Major Depressive Disorder. Interpersonal Deficits
Interpersonal deficits or sensitivity is the most difficult problem area to work directly with in IPT. It has been considered the IPT focal area of last resort. As IPT focuses on life events, therapists employ this non-life-event problem area only when none of the other focuses is present: the term “interpersonal deficits” really means that the patient has no life events and a paucity of attachments. These patients tend to have few social supports and difficulty in tolerating relationships, which puts them at risk for depression and complicates the therapeutic alliance. They see the depression as coming out of the blue. It is prudent to try to ensure that none of the other IPT problem areas exist, as it is easier to work on actual life events in the other problem areas. Moreover, depression triggered by life events usually leads to social withdrawal, so the patient may present with social isolation that should not be labeled “deficits” but considered an expectable part of the depressive picture of grief, a role dispute, or role transition.
Because depressive symptoms can exaggerate personality traits, a good history of prior functioning is crucial. The therapist should avoid prejudging personality in the presence of an Axis I disorder, as it is often very difficult to accurately discern it. Nonetheless, the therapist may try to distinguish between depression and personality during the first phase of IPT, as the interpersonal inventory allows extensive and detailed exploration of prior functioning. A decrease in number and quality of relationships when depressed suggests that the depressive symptoms have played a role in the change in functioning, whereas a lifelong history of few relationships, social awkwardness or solitary activities, avoidance, shyness or aloofness, could suggest personality or even chronic depression. It is important to understand the context. Keep in mind that some people’s seeming “personality” can change dramatically when depressive symptoms lift. In summary, the definition of interpersonal deficits relates loneliness and social isolation to an individual’s episode of major depression and should be used as a problem area only in the absence of life events (i.e., grief, role dispute, or role transition).
When interpersonal deficits is the primary problem area, and the patient is socially awkward, the therapist needs to consider how threatening or challenging it will be to directly address the problem. More often than not it is best done “through” another problem area if another can be plausibly invoked, for example working on adapting to a transition while shoring up interpersonal skills and supports. Remember that social awkwardness in the context of an individual’s depression may lead him or her to feel scrutinized by the therapist. Patients may avoid material that exposes them to perceived scrutiny from others and provokes anxiety. The therapist needs to adapt the pace and explicitly lower the goals of therapy: you are not trying to turn an introvert into a social butterfly! (And such a goal would terrify such a patient.) Other socially awkward individuals may not actually wish for or need interpersonal relationships. These instances will make forming a therapeutic relationship harder, and finding interpersonally meaningful material may prove elusive. The therapist’s stance thus requires attention to the therapeutic relationship and avoiding having the patient experience him or her as pushy or critical. Therapists vary in finding patients with interpersonal deficits easier or more difficult to work with. Experience matters, as does good supervision.
Judicious choice of language for describing interpersonal deficits as a problem area is important for patients, as “deficits” sounds derogatory. It helps to use terms such as “sensitivity,” “loneliness,” or “isolation.” Phrases for promoting change can also be challenging: I suggest “working on addressing isolation” or “working on loneliness” or “adding depth to your world” To an aloof patient, the therapist can describe “your unique individual world” as one that “therapy can enhance positively so that you are less depressed”—perhaps even avoiding the use of the word “interpersonal.” Certainly one option is to seek alternative paradigms for considering patients’ relatedness to others; the most common one I have found involves computer- and Internet-based technologies, although we do not want to promote complete isolation.
In short, be careful when deciding on deficits as a primary problem area, but when it is carefully chosen and addressed directly or indirectly, results can be rewarding.
The following case illustrates many of the difficulties of working with an individual whose key problem area is interpersonal deficits. This case illustrates the complexities of defining and exploring interpersonal deficits with a patient whose depressive symptoms had accented a unique personality style. I will describe the history, formulation, process of therapy, and the difficulties and successes in working with such a patient. An example of using the therapeutic relationship to advance the treatment and issues taken to supervision will also be outlined.