Treatment of Chronic Depression With a 12-Week Program of Interpersonal Psychotherapy
Case Presentation
Ms. A was a 38-year-old Caucasian woman who was married and had three daughters aged 2, 7, and 15. At the time of treatment, she was living with her husband and children in New York City and was receiving public assistance.Ms. A was referred to our clinic by her 15-year-old daughter’s therapist, who thought Ms. A might be depressed. Ms. A reported having felt depressed for the past 4 years, having little interest or pleasure in doing things, and experiencing feelings of worthlessness. She reported fatigability and low energy; she had to push herself to take care of household chores. She felt guilty about not doing enough for her children and making poor life choices and often felt hopeless and helpless. Ms. A denied recurrent thoughts of death and had no history of suicide attempts. She reported chronic oversleeping and overeating and was morbidly obese. She felt unattractive particularly because of her weight problem and felt easily criticized or rejected by others. Her baseline score on the 17-item Hamilton Rating Scale for Depression was 25, indicating depression of moderate severity. According to Ms. A, she had not experienced substantial changes in the severity of her symptoms throughout this episode before coming to treatment. She was assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (6); she did not meet criteria for another psychiatric disorder.The onset of the depressive episode coincided with the worsening of her difficulties with her husband. Ms. A was dissatisfied with the limited role that she and her children seemed to play in her husband’s life, even though at the same time he expected them to be always available and ready to please him.Ms. A’s first episode of major depression was at age 28. This happened immediately after she had found out that her husband had a second wife and two children in another country. While Ms. A had three daughters, she knew that her husband would always favor the other wife because one of these other children was a son. Initially, Ms. A considered divorcing her husband. However, she decided that the pain of losing him for a few months every year was less than the pain of losing him totally, so she slowly grew used to the situation. She saw a psychiatrist for the first 3 months after the onset of her depressive symptoms but stopped the treatment for financial reasons. This episode slowly remitted over 2 years. She consulted a psychologist at a university clinic about her depressive symptoms 4 years ago, shortly after the onset of the current episode, but discontinued therapy after two sessions because of “lack of progress.” She denied any lifetime alcohol or substance use or any other psychiatric disorders.Consistent with prior reports of a higher risk for depression in the offspring of mothers with a history of major depression (7), Ms. A’s 15-year-old daughter was also depressed. The daughter had been in treatment for depression when Ms. A was referred to our clinic, although session attendance had been sporadic. There was no other documented family history of psychiatric disorders.
Ms. A requested to be treated with psychotherapy and was scheduled to receive 12 sessions of weekly interpersonal psychotherapy. After much difficulty negotiating a mutually convenient time, the first 45-minute session was scheduled. Two hours before the appointment, Ms. A canceled because she was unable to find a baby-sitter for her 2-year-old daughter. The appointment was rescheduled, and Ms. A’s 15-year-old daughter agreed to baby-sit for her two sisters at the clinic. Ten minutes into the session, the 2-year-old insisted on entering the room, and the session had to be interrupted for 10 minutes until she agreed to go back with her sisters. After the second appointment was rescheduled (and missed) three consecutive times, the therapist suggested that the therapy be done over the phone; the duration and periodicity of the sessions were preserved. After this, no session was rescheduled or missed. Ms. A was never late for her phone sessions, although on occasion the sessions were briefly interrupted by the children coming into the room to ask her a question. The possibility of returning to in-person visits or coordinating them with the child’s visit was discussed twice more during the treatment, but Ms. A stated that she could not afford to pay for a baby-sitter to look after her children during the visits.
The first three sessions were devoted to reviewing symptoms, obtaining an interpersonal inventory, understanding current relationships, explaining the medical model of depression and the role of interpersonal relationships in the onset and course of depression, and formulating the focus of the therapy.Ms. A was born and raised in New York City, the only daughter of an Irish-American family. She lived with her parents until marriage. She described her father as a caring person who always had difficulty expressing his love. Her mother frequently devalued Ms. A’s social and intellectual capabilities, criticizing her friends and telling her that she would never be able to go to college.Before her marriage, Ms. A’s longest relationship had been with a man of the same age whom she had dated for 4 years. The relationship ended when they both realized that the passion had progressively disappeared. Ms. A met her husband at a party and fell in love with him immediately. She stated that the passion had grown more intense throughout the years and that the sexual aspects played a very important role in their relationship. Ms. A held several administrative jobs until her first pregnancy, when she quit. After that, Ms. A became progressively focused on her new family at the expense of other social contacts. She had intermittently considered returning to work or opening a business but was systematically discouraged by her husband, who insisted it would detract from the care of the children.
Because the onset of the first episode of depression and the subsequent course was clearly related to marital difficulties, this case was understood as a role dispute. Ms. A’s attempts to become more independent were incorporated into the therapy by formulating a secondary focus on role transition. This formulation, refined through the course of treatment, helped Ms. A and the therapist translate the difficulties in the relationship into specific, achievable goals of the therapy.When Ms. A started treatment, her stated goal was to be able to tolerate her marital situation without suffering. This seemed an unrealistic objective to the therapist, who worked with Ms. A to develop alternative goals. The therapist repeatedly raised the possibility of reconsidering the marital arrangement, but Ms. A made it very clear that leaving her husband was not an alternative she was willing to entertain. After much discussion, Ms. A and her therapist agreed to work on identifying positive aspects of the relationship with the husband that she would like to promote and aspects that she saw as sources of pain and wanted to change. Throughout the sessions, it became evident that the way she felt in his company, their sexual relationship, and their history together were aspects of the relationship that she cherished and wanted to preserve. Her emotional and economic dependency on her husband, and feeling humiliated at times by him, were aspects she wanted to change. A great deal of time in the sessions was spent obtaining the details of how specific situations developed, how she felt in those situations, and what could be alternative, more adaptive behaviors in response to such situations. References to similar situations in the recent past were discussed, but attempts at reconstructing the childhood roots or intrapsychic conflicts underlying those behaviors were discouraged.
On several occasions during the treatment, the therapist felt uncomfortable with Ms. A’s helplessness and was tempted to shortcut the therapeutic process by immediately offering a solution to the patient’s problems. However, the therapist was aware that he did not have “the right answer” to those problems and that he had limited knowledge of the culture of Ms. A and her husband. He was also careful to avoid substituting Ms. A’s dependency on her husband with a dependency on the therapist himself. Thus, he encouraged Ms. A to discuss her situation and possible solutions with her close friends, who would be better judges of her cultural norms and provide ongoing support should she decide to deviate from those norms. She would also see them as peers, making it easier for her to disagree with them than it would be to disregard the therapist’s advice. Increased contact with her friends would also improve her interpersonal relationships, increase her independence and self-esteem, and strengthen a social network on which to rely upon termination of therapy.
As the treatment developed, Ms. A focused on three specific goals to help resolve the role dispute:1) Renegotiation with her husband about their differences of opinion without giving in to his point of view but also without allowing the situation to become an argument. Ms. A identified a pattern in which minimal disagreements would very quickly impair their ability to listen to each other and would degenerate into verbally abusive arguments that made her feel unappreciated and disrespected and lowered her self-esteem. Areas of dispute included how much time they should spend together as a family and how to allocate their scarce economic resources.2) Weight loss. Ms. A stated that her husband enjoyed overweight women. However, she also believed that encouraging her to stay overweight served the additional purpose of limiting her ability to appear attractive to other men, thus allowing her husband to take her for granted emotionally and sexually.3) Work on obtaining a government-guaranteed loan to start a small clothing business. Ms. A had some experience in that specific type of business and was able to enroll the help of her former boss to advise her on how to set up the new store. She also found agencies that could help her make a business plan and other people that would provide accounting and other services for small fees to beginning small companies.Formulation of these goals helped Ms. A focus her energies, test her assumptions about her ability to make changes in her environment and her life, and measure her progress in the therapy. As Ms. A realized how much control she really had over her life, her self-esteem improved, her mood lifted, and she felt much more energetic.
The therapy progressed smoothly from the third through the eighth session. Increasingly, Ms. A was able to select the appropriate incidents for discussion during the session, consider alternative ways of handling difficult situations, and work toward achieving her stated goals. It became evident that she spent substantial amounts of time thinking about her difficulties outside the sessions and was progressively able to learn how to solve most of them without the help of the therapist. During the seventh session, the therapist announced he would be taking a 2-week vacation after the 10th session. During the ninth session, 2 weeks after that announcement was made, Ms. A reported that her husband would be returning to his native country for 5 months. The husband would be leaving the day after the therapist returned from vacation. Ms. A felt abandoned by her man, who was going back to his country to visit his other wife and children. The therapist, after exploring these feelings, encouraged her to find ways to cope with his absence, including relying on her friends for companionship and emotional support.Upon the therapist’s return from vacation, Ms. A stated that she was upset and a little down, but she was clearly not depressed. She scored a 6 on the Hamilton depression scale administered at the last session. Ms. A requested a referral to continue working “on issues.” However, she had difficulty articulating those issues. Given the acute stressor of her husband’s departure and her history of recurrent major depression, it was agreed to extend the treatment for two additional sessions. Ms. A continued to be euthymic and to work on her goals after the two extra sessions.
Three months after the end of the treatment, Ms. A was contacted by phone by the therapist as part of the clinic procedure. Although many of her chronic problems remained, Ms. A reported feeling considerably better than before treatment. She had lost 20 lb since her last treatment session, had continued to be euthymic, and communication with her husband had substantially improved. However, progress with the start of her business was lagging. She was informed that should she become depressed again, she could contact the clinic for a new evaluation and another course of treatment or a referral.
Conclusions
Footnote
References
Information & Authors
Information
Published In
History
Authors
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
There are no citations for this item
View Options
View options
PDF/ePub
View PDF/ePubGet Access
Login options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).