis & Ravitz (2007), many of these issues make women unsuited to short-term treatments in general. Despite careful selection procedures, participants may express current thoughts of suicide, child abuse, or report domestic violence during group sessions. Group leaders need the skills to be able to competently manage any such difficulties or crises that arise. Bernard and colleagues (2008) caution that patients who demonstrate poor psychological mindedness, motivation, or insight; high degrees of defensiveness; and elicit negative reactions from others are often poor candidates for

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group therapy. Despite some of the potential limitations of groups, our experience is that mothers tend to quickly establish highly cohesive, supportive environments and that conflict between members is infrequent. Further, clinical experience has revealed that many of the above issues can be addressed through careful client selection, thorough preparation of participants, clear group agreements, and addressing any conflicts that arise. THE IPT GROUP THERAPY PROGRAM

This program was developed during the trial of group IPT, piloted in the Australian Capital Territory (Reay et al., 2006). The program consists of two individual sessions and eight weekly, twohour group sessions. The decision to conduct a relatively brief intervention (10 sessions) was influenced by the positive findings of two interventions, IPT-G for PTSD (10 sessions: Robertson et al., 2004) and brief IPT for depressed women (8 sessions: Swartz et al., 2004). Further, there is empirical evidence that 80% of clinical improvement is obtained in the first eight therapy sessions; beyond that, participants are more likely to drop out (Howard, Kopta, Krause, & Orlinsky, 1986). In order to maximize participation, the groups were run at local community centers, and free childcare was provided by accredited childcare staff adjacent to the group facilities. Two therapists conducted the sessions, alternating the dual roles of actively facilitating the group and monitoring the group processes. A two-hour partner’s evening was incorporated, as partner support has been shown to assist women’s recovery (Misri, Kostaras, Fox, & Kostaras, 2000). Although increasing numbers of women are choosing to have children in the context of same-sex relationships, we have not trialled the program with lesbian or bisexual mothers and their partners. Whether this program addresses the unique issues experienced by these women would be an interesting area for further study. Group Stages

Individual pre-group session. The individual pre-group session has two essential aims: to establish interpersonally focused treatment goals and to facilitate active participation in therapy. As


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part of the orientation, it is essential that the therapist explain what happens in IPT-G and address any concerns and anxieties about participating. The therapist then needs to review symptoms, confirm the diagnosis, and begin an interpersonal inventory of the woman’s key relationships. During this process, the therapist emphasizes the link between depression symptoms and relationship issues. Then the patient and therapist draft three to four written goals, derived from the three IPT problem areas described above. Women are socialized into their role in the group in order to maximize participation, encourage helpful behaviors, and prevent disruptive actions (e.g., lateness, missed sessions, non-adherence to group rules). A written guide is provided on what happens in an IPT group and also contains practical information on the group times, dates, and location. Women are also provided with a written copy of their draft goals to bring to the first group, one of which will be identified as the primary clinical focus. Initial sessions. The focus of the initial two group sessions is to cultivate group cohesion and establish collaborative relationships. The group leaders set the scene by initiating an ice breaker exercise designed to welcome and introduce participants to each other. A psychoeducation session encourages women to share their experiences of postnatal depression and its impact on their relationships. The therapists establish the interpersonal focus of the group by linking the symptoms of members to the interpersonal context. To consolidate the principle problem areas and refine goals, the therapists encourage appropriate self-disclosure of each member’s focus. Group members are educated about the group structure and their role in treatment. These expectations include promptness, remaining focused on “here and now” interpersonal issues, working actively on goals between group sessions, and refraining from contact or socializing together during the duration of the group. The latter point is usually accepted by members when its rationale is explained in terms of preventing the development of divisive cliques. Members are encouraged to directly raise any issues with the group and any concerns or conflicts that may affect their full participation. By the end of this phase, each participant should have established several achievable treatment goals and have an understanding of her role in the group

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and the expectation to actively work on her problems both within and outside of therapy. Middle sessions. During the middle groups (sessions 3 to 6), the group therapists use the concepts and strategies of the IPT problem areas to address each member’s interpersonal focus. Each group begins with a brief “check in” by each participant. The therapist works to connect the women’s issues, highlight the universality of concerns, and encourage mothers to learn through the experiences of others in the group. Each session is designed to systematically address the IPT problem areas common to the postnatally depressed woman. As therapy progresses, the participants are encouraged to disclose their feelings and share more sensitive material about their relationships. A deeper understanding develops, allowing other members to connect and empathize with each other’s difficulties. As a result, insights into problems and solutions are generated either by the woman facing the difficulties or the other participants. Participants often receive positive feedback and encouragement from group members to implement change in their lives outside of the group. Partners evening. During the middle phase of the group, the therapists conduct a two-hour psychoeducational evening for the partners alone. This interactive session focuses on effective ways to support and respond to women affected by postpartum depression. Clinical experience and research evidence confirms that men are often reluctant to consult mental health professionals, even for their spouses’ issues (Matthey, Reay, & Fletcher, 2009). Therefore, this program was developed to maximize attendance and to address the format, content, and delivery style that men reportedly prefer. In order to boost participation rates, the partners evening is discussed at the first individual appointment with each woman and mentioned at all group sessions. Women receive an invitation to give to their partner and are encouraged to explicitly discuss it with him or her. A group leader follows up the invitation with a phone call. During the partners evening, the therapists co-lead a didactic, professional presentation on the nature, symptoms, causes, and consequences of PND, followed by a presentation of a “tool kit” of practical and communication strategies that couples have found to be helpful. The therapists facilitate


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discussion and reinforce effective approaches participants have used to assist their partners. Ending of acute therapy. In sessions 7 and 8, group members review their progress and continue to work actively toward their goals. The therapists emphasize that continuing efforts can result in further improvements in symptoms and relationships. The therapists’ stance becomes less active in order to instill a sense of competence in the mothers that they can address their own problems. The group members also work to anticipate and plan ways to address future difficulties, such as returning to the workforce or having another baby. An essential part of this process specifically addresses the ending of therapy. Mothers often become increasingly anxious about whether they will be able to cope without the structure of the weekly group and/or feel sad about the loss of their attachments to the group leaders and other members. The IPT model details explicit ways to address the ending of therapy, and a central theme is that the feeling of loss is a normal, human response to change. Women are encouraged to express and process their feelings about the loss, both positive and negative. The ending of therapy is also conceptualized as a role transition, moving “from the old role of group member to the new role of autonomy and interpersonal functioning” (Robertson et al., 2004). Participants are encouraged to understand their common reactions to loss and practice more effective ways of adapting and coping with the changes. Last, our approach is also to provide the women with a list of group members at the final group session, as they are usually eager to keep in contact with one another. Six-week follow-up assessment. In clinical practice, it is quite common to allow some time between the final IPT group session and an individual follow-up appointment. This is, in part, justified by the fact that many group participants become more symptomatic around the ending of the group, regardless of how long the group meets (Robertson et al., 2004). Patients also need to sharpen their newly acquired skills and develop a sense of competence at bringing about changes on their own. In the IPT-G program, participants are informed that they may contact the treating therapists should the need arise; however, a formal appointment is only made with each individual at six weeks post intervention. This

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conveys the positive message that the participants can manage with reduced support. At the completion of the group, participants each receive an appointment for six weeks later to review clinical progress, assess the need for further maintenance treatment, and plan for future difficulties. Due to the high rate of relapse in postpartum depression, a written relapse prevention plan is developed for each individual. This plan details the early warning signs, ways to monitor changes, high risk periods, coping strategies (developed during her participation in the group), and a list of contacts. Using the therapist’s clinical judgement, exceptions to the cooling-off period are made when a woman’s symptoms have not significantly improved or have seriously worsened. A decision can be made to either commence individual treatment with IPT, another type of psychotherapy, or introduce an antidepressant. THE EFFECTIVENESS OF IPT-G FOR PND

In light of the positive findings from our pilot study (Reay et al., 2006), the authors conducted a randomized controlled trial of IPT-G for PND described in detail elsewhere (Mulcahy, Reay, Wilkinson, & Owen, 2010); what follows is a brief summary. Fifty eligible women from the Australian Capital Territory were recruited from the community and randomly assigned to either IPT-G or treatment as usual (TAU). TAU encompassed all of the options for support and treatment for postnatal depression available in the community, including antidepressant medication, natural remedies, non-directive counseling, maternal and child health nurse support, community support groups, and individual psychotherapy or group therapy. This trial was conducted in a “real world” clinical setting in order to be generalizable and inform clinical practice. Mothers were compared on such variables as depressive symptoms, marital adjustment, social support, and mother-infant bond at baseline, mid-treatment, end-of-treatment, and three-month follow-up. Compared to the control group, IPT-G mothers significantly improved in their level of depressive symptoms and had continued improvements at three months post-therapy. A higher proportion of IPT-G women met criteria for recovery (IPT-G: 69.6% vs. TAU: 33.3%), whereas TAU participants were significantly less likely


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to experience any real change in depression scores and significantly less likely to reach recovery. Further, women who received IPT-G displayed significant improvement in their marital relationships, social support, and mother-infant relationships. The adherence rate was very high: out of 23 IPT-G participants only one woman dropped out due to reported improvement in symptoms and one woman was withdrawn due to domestic violence. A response to treatment analysis found no evidence that women with insecure attachment styles or poorer quality marital relationships or social supports had poorer outcomes (Mulcahy, 2007, unpublished thesis). Our experience has been that IPT-G can be adapted to the needs of these women and that this brief focal treatment seems well suited to the requirements of this population. The findings highlight that IPT-G not only improves outcomes for the mother but also potentially for the couple and the infant when compared to usual care. An Integrative Case Study: Susan Susan is 38-year-old married woman with a four-month-old baby, Mia. She was referred to IPT-G by her early childhood nurse who had been providing additional support following her diagnosis of postnatal depression. In the initial interview, Susan described feeling sad much of the time and guilty that she was not enjoying her new baby as she had expected to. She found it increasingly difficult to get organized and out of the house, which was distressing as she used to be a highly efficient person. Her energy levels and motivation were particularly low, thus, she had ceased many of her outside interests and social activities. Further, she described feeling “an overwhelming sense of responsibility for the baby” and an inability to trust her husband, Michael, to look after Mia. Maternity leave from her job gave her job security, but she missed the stimulation of socializing with others. Susan attended the initial individual session with one of the group therapists. She presented with a number of factors that contributed to her vulnerability to developing depression, including a family and personal history of depression, an insecure, avoidant attachment style, and perfectionistic traits. The transition to having a baby was in contrast to her excitement over its arrival, and it challenged her

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ability to cope. Susan generally found it difficult to trust others and became frustrated when the key people in her life did not understand her increased need for help and support. These problems occurred when her level of social support was fairly diminished, in part brought on by a recent house move and her own difficulties at maintaining her network. She eventually withdrew into herself, cutting off from her few remaining supports. The process of developing her Interpersonal Inventory highlighted the problem areas of “disputes” with Michael and her mother. She also identified having difficulties adjusting to the “role transition” of being a stay at home mother and being socially isolated. By the end of the initial session, Susan was prepared for the group, had developed several key treatment goals, and was aware of her role and the expectation to work actively both within and outside of the group. During the early group sessions Susan shared and refined her goals with the others. The therapists observed her to initially be a quiet group member who needed encouragement to participate. She did actively participate in the role transition exercise, where positive and negative aspects of the old and new roles were explored. Together with other members, she spoke about the aspects of her old life that she missed, such as the loss of her financial freedom, her social life, and her sense of independence. The group leader encouraged her to express her mixed feelings of sadness and anxiety about these changes (use of affect). Other mothers acknowledged their difficulties at prioritizing relationships and responsibilities. This validation of feelings appeared to help Susan reflect on her approach to these changes. Susan went on to identify some of the challenges of the new role, such as scheduling play time with the baby and pleasant activities with friends rather than focussing entirely on housework. Interestingly, Susan was able to acknowledge that her partner was similarly going through a significant transition in his roles, enabling a more empathic stance towards him. Throughout the initial sessions, the therapists were mindful of her avoidant attachment style and the need to take more time engaging her and expressing empathy frequently in order to establish a good therapeutic alliance. During a subsequent session, Susan arrived on her own, stating she had left the baby with her husband for the morning. The group


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congratulated her on this important step, and she then said, “Perhaps the people around us don’t understand what we want; maybe I’m giving out the wrong message.” The therapist observed that Susan had had an important insight into the dispute; however, it was important to assist her in communicating her needs more effectively to Michael. Importantly, the therapist was mindful of Susan’s avoidant attachment style, which often makes it more difficult for patients to trust their therapist and the more challenging techniques. During an exercise on disputes, the therapist prompted Susan: “Would you be willing to tell the group a bit more about the kind of communication patterns that you are noticing between you and Michael?” With her permission, the therapist went on to ask, “What are some of the communication patterns in your relationships that you want to keep and what would you like to change or improve?” Using communication analysis, the therapist encouraged Susan to describe her tendency to suppress her feelings and needs while looking after others, leaving her to often feel depleted and resentful. This resonated with some of the other participants, and the group leader encouraged them to express their empathy with and support of Susan. While being mindful of any reluctance or discomfort, the group leader invited Susan to role-play a scenario with her mother, played by another group member. With some assistance and encouragement from the others, Susan was able to talk with her “mother” and maintain the focus on the things she wanted to get out of the conversation. The therapist then said, “Susan, I’d like you to comment on what you think went well during that practice, then I’d like to get Karen’s reactions (playing the mother), followed by the rest of you who observed that role-play.” At the session’s end, Susan acknowledged that this session was a significant step forward in addressing her issues with her mother. The therapist noted how much more articulate Susan had become over the course of the group sessions, and other group members acknowledged how they were getting to know and better connect with her. While Susan found it difficult to invite Michael to the partners evening, the opportunity helped her recognize how challenging it is for her to directly ask for his support. The therapists observed that contrary to Susan’s description of Michael as remote and uncaring, Michael was the most vocal participant that evening.

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He discussed some of the stressors and frustrations of living with a depressed partner and the challenges they faced as a couple. Michael could relate to the lack of sleep, leisure time, and reduced sex and intimacy that other men spoke of. During the session, he stressed the importance of remaining supportive, helping with the baby, and finding innovative ways to spend time together. At the following group check-in, Susan commented on the change in Michael’s behavior and his willingness to help out more with the baby. Although she has still not found her mother to be particularly emotionally supportive, Susan has become aware of her mother’s growing bond with the baby. Susan and Michael arranged for her mother to watch Mia while they went out for a bike ride, an activity they always used to enjoy together. In a later group check-in, Susan reported a recent situation where she was very angry with Michael when he disappeared into the shed for an unknown period, leaving her to look after the baby. She appealed to the others with, “I don’t know when I have the right to ask for help or when what I want is unreasonable.” Other participants acknowledged their struggle to recognize the difference too. Susan related the way she handled the incident: “I was aware of how annoyed I was feeling and rather than just swallow it, like I always do, I decided to go out to the shed and tell him how I felt whenever he disappears like that.” Using the technique of interpersonal incidents, the therapist helped Susan to examine the interaction in detail and identify the kind of responses she wanted from Michael. The therapist withheld giving direct feedback about Susan’s communication style, which is often too challenging for avoidantly attached individuals. Instead, the therapist continued to link Susan’s issues with those of other group participants and involved them in the discussion with questions like, “How does Susan’s issue relate to others in the room?” and “Is anyone else connecting with this issue?” Aware that the group was quite cohesive and members were very supportive of one another, the therapist suggested a group brainstorm on ways they could obtain more help with their babies and more time with their partners. Over the following weeks, Susan and Michael agreed to negotiate each weekend in advance, to ensure that both their priorities were taken into account. She was pleasantly surprised that Michael was receptive,


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and she also received a lot of reinforcement from the other group members for her approach. Susan continued to explore ways to improve her relationship with her mother and recounted that on a recent occasion she was able to keep communicating her thoughts and feelings even when her mother tried to close off the conversation prematurely. The ending of therapy is an opportunity for members to review and consolidate their progress. The therapists were mindful of the anxiety and distress that can often arise at the conclusion of a group and ensured there was adequate time to explore each member’s thoughts and feelings about it. Susan had largely achieved her goals, although she was planning to continue to work on them. She reported she was enjoying her baby more than ever and felt closer to both Michael and her mother. Fortuitously, her work colleagues had established a book club, which she had started to attend, and she was investigating a local playgroup. The therapist made a note to review these plans at the follow-up appointment, as Susan previously had the tendency to avoid or withdraw from social contacts. Susan’s main anxiety about the future involved her ability to cope with returning to part-time work. She was already in discussions with Michael and her mother about how this could be successfully managed and was feeling more confident about her ability to deal with this upcoming change. CONCLUSION

Postnatal depression usually occurs in the context of multiple social and interpersonal relationships. Interpersonal psychotherapy, with its focus on current personal relationships and networks, holds intuitive appeal for women. IPT-G is a pragmatic treatment designed to: 1) offer rapid relief from distressing symptoms, 2) target key interpersonal factors implicated in the development and maintenance of postnatal depression, and 3) increase its appeal to mothers who historically find it difficult to access treatments. Grounded in a triad of theories, IPT-G provides the experienced therapist with a brief, focused, and manualized approach to helping women recover from the debilitating effects of depression. Based on a unique set of therapeutic factors, its strengths include the provision of peer

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support, validation, and encouragement. Social isolation is immediately reduced, enabling women to experience the cathartic and transformative experience of being part of a cohesive group. Finally, although group approaches have their appeal, they do not suit all mothers and should be viewed as another potential treatment choice with inherent benefits and challenges. REFERENCES Ainsworth, M. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Potomac, MD: Lawrence Erlbaum. Alexander, R. P., Feeney, J. A., Hohaus, L., & Noller, P. (2001). Attachment style and coping resources as predictors of coping strategies in the transition to parenthood. Personal Relationships, 8, 137-152. American Psychiatric Association. (1993). Practice guideline for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26. Appleby, L., Warner, R., Whitton, A., & Faragher, B. (1997). A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. British Medical Journal, 314, 932-936. Armstrong, K., & Edwards, H. (2003). The effects of exercise and social support on mothers reporting depressive symptoms: A pilot randomized controlled trial. International Journal of Mental Health Nursing, 12, 130-138. Armstrong, K., & Edwards, H. (2004). The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. International Journal of Nursing Practice, 10, 177-194. Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226-244. Bernard, H., Burlingame, G., Flores, P., Greene, L., Joyce, A. S., Kobos, J. C., Leszcz, M., MacNair Semands, R. R., Piper, W. E., Slocum McEneaney, A. M., & Feirman, D. (2008). Clinical practice guidelines for group psychotherapy. International Journal of Group Psychotherapy, 58, 455-542. Boath, E., & Henshaw, C. (2001). The treatment of postnatal depression: A comprehensive literature review. Journal of Reproductive and Infant Psychology, 19, 215-235.


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Rebecca Reay, Research Officer Academic Unit of Psychological Medicine ANU Medical School, Level 2, Building 4 The Canberra Hospital Woden ACT 2605 Australia E-mail: [email protected]

Original received: May 6, 2010 Final draft: December 1 2010 Accepted: December 2, 2010