IPT: Middle Phase

During the middle phase of IPT, I used specific interventions to address interpersonal communication and behaviors. Communication analysis of an interpersonal encounter helps connect the patient’s affect to the incident. The therapist has the patient describe the interaction in great detail, at each step asking the patient to reflect on her feelings moment to moment, helping the patient link incidents to affects. The clinician then creates opportunities for the patient to explore options, to try out new communications and behaviors between sessions. The IPT therapist might ask: “What would you have liked to have happened?” or “What else might you have said?” Clarification and attention to affect are prominent therapeutic tools. Role-play gives the patient the opportunity to try out new interpersonal strategies with the therapist. In the middle phase, Joy had a chance to reevaluate her attitudes toward her mother’s limitations and to “rewrite” the relationship contract between herself and her ex-partner (Weissman et al., 2007).

Session 5

During the week between sessions, Joy had visited her parents for her mother’s birthday. Joy related the following interaction that occurred on the car ride back to the airport.

joy: It was not a good visit, and we had the usual terrible goodbye. therapist: Tell me about it.

joy: On my last day there, on the way to the airport, my Mom started in on me again.

therapist: What do you mean, “started in on” you?

joy: She said, you know, real quiet, like I was a patient, that even if I didn’t care about my blood pressure, she did. And she didn’t want me to have another heart attack. And I told her to stop worrying about it. I had it under control. And I do. I don’t want to die.

therapist: What did you say?

joy: [sharply and loudly] “God, stop reminding me about it, Mom! It’s under control!” [sarcastically] “If I have another heart attack, I have another heart attack!” therapist: What were you feeling at that point? joy: Well, I was definitely pretty annoyed. therapist: Just annoyed? Was she raising your blood pressure? joy: [after a pause] I guess I was actually kind of angry. As in, “Obviously I don’t want to die, Mom, but your constant nagging isn’t helpful.” therapist: So you were understandably angry with your mom. Any other feelings come up?

joy: Well, I think I was also probably angry with myself. Like, why do I keep having the same kinds of arguments with her? They always end up the same way, with my feeling depressed and guilty, and neither of us satisfied. therapist: So you felt angry; and also depressed and guilty? [I purposefully clarified the link between the interpersonal communication and the patient’s feelings, using the patient’s words.] What happened after you said that? joy: She got all huffy and quiet, and refused to speak, right up until she dropped me off at the airport. Then, when I was getting out of the car, she reminded me again to take my medications. I said a curt “bye” and she drove away. therapist: What were you hoping for from your mother? joy: I don’t know. I guess . . . for us to have a better goodbye. therapist: What would “a better goodbye” look like?

joy: Her not focusing on my medical stuff, but asking about other parts of my life instead. The thing is, she’s always been clinical first. She made that clear the whole time I was growing up. And I guess I stupidly keep hoping that she’ll get away from the medical lingo and medication details, and instead show that she cares about me as a mother, not as a doctor. And then I get so angry, like I did in this case, even though I know it won’t do any good. She will never change. I keep acting like a teenager with her, even though I know better. Then I feel guilty. therapist: (Silence) joy: (Silence)

therapist: I can see how that would make you angry, when your mother treats you more like a patient than a daughter.

joy: (Silence)

therapist: Why do you think your mother is making medical interventions? joy: (after a pause) I think, she thinks, she is showing caring. therapist: Well, looking back, what else might you have said to her in that moment?

joy: I wish I had said, “I am a person, Mother. I wish you would take an interest in me personally, in my personal life, and not just treat me like a clinical problem to be solved with medication. Id like to have a better week with you and not have our visits end in silence."

therapist: What would it feel like to say that to her? joy: Well, I imagine it would feel risky.

I presented a video recording of this communication analysis to my supervision group. The patient’s appreciation that her mother wouldn’t change, followed by silence, seemed significant to me, because it didn’t seem to be a depressing idea to the patient, as I would have expected. It was more like an epiphany. Other members of the supervision group agreed. One resident noted that the communication analysis “felt significant” because the patient was authentically connected to her feelings. I shared with the group my own insight that Joy’s ability to articulate what she would have liked to say to her mother helped her clarify her feelings to herself. The supervisor suggested that the communication analysis had enabled the patient to draw her own conclusion that her mother’s behavior would not change, and that her own expectations of her mother might need to change. At the same time, he suggested that there was still the possibility that Joy could alter the relationship with her mother, by addressing her more directly. Later in the therapy, after another similar interaction with her mother, this time by phone, Joy thought that the conversation went better because she was more patient with her mother.

joy: I tried something different. I thanked her for the medications she had sent. That felt weird, I think to her too. Then I told her I’d like to change the subject to something else. And she was sort of silent. I realized it was unexpected. therapist: What did that feel like?

joy: It actually felt better; I mean, she is not a spontaneous person. But I was not angry. I felt in charge of myself. It was a good experience, though I am not sure what to do at this point.

therapist: You seem to be actively trying to figure out what you owe to your mother and what you owe to yourself. I am confident that you can be successful.

For Joy, the idea that she was in a process of figuring something out was appealing. Being in touch with her anger and sadness through the communication analysis, and having me validate her feelings, seemed to mitigate them in the moment and allow for change.

Session 7

In IPT, Joy’s success experience with her mother informed her role dispute with Laura as well. Joy’s anecdotes about her mother, coincident with her going home to celebrate her mother’s birthday, gave way to a renewed desire to vent about the day- to-day contentious interpersonal incidents with Laura over their daughter’s care. Joy came to the seventh session appearing withdrawn. She initially explained that she was worried about Maxine, who was sick with the flu. When I asked her when she had most recently seen her daughter, she paled as she said she had actually been with her for the past four days:

therapist: What happened?

joy: On Friday, I got a call from Laura. She said she really needed me to take care of Maxine, because Maxine was sick and she couldn’t stay with her. Laura had appointments and errands that she had planned during the day. therapist: And what did you do?

joy: Well, I’m home, so I think that Laura expected me to step up. But I also felt obligated to go over and take care of Maxine. She was sick! But then . . . well, I ended up staying over there for three nights, even though I really wanted to bring her home with me. therapist: What happened?

joy: Laura insisted that Maxine stay at her house. Even though I was supposed to have Maxine over the weekend and wanted her with me in my home, Laura said that she wanted to make sure that Maxine was as comfortable as possible, and that she would help take care of Maxine as well. Of course, it turned out that Laura wasn’t around at all, and Maxine and I were alone at her house almost the whole time. It kind of felt like I could justify being anywhere, if Maxine was there. At the same time, I guess . . . I was afraid Laura would freak out on me if I pushed the issue and said I wanted to bring her home with me. therapist: What were you afraid of?

joy: Well, she’s always rigid about her rules, and I didn’t want to provoke her and cause a scene, especially while Maxine was present. And then, of course, last night it all came to a head anyway. One of Laura’s rules dictates that Maxine can only watch one hour of children’s TV each week. But after I put Maxine to bed, she snuck out of bed to join me on the couch. When Laura returned home, she found us watching TV together and she became very upset. She went from zero to 95 in less than 5 seconds. She freaked out, and immediately looked like she was going to cry.

therapist: What did that feel like? joy: I felt angry and protective of Maxine. therapist: What did you do?

joy: Well, I wanted to tell her that Maxine was sick, and that she’d watched an additional half-hour of TV with me, and that her rule needed to be more flexible. I wanted to point out that I had been flexible and gave in when she asked me to stay at her house, because Maxine was sick. I wanted to tell her that I was sick of the emotional blackmail and that I didn’t want to be controlled or manipulated any more. But, of course, I didn’t say any of that. therapist: [looking questioningly and sympathetically at Joy] Why “of course?” j oy: I don’t know. What I did instead was apologize. Ugh!!! [looking frustrated, clenching hands]

therapist: It sounds like you were pretty angry with Laura, and maybe upset with yourself as well.

joy: Yeah. I guess I was pretty upset. I wish I didn’t always feel like I have to give in

to her.

therapist: What do you think makes it hard to respond to her the way you would like to respond?

joy: I don’t know. I am never quite ready to stand my ground with her. I feel so angry, so misunderstood and invalidated that I shut down, just to keep control of things.

therapist: And then you feel depressed. joy: Yes.

therapist: And you blame yourself, even though anybody might get angry under those circumstances. joy: Yes. I totally blame myself. therapist: That is depression talking. joy: (Silence)

therapist: What are you feeling right now? joy: Like a loser for doing this for so long.

therapist: I wonder if we could try role-playing this incident right now, here in this session. The difference is that this time, say what you wished you had said last night, what you want to express.

joy: [somewhat hesitantly] Um, OK. I’ll try it . . . but I don’t know if it will be helpful. And I guess you’ll be Laura in this?

I nodded and at this point, positioned my chair so it directly faced Joy.

therapist-as-laura: Were you actually letting Maxine watch TV? joy: Well, Laura, you can see that I was.

therapist-as-laura: [voice rising slightly] Don’t you remember the rule about TV? Why would you let her do this?

joy: She’s been feeling so sick and down, and I think she just wanted to stay close to me.

therapist-as-laura: But Maxine shouldn’t be watching TV! Don’t you care about our daughter’s well-being?

joy: [with a more assertive tone] The whole reason I let Maxine stay with me on the couch was because I care about her well-being. She’s sick and feeling pretty awful, and even though I knew you would freak out about it, I felt like it was important for her to feel comfortable right now.

therapist-as-laura: I can’t believe that you’re acting like this was for Maxine. You just wanted to upset me, and you didn’t care that you were harming our daughter.

joy: Here we go again. Get over yourself. This is about Maxine, this isn’t about you. The only reason I even stayed here for the past 3 days is because I love Maxine and care about her. I’m sick of feeling like I’m never good enough. You don’t have the right to make me feel this way. [deep inhale and exhale]

Joy repositioned her chair, sat back, and regarded me for a moment. joy: Wow. That... that felt really good. therapist: What felt good about that?

joy: I guess I’ve always had difficulty expressing how I’m feeling, especially when I feel bad. And I just tuck it inside when I’m upset or feel like I’m not good enough.

And Laura is really good at pushing that button. But, even though we were just pretending, to be able to verbalize to her that this is not OK . . . that felt cathartic. Like I can breathe a little freer now.

Role-play continued to be an effective tool for Joy. She found that by allowing herself to identify and access her emotions during frustrating interpersonal interactions, and then “rewriting” the interactions during sessions, she felt more empowered and less depressed. Nevertheless, as the sessions progressed, Joy continually expressed ambivalence about asserting herself in real-life interactions with Laura. I appreciated Joy’s bind. Joy had psychological barriers to asserting herself, and as we had discussed earlier in the treatment, a practical concern in that she did not want to jeopardize her relationship with Maxine.

I brought this dilemma and my own frustrations back to the group. As a new therapist, I was beginning to feel overwhelmed by the challenge of “fixing” this complicated family in short order. I wondered whether Joy was too enmeshed with Laura for a brief treatment to help her. The other residents in the supervision group shared my frustration. I wondered if family therapy was indicated and wanted to suggest it to Joy. The supervisor was not against family therapy down the line, but he reminded us that IPT with a role dispute focus is akin to family therapy for one. In IPT, the therapist is a catalyst for change in the office, but the patient is the catalyst for change outside the office.

In the next session, I asked Joy if she had considered family therapy for the three of them. Joy responded, “I know we need it. We are just not there yet. Laura and I are too far apart to even have a discussion about that.” I felt good that I had raised the idea of adjunctive family therapy to Joy. It was a recommendation I could return to later, perhaps at the end of treatment. We discussed this the following week, when I showed my tape in supervision. The supervisor encouraged me to continue to look for opportunities for Joy to challenge this difficult dilemma of asserting herself with Laura without losing access to Maxine and to role-play in preparation for a success experience that might help Joy feel more in control of the relationship and of her mood.

Session 11

Joy opened the hour by happily telling me that she had “done it”: she had definitively asserted her own needs in a tense situation with Laura. The dispute centered on a longstanding child care agreement that Laura wanted to break at the last minute. Joy and Laura had agreed months prior that Laura would care for Maxine on Memorial Day weekend because Joy planned to go away for the long weekend with Ben and some friends. Laura’s new girlfriend had invited Laura to accompany her to New York City on a business trip. Two weeks before, Laura told Joy that she couldn’t take care of Maxine that weekend after all, and that Joy would have to take care of her. Joy protested, reminded Laura of the agreement, and said she had already booked a hotel room. According to Joy, Laura seemed surprised that Joy didn’t give in right away, and she agreed to take care of Maxine that weekend. However, as the weekend approached, Laura called and emailed Joy with friendly but persistent requests that Joy cancel her trip. She eventually implied that Joy was interfering with her new relationship. Joy initially stalled Laura, but worried that she would give in. She felt herself becoming depressed at this prospect.

Then she reported having surprised herselfby emailing a reply to Laura in a “calm, non-provocative, detailed, and clearly written response” delineating their agreement. She also wrote that she felt that her own time was valuable, just as Laura’s was. She pointed out the imbalance in their relationship; she included a couple of written examples of how she felt devalued by Laura, one of which she’d discussed at the most recent IPT session; the other she had recognized and processed on her own. She also expressed her hope that they would have continued joint success in raising Maxine to be the amazing little girl that she was, reiterated her devotion to her, but emphasized that she also needed to take care of her own needs and time, especially in light of her recent health problems. She brought a copy of the email to the session and confidently read it aloud to me.

After reading the email, and calling to confirm that Joy was really not going to change her mind, Laura begrudgingly stopped asking Joy outright to cancel her trip, although she did drop several more hints. Although Joy’s first reaction was to feel guilty and consider canceling her trip, she did not, and reported that she “felt good about holding my ground and taking care of my needs instead of hers.” She went away for the long weekend and had a wonderful time with Ben.

In our clinic we give patients the BDI-II at the twelfth week. In Joy’s case, the BDI-II came at the eleventh session. She scored a 13, consistent with a partial remission from major depression. Joy looked like a different person. Her mood was improved and she was significantly brighter and calmer than when she first arrived.

Termination Phase (12-16)

The termination phase is an opportunity to review the successes in the treatment (Weissman et al., 2007). Nevertheless, in the last few sessions of any brief psychotherapy a patient may present with her original symptoms and complaint. The therapist must determine whether this represents a true recurrence of a major depression or a temporary reaction to ending the treatment relationship. It would be unhelpful to overreact to minor symptoms, or to confuse sadness at separation with depression, and to unnecessarily extend sessions beyond the agreed-upon end date. Instead, the therapist can help the patient distinguish between appropriate sadness and depression. A true recurrence may suggest a need to reevaluate the diagnosis and the utility of the model for that patient.

Session 12

Joy was angry about a recent handoff of Maxine, for which Laura was four hours late. Joy felt that to assert her needs here would potentially endanger the agreements they had made about the times she would be out of town in the near future: “I didn’t want to push my luck.” In addition, Joy reported a return of her fatigue and renewed hopelessness about her ability to manage “the three people in my life—Maxine, Ben, and Laura.” I made a point of acknowledging how angry Joy must have felt.

I brought the session to supervision. I had refrained from talking with Joy about the termination phase of the treatment, because she seemed so depressed. Joy’s presentation reminded the other residents in the group of how she looked at the beginning of her IPT course. Using the video-recorded session for reference, my supervision group noted that Joy’s affect became especially tender whenever she talked about Maxine. A resident confided that those moments on the tape made him feel real sadness for Joy and for Maxine, who was caught in the split between her parents. Other residents agreed. The supervisor asked the residents to reflect on where this feeling of sadness was rooted. He suggested asking Joy how she felt about her role as a parent. I brought this back to Joy in Session 13. Joy shared her hopelessness regarding the potential sequelae of her interpersonal interactions with Laura, not just for herself but for Maxine. Joy worried that her daughter would take on some of her own negative relationship patterns and end up feeling manipulated and having low selfesteem. Explicitly naming these feelings in the therapy appeared to increase Joy’s resolve about her self-agency and her role as a mother. She herself acknowledged the active role she had already taken as a mother to provide a secure environment for Maxine.

In the same session, I reviewed the IPT formulation of role dispute and how it related to Joy’s specific symptoms of depression. This was a prelude to acknowledging Joy’s accomplishments in the therapy. Joy responded animatedly that she felt good about the work. I asked her about ending:

therapist: What do you think it will be like when we aren’t meeting any longer?

joy: I think I’ve learned a lot. I think I’ll be fine.

therapist: Are there any interpersonal scenarios you’re imagining may come up? joy: Well, sure. I mean, I’m sure things will come up. But I’ll be fine. Thank you so much for helping me.

therapist: I really believe that you will be fine. Your progress here, as we’ve continually reviewed, has been really positive and consistent. I have every confidence that you’re going to build upon the progress you’ve made during the past thirteen weeks. Part of that is going to be thinking about what future challenges to prepare for and what future successes are going to look like. What do you think?

joy: I hope that I’ll keep doing well. I think these sessions have been very helpful.

It appeared that Joy’s representation of sadness and frustration in the 12th session was fleeting and not a recurrence of depression.

Session 14

Joy’s bright affect and energetic greeting in the waiting room were notable. In session, Joy described an experience she had earlier in the week when she had consistently refused Laura’s last-minute request to transport Maxine back and forth to a play date. The therapist used this as a launching point to again review Joy’s successes in asserting her own needs that had led to this, and again expressed her confidence in her continued stability after their termination, now two weeks away. This led to a much deeper discussion about the end of therapy:

therapist: I really have to reiterate that I have such great confidence in how you’re going to take care of yourself and your own needs after we end our therapy in two weeks. It’s been very inspiring for me to hear about the hard work you’ve been putting in, week after week, to take better care of your own needs in some difficult relationships, and to hear about all the successes you’ve had. Equally confidence-inspiring has been your willingness to keep trying and not feel dispirited if a certain plan of action didn’t work the way you had hoped. For some folks, especially when they are depressed, the idea of putting in the kinds of efforts you’ve put in might seem almost impossible. joy: You know, it’s true. When I was depressed and first started coming to see you, I never would have imagined that I would be able to handle myself and my relationship with Laura this way. I feel so much . . . healthier! therapist: As you know, we take a six-week break at the end of this treatment and then follow up for a check-in. What will it be like for you not to meet every week? joy: I think it will be fine.

therapist: I also think you will be fine. If you feel a little off, or sad around the time of our visits, that would be completely normal. joy: OK.

therapist: We should also talk about what to do if you start feeling depressed again. What are some Joy-specific warning symptoms of depression that you want to be aware of?

joy: At this point, I’ve been feeling so consistently good that I really hope that depression won’t strike me again, but if it does, I know that the first thing to go is my self-confidence, particularly around demanding people like Laura. I also recognize, what now seems so obvious to me, that when I get depressed, the last thing I want to do is ask for help from good people like Ben or friends, because I think I can handle it. And the way I handle it is to feel terrible and assume the blame in situations when I know I’m not at fault, and then lose even more self-confidence, and then feel even worse. So I need to keep doing what I’ve been doing lately, getting support from Ben and other people and not always trying to fix things which leads to me feeling guilty when they don’t work. therapist: Like what?

joy: Well, like this incident with Laura earlier this week. Before I started seeing you, I would have gone out of my way to take Maxine to her play date and pick her up, even if it meant rescheduling my own life, and would have resented Laura for asking me to do it but never would have said anything, and then just felt more down and depressed. therapist: And now, instead . . .?

joy: Now, I set a boundary, and it was clear, and Laura didn’t like it, but no matter how much she tried to make me feel like I was to blame for the situation, I didn’t cave in, because I really wasn’t to blame for it. She’s the one who wanted to schedule a last-minute appointment that coincided with the play date. And because I didn’t cave in, I don’t feel like crap about it. I actually . . . I actually really feel good! Like I handled it in a good way, and it’s a little easier to set the boundary every time now.

therapist: And what do you think it will be like after we stop meeting? joy: I’ll certainly miss having this hour with you every week, because it’s been very helpful for me, and I really like seeing you and checking in every week. What I’ve been realizing, though, is I can do it more and more on my own now. The last few sessions, I’ve been able to come in and tell you about problems that I solved from start to finish, and so we didn’t have to try to do the problem solving during the appointment, like we did before. therapist: And now?

joy: [smiling more and more broadly] Well, it’s kind of strange, but the word that comes to mind is “healthier.” I was depressed and not taking care of myself, and now because of all the work I’ve done in here, I’ve gotten better. So even though I’ll miss seeing you, I think I’m at a point where it’s not necessary the way it was before. [pause] Wow, that’s actually kind of nice! therapist: It’s very nice!

Joy completed the full sixteen-week course of IPT with a BDI score of 5. In this clinic, patients are scheduled to come back for a six-week check-in. Joy canceled her six-week check-in appointment because she had obtained a full-time job and did not want to jeopardize her new job by asking for an hour away. She assured me on the phone that she was doing quite well, had sustained her progress, and still felt “healthy” She also promised to call me should she ever experience a relapse in depressive symptoms. I imagined that once Joy settled into her new job, she would have the kind of relationship with her work where she also took care of herself. An alternate course might have been to come in for monthly maintenance sessions of IPT with me (Frank, Kupfer, Buysse, et al., 2007; Frank, Kupfer, Wagner, et al., 1991).

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