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Grand Rounds |
Received May 13, 1999; accepted June 7, 1999. From the Department of Psychiatry, Columbia University, 1051 Riverside Drive, Box 103, New York, NY 10032. Send correspondence to Dr. Mellman at the above address.
Key Words: Psychotherapy Supervision and Training • Psychotherapy, Psychodynamic • Psychotherapy, Cognitive-Behavioral • Interpersonal Therapy (IPT) • Depression • Grand Rounds
INTRODUCTION
Lisa Mellman, M.D.
Psychotherapy is an important tool for a psychiatrist. The Residency Review Committee currently requires that psychiatric residents have an experience in conducting several specific types of psychotherapy.1 In an effort to determine psychotherapy training objectives, a recent survey revealed that a majority of training directors believe residents should develop proficiency in cognitive-behavioral, psychodynamic, and supportive psychotherapy (P. Mohl et al., unpublished). Only recently, however, have psychiatric educators begun to define, codify, and measure the core psychotherapy skills and proficiencies for residents. Meanwhile, the amount of time spent on psychotherapy training has diminished as managed care, pharmacological and neuroscience advances, and other forces affect how psychiatrists are trained.2
Although residents are exposed to several types of psychotherapy, many training programs focus on one or two for more comprehensive teaching. As a result, these often become the only types recommended to patients. Additionally, the type of treatment a resident offers may be determined by training needs at that particular time. Lastly, a patient's insurance coverage may restrict the type and duration of treatment. These factors may limit the type of psychotherapy recommended. Residents are rarely trained to provide a full differential review with pros and cons of each type of treatment appropriate to a patient's illness and to enlist the patient's input in determining the type of treatment to provide.
Even in residency programs with significant psychotherapy training, the same case material is rarely presented and discussed from different psychotherapeutic points of view. In this Grand Rounds, we will present case material from the evaluation phase of a treatment conducted by a resident in the third postgraduate year. The clinical material will be presented to experts representing three different psychotherapeutic points of view—long-term psychodynamic psychotherapy (Glen O. Gabbard, M.D.), cognitive-behavioral therapy (CBT; Michael Thase, M.D.), and interpersonal therapy (IPT; John Markowitz, M.D.). After the initial presentation and discussion, the actual treatment provided will be presented and also discussed from the three different points of view.
CASE PRESENTATION
Steven Hamilton, M.D.
Identifying Information: Ms. A. is a 25-year-old single, unemployed, Christian woman of African-Cuban descent, currently living with her mother. She presented to a resident-staffed mental health clinic with the chief complaint, "I have been feeling depressed...stopped being involved in my church and business activities...and don't want to be around other people." These complaints had been of 5 months' duration.
History of Present Illness: Until 5 months prior to her presentation, Ms. A. had been doing well designing, manufacturing, and retailing beauty products in her own business. A graduate of a program promoting young urban entrepreneurs, she also delivered motivational talks at area schools. She began to feel depressed and lacked energy. At the same time, acute neck swelling led her to an ear, nose, and throat (ENT) physician who on physical examination found lymphadenopathy in her neck and under her tongue. CT scan showed submental swelling, and a biopsy demonstrated chronic lymphocytic inflammation. During the erratic 2-month course of antibiotics that followed, she felt increasingly depressed and isolated.Upon self-referral for a psychiatric evaluation, Ms. A. reported sadness, anhedonia, and decreased appetite, accompanied by a 17-pound weight loss over 5 months. She even did not feel like going to a favorite restaurant where she was a regular. She reported 2 weeks of insomnia with difficulty falling asleep, several hours' less sleep nightly than usual, and an "uneasy and unpeaceful" feeling upon awakening. She found the insomnia disturbing, as sleep was one of her favorite activities. She described periods of restlessness, with pacing, alternating with periods of feeling sluggish. Ms. A. said her energy level was "very, very low," leading her to cease running her fledgling business, attending church, going out dancing with friends, and exercising. She admitted to forgetfulness and indecision, sometimes entering a room and forgetting what she set out to do. She also described that when she wrote a sentence, some words might be entirely omitted or missing letters. She denied suicidal ideation, believing that "life is too precious for that."
Ms. A. reported feeling no enjoyment from recent advances in her life. These included an upcoming move to her own apartment across the hall from her mother, an offer to publish some of her motivational writings, and an appearance in a feature broadcast on national television describing her success in business. She admitted to a "fear of success," a pattern of behavior in which she would start an enterprise, excel at it, and then back out on the brink of success. She said that "people begin to expect" excellence or depend on it, and that she was wary of the pressure to stay on top. Yet she worried about letting others down.
Although Ms. A. denied symptoms of psychosis, mania, or panic, as well as any history of substance abuse or psychiatric treatment, she reported feeling distrustful of others and uncomfortable in crowds. Despite considering herself attractive, she felt distressed by "admiring looks and whistles" on the street. She said that "crazy people out there do evil things," and she worried that someone might stab her with a needle on a subway, as in news reports she had heard. On the other hand, she noted that when she felt normal, she was energetic, motivated, and sociable. At those times she was "good at networking" and could be the life of the party, without difficulty speaking in public. Ms. A. denied any trauma or sexual or physical abuse.
Past Psychiatric History: Ms. A. said that beginning in high school, she experienced anhedonia and depressed mood every year sometime between spring and early fall. The first episode coincided with attending a magnet school for students interested in fashion design. She did not know anyone and felt awkward about social situations and the crowds of students hanging out outside the school. She skipped school or left early, going home to sleep all day. She saw a counselor on occasion during her depressive bouts, but had no other treatment.
Social History: Ms. A. is the youngest of three. Her father died in a motor vehicle accident when she was a year and a half old. She described her mother as "cautious," "paranoid," "overprotective," and having a "generous heart." Ms A. stated that she is honest and open with her mother, sharing most things, but at times would also like to be left alone. Ms. A. expected her mother to "be there for me" but would like her to not be "so concerned with things."Her two brothers, 5 and 10 years older, live in the neighborhood. She described them vaguely, nearly indistinguishably. When asked what she would like to change in her relationship with her brothers, Ms. A. reported hoping that both brothers, Matthew and John, would become more sociable and communicative with her. Until immediately prior to presentation, for 3 years Ms. A. had lived with John. During that time their mother had, on several occasions, come looking for Ms. A. at 5:00 A.M. when she did not know her whereabouts the previous evening. Ms. A. had notable difficulty describing her relationships and illustrating them with examples.
Ms. A. reported having a learning disability, identified in elementary school. She found it difficult to discuss this problem, which she said affected her reading, writing, and pronunciation. She described having difficulty spelling common, simple words, and she found writing a letter almost impossible at times. This disability led her to repeat a grade in elementary school and to have persistent problems in liberal arts classes. In high school, Ms. A. kept to herself and described herself as a loner who dealt with her own problems.
With the support of a mentor and a business development program in high school, Ms. A. recognized her own entrepreneurial talent and thrived, developing her own business, which led to foundation awards and press exposure. After graduating from high school she attended a nearby vocational school and lived for the first time away from home. There Ms. A. developed few friendships and experienced occasional bouts of depression, leading her to again stay in bed all day and ultimately to take a leave of absence to pursue part-time work.
Ms. A. reported an engagement to a man for 3 years in her early twenties. According to Ms. A., the couple was admired by others and considered "good-looking." She described her fiancé as "jealous, possessive, and controlling," becoming upset when other men looked at her. He forbade her on occasion to wear flattering clothing, leading to arguments. In one incident, he tore and burnt one of her shirts. She denied physical abuse, but did admit to shoving matches with him. They broke up about one year prior to her presentation.
Ms. A. hoped to complete her degree, start a family, and ultimately become a television personality.
Mental Status Examination: Ms. A. is a tall woman, usually dressed in black, wearing appropriate cosmetics and fragrances. Eye contact is not sustained. She shifts position frequently but does not appear anxious. In morning appointments, she may yawn a dozen times during the session. Her mood is at times depressed and her affect somewhat constricted. Her speech is nonpressured, nearly inaudible at times, marked by errors such as dropping plural forms, and is notable for lack of spontaneous output. On occasion she appears alexithymic, struggling to find words to define her experience. She denies hallucinations, delusions, or ideas of reference, but is preoccupied with the notion that people on the street, particularly males, can make her uncomfortable by their staring or whistling. She denies obsessions or compulsive behaviors. She denies suicidal or homicidal ideation. Cognitively, she demonstrates no deficits except losing words or letters in her written work. Her insight is fair, demonstrated by recognition she is depressed but difficulty describing related events and feelings. Her judgment is good, and she does not display impulsivity. Her initial Beck Depression Inventory (BDI) score was 16, and she scored a 20 initially on the Hamilton Rating Scale for Depression (Ham-D), indicating mild/moderate depression.
Diagnoses: Axis I: Major Depressive Disorder, Recurrent, Moderate; rule out Seasonal Affective Disorder. Axis II: Personality Disorder Not Otherwise Specified with dependent, avoidant, paranoid, and self-defeating traits. Axis III: None. Axis IV: Unemployment, problematic family relationships. Axis V: Current 60, past year 75.
TREATMENT SELECTION
Long-Term Psychodynamic Psychotherapy
Glen O. Gabbard, M.D.
Ms. A. may or may not be a good candidate for a trial of long-term psychodynamic psychotherapy. She has the ability to express herself verbally and some degree of frustration tolerance. She also demonstrates perseverance and initiative in her work history. However, her history of object relations presents a more problematic picture. Ms. A. has difficulty trusting others and forming mutually gratifying relationships. These features may make the establishment of a solid therapeutic alliance a slow and difficult process.
Certainly not all patients who present with uncomplicated major depression require long-term psychodynamic psychotherapy. In Ms. A.'s case, there are characterological difficulties that may make response to standard treatments of depression less than optimal. The psychodynamic approach assumes that stressors have a specific impact on the patient's preexisting vulnerabilities, particularly involving self-image and self-esteem. An exploration of stressors, especially with regard to their idiosyncratic meanings to the patient, is a major thrust of the approach. Dynamic therapy also works with the way that others are represented in the patient's internal world. Ms. A. has some difficulty describing important people in her life, and it is not clear from the presentation whether or not she can recognize that her perceptions of others are representations rather than exact replicas of how they are. Nonetheless, she has sufficient strengths and capacities that dynamic therapy would be worth a trial.
The history suggests that several ongoing stressors in her life would be worthwhile exploring. Ms. A. has been unable to separate from an overprotective and intrusive mother. She also has had difficulty establishing a romantic relationship that is mutually gratifying. This difficulty may be linked to the conscious or unconscious meanings of moving away from her mother and becoming a separate individual. Moreover, the meaning of separation within her Afro-Cuban culture must also be taken into account. Ms. A. has difficulty taking pleasure in her achievements. There appears to be a cycle of success followed by guilt feelings followed by efforts to undermine herself. Success may also have special meanings in relation to separation and autonomy; as well, it may be linked in her mind with envious attacks by others. I also think there is some internal conflict about being a sexual woman and having others respond to her sexually. I would probably approach her by prescribing an antidepressant to deal with some of the vegetative signs of depression while also exploring feelings she has about herself and the meaning of the stressors enumerated above. In my experience, antidepressant therapy often facilitates dynamic therapy and works synergistically with it.
Cognitive-Behavioral Therapy
Michael E. Thase, M.D.
This patient is a good candidate for cognitive-behavioral therapy. Many clinical trials of CBT have demonstrated substantial improvement in outpatients diagnosed with major depressive disorder. In CBT, belief-based difficulties are addressed by determining the type of difficulty, learning about the automatic thoughts that reinforce the difficulty, and then determining alternative approaches. In depression, the goal is to decrease each symptom related to depression, increase daily activity, and increase the patient's awareness of his or her mental world. Areas of particular relevance, as suggested by Ms. A.'s life history, might include core beliefs about incompetence (her self-described "fear of failure") and intimacy. It seems likely that Ms. A. has maladaptive attitudes and beliefs that intimate relationships are potentially dangerous. This is a bad combination of cognitive vulnerabilities that deprive her of stable reinforcements from both the love and work domains.
Ms. A. presents with recurrent major depression, with periods of good functioning interepisodically. Her work history, indicative of perseverance, suggests that she would be able to complete the homework assignments and the regular attendance required. However, her difficulty describing feelings and details of her relationships will be an impediment in therapy, and it seems likely that a trusting, collaborative therapeutic relationship will take some time to develop.
Ms. A. is presenting because of depression, not because of interpersonal or intrapsychic problems. Therefore, psychoeducation regarding depression, naming the symptoms of depression, determining the thoughts reinforcing each of the symptoms, and helping her gain mastery over them, as well as helping her become more active and social despite her feelings of depression, will be immediately useful to Ms. A.
An early focus on Ms. A.'s symptoms will help her feel understood, instill hope for improvement, and shore up the therapeutic alliance and her willingness to collaborate. Since Ms. A. is looking for improvement in symptoms and has not indicated any expectation of a long-term process, a time-limited treatment will address her presenting problems and give her new tools to prevent and treat depression.
Therapy would be conducted across 3 to 6 months. Initial sessions would focus on developing a problem list, implementing behavioral exercises (i.e., activity scheduling and graded task assignments), and identifying cognition-mood-behavior relationships. As evidence of "hot" (emotionally tied) cognition emerges, the cognitive model of testing for distortions and examining more adaptive alternative statements about self, world, and future would be introduced. This usually constitutes the middle phase of therapy, requiring 4 to 10 sessions and regular homework. As the patient improves and gains greater mastery of the cognitive model of treatment, attention can be turned to maladaptive core beliefs. This final phase of therapy, frequently constituting 4 to 6 sessions prior to termination, aims to reduce longer term vulnerability. If there is minimal symptomatic improvement after 6 or 8 weeks of therapy, concomitant antidepressant medication should be considered.
Interpersonal Therapy
John Markowitz, M.D.
Suitability for interpersonal therapy is determined primarily by the presence of a disorder that IPT has been demonstrated to treat. Ms. A. meets criteria for recurrent major depression and hence is a suitable candidate. Moreover, although the chronology of events is a little difficult to discern, she describes recent life events that may relate to the onset of her mood episode. The goal of IPT is to help the patient understand the connection between her life situation and her mood disorder, and to use this understanding to help her ameliorate that life situation, thereby both improving her life and relieving her mood symptoms. Ms. A.'s verbal vagueness and her apparent limitations in connecting life events to mood—the focus of IPT—suggest that the therapist has his work cut out for him.
I agree with Dr. Mellman that the patient should have a choice in the treatment selection, and that the limits of the therapist's expertise should not restrict that choice; patients can be referred if necessary. I agree with Dr. Gabbard that combined treatment might well help Ms. A., but for training purposes I believe it important to use IPT alone if you're going to try it: Dr. Hamilton might otherwise attribute improvement to the medication rather than to this seemingly simple therapy.3 I certainly agree with Dr. Thase on the importance of psychoeducation. The more that depressed patients know about depression and its many treatment options, the less hopeless they should feel.
Ms. A. presents with recurrent major depression, with periods of good intermorbid functioning. Dr. Hamilton gives her an Axis II diagnosis, but I would argue that it's difficult to make this assessment in the setting of an Axis I disorder. Dependent, avoidant, and self-defeating traits could all well reflect the tinge of depression, and "paranoid" might really be another word for avoidant, as the patient shuns the spotlight of attention. It's safer to wait until the patient is euthymic before making an Axis II diagnosis. The IPT stance of blaming seeming personality traits on the depressive illness rather than on character provides a more optimistic therapeutic outlook for both patient and therapist. We would also want to rule out an Axis III etiology for the mood symptoms, given Ms. A.'s ENT problems.
A key goal of the first phase of IPT is to develop an interpersonal focus,4 based on recent life events, that fits into one of four categories: grief (complicated bereavement), role dispute, role transition, or interpersonal deficits.5 The therapist tries to determine one or at most two problem areas, and needs the patient's agreement on this formulation before using it as a focus for the middle phase of treatment. The death of Ms. A.'s father when she was a baby, while a risk factor for later depression, is too remote to provide a likely focus for treatment. Her relationship with her mother and/or her ex-fiancé might suggest a role dispute as a focus, whereas her career and housing moves, or perhaps even her physical illness, might suggest a role transition. Interpersonal deficits is reserved as a default category (whether or not the patient has interpersonal difficulties) used when none of the other potential foci apply.
THE TREATMENT
Dr. Hamilton decided to provide interpersonal psychotherapy because Ms. A. had a major depression, for which IPT is a treatment of choice. In addition, he was looking for a suitable IPT case for his own training. Dr. Hamilton and his supervisor conceptualized the treatment in three phases: the initial phase (sessions 1–3), intermediate phase (sessions 4–15), and termination phase (sessions 16–18).
Initial Phase (sessions 1–3): The task of the first three sessions was to gather the initial history (summarized above), develop a treatment formulation, and offer a verbal treatment contract. The type of depressive syndrome Ms. A. suffered from and the nature of the interpersonal issues related to her depression needed to be determined. Dr. Hamilton reviewed Ms. A.'s depressive symptoms and, using the Ham-D, arrived at a score of 20 on the 21-item scale. He told Ms. A. the name of her illness was major depression, and he explained that it is a medical illness with biological foundations that can be triggered by environmental and life events. He described the somatic and psychological treatments that are suitable and the likelihood of recovery. He assigned Ms. A. the "sick role" and explained that her illness made her in need of help, requiring an effort toward recovery that would exempt her from many of her social obligations. Although she had a mixture of melancholic and atypical depressive features, her depression appeared mild to moderate and did not necessarily warrant the use of antidepressants. Ms. A. listened to this explanation without much emotion.In the second session, Dr. Hamilton related Ms. A.'s depression to its interpersonal setting. Using the iterative approach suggested in the IPT manual for determining the interpersonal inventory,5 he gathered four domains of information about each important relationship in Ms. A.'s life: the nature of the relationship interaction, the bilateral expectation within the relationship, good and bad aspects of the relationship, and changes the patient desired in the relationship.
Ms. A. quickly demonstrated her difficulty with this task. She was 30 minutes late for her second session, her answers to the open-ended questions were vague and concrete, and Dr. Hamilton had trouble eliciting more specific answers. For example, he asked Ms. A. how much time she spent with her mother. She replied, "I'm usually there." When asked if she spends more or less time with her mother than in the past, she responded, "We're not that close." Dr. Hamilton inquired what Ms. A.'s expectations were toward her mother. She responded, "To respect her." When he asked what Ms. A. wanted to change in the relationship with her mother, she replied that her mother should "not be concerned" about her.
Ms. A. was predictably late for the third session. She was asked to explore the last of her important relationships, the relationship with her ex-fiancé. Next, the temporal connections between her symptoms and the events in her life, such as quitting her internship and contemplating moving away from her mother, were linked with her depression. The remainder of the session was spent identifying the problem area that related most to her current depression.
This area was determined to be role transitions because of Ms. A.'s difficulty maintaining the transition to successful, independent, adult womanhood. She had developed entrepreneurial success and promise when mentored in high school and had been unable to sustain these gains on her own. Role disputes regarding her relationship with her mother were considered and rejected because she did not clearly feel this was a problem. Grief was not a consideration. Although the barren nature of Ms. A.'s history and interpersonal inventory suggested a possible interpersonal deficit, Dr. Hamilton suspected that the apparent paucity of relationships was a function of his history-taking or her communication style. Otherwise, there was no good explanation for her strengths, evident in the ability to socialize and the motivational speeches she delivered.
Dr. Hamilton outlined his understanding of Ms. A.'s difficulties in transition to career success and independence. They agreed on the treatment goals of returning to work and maintaining independence away from her mother, as well as reducing her depressive symptoms. Dr. Hamilton explained the utility of using a time-limited, 16-week session treatment and the likelihood of change. He emphasized that Ms. A. would learn to connect her problem area with her mood. She agreed to the treatment contract.
Intermediate Phase (sessions 4–15): In the intermediate phase, the "heart of the treatment," the tasks were seemingly few in number: to help Ms. A. discuss events related to her problem area of transition to work and independence, monitor her affective state, foster the therapeutic alliance, and promote her self-disclosure. Using the role transition paradigm, Ms. A.'s tasks were to mourn the loss of her old roles, express emotions about the change itself, acquire new skills appropriate for her new role, and establish new interpersonal relationships and social supports. Ms. A.'s attendance was erratic during this phase of treatment. She was typically 15 to 30 minutes late for every session, and she missed 10 appointments between sessions 8 and 15. Missed sessions were rescheduled. For most missed sessions, Ms. A. did not call beforehand; occasionally she called 15 to 20 minutes into her early afternoon session time to state that she had just gotten out of bed. During one week she missed two separate appointments. This behavior was later integrated into her problem area. Sessions usually began with Ms. A. completing a BDI, followed by Dr. Hamilton inquiring about any progress regarding her role transitions since the last session. She reported somatic symptoms before tangentially answering his questions. Dr. Hamilton frequently felt like an interrogator, prodding her for information, and was tired at the end of each session.The first several sessions of the intermediate phase were unfocused, as they touched on Ms. A.'s irritation with her mother, her inability to get work projects off the ground, and a succession of uncomfortable social situations in which she became suspicious of others. Many early interventions involved clarifying the details of these vignettes. Dr. Hamilton felt that the focus was straying into the area of interpersonal deficits. In session 5, when using the behavioral change technique of role playing suggested in the IPT manual, Ms. A. came to life. Seizing a situation in which she felt uncomfortable when stared at by a nightclub disc jockey, she articulated a desired response of fending off unwanted attention, whereas in reality she nearly fled in panic. Several minutes later Ms. A. again used role playing to discuss an argument with her mother. This led to an animated exchange that suggested feelings of hostility toward her mother that had not come across in her descriptions. Although the IPT manual recommends that role play be used sparingly, for Ms. A. role playing served as a very useful tool for exploring her communication style and her feelings about others. Dr. Hamilton also employed more directive techniques, including, in session 5, suggesting Ms. A. look for a part-time job since she spent her days in bed and her nights out socializing.
In sessions 6 and 7, the focus shifted to Ms. A.'s mistrust of others, particularly her former fiancé, who had insinuated his way back into her life, showing up at her apartment building and asking her out for dates. Dr. Hamilton again felt he was not adequately performing his job of keeping to a topical focus. He suspected several possibilities, including choosing the wrong problem area or not explaining it carefully enough. Or perhaps Ms. A. misunderstood the problem area or was minimizing her problems and feelings. Dr. Hamilton wondered whether to abandon or modify the chosen problem area of transition to independence, and further worried what impact any such change might have on the treatment.
Ms. A. mollified this doubt in the next session when she began to describe yet another scuffle with her ex-fiancé. She reported she recalled the role play with Dr. Hamilton as she told her ex that she was "not ready for a relationship." Dr. Hamilton commented that this sounded like a role transition for her, but it also could be understood as a role dispute. She agreed, emphasizing that it was a conflict. Dr. Hamilton inquired whether this was similar to the role transition she was undertaking with her mother. In her response, Ms. A. focused on her difficulty returning to work and moving away from her mother. These two role transitions overlapped. Without a job her bills were mounting, and she could no longer afford to live in her own place, forcing her to contemplate moving back across the hall to live with her mother. Although she stored belongings with her mother and slept there frequently, she did not want to leave her own apartment where she was able to see her hairstyling clients. Living with her mother would prevent her from making the money that would allow her to move out.
Dr. Hamilton brightened when Ms. A. reported that these problems were affecting her mood. She said she had not wanted to come to the session that day but also did not want to miss an opportunity to work on her problems. They explored the fact that she had no phone in her apartment, which had the dual liability of preventing contact between her and her clients and forcing dependence on her mother in order to use her phone. They agreed that getting a phone was a step toward independence and addressed ways to obtain the money. She considered borrowing money but instead decided to find a job.
Ms. A. reported her successes in the next session. She announced her new phone number and said that she had found out about a vacant apartment three floors above her mother and wanted to rent it. Dr. Hamilton and she discussed the pros and cons of moving into a new apartment away from her mother, as well as feelings about leaving her behind. After describing new assertiveness with her mother, she reported a sense of adventure and trepidation about three recent dates with a new man, her first with a Caucasian. Up to this point, the usual review of depressive symptoms at the start of each session had seemed unrelated to the discussion that followed of life events. She would complete a BDI, then Dr. Hamilton would elicit details of sleep disturbance or somatic complaints. By this point, however, Ms. A. found it easier to relate her depressive symptoms to difficulty in coping with particular situations in her life, and conversely, to associate elevations in her mood to small victories.
Ms. A. felt "happy" and "good" after moving into her own apartment three floors away from her mother. She explored her feelings about the change and her suspicions about the new neighbors, whom she felt might not like her or might be too inquisitive about how she was able to obtain the apartment. She was able to evaluate realistically what she had left behind, feeling that there was now more distance between her and her mother, but that mother was still nearby. Her newly found independence, however, resulted in her mother tightening the reins and paging Ms. A. with feigned emergency messages such as "call 911." Ms. A. also reviewed the positive and negative aspects of her own pattern of becoming involved and then withdrawing, which she recognized was occurring with her new boyfriend.
In session 11, Ms. A. reported that her mother's behavior affected her mood, making her feel "annoyed" and "disrespected." She then retreated, saying that it was "no big deal." Dr. Hamilton thought to himself that since she spent more than 30 seconds on the topic, it was a big deal. He and Ms. A. role played a strategy in which she would tell her mother that she did not have to always know her whereabouts, and that she should page her only for truly important matters. Ms. A. returned and, in session 12, reported in an offhand way that she had spoken to her mother, who had subsequently stopped paging her. She had also begun meeting with an acquaintance whom she felt could help her with marketing matters to launch a cosmetology business. She connected her anxiety and low mood to indecisiveness and difficulties motivating herself, and started to plan out how to obtain a cosmetology license so she could practice her hairstyling trade legally.
Although Ms. A. had missed seven appointments by the 13th session, Dr. Hamilton and his supervisor felt that she was starting to make progress using IPT. They felt that adding two more sessions would capitalize on the momentum that was building. Other than data from research trials of IPT versus medication, there were no empirical data demonstrating why 16 sessions was best. Dr. Hamilton was aware it was potentially dangerous to alter a specific contract made at the outset of treatment, and extending the treatment might reinforce dependent and avoidant behavior. As a compromise, in session 13 he suggested a total treatment of 18 sessions and a tentative termination date. He broached Ms. A.'s lateness and missed sessions as an indirect and inefficient means of interpersonal communication, behavior with interpersonal repercussions related to her problem areas of transitioning to work and independence. She did not overtly respond. She commented that her mood was better when she was working, and she was proud that she had developed three new fragrances in her kitchen laboratory. She described what she needed to do to actually produce her beauty products, and the rewards and dangers of other people helping her.
In session 14, she was elated that a local retailer wanted some of her beauty products, and she was able to connect this to a productive feeling and improved mood. Role playing followed, directed at helping her rehearse being assertive in setting prices with her hairstyling customers. In the deficit arena, officially outside of the focus, Ms. A. made further connections between her mood, somatic complaints, and the reentry of her ex-fiancé into her life. She and her friends were placing flyers in the community to advertise her services. The positive and negative result was that people would become aware of her. She worried that potential customers might not like her or would be dissatisfied with her work. She discussed this and weighed the benefits of increased business against the possibility of crank calls from lascivious neighborhood clowns. She felt the risk was worth it. She entered the remaining sessions into a brand new electronic calendar, and was early or on time to her final three sessions–an indication that her depression had lifted.
Termination Phase (sessions 16–18): The goals of the final phase of treatment were to openly discuss the end of treatment, acknowledge termination as a potential time of sadness, and help Ms. A. recognize her newly found independence. Session 16 began with a discussion of the reality of termination and how it might lead to some sadness at the loss of therapeutic teamwork. Ms. A. responded with wanting to definitively "call it quits" with her former fiancé, primarily because she viewed him as "a fake" and "a liar." Dr. Hamilton restrained himself from any transferential interpretation. Instead, to bolster her sense of independence as termination approached, Dr. Hamilton asked her to list and evaluate her successes in treatment. She could now "do things on a positive note," felt more "secure," had moved away from her mother, had obtained a phone, had become more aware of her depression, and was excited about producing beauty products for an upcoming trade show. These victories, as well as a mental status indicative of a more cheerful affect with increased relatedness and energy, occurred despite little change in her BDI, which was 16 at the start of treatment and 15 at the final session. It had ranged from 7 to 18. Her score on the Ham-D changed from 20 to 12.In the final session, Dr. Hamilton returned to the issue of grieving and termination. Ms. A. reported Dr. Hamilton had helped her to be "more on track," that she felt more independent and was "looking forward to new things." She presented a problem and explored possible contingency plans. The problem involved an older man perched on a stoop in her neighborhood who would inexplicably curse in Spanish as Ms. A. walked by, leading her to fear leaving her apartment. She discussed how this affected her mood and how the treatment had taught her strategies to help her through the situation. They discussed the warning signs of relapse and agreed on a single follow-up in 1 month to reassess Ms. A. Medication or further treatment would be considered if depressive symptoms persisted despite the progress she had made. Finally, she was asked to evaluate the treatment. She said she had learned that the stress in her life affects her mood. She ended by describing plans to "close chapters," meditate, become more spiritual, and to learn how to drive.
Follow-up Session: The follow-up session was scheduled for 4 weeks later, but Ms. A. called several days ahead of time and said she had to cancel because she was having surgery the day of the appointment. When Dr. Hamilton called to reschedule, the phone was out of service. He sent a letter, and Ms. A. eventually responded and scheduled an appointment for 3 weeks later, or 7 weeks after the final session.Ms. A. arrived several minutes late to the session and seemed somewhat reserved. She had undergone excision of a thyroglossal cyst and her mood was "good," but she had made little progress. She said she had stayed with her mother for 2 weeks after her surgery and felt dependent on her. Her phone was disconnected while she recuperated. Although she felt that she was not back on track yet, she was back in her own apartment and had reconnected her phone. She reported that she was looking for a part-time job, taking driving classes, and trying to write a motivational workbook. She had started dating a man she met at a dance and reported talking for hours at a time on the phone with him, "trying to express things." Ms. A. reported that she was reading psychology books and that she distilled from them that her relationship with her mother was "damaging" and "clingy." Dr. Hamilton told Ms. A. that she was using the tools she developed in treatment to learn to rely on herself and to handle the problematic relationships in her life. When he said no further treatment seemed necessary, but that his door was open, Ms. A. asked if he would see her weekly if she returned to treatment. Caught off guard, he responded that he did not know, and she said she would not want to tell her story again to another person. They agreed that if she felt overwhelmed or that her depressive symptoms were returning, she could contact him for assistance with a referral.
In many ways, Dr. Hamilton felt uneasy about the treatment. Neatly packaged problem areas were hard to formulate with this patient. He did not feel particularly skillful with Ms. A., and found some solace in the NIMH TDCRP (Treatment of Depression Collaborative Research Program) study that showed patient difficulty was related to the therapist's evaluation of his or her own performance as clinician.6 It was difficult to keep Ms. A. focused on topics pertinent to the problem areas, and he felt unskilled. He was troubled by her lateness, missed appointments, avoidance of important topics, and difficulty with self-disclosure. Her suspiciousness was prominent, and she was distrustful, particularly toward men. Yet there were glimmers of a therapeutic alliance and forward movement. As this was his first IPT case, he had expected Ms. A. to develop earth-moving strides in self-confidence and had hoped her symptoms would evaporate. This did not happen. He did, however, see hesitant steps toward independence, new approaches to meeting her needs, and a newfound sense that she can learn from human relationships. Ms. A. incorporated the core IPT principle of linking her mood and the events of her life. By the end, she could also begin to rely on herself to make the transition to being more productive, more independent, and less depressed.
COMMENTARY ON THE TREATMENT
Interpersonal Therapy
John Markowitz, M.D.
Residents attempting a focal, time-limited treatment like IPT are going out on a clinical limb. Those among them who present their treatment are even more daring. We owe Dr. Hamilton gratitude for his candid presentation. Dr. Mellman, in her introduction, mentioned some "proficiency" in psychotherapy as a goal of residency training, but I'd argue that residents should leave training as "advanced beginners" in psychotherapy. Even a relatively simple treatment like IPT is hard to do well at first: it takes some practice. Psychotherapy training is an ongoing education that hardly ends with residency. It's encouraging that some residency training programs, like Dr. Hamilton's at Columbia, are making the effort to teach residents new skills such as IPT.3
So Dr. Hamilton is not supposed to be technically perfect in his first IPT case. And he isn't. Nonetheless, I think he gets crucial points right, and that this accounts for his patient's improvement—which he to some degree minimizes.
What does he do right? First, he diagnoses major depression and presents it as a medical illness to the patient. I would have added, "...and, it's treatable"; perhaps he did as well. He also explains to her the basic IPT principle of the (nonetiologic) connection between mood symptoms and life events. He then begins the work of exploring the interpersonal inventory. Usually this history-taking precedes the explanation of IPT: it's on the basis of having developed a hypothesized focus from the interpersonal inventory that one presents the explanation of IPT to the patient. But that's okay.
Despite the frustrations this patient presents and the insecurities that attempting IPT evokes, Dr. Hamilton also explains the therapy, offers an explicit contract, builds a treatment alliance, and tries hard to work with this patient. When Ms. A. has trouble abstractly linking mood to situations, Dr. Hamilton appears to stumble upon role playing as a helpful way to explore interpersonal situations. This is fine: indeed, this is probably what he should have been doing from the start. What the therapist seeks to learn from sessions is the patient's affect (feelings about) and behavioral patterns in particular recent interpersonal situations. There are different ways of eliciting this, but role play is as good as any. I disagree with the idea that it has to be used sparingly.
Using role play, Dr. Hamilton does manage to keep the patient reasonably focused and helps her achieve success experiences: getting a new phone, asserting herself toward and moving away from her mother, and so forth. Getting the patient to change her life—and to feel successful in doing so—is probably a key, active ingredient of IPT. It gives the patient a sense of mastery over her role at a time when depression has made her feel weak and incompetent. Dr. Hamilton also nobly maintains the purity of the treatment by refraining from transferential interpretations. By the end of treatment Ms. A.'s symptoms have diminished, albeit not vanished. Moreover, she has apparently learned new social skills (e.g., asserting her needs to her mother) and has gotten the IPT message that—in her own words—"stress in her life affects her mood." This is good work. I suspect Dr. Hamilton will feel somewhat more comfortable and confident on his next IPT case, but he sounds to me somewhat too harsh in his self-evaluation on this one.
There are a few points to clarify for that next case.
Psychodynamic Psychotherapy
Glen O. Gabbard, M.D.
Dr. Hamilton describes an effective psychotherapeutic treatment of Ms. A. A psychodynamic perspective would cover many of the same issues, but for the sake of educational value, I will highlight the differences. One of the first orders of business in psychodynamic therapy is the establishment of a therapeutic alliance. Because of her tendency to be mistrustful of others, Ms. A. does not bring to the table the type of internal object relations that lend themselves to a smooth development of such an alliance. Her suspicions about the therapist and the value of the therapy take the form of frequent lateness and missing 10 appointments between sessions 8 and 15. In dynamic therapy, I would have explored the meanings of those absences and also shared with her my experience of her participation in the sessions. I would have pointed out that in many of the sessions I felt that I was "pulling teeth" to get her to participate. I would have asked her about reservations she might have about me or the therapy process. I would also have pointed out that therapy has to be a collaborative venture and that I wasn't sure if she was seeing it the same way.
A basic principle of dynamic therapy is that the patient repeats her habitual mode of object relatedness in the transference with the therapist. I would have emphasized that her ambivalence about the optimal distance from her mother was being repeated in the therapeutic relationship with me. Just as her mother would get concerned when she did not know where she was and page her with "911" messages, I would also get concerned when she did not show up for 10 sessions and when she came 30 minutes late. The transference exploration would lead directly into her feelings about growing up and leaving her mother and would increase her capacity to reflect on the unconscious messages she gives out in relationships. This discussion of the mode of relatedness with her mother and with me would also serve as a convenient segue into the stressors of leaving her mother's apartment and becoming an independent adult.
Cognitive-Behavioral Therapy
Michael E. Thase, M.D.
Of course, one can never be sure what are the active ingredients of an individual's improvement. In CBT, we sometimes examine changes in dysfunctional attitudes or attributional style, although improvements in these measures are somewhat mood-dependent. Another potentially useful guide is the patient's use of CBT self-help activities—that is, whether the patient has actually "bought into" the model of treatment and continued to apply the methods in vivo.
Dr. Hamilton has good reason to be concerned about Ms. A.'s vulnerability to subsequent episodes of depression. In our work, patients with recurrent depression and incomplete remission at therapy termination had a 50% one-year relapse risk.8–10 Recognition of this risk has caused us to change our approach to CBT.11 Rather than automatically terminating therapy after a predetermined number of sessions (e.g., 16 or 20), a patient with a vulnerability profile like Ms. A. would be offered three alternatives: 1) eight additional weekly sessions aimed at symptom remission, 2) a further course of every-other-week and monthly sessions of continuation-phase therapy,11 or 3) antidepressant medication. Time-limited treatment appears justified only when the depressed patient is able to achieve a complete and stable remission.8,9
Acknowledgments
The authors thank Dr. Michael Devlin for his helpful supervision of this case. J.C.M.'s work is funded in part by Grant MH49635 from the National Institute of Mental Health and a fund established in The New York Community Trust by DeWitt-Wallace.
References
This article has been cited by other articles:
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  J. Lichtmacher, S. J. Eisendrath, and E. Haller Implementing Interpersonal Psychotherapy in a Psychiatry Residency Training Program Acad Psychiatry, October 1, 2006; 30(5): 385 - 391. [Abstract] [Full Text] [PDF]
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 J. L. Cutler, A. Goldyne, J. C. Markowitz, M. J. Devlin, and R. A. Glick Comparing Cognitive Behavior Therapy, Interpersonal Psychotherapy, and Psychodynamic Psychotherapy Am J Psychiatry, September 1, 2004; 161(9): 1567 - 1573. [Full Text] [PDF]
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