Rationale for Adapting Group Interpersonal Therapy for the Treatment of Psychological Distress Among Seafarers

Mental health has become an increasingly salient topic in the workplace. The World Health Organization estimates that 15% of the global workforce experiences psychological distress at any given time, costing the global economy billions of dollars each year in lost productivity (1). Workers employed in hazardous or isolating environments with long shift hours are especially at risk for developing mental disorders, the most prevalent of which are anxiety and depression. The COVID-19 pandemic has further exacerbated occupational stressors and illuminated the challenges faced by many essential workers.

Seafarers constitute an essential but often overlooked segment of the global workforce. They are critical to the global supply chain—an estimated 90% of all trade is transported by sea (2). The millions of men and women who make up this workforce are not only sailors but also engineers, stewards, fishermen, and more, and they serve aboard a multitude of vessels, ensuring that passengers and goods reach their intended port.

Work conditions on ships are frequently adverse and hazardous. Regardless of the vessel, crew quarters are usually small, enclosed, and shared, offering little privacy or respite from operational noise, heat, vibration, or the rolling motion of the sea (3). The ship setting can also be dangerous; in the United States, seafarers are six times more likely to die while working than workers in any other occupation (4). Injuries frequently occur from heavy lifting, slippery surfaces, confined passageways, severe weather, and exposure to biological hazards (4). Complicating matters, few ships have health care staff aboard or adequate access to medical resources (2).

Compounding these physical occupational challenges, seafarers travel thousands of miles from home, for months at a time, with limited access to affordable telecommunication infrastructure (5). This distance and limited access severely hamper seafarers’ ability to connect with friends and family on land, engendering feelings of loneliness and isolation, according to a seminal report that surveyed 1,507 active mariners (6). Moreover, separation from home was found to exacerbate grief, especially among seafarers who learned of a death while at sea (6).

Interpersonal conflict is also of particular concern in the maritime industry (4). In one report, 51% of respondents reported having been bullied, 64% reported quarreling with colleagues, and 72% felt unfairly blamed for adverse events while on the ship (6). Of note, language barriers and cross-cultural misunderstandings, which can arise in an internationally diverse workforce, contribute to strife among crew members (3).

These challenging work conditions provide fertile ground for the development of psychological distress. A joint effort by the International Transport Workers’ Federation Seafarers’ Trust and the Yale Occupational and Environmental Medicine Program surveyed a broad sample of 1,572 seafarers and discovered that 25% were experiencing clinically significant, moderate-to-severe symptoms of depression as measured by the Patient Health Questionnaire–9 (PHQ-9) (7). This study also found that 20% of respondents reported having suicidal ideation within the preceding 2 weeks, an alarming statistic given the remote nature of working at sea (7).

The COVID-19 pandemic negatively affected the mental well-being of this essential workforce, because many seafarers were stranded aboard their vessels, unable to disembark because of pandemic-related policies and delayed repatriation. A large-scale study that compared surveys from before the pandemic with those conducted during the pandemic found that the percentage of seafarers who had never experienced depressive symptoms at sea was reduced by almost half, from 18.7% to 10.9% (8). These findings lay bare the critical need for early mental health interventions and ongoing maintenance for people working at sea.

Current Obstacles to Care

Few interventional resources are available to treat this hard-to-reach, internationally dispersed workforce (2, 6). Not every ship has general medical staff on board, and fewer still have personnel trained to provide mental health services (2). Although helplines and telecounseling services are available through labor unions, employers, and third parties, the communication infrastructure at sea is inconsistent, curtailing seafarers’ ability to engage in telehealth (5). In addition, ship designs offer limited private space (3).

Although mental health clinics may be available at port, seafarers spend little time docked, making use of land-based services impractical (2). Furthermore, many seafarers function as migrant workers under temporary contracts, operating within a complex, decentralized system that leaves them vulnerable to gaps in both general medical and mental health care (2). These barriers and systemic loopholes may, in part, explain why existing resources and measures to safeguard seafarers’ mental health are insufficient.

Rationale for Adapting Group Interpersonal Therapy (IPT) for Seafarers

Seafarers approach employer-sponsored services cautiously (3) but have been reported to be more receptive to peer support (7). On a ship, this preference lends itself to community-driven, group interventions. One such evidence-based intervention is group IPT, a time-limited, manualized treatment for depression that is delivered in a group format to alleviate psychological distress by clarifying links between an individual’s depressive symptoms and four core categories of interpersonal stressors: loneliness, role transition, grief, and interpersonal conflict (9). Of note, these four themes frequently underlie psychological distress in seafarers.

Group IPT begins with a facilitator meeting separately with each prospective group member to better understand their unique symptoms and circumstances. During this meeting, the facilitator encourages commitment to the therapeutic process, provides psychoeducation, and sets treatment goals. This individual session is followed by three phases of group therapy. During the initial phase, group members become acquainted with one another and learn about each member’s depressive symptoms. In the middle phase, group members explore problem areas contributing to their depression while practicing interpersonal skills and supporting one another. In the final phase, group members review their progress, strategize how to handle future challenges, and say their goodbyes (9).

Since group IPT’s development in the 1990s, researchers have adapted the manual for various contexts. For example, group IPT has been modified to treat occupational distress. The effectiveness of this modification was evaluated in two separate pilot studies that assessed clinical and occupational outcomes (10, 11). In both studies, group IPT outperformed treatment as usual, significantly decreasing workers’ depression while improving their occupational self-efficacy and work attitude (10, 11).

Group IPT has also been implemented in settings with limited health care infrastructure. For example, a culturally specific adaptation of the group IPT manual was developed for nonclinician group facilitators as part of a clinical trial in rural Uganda (12). Participants treated with group IPT experienced a nearly fivefold improvement in their depressive symptoms compared with participants assigned to receive treatment as usual (12). The modality’s broad adaptability and successful delivery by nonclinicians make group IPT especially promising for treating psychological distress among seafarers.

Theoretical Implementation of Group IPT for Seafarers

In an adaptation of group IPT for seafarers, the basic structure of the intervention would stay intact, but screening, group formation, and delivery would depend on crew size and vessel type. For example, cruise ships have crews that are large enough to include a health care worker on staff who could be trained in group IPT before departure. This crew member could periodically distribute a screening tool, such as the PHQ-9, and facilitate groups as needed (9). Cargo ships and tankers, however, have smaller crews and are unlikely to have a health care worker aboard (2). In these cases, screening could be conducted while docked at port, and a trained third-party facilitator could be brought aboard for the duration of treatment. Alternatively, one or two crew members could be proactively identified and trained as group IPT facilitators. However, when cases that are inappropriate for group IPT arise, such as severe substance use, psychosis, or active suicidality, emergency resources should be activated.

Limitations of Group IPT for Seafarers

Adapting group IPT for seafarers is not without limitations. For instance, small crew sizes and workplace hierarchies may interfere with open therapeutic discourse. In addition, delivering group therapy in every participant’s native tongue may not be possible for multinational crews. Depending on the circumstances, individual delivery of IPT may be more appropriate.

Conclusions

Seafarers make up an essential workforce that experiences high rates of psychological distress, and their occupational environment makes treatment of their mental health conditions difficult. Group IPT is an evidence-based mental health intervention that has been successfully adapted for occupational contexts as well as low-resource settings and therefore has the potential to meet the needs of this vulnerable population.