Personal Journeys with Interpersonal Group Therapy: Qualitative Exploration of Experiences of People Facing Depression in the City of Mosul, Iraq

1. Introduction

Key implications for practice:

• IPT-G is being experienced as positive and useful, while concepts and techniques are generally suitable for the needs in the post-conflict context of Mosul.
• Introducing culturally appropriate ways to tackle sensitive issues, particularly conflict-related, as well as to sustain the groups, might contribute to greater value and effectiveness of IPT-G in the local context.
• Introduction of practical and creative activities, and relaxation techniques, as well as sensitive use of existing techniques such as role play may support acceptability of the intervention.

Interpersonal therapy (IPT) is a therapeutic approach derived from theories that focus on the importance of interpersonal functioning for psychological adjustment, originally developed for treating depression (Wilfley & Shore, 2015) Loss of significant other, role change, disputes and social isolation are the interpersonal circumstances in focus (Markowitz & Weissman, 2004) while the introduction of a “sick role” as recognition of depression as a medical, but treatable condition (Kendler et al., 2008) is another defining component of the treatment approach. Although originally an individually delivered intervention, it has also been modified for group delivery (Wilfley et al., 1993; World Health Organization [WHO] & Columbia University, 2016). Numerous, mostly quantitative studies have confirmed the efficacy and acceptability of IPT (de Mello et al., 2005; Cuijpers et al., 2011; Spelke et al., 2022; Hankin et al., 2023), showing it to be an empirically well proven intervention for the treatment of depression (Markowitz & Weissman, 2004).

Qualitative research observes interventions in real-life context in which they are implemented, provides insights into how mechanisms of change work in that specific context, reveal individual differences and validate quantitative findings (Sandelowski, 1996). When it comes to IPT, qualitative evidence is less available, with notable exceptions. Existing qualitative studies have found IPT to be acceptable, positively experienced, and useful in addressing mental health concerns for different groups, such as adolescents with depression in Nepal (Rose-Clarke et al., 2022), clients with HIV (Bernard et al., 2024; Yator et al., 2020), ethnic minority mothers (Palmer Molina et al., 2024), women with perinatal depression (Grote et al., 2021), and residents in rural Uganda (Lewandowski et al., 2016). Numerous positive outcomes of participation are reported: reduced depression symptoms, stress and interpersonal distress (Lewandowski et al. 2016; Bernard et al., 2024; Palmer Molina et al., 2024, Grote et al., 2021), increased hope, empowerment, and self-awareness (Yator et al., 2020; Palmer Molina et al., 2024), improvements in social and occupational domains (Bernard et al., 2024) as well as increased cohesion at the community and family levels (Lewandowski et al., 2016). Improvements in a range of skills were found too: interpersonal skills, decision-making, role-playing, relaxation; emotional identification and regulation (Rose-Clarke et al., 2022; Bernard et al., 2024; Yator et al., 2020; Grote et al., 2021). Challenges and limitations observed include confidentiality and privacy concerns, time demands, access to health care (Bernard et al., 2024), stigma for participants with depression (Palmer Molina et al., 2024), and absence of positive outcomes in social support from significant others (Grote et al., 2021).

The general paucity of qualitative evidence and the diversity of IPT formats, delivery contexts, and target populations in the reviewed studies limits conclusions about the suitability of Interpersonal therapy in groups, for people with depression in the city of Mosul. It is the second largest city in Iraq, located in the Nineveh region. The city was severely affected by the occupation of the Islamic State (IS) from 2014 to 2017. The occupation and final battle of Mosul led to a humanitarian crisis, damaging the city’s economy and infrastructure, causing massive suffering for its population and significantly affecting mutual relations and trust in society (Nummenmaa & Allaw, 2023). Many have lost their loved ones or their homes, faced violence, displacement, unemployment or conflicts, often related to IS involvement of community and family members. This study represents the first evaluation of IPT-G implementation in Iraq, to the best of our knowledge, thus contributing to the exploration of the cultural appropriateness of its format and concepts in local context. This is of great importance given the critical role that culturally shaped perceptions and behaviours play in participants’ responses to therapy (Sodi & Bojuwoye, 2011) and to prevent unreflective or unadjusted transfer of psychotherapeutic practices developed in contexts of the Global North to Global South communities (Bedi, 2018).

2. Subjects and Methods

2.1. Intervention

IPT-G was applied as part of a project implemented in the inner city of Mosul, west part, to address the social and mental health needs of the community. It was conducted in four cycles, between July 2023 and December 2024. Inclusion criteria for participation were: 1) being 18 years of age or older and 2) having a depression score of 10 or higher on the PHQ-9 questionnaire (Kroenke et al., 2001) [1]. Exclusion criteria were 1) presence of acute suicidality and 2) presence of neurological impairment. Participants were recruited through community outreach, other project-related activities, word of mouth, and referrals from other organisations.

The IPT-G was implemented in line with the WHO and Columbia University (2016) manual, particularly suitable for unstable conditions, delivered by facilitators without previous professional training in psychotherapy. The manual is structured around four problem areas to which the participants assign their main issues: grief, social isolation, role transformation and interpersonal conflict. The techniques used include rating of depression, linking mood to event and event to mood, communication analysis, interpersonal skills building, decision-making analysis, role play and setting practice exercises. While the intervention was implemented in line with the manual, the project team included external techniques that appeared useful in the context. The “talking stick” technique was used to avoid interruptions, while breathing exercises were occasionally implemented when the facilitators recognised that participants needed to recharge, regroup or reconnect.

Two psychologists (second and third author) who facilitated the groups, took part in training and were supported and supervised throughout the delivery. The intervention consisted of two individual, pre-group meetings with each participant and eight group sessions. The sessions lasted one and a half hours on average, and were implemented in a confidential room, in the community centre. Groups consisted of eight participants of the same gender.

2.2. Qualitative Study

Semi-structured interviews allow for a structured approach to the interviews, while providing space for unforeseen, relevant topics to emerge and for participants to share their experiences in their own words (Karatsareas, 2022). In total, 32 semi-structured interviews (53.13% female; Mage=28.4) were implemented with purposefully sampled participants in different cycles throughout the project. The selection of the participants in each cycle was implemented with the goal of balancing gender, age, main problem area, as well as perceived level of improvement during therapy, but also depended on their availability and willingness to participate. Given that grief was the most frequent main problem area that participants addressed, this also resulted in higher numbers of participants with respective issues. Importantly, however, despite the focus on the main problem area in the therapeutic process, participants often also discussed additional issues and outcomes related to their particular life stories and daily experiences. The general description of the sample can be found in Table 1.

The interviews were conducted seven to ten days after the last group session, mostly within the community centre, while six interviews were conducted in the respective participants’ personal facilities, as it was more convenient for them. Privacy was ensured during the interview, with only the interviewer of the same gender of the interviewee being in the room (second or third author). The language used was Arabic and the average duration was 25 minutes.

As the IPT-G facilitators also conducted the interviews, it was particularly important to focus on minimising the risk of social desirability bias (Karatsareas, 2022). Therefore, during the interview the importance of honest responses and one’s own perspectives, and the value of sharing both positive and negative experiences was emphasised. As some participants expressed the feeling that giving negative feedback would imply criticising the facilitators in some way, they were careful to explain that the purpose of feedback was not to evaluate them personally, but rather to acquire relevant insights into the intervention method. Nevertheless, this challenge might still have affected the amount of negative experiences reported to some extent. Written and, in exceptional cases of illiterate participants, verbal informed consent was obtained from participants.

The interview agenda consisted of questions about initial expectations of the intervention, general evaluation and specific positive and useful as well as challenging aspects. This was followed by questions about the perceived impact of the intervention on the main problem addressed, on life in general and on skills developed. The questions were first asked in a more open manner, e.g., “What aspects of the program were particularly useful to you and how?”. This was followed by prompts, e.g: “Is there anything specific related to the relationship with the psychologists; interaction with other participants; specific exercises; specific sessions…”.

The interviews were recorded and transcribed with the permission of the participants. The audio recordings were transcribed and translated from Arabic to English by a bilingual speaker. Thematic analysis was applied to the English transcripts with the aim of recognising data patterns in the participants’ experiences (Braun & Clarke, 2012). The data were analysed using MAXQDA qualitative analysis software. After initial familiarisation with the transcripts, the transcripts were coded by the first author using the line-by-line procedure. The coding process was applied back and forth and as the broader themes emerged, it was necessary to return to the codes and modify them. The interviews were first analysed individually and then transversally to explore possible differences in the salience of themes and codes according to gender, age or problem area. Peer debriefing was used to ensure the trustworthiness of the data analysis. The draft coding structure and draft analysis were shared and discussed with the research team and modified as needed.

3. Results

The thematic analysis carried out revealed several themes, some of which concerned the experienced benefits and some the challenges while participating in the IPT-G intervention. The topics are discussed in detail in the following text, while their overview, together with the assigned codes can be found in Table 2 (Appendix A).

3.1. IPT-G as an Opportunity for Learning

Irrespective of the problem area, the majority described their participation in the IPT-G as an opportunity to learn valuable skills, gain insights and receive guidance. They reported that they already started applying what they have learned in their “real life”, and shared their perception that they will apply it in the future. In particular, the techniques regarding communication and building interpersonal skills were mentioned as valuable tools that enabled them to improve their social skills. The decision-making analysis was also reported to support their approach to solving problems and especially for women to increase their awareness of their role in decision-making. While for some women, this led to increased agency, for those who faced greater restrictions, application was limited.

The communication analysis was most beneficial. I started communicating much better with my friends as a result of the sessions. (Male, 24, life change)

Decision-making [was the most useful technique]. Many women think that men should bear all the responsibility and that a woman can’t live without a man. But in reality, women also have a role to support their husbands and help create a comfortable, loving environment. (Female, 23, conflict).

Several participants described the breathing exercises that were incorporated in the manual as helpful in dealing with overwhelming emotions related to loss, or stressful situations, such as those stemming from interpersonal conflicts.

The breathing exercises helped me relieve stress. (...) Initially, after losing my father and brother, I experienced intense loneliness and depression. However, with the breathing exercises and techniques for managing stress, I can now handle these situations better and don’t react as strongly as I used to. (Female, 19, conflict).

Some participants also reported that they were understanding their mental and emotional states better as a result of taking part in the intervention.

Yes. Before the sessions, I often felt sadness or annoyance without knowing why. Now, I understand my emotions better. (Male, 24, life change)

In addition, hearing about the problems of others made them realise that they were not alone in their pain, while their own problems sometimes seemed less troubling when compared to the problems of other participants. It was often mentioned that the presence of other participants in the therapeutic process was beneficial. First of all, participants provided mutual practical advice to one another and offered perspectives on their problems and possible solutions. Some participants particularly stressed the learning from others who experienced similar situations or were in a relatable situation as a particularly relevant experience. Particularly, other participants served as “role models” for one another. Observing other participants’ open up encouraged others to share as well. Participants also supported each other in navigating through the understanding of psychoeducational aspects of IPT-G.

Yes, it [the group format] was beneficial. For instance, one participant suggested a solution to a relationship issue I was dealing with. I applied their suggestion, and it actually worked. So, it’s definitely helpful to have other people in the group who share the same problems because they can offer more than one solution. (Male, 18, grief)

3.2. IPT-G as a Facilitator of Positive Life Changes

The majority of participants mentioned that taking part in IPT-G supported them to deal with problems in the main focus, particularly coping with grief and isolation, and solving disputes. Positive changes were observed in participants’ behaviour and, as a reaction, in their surroundings. The most notable change is greater openness to socialising and participation in community life, as well as better quality of communication and connections, particularly with significant others.

I learned how to communicate with people and how to be comfortable sitting with them. After losing a close friend, I had isolated myself and avoided forming close connections to prevent feeling that loss again. However, through the sessions and the solutions you presented, I was able to reconnect with people and rebuild relationships. (Male, 33, grief)

(...)I would avoid my children, and when they came to me, I would respond angrily and harshly. Deep down, I knew it was wrong, but I couldn’t stop myself. After the program, I learned how to express my emotions and manage my anger. I stopped treating my children in that way. Instead, I worked to understand them and meet their needs. Gradually, our relationship improved. (...) My siblings, too, have seen the difference — I used to fight with them often, but now we get along. This program has truly transformed my relationships, and I couldn’t be happier about it. (Female, 27, social isolation)

Many participants reported that taking part in IPT-G was enabling them to catalyse general improvement in their mental health, mood, level of energy and reduction of depression symptoms. Some participants mentioned being more optimistic, motivated and hopeful. Positive change is also mentioned in terms of increased self-esteem, and sense of strength and empowerment, particularly relevant for female participants. Visible improvements were also noticed in terms of resuming or engaging with hobbies, activities and life goals that were important to them.

I had trouble sleeping and struggled with anger. I would get upset over the smallest things. But now, everything has changed for the better. (Female, 43, social isolation)

Before, I never went out, as my husband restricted me. I felt trapped. But the organisation showed me that I could do things independently. I can now go to the market and even take a taxi by myself. I didn’t even feel comfortable going to the doctor alone, fearing people’s judgment. The organisation helped me build confidence. (Female, 40, grief)

3.3. IPT-G as a Space for Sharing

Regardless of the nature of the problems the participants faced, most of them reported that IPT-G was a unique platform where they were able to talk about their issues. Some participants, particularly those who were coping with grief from a previous loss, also expressed that participation in IPT brought relief and comfort through sharing and “lifting off the pain”. As one participant noted, although the loss is something that cannot be forgotten, the sharing in the group and the compassion of the others was described as an encouraging and relieving experience.

Through this group intervention, I was able to speak up about my problems and hardships. Previously, we would reach out to relatives and neighbors, but they couldn’t really understand us. Now, this space has become a heaven for us, where we can discuss and relieve what’s in our hearts. (Female, 30, grief)

While sharing, participants experienced mutual emotional support and empathy, and a sense of connection to the group. This made them feel supported and understood. This effect of the intervention was particularly relevant for female participants, who were emotionally expressive to a greater extent during the sessions compared to men.

No one can truly replace someone or make you forget them, but the support and compassion in these sessions helped me feel comforted. Before, I felt isolated and overwhelmed, but talking with others and feeling their support has made a big difference. (Female, 23, conflict)

3.4. IPT-G Group Members as an Expanded Social Network

Many participants, particularly those facing social isolation, reported that the members of the group itself started representing an important role in their life. Participants and facilitators were described in terms of “family” or “friends”. In that way, the expansion of the social network was a direct effect of the participation, as they got the chance to meet new people. This was of particular importance also for women who spent the majority of time in the household. In this light, some participants expressed the wish that the group continues its coexistence, expressed the sorrow that the group ended, and talked about the topic of “letting go of friendship”.

(...) The psychologist and the other participants became like family to me, even closer than my actual family. (...) Since the group setting helps you meet different people and build friendships, I suggest adding a topic on how to let go of a friendship, as sometimes friendships can end. (Male, 18, grief)

The group intervention was beneficial for me because it got me out of the house. I had the chance to meet new participants and form friendships while participating in the intervention. (Female, 18, conflict)

3.5. IPT-G as a Trigger for Discomfort and Challenging Emotions

Often, the initial group sessions were described as difficult and discomforting. For some, particularly those who faced social isolation, the mere requirement to interact with the unfamiliar group of people was experienced as intimidating to some extent. For most of the participants, to open up and speak about their personal issues in front of a group was particularly challenging, as this was not something they were used to. They referred to this initial feeling as being “out of their comfort zone”. This barrier, however, has been reported to have been overcome after several sessions, particularly by observing others who opened up. Only a few participants mentioned that the feeling of discomfort persisted during the whole program.

A friend initially invited me. At first, I thought I might feel pressured or embarrassed. But I decided to step out of my comfort zone and see for myself. Once I saw others speaking confidently and sharing their thoughts, I started to see positive results, which motivated me to continue. I began looking forward to each session, excited to build relationships with my new friends. (Male, 21, conflict)

In retrospect, the majority of participants said that they prefer the group setting to the individual interventions, while only some said to prefer individual settings instead. However, many of the participants, mentioned having some topics that would not be comfortable for them to discuss within the group ― this concerned in particular sensitive topics ― such as having relatives associated with IS, experiences of harassment, violence and family issues, particularly relevant for women, as well as traumatic experiences or other potentially stigmatised topics such as sorcery mentioned by this women:

There are certain things about my personal life that I can’t share, for example, the sorcery issues within my family. If I discuss such things in a group setting, the other participants might think I support those practices. Similarly, discussing harassment from someone close to me might make others think I’m pointing fingers at specific people. (Female, 30, grief)

Some participants also mentioned that the role-playing exercises made them feel uncomfortable and shy, brought unpleasant memories or were not taken seriously by the group.

Role-playing was challenging for me; I felt embarrassed during those exercises. (Female, 19, conflict).

Also, empathising with other participants, when they have shared particularly disturbing and sad experiences was perceived as an emotional burden to some extent.

I liked that we were all together as a group, sharing our problems. But when someone would share a sad experience, we all felt sad together, which was difficult. (Female, 19, conflict)

3.6. IPT-G as a Demanding Activity Regarding Its Practical Organisation

When discussing challenges, participants often reported practical and organisational issues. Firstly, they mentioned that it was sometimes difficult to adhere to the schedule, as it interfered with work, family responsibilities, study, or other commitments. Secondly, some participants described the intervention as time-consuming and as taking energy away from others, for them relevant activities, such as studying. Scheduling problems and interference with other commitments were often cited as reasons for skipping sessions. Additionally, the location of the community centre was for some participants who resided in other neighborhoods unfamiliar and far away, and it was a barrier for some female participants to get the approval of their family to participate.

The only challenge I had was with the timing of the sessions, but I was able to adjust my schedule. (Male, 46, grief)

The only downside for me was that it took up time I could have used for studying. (Male, 21, grief)

Only the location. If the sessions were held outside the organisation, it would have been better because we usually can’t leave the house. Coming to the organisation feels the same, so an external location would have been better. (Female, 33, conflict)

Some participants felt that the groups were too large, or that some participants were utilising more space, which prevented participation of some other participants. For some, the perceived heterogeneity of the group in terms of demographic and contextual features negatively affected their mutual understanding.

There was one person who would dominate the conversation, not allowing others to speak. It was frustrating for us. (Female, 40, grief)

Additionally, groups should consist of individuals with similar cultural backgrounds to ensure compatibility in their experiences and time commitments. (Male, 33, grief)

3.7. IPT-G as Monotonous Activity

Some participants commented on IPT in terms of its monotonous character, as each session entails the same type of activity: talking and sitting in the room. For that reason some participants expressed that they expected more practical activities, such as joint projects, productive and creative activities, therefore suggested to include those in future programs. Some female participants also suggested organising sessions outside as beneficial, particularly for those who spend most of the time inside households.

The group activities were beneficial. Perhaps we could expand them into collaborative projects, where we learn and grow together, since we’re comfortable with each other and share our problems openly. (Female, 19, conflict)

I think you should take us out to places more often and do activities. Before, our families wouldn’t let us go out much. But when we say it’s with the organisation, they don’t mind if it’s us girls only. We are always stuck between four walls, so having sessions outside the organisation would be better. (Female, 21, social isolation)

4. Discussion

The aim of this study was to explore experiences with IPT-G implemented in the city of Mosul, Iraq. Consistent with prior findings (Lewandowski et al., 2016; Rose-Clarke et al., 2022; Yator et al., 2020; Bernard et al., 2024; Palmer Molina et al., 2024), the results indicate that IPT-G is experienced as a positive and effective intervention. Also in line with prior findings (Rose-Clarke et al., 2022; Bernard et al., 2024; Yator et al., 2020; Palmer Molina et al.; 2024; Grote et al., 2021; Lewandowski et al. 2016), numerous positive personal outcomes were reported, including: improved mood and reduced depression symptoms, increased hope, optimism and empowerment; development of social and emotional regulation skills, increased quantity and quality of interactions, solved disputes, enhanced coping with grief, and resuming of beneficial activities such as education or hobbies. IPT-G was described as a space for learning valuable skills. Foremost, communication analysis and learning interpersonal skills were the most often mentioned as the most useful techniques that helped many participants to improve their social interactions, engage more socially and solve disputes. Decision analysis was also often mentioned as valuable, but with certain limitations when applied by some women in their surroundings. Role-playing is a widely accepted psychotherapeutic technique to help clients gain a deeper understanding of their own and others’ emotions (Pratiwi et al., 2022). In this present study, it was often experienced as unnatural, discomforting or even aversive. It suggests a lack of cultural fit in the Iraqi context, especially for participants who are not used to participating in such activities, and given the limited time available to become familiar with it within the IPT-G cycle. The spontaneously introduced breathing technique nevertheless fitted well and was for some participants a valuable meditative skill to carry into their lives, particularly in dealing with difficult emotions and thoughts.

While individual therapy is considered the gold standard in depression treatment, a growing body of research suggests the comparable effectiveness of the group approach (Olsson, 2022). The group format is less associated with stigma (Olsson, 2022) and provides the opportunity to learn from others, benefit from shared experiences, mutual support and practicing interpersonal skills (O’Shea et al., 2015). In retrospect, the vast majority of participants in the present study recognised the significant role of other participants in their therapeutic journey. The role of the group appeared especially relevant in comparison to the role of techniques and facilitators, which acquired less recognition in the literature. In addition to the emotional support they received from one another, the group approach allowed for exchange of information, appraisal support, and facilitating psychotherapeutic education, consistent with prior evidence (Palmer Molina et al., 2024; Rose-Clarke et al., 2022). IPT-G itself represented an expansion of the social network, whereas participants and facilitators often were perceived as the new significant others. This played a supportive role in reducing loneliness and improving social wellbeing, particularly relevant for those experiencing social isolation. Therefore, difficulties in the termination phase are to be expected (Palmer Molina et al., 2024). In order to make the groups sustainable after the termination phase, the encouragement of culturally appropriate implementations of self-organised activities or their integration in available community structures is recommended.

Research on the relevance of IPT problem areas in the Global South is limited. In line with results from Uganda (Verdeli et al., 2003), problem areas of IPT-G corresponded with the psychosocial needs in the local context of Mosul. In the context of (post-)conflict experiences of loss, damaged relationships and trust, and displacement (Nummenmaa & Allaw, 2023), grief and social isolation were most often primary concerns. Additionally, social isolation and conflicts for some women stemmed from the restrictions and labor division that confines them to the household. However, the particularly sensitive, but relevant triggers of mental health challenges often remained outside the scope of IPT-G due to its group format. In the case of Mosul, this is mainly related to sensitive or stigmatised experiences, such as having relatives associated with IS, gender-based violence and marital problems, or traumatic experiences during conflict. Complementary individual counseling or conducting IPT-G with more homogeneous groups of participants who face similar problems, could help to create a more comfortable space to address such issues. Also, as the manual used in this study (WHO & Columbia University, 2016) does not explicitly address traumatic experiences, in similarly burdened contexts such as that of Mosul, it may be appropriate to base the procedure on versions modified specifically for trauma-related issues (Campanini et al., 2010).

Additional cultural factors played a role in IPT-G’s acceptance and outcomes. The cultural appreciation of practical group activities over the “talking therapy”, suggests the added value of including additional activities into the intervention in this context. Also, the majority of participants mentioned initial mixed feelings and intimidation related to participation, as previously evidenced (Rose-Clarke et al., 2022). It points to the necessity to additionally focus on normalising discomfort in the initial phase and destigmatising the intervention. For a similar purpose, Rose-Clarke et al. (2022), framed IPT-G for adolescents in Nepal, as a program for developing skills and incorporated practical activities that would detach it from the psychopathology narrative.

Follow-up studies are needed to explore whether experiences and use of learned techniques and outcomes persist, and if and how they change over time. Future research should focus on the role of group homogenisation ― be it by symptom severity, demographic variables or problem type ― in participants’ experiences and outcomes. As mentioned above, a positivity bias needs to be considered when interpreting the results. The use of an external research team in future studies could be a possible solution. However the dual role may also have had a favorable effect on gaining insights in the present study, as participants expressed gratitude to the facilitators and established rapport, which encouraged open discussion. In addition, there was no systematic selection of participants with different levels of depression symptoms or improvement, but rather an unsystematic attempt to include participants with different levels. It is recommended to systematically control this in future studies to ensure balanced results.

5. Conclusions

While experiences with IPT-G are multifaceted, it proved to be a well-suited approach in Mosul, particularly with its focus on grief and social isolation - common problems in the post conflict context. However, specific tailoring to local needs improves acceptance and effectiveness. This includes the limited and careful use of role-play, the inclusion of practical exercises, relaxation breaks, space to discuss sensitive issues, as well as a particular focus on reduction of stigma and discomfort.