The difference between trying to help Mr. Jones with IPT initially compared to the second round necessarily included his worsening cognitive impairment and its effect on his work role. Family meetings made clear that Mr. Jones’ wife and daughter were becoming caregivers, providing more surveillance and trying to steer him to gradually pull back from work he was obviously finding too stressful to perform. Mrs. Jones and Gloria initially did not understand that his cognitive impairment directly affected his ability to make complex business decisions and manage employee interpersonal conflicts. Diplomatically educating Mr. Jones’ family about his cognitive limitations was important to allow them to readjust their expectations of his performance to realistic levels. This psychoeducation indirectly benefited Mr. Jones, as the family could then better help him to reassess his role in his company and maintain his self-esteem with appropriate increases in social support, rather than harboring unrealistic expectations that he would somehow return to his former authoritative self.

It became clear that Mr. Jones’ family neither wanted to see him highly frustrated attempting work he could no longer manage, nor to feel pushed into retirement, as they knew that his whole life’s focus and purpose was tied to his business. The role of the IPT-ci therapist was to first grasp the big picture and all contributing elements (identified patient role and ability, caregiver agendas, workplace demands, etc.), and then to explore possible interventions in this role transition scenario that best advocated for Mr. Jones by helping all parties to understand the reality of his cognitive impairment and to prepare them to appropriately help him decide how to move forward. This needed to be done in a way that was not continuously demoralizing and helped to maintain his self-esteem and preserve his role as the company’s respected founder, while allowing him to remain confident that his children were now cooperating to keep the business going.

In traditional IPT, the therapist provides a forum for the patient to explore the agreed-upon focus in sufficient depth to understand it. The goal of IPT is to use the realized understanding of the problem focus to implement change, thus relieving depressive symptoms. In contrast, the patient who suffers from cognitive impairment often has limited ability to use insight, process complex information, see problems from multiple angles, and integrate the specific problem area into the larger sphere of the social community within which he or she operates. Although traditional IPT is often no longer possible for such a patient, the therapist can still assess the problem area, solicit other concerned parties to jointly explore greater understanding of the problem area, and incorporate their participation into a treatment plan to benefit the identified patient, reducing depressive symptoms and helping to realign unrealistic expectations about current cognitive abilities. The IPT-ci therapist acts more like a surrogate or advocate for the identified patient’s best interests to the extent that the patient can no longer fulfill that role due to cognitive impairment.

One could argue that the IPT-ci therapist’s actions might appear paternalistic rather than facilitating the patient’s ability to better understand his or her own feelings about the identified problem area. On the contrary, the IPT-ci therapist does his or her best to determine the patient’s struggle that precipitated the depression, taking any cognitive impairment into account, and then to help the identified patient to understand the overview pieced together from all available sources. This must be done before trying to help the identified patient to implement the most effective coping strategy commensurate with current (realistic) cognitive ability. This might mean, for example, helping the patient to cope with and plan alternative strategies for ceasing to drive an automobile if such a restriction is mandated or inevitable.

A preliminary task to achieve before implementing changes that involve the participation of others is to assess the caregiver’s understanding of the identified patient’s cognitive impairment and to correct any unrealistic conclusions. A thorough understanding of basic gerontology is a prerequisite. Once educated and realistic in their expectations, caregivers can be approached to help implement appropriate changes in conjunction with changes the identified patient is attempting to achieve desired goals.

In the case of Mr. Jones, all concerned parties could see his frustration at work, but they needed help to understand the role his executive dysfunction played in limiting his work role. Once educated about Mr. Jones’ cognitive disability, they could support efforts to convert his company role to one he could manage, allowing him to preserve his self-esteem while relieving him of the burden of responsibility.

Caregiver agendas that run counter to the IPT-ci therapist’s view of the best course of advocacy for the identified patient may also need appropriate negotiation. Insofar as the identified patient cannot always be his or her own best advocate due to cognitive impairment, the IPT-ci therapist tries to orchestrate what might be a series of steps, like a conductor of a symphony, to seek the participation of all willing parties who want to help relieve the depression, maintaining the highest self-esteem, independence, and quality of life possible for the identified patient.

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