Problems that arise in the course of psychotherapy may be based on the patient's social or cultural beliefs, the patient's unfamiliarity with therapy, or the inherent awkwardness of the therapeutic relationship. The problems described here are general ones, applicable to the original IPT approach, its adaptations, and probably much of psychotherapy. Problems unique to specific adaptations can be found in those chapters.
These common problems, while obviously overlapping at points, can be roughly grouped as (1) problems reflecting the patient's depression, (2) problems in the therapy itself, and (3) common patient concerns.
THE PATIENT'S DEPRESSION
Some patients have an acute episode of depression superimposed upon a less symptomatically severe but chronic depression, i.e., dysthymic disorder. The acute worsening of symptoms is then termed a "double depression" ( Keller et al., 1982, 1984). For these patients, defeat, pessimism, and low self- esteem have become a characteristic way of viewing the world and dealing with others. Interpersonal difficulties such as shyness, social discomfort, lack of self-assertion, and difficulty in expressing anger are hallmarks of dysthymic patients. It may be difficult to assess the chronic nature of the dis-