Group interpersonal psychotherapy

1. Introduction

Version followed: WHO / Columbia University Group Interpersonal Therapy (IPT) for Depression, generic field-trial version 1.0 (WHO/MSD/MER/16.4, 2016; authors Verdeli, Clougherty, Weissman), one individual pre-group meeting plus 8 weekly group sessions, read in its PAHO Spanish (2022) and Russian editions. Where a clinician-led, longer format is wanted, the structure of Wilfley et al.'s IPT-G (2000; 20 group sessions) and MacKenzie & Grabovac's IPT-G for depression (2001; 14 sessions) is given alongside. Only chapters 1–3 of the WHO manual (pre-group phase, Session 1) are drawn on; its Chapter 5 (step-by-step problem-area strategies) and Chapter 6 (group challenges) are not, so those parts below rely on the other sources and are flagged [uncertain] or [synthesis].

Group interpersonal psychotherapy (IPT-G) is interpersonal psychotherapy (IPT) delivered to a small group. It keeps individual IPT's structure and focus: depression is linked to a current problem in relationships or social roles, and one or two of four problem areas becomes the focus: grief, disputes, life changes (role transitions) and loneliness/social isolation (interpersonal deficits). Change happens when members understand their low mood as connected to what is going on in their relationships, try new ways of handling that problem between sessions, report back, and get support and suggestions from the group. The group format adds something individual IPT lacks: it is itself an interpersonal setting, members see that others share their symptoms and problems (which counters isolation and self-stigma), and skills practised with several people may carry over to daily life more easily. [source: WHO 2016 ch. 1–3; IPT Institute, IPT for Groups; Bolton et al. 2003]

IPT-G is a manualised therapy, not a licensed programme. The WHO version was written for supervised facilitators who may have no mental health training, and WHO lists IPT as a possible first-line treatment for depression. The WHO manual sets training and supervision standards rather than a licence: trainers must have supervised at least three full groups; new facilitators are supervised through at least three complete 8-session groups. The IPT Institute says Wilfley's IPT-G calls for working knowledge of IPT and of group psychotherapy plus specific IPT training; it does not mention a certificate. Formal IPT credentialing by the international IPT society is not verified [uncertain]. [source: WHO publication page; WHO 2016 ch. 1; IPT Institute]

2. Framework

Versions at a glance

Version	Pre-group	Group sessions	Size / leaders	Notes
WHO IPT-G 1.0 (2016)	1 individual meeting (about 90 min), ideally about 3 weeks before start; regular contact afterwards	8 weekly × 90 min (up to 2 h if more than 10 members); 12-session option	6–10 members; usually single-sex; facilitator shares the members' language	Derived from 16-session IPT-G-U (Uganda)
IPT-G-U (Uganda trial)	Screening and consent interviews	16 weekly × 90 min	5–8, single-sex, one same-sex local lay leader	14 of 15 groups kept meeting without leaders afterwards
Wilfley IPT-G (2000)	Individual meeting(s): diagnostic interview, interpersonal inventory, problem areas, explicit treatment contract	20 sessions	Not stated	First tested for binge eating disorder; also used for depression, PTSD, older adults, adolescents, veterans
MacKenzie & Grabovac (2001)	2 assessment sessions + Inventory of Interpersonal Problems (IIP-32) + preparation handout	14 weekly × 90 min	8 members; IPT-experienced psychiatrist + resident co-therapist	Up to three written target goals per member

[source: WHO 2016 ch. 1–3; Bolton et al. 2003; Bass et al. 2006; IPT Institute; MacKenzie & Grabovac 2001]

Phases and goals (WHO version)

Pre-group phase (individual meeting). Goals: recognise depression and start treating it (assess symptoms and functioning, name depression without blame, give hope, set up the sick role, mobilise resources); screen out imminent suicide risk, psychosis, harmful alcohol or drug use, severe intellectual disability and dementia, and refer them on; link the depression to problem areas via a timeline and interpersonal inventory; choose one or two problem areas and one or two goals; invite the person, without pressure, and explain format and rules. Move on when: the person is eligible, has agreed to join, and has a named problem area and goal. [source: WHO 2016 ch. 2]
Initial phase (Session 1). Goals: introductions, confidentiality norms, group psychoeducation about depression, instilling hope (about 30 min); linking each member's problems to depression and reviewing goals (about 45 min); explaining how the group will work (about 15 min). [source: WHO 2016 ch. 3]
Middle phase (Sessions 2–7). Each session follows four tasks: (1) rate depression; (2) link the depression to events of the past week; (3) apply the strategies for each member's problem area; (4) set practice exercises and close. [source: WHO 2016 ch. 1, 4 overview]
Termination phase (Session 8). Review progress and close the group, using a written reminder note for each member (WHO Annex 8). Detailed content not drawn on here [uncertain]. [source: WHO 2016 ch. 1 overview]

Criteria for moving on and for referral: the WHO manual has the facilitator rate depression every week and consult the supervisor whenever a member's weekly scores show no improvement; referral is planned for members who do not improve or turn out to be unsuited to a group. [source: WHO 2016 ch. 1]

Phases and goals (Wilfley IPT-G, 20 sessions)

Pre-group individual meeting(s): standard diagnostic interview, interpersonal inventory, target problem area(s), explicit treatment contract.
Initial phase (sessions 1–5): manage negative feelings, develop positive group norms, test and refine each member's target problem area.
Intermediate phase (sessions 6–15): work towards goals and practise new social skills inside and outside the group.
Termination phase (sessions 16–20): consolidate gains and prepare for the end of the group.

[source: IPT Institute, IPT for Groups]

The MacKenzie & Grabovac depression group added a structured start (session 1 goal-centred introductions; session 2 symptom review; sessions 3–4 detailed goal review with a written Target Goals Form), a midpoint review around session 7 with the BDI repeated, and a 4-month follow-up. [source: MacKenzie & Grabovac 2001]

3. Guiding principles

Depression is an illness, not a fault. Say it is not the person's fault and use local, non-blaming words for it; never read a missing greeting or low energy as rudeness, since it may be a symptom. [source: WHO 2016 ch. 2]
Give realistic hope, never false promises. Say depression is treatable; do not promise cure, money or material help, and say plainly that the programme gives no material benefits. [source: WHO 2016 ch. 2]
Interpersonal focus on the present. Link the onset and course of depression to current relationships and roles; MacKenzie & Grabovac kept work on current external relationships, used family-of-origin patterns only to understand present ones, and avoided long exploration of what group process means. [source: WHO 2016 ch. 2; MacKenzie & Grabovac 2001]
One or two problem areas, one or two goals per member. Keep the focus narrow; if the person cannot choose, narrow the list and suggest the one likely to help most. [source: WHO 2016 ch. 2]
Voluntary participation. Invite without pressure; explore hesitation (confidentiality worries, hopelessness) rather than push. Never force anyone to speak in the group; invite gently. [source: WHO 2016 ch. 2–3]
Confidentiality with stated limits. Nothing said in the group is repeated outside; the only exception is serious risk of harm to self or others; notes are kept secure; local law may differ. [source: WHO 2016 ch. 2–3]
The group is the vehicle. Use universality (name symptoms and losses members share), mutual support and group problem-solving; the Uganda testimonials pointed to group problem-solving as important (the authors call this inconclusive). [source: WHO 2016 ch. 3; Bolton et al. 2003; IPT Institute]
Work happens between sessions. Members try new approaches during the week and report back; the group is a place to report on outside efforts. [source: WHO 2016 ch. 1; MacKenzie & Grabovac 2001]
Active, supportive, at times firm leadership. Be supportive, challenging and motivating; take a firm stance when a problem area is being avoided. Leaders trained in psychodynamic or Yalom-style groups need restraint, as the model is not a process group. [source: MacKenzie & Grabovac 2001]
Decisions belong to the member. Insist that a member's decisions are their own, not other members' suggestions. [source: MacKenzie & Grabovac 2001]
Handle tension between members by problem-solving, not interpretation. Address negative interpersonal themes between members early. [source: MacKenzie & Grabovac 2001]
Measure every week and use supervision. Weekly depression ratings, weekly facilitator notes written right after each session, task checklists, and supervisor contact when scores do not improve. [source: WHO 2016 ch. 1, 3]
Limited self-disclosure. Keep facilitator self-disclosure minimal and turn the attention back to the group. [source: WHO 2016 ch. 2–3]
Cultural fit. Single-sex groups where that is more acceptable, shared language, local terms for depression, respect for local mourning customs. [source: WHO 2016 ch. 1–2; Bolton et al. 2003]

4. Intervention inventory

Order follows the course of a WHO group. Example language is illustrative unless quoted. [source for 4A–4B: WHO 2016 ch. 2–3, PAHO Spanish and Russian editions]

A. Pre-group individual meeting

4.1 Opening, confidentiality and its limits

Purpose / when: first minutes of the pre-group meeting; sets safety and trust.
Steps: (1) Introduce yourself and your organisation (in community work, say why you are visiting). (2) Explain that what is said stays private, with exceptions for serious risk of harm to self or others; say notes are stored securely; check local law. (3) Say plainly that the programme offers no money or material goods.
Example language (illustrative): "What you tell me stays between us and, later, inside the group. The one exception is if I think you or someone else is in serious danger; then I would have to get help."
Watch for: suspicion about records or community gossip; expectations of material help, which later fuel disappointment and dropout.

4.2 Assessing symptoms and functioning

Purpose / when: confirm depression and set a baseline for weekly ratings.
Steps: (1) Use a locally validated depression scale (the manual suggests the PHQ-9) or mhGAP-IG criteria. (2) Rate functioning with WHODAS 2.0 (12-item interviewer version) or by interview, covering roles such as providing for the family, caring for children, attending community meetings. (3) Ask how symptoms affect daily life. Do not read out or reproduce scale items beyond the licensed form.
Example language (illustrative): "In the last two weeks, how have you managed with looking after the children and your work at home?"
Watch for: severe impairment (add a resource-mobilisation goal, see 4.6); signs of exclusion criteria (see 4.3).

4.3 Risk and eligibility screening, with referral

Purpose / when: before inviting anyone to the group.
Steps: (1) Ask respectfully about thoughts of death and suicide plans (WHO Annex 2). (2) Anyone with a plan to end their life in the near future is not suitable for the group and needs urgent specialised help that day; passive wishes to be dead without a plan or recent attempt do not exclude. (3) Screen for psychosis, harmful alcohol or drug use, severe intellectual disability and dementia (Annex 3); these people need other care. (4) Consult the supervisor about any referral. MacKenzie & Grabovac also excluded active suicidality and marked borderline features.
Example language (illustrative): "Sometimes when people feel this low they think about dying or about ending their life. Has anything like that been on your mind?"
Watch for: minimising; follow current local risk-assessment standards and safety planning; lethal-means counselling covers safe storage and removal only. [synthesis for the last point]

4.4 Naming the depression and instilling hope

Purpose / when: once criteria are met; turns a vague misery into a treatable condition.
Steps: (1) Tell the person they appear to have depression, using a local non-stigmatising term. (2) Say it is not their fault. (3) Say it is common and treatable, and that people get better with support and group work; avoid promises.
Example language (illustrative): "What you describe has a name: depression. It is common, it is not a weakness, and people do recover from it."
Watch for: relief (a good sign) versus shame; if a local term carries stigma, choose another.

4.5 The sick role

Purpose / when: pre-group meeting, repeated as needed; lowers self-blame and expectations temporarily so recovery can start.
Steps: (1) Explain that, as with a physical illness, the person may not manage everything for now. (2) Use an analogy (the manual uses a broken leg). (3) Agree on telling a family member what is happening, if safe and wanted. (4) Suggest postponing major life decisions until they can be discussed in the group. (5) Advise regular sleep without oversleeping.
Example language (illustrative): "If you had a broken leg nobody would expect you to carry water. Depression is similar for a while: we lower the load, and you keep doing what you can."
Watch for: the sick role becoming withdrawal from everything; it is temporary and paired with doing what one can. [synthesis for this caution]

4.6 Resource mobilisation

Purpose / when: when functioning is badly affected or practical needs press.
Steps: (1) Identify practical and emotional supports for food, health care, childcare, housing, income. (2) Name concrete people or places. (3) If none come to mind, ask the person to think about it over the coming week. (4) If functioning is very poor, make "identify people and places that can help" one of the goals.
Example language (illustrative): "Who could take your daughter to the clinic on Thursday, so you don't have to manage it alone?"
Watch for: reluctance to ask for help, which often points to a loneliness or dispute problem area.

4.7 Timeline of onset

Purpose / when: pre-group; links the depression to events in relationships and roles.
Steps: (1) Ask when the low mood started; if unclear, ask when they last felt well. (2) Ask what was happening in relationships and life roles at that time. (3) Write symptoms and events on a timeline (WHO Annex 5), anchoring dates to local events such as seasons.
Example language (illustrative): "When did you last feel like yourself? What changed around then, at home or with the people close to you?"
Watch for: a clear interpersonal event near onset is the likely focus.

4.8 Interpersonal inventory

Purpose / when: pre-group; maps relationships and finds the problem area.
Steps: (1) Ask who the most important people in the person's life are. (2) For each: is the relationship a source of support or stress, how has it changed, what would they like to change, what to keep. (3) Ask conversational screening questions for each problem area: grief (recent deaths, chance to talk about them, support received, funeral and mourning customs); disputes (current or past disagreements, how handled, who makes them worse or better, what they would change); life changes (changes in the household, moving, relationships, income, illness, trouble with authorities); loneliness (whether they feel supported by family and friends; difficulty making or keeping relationships). The manual's questions are a guide, not a script. (4) Variant: in adolescent IPT the inventory is drawn as concentric closeness circles with the person at the centre [source: Cohen, IPT-A slides]. MacKenzie & Grabovac added the IIP-32 questionnaire, reviewed by therapists across the group.
Example language (illustrative): "Tell me about the people who matter most to you. With your husband, is it mostly support, mostly strain, or both?"
Watch for: important people left out (often the disputed one); total absence of close ties points to loneliness/isolation.

4.9 Formulation, goals and invitation (treatment contract)

Purpose / when: end of the pre-group meeting.
Steps: (1) Explain the link between the depression and one or two problem areas using the person's own story. (2) Choose one or two goals together (MacKenzie & Grabovac allowed up to three written target goals; Wilfley uses an explicit treatment contract). (3) Ask whether they want to join; if hesitant, restate the benefits, say when the group starts, explore concerns. (4) Give practical information: 8 weekly sessions of about 90 minutes, confidentiality, punctuality, transport, possible schedule changes. (5) Confirm agreement, plan follow-up contact, and write up notes (Annex 6), stored securely. MacKenzie & Grabovac gave a handout on what groups are like, covering confidentiality, attendance, substance use and common myths, to build cohesion and reduce early dropout.
Example language (illustrative): "Your low mood started after your move here, when you lost your friends and your work. In the group we would work on settling into this new life and building some support. Would you like to try it?"
Watch for: a goal that depends wholly on another person changing; reshape it into what the member can do. [synthesis]

B. Session 1 (initial phase)

4.10 Introductions and icebreaker

Purpose / when: first 30 minutes of Session 1.
Steps: (1) Members greet a neighbour and introduce each other. (2) Optional exercise: small groups find things they have in common and report back (named in the Spanish edition as a "punto de convergencia" exercise); or members name a place that brings them peace. (3) Remind everyone of confidentiality: nothing said is repeated outside, so it is safe to try new ways of thinking and acting.
Example language (illustrative): "Turn to the person next to you, find out their name and one thing about them, and then introduce them to us."
Watch for: very withdrawn members; let them introduce through a partner.

4.11 Group psychoeducation on depression

Purpose / when: Session 1 (MacKenzie & Grabovac used session 2 for a symptom review).
Steps: (1) Use non-stigmatising language; say depression is common. (2) Walk through symptoms on the rating scale (sadness, loss of interest, low energy, sleep problems, hopelessness). (3) Watch for nods and name shared symptoms aloud to build connection. (4) If someone nods at suicide-related content but did not report it before, check their risk privately after the session. (5) Instil hope: people improve with support, and coming today was a brave first step.
Example language (illustrative): "I see several of you nodding about sleep. You are not the only one here living with that."
Watch for: members comparing who is "worse"; keep the frame on shared illness.

4.12 Linking members' problems to depression

Purpose / when: Session 1, about 45 minutes; repeated briefly as new members speak.
Steps: (1) Explain generally that problems such as illness, a death or conflict in a relationship understandably affect mood, and that the group will work on the main problem for each person. (2) Review each member's problems and goals from the pre-group meeting; ask who remembers what brought on their depression. (3) Invite members to say why they came and what problems seem to have triggered the depression. (4) Acknowledge each answer, link the feeling to the life problem, then ask whether others have had similar experiences. (5) If nobody volunteers, say talking gets easier with time and ask who would like to start; never pressure.
Example language (illustrative): "So since your husband left, the sadness has been heavy. Has anyone else here had a big change at home before the low mood began?"
Watch for: members telling stories without the link to mood; gently restate the link.

4.13 Explaining how the group works

Purpose / when: last 15 minutes of Session 1.
Steps: explain the weekly routine (rating, the week's events, work on problem areas, practice between sessions), attendance and punctuality, and what happens if a session must move. [source: WHO 2016 ch. 3; routine from ch. 1 overview]
Example language (illustrative): "Each week we start by checking how your mood has been, talk about what happened that week, work on your problem, and agree on something to try before we meet again."
Watch for: questions about the end date; say it now, so termination is no surprise.

C. Middle phase (WHO Sessions 2–7; Wilfley sessions 6–15)

The four-task routine (4.14–4.16, 4.21) comes from the WHO manual and the Uganda papers. For the problem-area work (4.17–4.20), the goals come from the WHO manual and the case material from MacKenzie & Grabovac. The numbered steps under each are [synthesis]: they apply the WHO goals in a group and are not the text of WHO Chapter 5, which is not drawn on here [uncertain].

4.14 Weekly depression rating

Purpose / when: start of every middle-phase session; tracks progress and flags non-response.
Steps: (1) Each member completes or answers the depression scale used at intake. (2) Note scores in the weekly facilitator notes. (3) Comment briefly on changes. (4) Consult the supervisor about any member whose scores do not improve. [source: WHO 2016 ch. 1, 3]
Example language (illustrative): "Your score came down this week. What do you think helped?"
Watch for: rising scores or new suicidal content: check risk privately after the session.

4.15 Linking mood to the week's events

Purpose / when: after the rating, every session; the core IPT move.
Steps: (1) Each member describes the past week's events. (2) Help them link positive and negative events to how their mood changed. (3) Tie the events back to the member's problem area. [source: WHO 2016 ch. 1; Bolton et al. 2003; Bass et al. 2006]
Example language (illustrative): "You felt a bit lighter on Tuesday, after you spoke with your sister. And Friday, after the argument, it dropped. What do you make of that?"
Watch for: members learning to make the link themselves; this is a sign the model is taking hold.

4.16 Group support and group problem-solving

Purpose / when: throughout the middle phase, after a member has described a problem.
Steps: (1) Invite others to offer support and suggestions for change. (2) Ask whether others have faced something similar (universality). (3) Link themes across members, e.g. one member's loss to another's (MacKenzie & Grabovac). (4) Bring the choice back to the member: the decision must be theirs, not the group's. [source: Bolton et al. 2003; Bass et al. 2006; MacKenzie & Grabovac 2001]
Example language (illustrative): "Several people have ideas. Which of them, if any, fits your situation? What would you want to try?"
Watch for: one member pressing advice on others (MacKenzie & Grabovac noted forceful advice-giving as an early concern); superficial solutions that skip over ambivalence.

4.17 Problem area: grief

WHO definition and goals: the death of a significant person; ordinary grief usually eases within months, IPT is for grief that persists and impairs functioning. Goals: help the member grieve the loss, and build new activities, roles and supports. [source: WHO 2016 ch. 1–2]
Steps [synthesis]: (1) Invite the member to describe the person who died, the death and the time around it, at their pace. (2) Ask what the relationship was like, good and difficult sides. (3) Invite feelings and let the group respond. (4) Ask about mourning customs and whether they could take part. (5) Plan small steps towards new activities and people; set them as practice exercises.
From MacKenzie & Grabovac: therapists linked other members' loss themes to a grieving member's experience; around session 7 he described the death in detail and others shared their losses; at the therapist's suggestion he visited the grave and put up photographs at home. The authors note that drawing out full detail is harder in a group.
Example language (illustrative): "Would you tell us about your mother: what she was like, and what those last weeks were like for you?"
Watch for: the member being cut off by others' stories; protect their time. Overwhelm: slow down and ground (see 5).

4.18 Problem area: disputes

WHO definition and goals: an open or hidden disagreement with someone important. Goals: clarify what each side wants and expects, build communication skills, practise them, and involve people who can help. [source: WHO 2016 ch. 1–2]
Steps [synthesis]: (1) Clarify the dispute: who, about what, what each side wants. (2) Ask how past attempts went, word by word (see 4.23). (3) Generate options with the group (see 4.22). (4) Rehearse the chosen approach in role play (see 4.24). (5) Agree a practice exercise: try one conversation this week; report back.
From MacKenzie & Grabovac: work with a member in dispute focused on loosening enmeshment with her daughter, sharing caregiving with others, and setting firmer limits with a tenant and a boyfriend.
Example language (illustrative): "What do you want from him, and what do you think he expects from you?"
Watch for: safety. If the dispute involves violence, safety planning comes before confrontation practice. [synthesis]

4.19 Problem area: life changes (role transitions)

WHO definition and goals: positive or negative transitions such as marriage, moving, illness, loss of job or income, separation. Goals: name the feelings the change brings, look for meaning or growth in it, build coping skills and find support. [source: WHO 2016 ch. 1–2]
Steps [synthesis]: (1) Ask what was lost and what, if anything, was gained. (2) Name feelings about the old and new role. (3) Identify skills and supports the new role needs. (4) Set small steps and use the group as a sounding board.
From MacKenzie & Grabovac: a member in transition first brought distress about her fiancé's drug use; the group helped her see it more clearly, which led to assertive limit-setting and then to planning a career change.
Example language (illustrative): "What did you lose when you moved here, and has anything new come with it?"
Watch for: idealising the old role; help the member grieve it and also see what is possible now.

4.20 Problem area: loneliness and social isolation (interpersonal deficits)

WHO definition and goals: chronic loneliness or difficulty starting or keeping relationships. Goals: identify what contributes to the isolation, then learn to start and keep friendships. [source: WHO 2016 ch. 1–2]
Steps [synthesis]: (1) Review past relationships: what went well, what went wrong. (2) Use the group itself as a place to practise contact (greeting, asking, sharing). (3) Choose one small outside contact each week and report back.
From MacKenzie & Grabovac: a member in this area was supported by the group and showed warmth indirectly (handmade gifts); the paper names no specific technique. The three members with personality disorders (two avoidant, one schizotypal) did not improve.
Example language (illustrative): "You said hello to two people here today. Is there one person outside the group you could do that with this week?"
Watch for: slow progress is expected; consider referral if there is no change by the midpoint. [synthesis]

4.21 Practice exercises between sessions

Purpose / when: end of every middle-phase session.
Steps: (1) Each member agrees one concrete thing to try that links to their goal. (2) Next session, they report what happened and how mood was affected. (3) The group gives feedback. [source: WHO 2016 ch. 1]
Example language (illustrative): "So this week you'll ask your neighbour to help with the market run. Next week tell us how it went."
Watch for: tasks that are too big; shrink them rather than drop them.

4.22 Decision analysis

Purpose / when: a member is stuck choosing how to handle a problem.
Source status: named as an IPT technique, likened to a cost-benefit analysis, in the IPT-A training slides; whether and how WHO IPT-G uses it was not confirmed [uncertain]. Steps are [synthesis].
Steps [synthesis]: (1) State the problem in one sentence. (2) Brainstorm options with the group without judging them. (3) Weigh the likely good and bad results of each. (4) The member picks one and plans it as a practice exercise.
Example language (illustrative): "Let's list every way you could handle this, even ones that sound unlikely, and then look at what each might lead to."
Watch for: the group choosing for the member.

4.23 Communication analysis

Purpose / when: disputes, or any problem where conversations go wrong.
Source status: named in the IPT-A training slides; no group procedure described [uncertain]. Steps are [synthesis].
Steps [synthesis]: (1) Ask for one recent conversation in detail: what was said, by whom, in what tone. (2) Ask what the member intended and what the other person likely heard. (3) Ask the group for other ways it could have been said.
Example language (illustrative): "Tell us exactly what you said and what she said back."
Watch for: blame; keep it on what can be changed.

4.24 Role play

Purpose / when: before a difficult conversation in the real world.
Source status: role play is used heavily in WHO facilitator training and supervision and named as an IPT technique in IPT-A slides; in-group procedure not drawn on [uncertain]. Steps are [synthesis].
Steps [synthesis]: (1) Ask consent. (2) The member chooses who plays the other person. (3) Run a short exchange. (4) Debrief with the member, then the group. (5) Repeat with changes. (6) Set the real conversation as practice.
Example language (illustrative): "Would you like to practise that with Mary playing your brother? Stop whenever you need."
Watch for: distress during the role play; stop and debrief.

4.25 Encouraging affect and exploratory questions

Purpose / when: throughout; helps members name feelings linked to the problem area.
Source status: named in IPT-A slides; WHO describes active listening, reflecting feelings and nodding. [source: Cohen, IPT-A slides; WHO 2016 ch. 2–3]
Example language (illustrative): "When you talk about him, your voice changes. What are you feeling right now?"
Watch for: feelings that overwhelm; see 5.

4.26 Midpoint goal review

Purpose / when: around the middle of the group (MacKenzie & Grabovac: about session 7 of 14).
Steps: (1) Each member reviews their target goals and progress. (2) Repeat the depression measure (BDI in that study). (3) Therapists review the written goal sheets to spot avoided issues and take a firm stance where needed. [source: MacKenzie & Grabovac 2001]
Example language (illustrative): "We're halfway. Look at your goal sheet: what has moved, and what have we not touched yet?"
Watch for: members with no change: consult supervision and consider referral.

D. Termination and after

4.27 Termination session(s)

Purpose / when: WHO Session 8; Wilfley sessions 16–20.
Steps: (1) Review each member's progress (WHO). (2) Give each member a written reminder note (WHO Annex 8; exact content not drawn on here [uncertain]). (3) Consolidate gains and prepare for the end (Wilfley). (4) Encourage a treatment-free period to consolidate gains (MacKenzie & Grabovac). (5) Variant from IPT-A: explore feelings about ending, review warning signs, preview likely future stressors, review strengths gained, and decide on further treatment or booster sessions. [source: WHO 2016 ch. 1; IPT Institute; MacKenzie & Grabovac 2001; Cohen, IPT-A slides]
Example language (illustrative): "Before we finish, tell the group one thing you now do differently, and one sign that would tell you the depression is coming back."
Watch for: members whose scores have not improved: refer on.

4.28 After the group

Purpose / when: after the last session.
Steps: follow-up assessment (MacKenzie & Grabovac: BDI and interview at 4 months); optional monthly maintenance (Bolton et al.); support members who wish to keep meeting on their own (14 of 15 Ugandan groups continued without leaders). [source: MacKenzie & Grabovac 2001; Bolton et al. 2003; Bass et al. 2006]

4.29 Facilitator notes, checklists and supervision

Purpose / when: every session.
Steps: write weekly notes (Annex 6) straight after each session; use the task checklist (Annex 7); attend supervision weekly or at least twice a month, in groups of 4–5 for at least 2 hours; supervisors also meet facilitators individually and sit in on sessions. [source: WHO 2016 ch. 1, 3]

5. Handling problems

The WHO manual's Chapter 6 lists these group challenges: members who will not talk, members who dominate, intoxicated members, rumours in the community, children or friends brought to sessions, and members who want to leave. Its recommended responses are not drawn on here [uncertain]; the responses below are marked by source.

Suicidal thoughts appear during the group. If a member nods at suicide-related content they had not disclosed, speak with them privately after the session and assess risk. A member who now has a plan for the near future needs urgent specialised help and referral via the supervisor. Confidentiality is broken only for serious risk to self or others, and the member was told this at the start. [source: WHO 2016 ch. 2–3] Use current local risk-assessment and safety-planning practice; lethal-means counselling covers storage and removal only. [synthesis]
No improvement in weekly scores. Consult the supervisor whenever a member's scores show no improvement; plan referral for those who do not improve or who are unsuited to a group. [source: WHO 2016 ch. 1] Check first whether the focus is the right problem area and whether practice exercises are actually being tried. [synthesis] Members with marked personality pathology may not respond (MacKenzie & Grabovac: three such members did not improve); consider individual therapy alongside or after. [source + synthesis]
Avoiding the problem area (being stuck). Review written goal sheets regularly to spot avoided issues; take a firm stance and ask the group to support the member. Watch for quick, superficial solutions that skip over the member's ambivalence. [source: MacKenzie & Grabovac 2001]
Silent or withdrawn member. Never pressure; invite gently, say talking gets easier with time. [source: WHO 2016 ch. 3] MacKenzie & Grabovac describe a member who withdrew and did not respond to linking comments; the therapist then took a firm stance. [source] Practical additions: a short check-in with them at the start, pairing them with a neighbour, a private word after the session. [synthesis]
Dominating member or forceful advice-giving. MacKenzie & Grabovac noted one member's forceful advice to others as an early concern and do not describe a specific fix. [source] Response [synthesis]: thank them, then share time out ("Let's hear from someone who hasn't spoken yet"); bring decisions back to the member concerned; if it continues, speak with them privately about the group norm.
Very intense or destabilising member. Discuss containment strategies early with co-therapist and supervisor, and review the formulation; in MacKenzie & Grabovac's group such a member settled in the middle phase. [source]
Conflict between members (in-group rupture). Address negative interpersonal themes between members early, using problem-solving rather than interpretation, and avoid extended exploration of process. [source: MacKenzie & Grabovac 2001] Steps [synthesis]: stop escalation; let each side say what they need; link it to their outside problem area if relevant; agree a group rule; check in with both afterwards.
Rupture with the facilitator. [synthesis] Acknowledge the member's complaint in the group or privately, take responsibility for your part, restate the shared goal; repeated unhappiness may signal a dispute pattern worth naming gently as part of their problem area.
Absences and non-adherence. The WHO manual keeps regular contact with members between pre-group and group and allows sessions to move for events such as funerals. [source: WHO 2016 ch. 2–3] For missed sessions [synthesis]: contact the member before the next session, give a short summary, ask what got in the way; for practice exercises not done, shrink the task rather than drop it, and explore what made it hard (often the problem area itself).
Early dropout. Pre-group preparation and a handout on what groups are like (confidentiality, attendance, substance use, common myths) aim to reduce early dropout and build cohesion. [source: MacKenzie & Grabovac 2001] Members who want to leave: talk privately, explore the reason, restate the remaining sessions; if they still leave, arrange other care. [synthesis]
Overwhelm (e.g. during grief work). [synthesis] Slow down, invite a breath, let the member set the pace, ask the group to offer support rather than questions, and check how they are before they go home.
Intoxication in session. [synthesis] Speak privately, ask them to leave this session safely and return sober; reassess for harmful use, which is an exclusion criterion in WHO. [source for exclusion: WHO 2016 ch. 2]
Rumours in the community or confidentiality breaches. [synthesis] Restate the confidentiality rule in the group; address the breach without shaming; agree how members greet each other outside (e.g. not mentioning the group).
Children or friends brought along. [synthesis] Do not let non-members sit in; help arrange childcare as part of resource mobilisation, or plan session times around it.
Expectations of material help. Say clearly from the start that the programme gives no material benefits. [source: WHO 2016 ch. 2]
Leader drifting into a process group. Leaders trained in psychodynamic or Yalom-style groups need restraint; keep the focus on outside relationships and the problem area. [source: MacKenzie & Grabovac 2001]
Group too large or too varied. WHO: 6–10 members, usually single-sex, a shared language. [source: WHO 2016 ch. 1]

Sources

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