Interpersonal Counseling for College Students: Pilot Feasibility and Acceptability Study

We set out to conduct a pilot study examining the feasibility, acceptability, and effectiveness of IPC-C. Our a priori expectation was a ≥80% retention rate and an average satisfaction score ≥5 on a 6-point satisfaction scale, with higher scores indicating greater satisfaction. We also expected to find a clinically significant reduction in depressive symptoms and a rise in adjustment to college life.

Participants were 10 students seeking treatment (January through June 2017) at the counseling centers of two separate higher education institutions located on the U.S. East Coast. Approval was obtained from both institutions’ institutional review boards, and consent was obtained from all participants. The inclusion criterion was a Patient Health Questionnaire–9 (PHQ-9) score of 5–14, which reflects mild to moderate depression. Exclusion criteria were any significant risk of danger to self or others, as well as any diagnosis of a psychotic, eating, or substance dependence or use disorder. If participants were to develop more severe depression (defined as a PHQ-9 score ≥15), they would be withdrawn from the study and referred for necessary and appropriate care; this did not occur with any of the participants. Participants’ ages ranged from 18 to 28 (mean±SD=20.0±2.0). Most of the participants were women. At both counseling centers, diagnostic impressions were obtained thorough intake interviews. All participants were assessed as having one of the following conditions: dysthymia, adjustment disorder with depressed mood, major depressive disorder, or bereavement. Participants ranged from first-year students to graduate-level students.

IPC-C was developed for use with students receiving services in university counseling centers. This intervention adheres to the core components of IPT and IPC (26), spanning three treatment phases (initial, middle, and termination). (The unpublished manual is available by request from the first author [A.K.R.].) During the initial phase, the therapist provides psychoeducation about depression, likens it to a medical illness, and conducts an interpersonal inventory, which is a register of the key relationships in the individual's life. Through the interpersonal inventory, the patient’s social functioning problems are identified and then attributed to one of four problem areas: role disputes, interpersonal role transitions, interpersonal deficits, and grief. In the middle phase, the therapist focuses the work on resolving social functioning problems (e.g., by practicing alternative methods for communication, recognizing and regulating affect, or problem solving interpersonal challenges). During the termination phase, the therapist notes the patient's accomplishments, jointly explores with the patient how he or she can continue applying the acquired skills once therapy has concluded, and acknowledges the patient’s (often mixed) feelings about termination. Together, the therapist and patient also assess whether referral for additional psychotherapy or other mental health intervention is warranted.

Some characteristics of the target population led us to go beyond IPC and to incorporate additional ideas into what became the IPC-C manual. First, because college students are typically undergoing the developmental stage referred to as emerging adulthood (4), we reasoned that clinical work with them should also draw from interpersonal psychotherapy for depressed adolescents (IPT-A) (31). Relatedly, IPC often addresses the patient’s “sick role,” which helps allay some of the guilt inherent in depression. We found that for this patient population, the IPT-A concept of a “limited sick role” offered a better fit, promoted a sense of agency, and helped take into account broader identity formation processes (36), such as intersectionality (37, 38). Third, depression, both in general (39, 40) and in this target age group (41–43), is often comorbid with anxiety disorders; in particular, the social challenges of adolescence and emerging adulthood and the transition from home life to college life often have the most severe impact on socially anxious individuals (44). As such, we applied lessons learned from efforts to address social anxiety with IPT (45). Additionally, because cognitive-behavioral therapy (CBT) is often effective in treating social anxiety (46), we incorporated some optional CBT techniques (47) to be used if clinically indicated. Finally, university life often involves daily stressors, frequent exam periods, academic assignments, and heavy reading loads. Students are expected to possess self-discipline and adequate time management skills while effortlessly and perfectly balancing their schedules to socialize, forge new relationships, and set long-term personal and professional goals. We found it important to provide our student patients with tools that would help them cope with such serious, although common, stressors. For this reason, the adaptations included a self-care checklist to help ensure that students followed healthy routines (i.e., healthy eating, sleeping, and regular exercise) (48) known to affect mood. (For further information about the development of the IPC-C manual or for the manual itself, please contact the authors.)

For this study, three clinicians delivered IPC-C. At one counseling center at a 4-year liberal arts college, IPC-C was delivered by the developer of the intervention. At the other counseling center at a university, IPC-C was delivered by two psychology interns trained in the approach. Prior to implementation of the study, these two clinicians attended a 1-day IPC-C training workshop. Two authors (A.K.R., L.M.), both certified trainers and supervisors in IPT, reviewed all audio-recorded sessions for fidelity to the IPC-C manual. This review served as the basis for weekly supervision conference calls with these two authors and the two additional therapists and were held for the duration of the study. IPC fidelity checklists were completed for the trainee therapists’ audio-recorded sessions. Fidelity ratings averaged 3.39 on a scale of 1 to 4 (3, satisfactory; 4, superior).

Nine of the 10 participants (90%) completed the study; we were unable to follow up with one participant who dropped out after two sessions. Despite efforts made by the therapist, there was no response after dropout; therefore, we have no information regarding the student’s reason for leaving therapy. No participants were withdrawn from the study for an elevated PHQ-9 score above 14. Among completers, the mean number of therapy sessions attended was 5.4±0.7 (range 4–6), over an average of 5 weeks (range 2–10). On average, completers found the intervention to be quite satisfactory; all satisfaction scores were above the midpoint of the 0–6 scale (denoting moderate satisfaction). The scores ranged from 3.8 to 6.0, with a high average (mean=5.1±0.7).

Table 1 shows the means, standard deviations, and scores of the participants’ PHQ-9 and CAT scores, pre- and posttreatment. One participant (labeled 4 in Figure 1) dropped out after the second session; therefore, his last scores were carried forward. Paired t tests showed that posttreatment PHQ-9 scores (mean=4.45±2.5) were significantly lower than pretreatment scores (mean=10.2±1.6; t=–7.74, df=9, p<0.001). The estimated effect size of the PHQ-9 from baseline to termination was very large (Cohen’s d=2.45). Of note, 80% (N=8) of the patients demonstrated a reliable change (49) in their depressive symptoms during the treatment (a decline in PHQ-9 score of at least 5 points), and 60% (N=6) of the patients showed depressive symptoms below the clinical threshold (score <5) after the treatment (33, 50). We also performed a multilevel regression analysis, in which patients’ session-level PHQ-9 reports were regressed on session number. In this model, the intercept and slope (i.e., session number) were estimated as both fixed and random effects. The results indicated that the patients showed a significant linear decrease in depressive symptoms over the course of treatment (estimate=–1.25, SE=0.22, p<0.001).

Paired t tests showed that posttreatment CAT scores (mean=94.3±16.25) were marginally higher than pretreatment scores (mean=78.7±18.06; t=2.90, df=9, p=0.017). The effect size of this pre-to-post increase in adjustment was large (Cohen’s d=0.92).

We performed a set of regression analyses to test whether changes in patients’ depressive symptoms and college adjustment were associated with pretreatment depression level (mild versus moderate), number of therapy sessions received, patients’ age, and patients’ years in school. None of these variables were significantly associated with levels of change. Complete results can be obtained from the first author (A.K.R.).