iii

The Guide to Interpersonal

Psychotherapy
Updated and Expanded Edition

MYRNA M. WEISSMAN

JOHN C. MARKOWITZ

GERALD L. KLERMAN

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5

Role Disputes

DEFINITION

Relationships require compromise. Individuals inevitably differ in their needs and

distastes. In good relationships, two people recognize their own and their partner’s
needs and aversions, discuss them, and negotiate an arrangement that both find
satisfactory. Relationships thrive through equitable compromise. Psychiatric dis-
orders can disrupt or make it difficult to negotiate such relationships. Conversely,
disputed relationships may generate depressive symptoms or episodes. IPT defines
an interpersonal role dispute as a situation in which the patient and an important
person in the patient’s life have differing expectations about their relationship. This
leads to either an open or a tacit struggle. The depressed individual is invaria-
bly losing out in this conflict, which may be either a source or consequence of a
depressive episode.
An example is a wife who expects her husband to take care of her financially but
who has had to hold a job herself to help pay the bills. The spouse, on the other
hand, may expect the wife to share financial responsibility. The pair have nonre-
ciprocal expectations. Or a boss may expect a worker to put in extra time without
recompense, a tacit assumption that the worker may resent but feel powerless
to confront. One partner in an intimate relationship may become involved in a
second relationship, overt or hidden, and the aggrieved other partner may suffer
from the change in intimacy. In each case, the two parties have different—​and
conflicting—​expectations of the relationship. A patient’s depression can be linked
to unhappiness about the balance of these expectations in the relationship, and its
solution lies in their renegotiation. The patient typically feels unable to effectively
confront the other person, to assert her needs or to express displeasure.
Disputes usually become the focus of IPT when disagreements have stalled,
become repetitive, or stalemated, offering seemingly little hope of improvement.
The parties often feel they have reached an impasse. This situation may make the
patient (or both parties) feel out of control, thus threatening the relationship.
Depression can make it difficult for the patient to recognize the options available
to pull the relationship out of a rut or to resolve a dispute. Even recognizing the
option, the patient may feel inadequate to employing it: for example, confronting
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the other person and saying, “I need this” or “I feel like you’re not listening to me.”
The therapist’s goals are to diagnose the seriousness of the dispute and then to
help the patient to reach some resolution. A role dispute is one of the most com-
mon problem areas for depressed patients seeking outpatient treatment.
Role disputes frequently coexist with role transitions. A change in job, birth of
a child, or geographical move (role transition) may strain a marital relationship,
causing a role dispute over responsibilities at home. Conversely, a difficult rela-
tionship with a coworker (role dispute) may lead to bad work decisions, triggering
a demotion or unwise career choice (role transition). In order to keep the treat-
ment organized, try to focus treatment on only one problem area, depending on
which one seems most important to the patient.

GOALS OF TREATMENT

For a role dispute, the goals of treatment are to help the patient identify the disa-
greement, choose a plan of action, and modify communication or expectations or
both to resolve the difference of opinion. Although the patient is likely to present
the situation as impassible and impossible, some solution often exists. The ther-
apist must help the patient to consider what options exist to attempt a renegotia-
tion of the relationship. If renegotiation proves successful, which is the outcome
in the vast majority of cases, the patient will have learned a social skill (e.g., better
self-​assertion, a more effective way of expressing anger to defend oneself) and a
better understanding of the dynamics of the relationship, and will have resolved
the conflict. Even if attempts to resolve the dispute prove unsuccessful, the patient
will have learned to better communicate her feelings during a disagreement.
Further, the initially guilty patient may come to recognize that the problem with
the relationship does not lie entirely with her: the patient has at least made a good-​
faith effort to try to change things, and it may be the partner’s unwillingness to
change that is the problem. When the relationship cannot be successfully renego-
tiated, examining the options also helps the patient to decide whether staying in
the troubled relationship is the best alternative.
Role disputes emerge from taking a careful history and collecting an interper-
sonal inventory. Sometimes the patient announces it in her chief complaint: “I’ve
been depressed since I discovered my partner’s having an affair.” If not, the key
initial question is:

Are you having disagreements or a dispute with someone? (Is there someone
important with whom you haven’t been getting along?)

If so, and if this dispute distresses the patient, the next step is to determine the
stage of the disagreement. It is helpful to have a sense of how the patient generally
handles anger and hurt in her dealings with other people. Does she recognize the
connection between an interpersonal dispute and the rise of emotions like anger,
frustration, or disappointment? The following questions will help:
 
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Chapter 6  Role Disputes57

• How do you feel when you want something and he doesn’t agree? What do
you do with that feeling?
• How do you fight?

Ask for blow-​by-​blow examples: “What did you say? What did she say? How did
you feel then? Then what did you say?” and so on. This reconstruction of interper-
sonal encounters will give you a better sense of how the patient functions inter-
personally, what may be going wrong in the relationship, and where the patient
ignores or suppresses emotional responses to the other party.

STAGE OF THE DISPUTE

Identify the stage of the dispute. Is the dispute in a state of renegotiation, impasse,
or dissolution? Are the patient and the significant other communicating at all, and
if so, how?

Renegotiation

Renegotiation means the parties are in active contact about their differences:

• Are you and [the other person] aware of the differences between you?
• Have you been trying to change things, even if unsuccessfully?

Sometimes it emerges that the patient simply needs to express her needs and
lacks the social skills to do so:  “If I  were to ask for a raise, I’d just get fired.”
Depressed patients tend to put their needs second to the needs of others, and
may need your encouragement to recognize a modicum of healthy selfishness.
Once she has accepted her desire as reasonable, the patient may benefit from
role play in order to express her need to another person (e.g., to ask the boss for
a raise).

Impasse

An impasse exists when discussion between the patient and the other person has
stopped. There is smoldering, low-​level resentment and hopeless resignation but
no attempt to renegotiate the relationship. The individuals involved may deal with
each other using the “silent treatment”:

• Have discussions between you and [the other person] about important
issues stopped?
• Some disputes are quiet. You feel misunderstood and angry, but you don’t
talk about it. You are at an impasse.
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In renegotiation, as discussed above, the therapist emphasizes learning new ways

of communicating a solution. If the situation has reached an impasse, the ther-
apist may attempt to bring the issues between the parties out in the open. This
can result in increased disharmony, at least at first, as the patient brings long-​
suppressed disagreements and disputes back out into the open. Arguments may
ensue. The objective, however, is to develop better ways of dealing with the con-
flict, better communication, and effective compromise. This may help the patient
understand how differences in expectations in the relationship may be related to
her symptoms.

Dissolution

Dissolution may be appropriate when the relationship is irretrievably disrupted by

the dispute and one or both parties actively strive to terminate it through divorce
or separation, by leaving an intolerable marriage or work situation, or by ending
a soured friendship. Dissolution is usually not the first option, but it remains an
option if the patient cannot renegotiate a relationship to her satisfaction:

• Are the differences between you so large or unsolvable that you want to end
the relationship?
• Some relationships end because of irreconcilable differences. If you feel
you’ve reached that point, how can you dissolve the relationship with the
least harm?

A dissolution triggers a role transition (Chapter 7), in this case the loss of a rela-
tionship. You can then help the patient to deal with the sadness and/​or guilt
associated with the loss of the relationship and also with accepting it as the best
alternative. In this role transition, the patient must mourn the loss of the relation-
ship and recognize opportunities in the new role.

THERAPIST NOTE

In some cultures, dissolving a marriage may be impossible or irreparably damag-

ing. In such circumstances, you and the patient can explore new ways to maintain
the relationship with minimal distress.

MANAGING ROLE DISPUTES

Regardless of the phase of the dispute, it is important to help the patient realize the
degree of influence she had on the final outcome. Depressed individuals doubt they
have control over their environments, yet in fact they can exercise some control. Even
when the outcome is less than ideal, patients feel generally better when they recognize
 
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Chapter 6  Role Disputes59

the result is partly due to their own efforts, rather than somebody else’s. An accurate
sense of agency is more empowering than the depressive feeling of helplessness.
In order to manage a role dispute, patients need to recognize their own feelings
about what they want and don’t want, feelings about the relationship and the other
person, and what might constitute a reasonable compromise. Many depressed
people have great difficulty with relationships because they tend to put the other
person’s needs before their own. Some patients feel selfish asserting their own
needs. Anger feels like a “bad” emotion or one that will drive others away. IPT
therapists validate these feelings as normal responses to interpersonal situations:

• Everyone has needs, and it’s important to assert them; otherwise, other
people won’t know what you want. If you’re selfish all of the time, people
don’t like that, but if you never tell other people what you want or need,
they may not know these things, and you are unlikely to get them. That
is not fair to you and may at times create resentment for not being
understood or cared for. This often spoils relationships in the long run.
• People expect others to stand up for what they want. If you don’t, who will
speak for you?
• Anger is a useful, normal signal that someone else is bothering you. You
seem to have some reasons to feel angry. If you don’t tell someone what is
annoying you, that person is likely to continue doing it.
• It’s particularly hard to express these feelings when you’re depressed, but
doing so may help to improve your situation in this dispute, and that may
relieve your depression.

The usual sequence of events is to:

• Elicit the patient’s feelings in her description of an interpersonal

encounter: “What were you feeling?
• Validate and normalize them (except, for example, inappropriate guilt,
which can be identified as a symptom): “Is it reasonable that you were
feeling angry?”
• Explore options: “Looking back, what could you have done in that
situation? What might you do when it arises again? Have you expressed
those feelings to your spouse?”
• Then role play to help the patient put those feelings into a statement and
tone of voice in order to communicate it to the other person.

Negotiation requires expressing wishes directly (“I would like …”) and objecting
to the excessive demands of others (“I don’t like it when …”; “Please stop …”). If
the patient reopens negotiations with the other person, a clearer understanding of
the nature of the dispute emerges. As the therapist, you will also help the patient
to consider the consequences of many different alternatives before taking action.
Note that the role play is not assigned as formal homework, but role play in ses-
sion primes the patient to return to daily life and try out a potential new skill. The
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time pressure of brief therapy then pushes the patient to take the risk of trying
something new, changing a dysfunctional pattern.
To work out a resolution requires airing the needs and wishes of both the
patient and the other party. Sometimes in a marital dispute it is useful for the
partner to also enter treatment. You might support the patient in a separate nego-
tiation for marital therapy, in which both the partner and the patient see a ther-
apist together in conjoint marital therapy (see Chapter 25). More often, IPT of
role disputes functions as a kind of unilateral marital therapy in which the patient
works on the marriage with coaching from the therapist. The advantage to this
approach is that, because much of the work on the marriage takes place outside
the office rather than in the therapist’s presence, the patient can take credit for the
gains achieved. This sort of “success experience” and embodiment of agency may
bolster a patient’s sense of mastery over a relationship and sense of independent
autonomy as treatment termination approaches.
A theme in many marital disputes is that the patient feels left out and does
not share activities with the spouse. On the other hand, the patient may be mak-
ing little attempt at involvement and may expect the partner to know what she
wants without being told. In these situations, you can blame depressive symptoms
(social withdrawal, low energy, loss of pleasure) for the patient’s difficulty in get-
ting involved. Help the patient to recognize and speak clearly about specific things
she wants (but has not been getting) from the spouse and to develop more direct
and satisfactory ways of communicating with the partner. Exploring options and
role play are key techniques for preparing the patient for such confrontations:

• I’m interested in how you feel about these things, what you would like,
and how you would like to get them. And what is [the other person’s] point
of view?
• How much of what you’d like to do have you actually told him?

At times it may be appropriate to encourage the patient to directly discuss with

the partner what the patient sees as the dispute, to listen to the other side, and to
describe how they talk to one another:

Are you reluctant to approach each other? How do you handle differences?
Can you handle them in a nondestructive way?

In the wake of such an exchange, (1) congratulate the patient for having had the
courage to risk the encounter; (2) note the link between any mood shift and the
handling of the interchange; (3) reinforce the adaptive maneuvers the patient used;
and (4) commiserate and explore alternative options if things have not gone well.
If the patient engages in discussions with the other person about the dispute,
you may ask afterward:

• How did you and [the other person in the dispute] communicate with
each other?
 
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Chapter 6  Role Disputes61

• How did the discussion proceed? What did you say? What did he/​she say?
How did you feel then? Then what did you say?
• What was the outcome?
• What did you like about the way you handled it?
• What didn’t seem to work?
• Are you glad you had the discussion?
• What do you see as the next step? What options do you have?

CASE EXAMPLE: OVERBURDENED
AND UNAPPRECIATED

Joan, a 42-​year-​old college graduate with three teenage children, had recently started
a new, part-​time administrative job. Her depression involved a role dispute with
her husband, Harry. She felt that he did not help her around the house, criticized
her cooking and manner of dress, and generally made her feel terrible. Because her
return to work was a response to Harry’s concern of several years that she contribute
to their income, Joan had expected he would give her more attention. Harry had felt
that they could not afford to send the children to college on one income and that he
had assumed a disproportionate burden. Joan, on the other hand, felt he had never
appreciated the time and energy it took to raise the children: feeding, clothing, dress-
ing, and transporting them, arranging play dates and recreational activities, and
checking homework assignments. As all this already constituted a full-​time job, out-
side employment would only increase her burden.
Her new job, as predicted, made her feel overworked and unappreciated. Although
she relieved financial pressure by bringing in extra income, the marital relationship
deteriorated further. Their sexual relationship came to a halt, and they barely spoke
to one another. Their marriage had reached an impasse. Joan felt sad, listless, and
resentful around the house and argued more with her children. She started to have
problems falling sleep, found herself overeating, and had gained eight pounds in the
preceding three months. Harry, who had exacting opinions about Joan’s physical
appearance, then criticized her about the extra weight. Her initial Hamilton Rating
Scale for Depression score was 22—​moderately to severely depressed.
Therapy began with a discussion of Joan’s symptoms and their onset. It was
clear that the symptoms had started after she began working and that the heart
of the dispute lay in her feeling unappreciated and overworked. The therapist
encouraged her to discuss these feelings with her husband, and they role played
this during a session. When Joan later broached the topic at home, the discussion
resulted in far better communications in which Harry was able to express some
of his own feelings of disappointment in the relationship, as well as his positive
feelings about the home and the security Joan had created for him. They spontane-
ously planned to spend at least two nights a month together doing something just
for fun. Their sexual relationship improved, and Joan’s depression began to lift. By
the end of the twelve-​week treatment, her Ham-​D score had fallen to 7—​within
the normal range.
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CASE EXAMPLE: FIGHTING BACK

Lindsay, a 29-​year-​old married Catholic social worker, presented in tears with the
chief complaint:  “My life is miserable.” He reported years of intermittent milder
depression that had worsened in the previous six months. When his therapist
asked what might have been happening in his life to make him feel worse, he first
mentioned work tension, but then ruefully revealed his concerns that his mar-
riage was “failing.” Jen, his wife of three years, had grown increasingly distant, sex
had stopped for the past year, she no longer mentioned having the children they
had both fantasized about, and she seemed preoccupied with text messages on her
phone. Lindsay, whose approach to relationships was generally submissive and pas-
sive, went through Jen’s credit card statements and found charges for expensive gifts,
restaurant meals, and hotel stays of which he had been unaware. Guiltily, he broke
into Jen’s cell phone and found steamy text messages between her and someone
named Edward.
Heartbroken at the prospect that Jen might be having an affair, and that his imag-
ined “forever relationship” marriage could be crumbling so soon, Lindsay had kept
silent for weeks. He felt depressed, anxious, and guilty (including guilty for having
been spying on Jen); had difficulty falling and staying asleep; and began overeating
and gaining weight. He reported passive suicidal ideation, although “I would never
do anything [to hurt myself].” His Ham-​D score was 28, indicating severe depression.
He struggled to work with his patients and colleagues in a health-​care setting.
The therapist gave Lindsay the diagnosis of a major depressive disorder and linked
it to his marital crisis: “A marriage is supposed to provide more support than dis-
tress. No wonder you’re upset if your wife is having an affair!” Lindsay agreed to
a twelve-​week course of IPT. The therapist explored his feelings about Jen, noting
his difficulty in acknowledging anger. “I don’t like that feeling,” said Lindsay. “And
who am I to get angry? She must see me as an inadequate husband, and that’s why
she’s looking elsewhere.” As this fairly religious couple had never agreed on an open
relationship, the therapist explored Lindsay’s feelings about the transgression of Jen’s
seeming affair. The therapist elicited his “irritation” (a word he tolerated better than
“anger”) in daily encounters with his wife, who continued to act in a distant and
somewhat condescending matter. They then discussed whether this was a reasonable
feeling: Jen seemed, at least, to have broken their marital vows.
The therapist asked: “What do you want to happen? What would make you feel
happier?”
Lindsay said he would like to save the marriage, to make it better again.
“What options do you have to achieve that?” asked the therapist.
Lindsay’s first answer was “none,” but he decided it was worth trying to talk to Jen.
The therapist agreed that communication about one’s feelings was crucial to any good
relationship. After several sessions of validation of his feelings of hurt and anger, and
role playing the content and tone of their expression, Lindsay acted—​although not
as the therapist had anticipated. He confronted a difficult coworker: “I’m annoyed,
even a little angry, that you didn’t tell me about transferring that patient.” Lindsay
 
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Chapter 6  Role Disputes63

was somewhat surprised that these words came out, and surprised as well by the
coworker’s response, which was an unexpected apology.
After discussing this in session 7, Lindsay felt emboldened enough to confront
Jen: “I’m not happy with the way our marriage is going, and I don’t think you can
be either.”
Jen initially professed not to know what he was talking about, and Lindsay was
tempted to let this go. Then, however, the dialogue grew: Lindsay said he was “angry
and hurt at the way you’ve withdrawn from me.” She softened, they both cried,
and Jen confessed to having been troubled by her work situation and to have been
seduced by a younger man there. Lindsay, prompted by role play rehearsal, found
himself saying: “You shouldn’t have done that. You owe me an apology!” Jen apolo-
gized and said she felt terrible for hurting someone she really did love, but did not
commit to ending the affair.
Lindsay came to session 8 perplexed. On one hand, he felt validated in his
feelings—​he hadn’t been imagining things, he had been able to express his anger, and
he had even gotten an apology. (The therapist underscored and congratulated him
on tolerating and expressing his feelings.) On the other hand, nothing was resolved,
although his relationship with Jen did feel closer. Lindsay and the therapist discussed
how he felt, whether it was reasonable, what he wanted to happen, and what options
he had to achieve them. Lindsay role played telling Jen that he was angry but still
loved her, their marriage was worth saving, and she should recommit to it.
Both again tearful, Jen agreed to do it and quickly submitted a request to transfer
to a different office where she would no longer have contact with Edward. The mari-
tal sexual relationship resumed. Lindsay’s Ham-​D score fell to 6, denoting remission.
As termination approached, the therapist asked him why he was so much better.
Lindsay at first modestly credited the therapist for saving his marriage, but then
spontaneously acknowledged his own active role in improving things. They discussed
his toleration of negative emotions like anger, and his using them to assert himself
to manage his relationships. At the six-​month follow-​up he remained euthymic, Jen
seemed faithful, and she had become pregnant.