Symptom-Specific Reflective Function as a Potential Mechanism of Interpersonal Psychotherapy Outcome: A Case Report

In the 1970s, in developing IPT in the pre-evidence-based era, Gerald L. Klerman, M.D., famously asked, “If a treatment doesn’t help, who cares how it works?” (3). Accordingly, during more than 40 years of subsequent research, studies of IPT have focused more on treatment outcomes than on its processes. IPT efficacy is now well established for mood (4) and eating disorders (5), with encouraging if lesser support for PTSD (6) and anxiety disorders (7). The question facing IPT, and all evidence-based psychotherapies today, has become, What specific mechanisms bring about symptomatic change?

Psychotherapy mediation factors are generally understudied, and only limited IPT process-outcome literature exists (e.g., 8). Researchers have struggled to find appropriate mechanistic measures for IPT, partly because IPT process research has been limited. IPT’s clinical focus resides in the interpersonal—in helping patients to understand and better negotiate social interactions, mobilize social support, and improve interpersonal functioning (9). Yet interpersonally focused assessments (10–12) have yielded underwhelming results. None addresses the core interpersonal skill inherent in the IPT treatment process and patient functioning at the level of the interpersonal encounter.

Our search for such an instrument led to core attachment dysregulation, which plays a formative role in the development of an interpersonal world (13). The Reflective Functioning (RF) Scale (14), derived by Fonagy and colleagues from the Adult Attachment Inventory (AAI) (15), assesses aspects of attachment dysregulation and the ability to mentalize (i.e., to reflect on the emotional aspects of one’s life, on one’s understandings of relationships with core attachment figures, and on oneself) (16). This measure seems a promising fit for IPT. RF measures one’s ability to understand one’s own and others’ feelings and perceptions of attachment relationships—the core backdrops of any interpersonal encounter and a potential missing mechanism link in IPT research. In helping patients to understand that their feelings are not dangerous but instead provide informative cues to interpersonal encounters, IPT would be expected to improve RF before patients make the interpersonal changes needed to resolve a role dispute, role transition, or other interpersonal crisis (17). Yet RF, capturing aspects of global ego functioning, may change too gradually to yield measurable differences in a brief psychotherapy. Hence Rudden et al. (18) developed the Symptom-Specific Reflective Functioning (SSRF) Scale, paralleling the RF scale, to assess patients’ understanding of their psychological symptoms. For example, symptomatic patients with panic attacks might attribute their panic to external causes (“I get my panic attacks from red bell peppers” rates a low SSRF score), whereas a patient who more deeply understands the symptoms’ emotional underpinnings might say, “I realize that since my daughter got into college and is about to leave home, I wake up almost every day with a sense of rising panic in the pit of my stomach. I’m going to have to deal with this loss!” Recent research has applied the RF and SSRF scales as change measures, potential assessment tools for moderators and mediators in outcome studies (19).

Rudden et al. (20) found that among patients with panic disorder, SSRF, but not RF, improved during panic-focused psychodynamic psychotherapy (PFPP) (21), which, like IPT, is an affect-focused time-limited treatment, but not in applied relaxation, a cognitive-behavioral therapy (CBT). Ekeblad et al. (22) reported that IPT, but not CBT, improved RF rated on AAI for depressed patients. SSRF has been reported to improve more with PFPP than with CBT (20), and SSRF improvement across both treatments has been shown to lead to subsequent improvement in panic symptoms (19). We are conducting an open 14-week trial of IPT for patients with PTSD to explore whether improvement in SSRF precedes improvement on the CAPS-5 (1). Here, we use a case example to illustrate this concept.

This case discussion comes from our ongoing open clinical trial in the New York-Presbyterian Military Family Wellness Center (MFWC) at Columbia University Irving Medical Center/New York State Psychiatric Institute (NYSPI). The MFWC provides no-cost psychiatric treatment to veterans and military family members in a non–Veterans Administration setting (23). Eligible patients with PTSD may choose IPT for PTSD (24) from among other treatments and sign informed consent for this protocol, which was approved by the NYSPI institutional review board. The protocol entails RF and SSRF interviews at weeks 0, 4, and week 14 termination, with standard symptom measures (i.e., CAPS-5 and HAM-D) (2) at weeks 0, 7, and 14. Patients receive $50 compensation for completing the three RF and/or SSRF interviews. We hypothesized that SSRF score would improve (at week 4) before CAPS-5 score (at weeks 7 and 14).

The semistructured RF interviews prompt the patient to describe a key relationship with a parent, changes in that relationship over time, and the impact the patient feels the relationship has had. The SSRF interviews focus on the affective dysregulation characteristic of PTSD. The patient is asked, “Have you experienced alterations in overall intensity of your emotions in your daily life? Specifically, have you had experiences of numbing and/or heightened emotional states?” (20) The interviews are audio taped, transcribed, and scored by trained, reliable raters. The RF and SSRF scales, scored like the AAI (15), range from –1 (bizarre, not at all reflective) to 9 (extremely reflective), with 5 as a normative score, based on the emotional depth of the patient’s understanding (19).

We are recruiting 25 completed IPT-PTSD cases to test for possible attachment-based mechanisms in IPT. IPT for PTSD (24) follows basic IPT principles, with adaptations including an early focus on affective attunement in numb PTSD patients and on using anger to confront others in order to determine their trustworthiness. This case vignette serves as an illustration of improvement in SSRF as a potential mechanism of IPT outcome.

Matthew agreed to participate in 14 weekly IPT sessions. The therapist took an interpersonal inventory (5). Matthew recalled vague, fond memories of early years with his mother and unhappiness at moving to his father and stepmother’s at age 7. His parents had never discussed these moves with him or asked about his feelings. Matthew stated, very casually, that his stepmother frequently hit him with a hairbrush or kitchen utensil, often drawing blood; his father turned a blind eye on the rare occasions he witnessed this behavior. Matthew’s stepmother belittled him and complained bitterly about having to care for him. Matthew happily returned to his mother at age 12, but again, no one ever discussed the reasons for or his reactions to moving, nor did Matthew expect such discussion.

The therapist asked Matthew to whom he turned when angry or sad. Matthew responded with a quizzical look. He described avoiding drawing attention to himself and taking care never to upset or burden parental figures. He acknowledged anger toward his stepmother for hurting him and toward his father for not protecting him, but he quickly defended his mother: “Well, she had her own problems and I understand she couldn’t manage me—I was not the easiest kid.” The therapist, mildly incredulous, wondered about this statement and about why Matthew never told his mother about the physical abuse. “What could she have done, anyway?” Matthew shrugged. He resisted the therapist’s attempts to probe his justification for his mother’s abandonment, demonstrating his discomfort with feeling disappointed in her.

Matthew described scarce social relationships growing up, always feeling different because of his size and sexual orientation. He was teased in elementary school for being fat and in adolescence for being awkward and shy. In his later teens, Matthew lost weight and gained muscle. Peers no longer teased him, but he still struggled to form friendships. (The therapist’s suggestion that Matthew was slow to trust elicited another shrug.) Attracted to boys, he too feared rejection or discovery to initiate contact.

In the military, Matthew’s social life improved. He found acceptance and admiration: his work ethic, dedication, and care for others earned him popularity. These relationships faded following exposure to combat trauma, traumatic loss, and consequent depression and PTSD. Matthew felt criticized and shunned for his “weakness” and decision to seek help. He wistfully described his final years in service. Military service had held great meaning and provided close friendships until then. Matthew had quietly experimented with romantic relationships in his early military years when opportunities arose, but he stopped when he became depressed. During his previous psychotherapy, he had experimented with longer-term relationships, but none had lasted. In a repeating pattern, he would do everything for his partners, who did not reciprocate his devotion to the relationship and eventually left or cheated on him. Ashamed, Matthew admitted maintaining contact with one ex-boyfriend who had betrayed him and whom he recently had helped move when asked. The therapist gently reflected that it was curious Matthew spent so much of his life trying to care for and please others—his mother, military superiors, romantic partners—often at a cost to his own needs and desires. Matthew shrugged, “I like to help other people. But yeah, I’ve been told before that I need to look out for myself.”

In session 3, the therapist established the treatment focus, emphasizing that PTSD and depression were treatable medical disorders, not Matthew’s fault, and explained his social withdrawal and functional impairment, connecting them to Matthew’s comment about not looking out for himself. He suggested that Matthew faced a role transition; he had done well until a trauma disrupted his life. The bar incident had re-opened old wounds, resurfacing lingering problems that previous treatment had not fully addressed, leaving him vulnerable to re-traumatization and symptom relapse. The therapist suggested focusing the remaining sessions on Matthew reconnecting to his feelings and using them to understand and negotiate social interactions in order to improve his mood and symptoms. Without assigning formal homework, the therapist would encourage Matthew to try out options they discussed. Matthew amiably agreed.

Answering the initial question, “How have things been since we last met?” Matthew reported feeling depressed and struggling to find a job while enduring pressure from his stepfather, who constantly harangued him to get work. The therapist agreed Matthew’s mood reflected current circumstances and asked about Matthew’s interactions with his stepfather. Matthew explained, “I can’t really blame him. I know he’s trying to help me. He’s been giving me money and he’s frustrated.” Opening his phone, Matthew read his stepfather’s excoriating texts verbatim: “You need to get off your [expletive] ass and go out there! You only applied to one place yesterday, that’s complete [expletive]!” The therapist asked Matthew how he felt reading these messages. Matthew said he tried to ignore them, only responding when he could no longer delay. The therapist pressed: “How do the messages make you feel?” Squirming, Matthew admitted they bothered him.

Matthew gradually acknowledged, in this and subsequent sessions, that his stepfather’s messages hurt his feelings and made him feel much worse. He felt his stepfather neither understood nor respected his mental health challenges, which reminded him of when he left the military, belittled for being “weak.” Brushing away tears, Matthew complained that everything could be so different if his stepfather only spoke to him kindly. Gently, the therapist noted the tears, observing that Matthew felt strongly about this. Matthew nodded. “And yet,” the therapist observed, “it took quite some effort to say this.” Matthew nodded again. “I guess I’m not used to talking about my feelings. Nobody really ever asked me these kinds of questions.”

Subsequently, in discussing the text messages, the therapist asked Matthew if his anger made sense. Matthew struggled, stating his stepfather had good reason to be frustrated with him. The therapist challenged this comment, asking if his stepfather had the right to address him however he pleased and whether sending such texts was okay.

Matthew described how shameful it felt to accept his stepfather’s help; in reading the messages, he often felt his stepfather was right about Matthew’s laziness and selfishness, meaning he shouldn’t feel angry or sad. “That sounds like the PTSD and depression talking,” the therapist offered. “Of course, you’re not expected to be at your peak when you’re ill. But it’s not your fault you’re struggling and doesn’t mean you’re not trying your best. Actually, knowing how you’re feeling—and figuring out how to communicate your feelings effectively—should help you feel much better.” The therapist suggested he “live dangerously” and try tolerating and acting on his feelings.

By session 5, Matthew was identifying feelings more quickly and dismissing them more slowly. He more readily linked the week’s events to his feelings, and he more openly considered that others in his life, not just his stepfather, were not treating him as he desired. Matthew noted having helped many friends in times of need but that these friends were absent during his own struggles. He acknowledged feeling uncomfortable asking for help or requesting attention but agreed he might feel better having more support. When asked what made requesting help so uncomfortable, he explained, “Everyone has their own problems. I hate to think someone’s inconveniencing themselves for me.”

In the following weeks, they explored his reluctance to confront others. The therapist gave more-explicit and connected feedback, attempting to evoke Matthew’s curiosity about himself. The therapist wondered aloud how curious it was that despite mistreatment by his mother, stepfather, romantic partners, supervisors, and coworkers, Matthew remained unfailingly considerate of everyone’s feelings.

In session 8, Matthew, downcast and upset, reported spontaneously confronting his stepfather during dinner. He described his stepfather again yelling and berating him, his mother saying nothing, his feeling humiliated and angry. Matthew stood and yelled at his stepfather that he never listened, didn’t understand what depression felt like, and always made him feel worthless.

Matthew had sat back in his chair, silent, trying to restrain tears, and waited for his stepfather to stop. The family then continued the meal as though nothing had happened. He returned home feeling extremely depressed.

The therapist gave Matthew positive feedback, encouragement, and sympathy. He applauded Matthew’s efforts and commiserated with his sense that speaking up had not worked. Having explored Matthew’s feelings—anger and sadness—and whether these feelings made sense to Matthew, which they did, the therapist asked, “What are your options?” Matthew considered never speaking to his stepfather again, apologizing, and yelling at him. With some guidance, Matthew settled on having a conversation to express himself to his stepfather. He and the therapist role-played this situation. They discussed the benefits of expressing angry feelings before they reach the blow-up stage, and of speaking up “even if you don’t get what you want.”

Matthew did not directly confront his stepfather again. He began setting limits, however, no longer responding to irritating texts and texting his stepfather that he didn’t want to be addressed insultingly. Matthew’s mood improved. He re-engaged socially. He incrementally began telling friends about his depression and that he needed them to persist more in trying to reach him, that their distance bothered him. Seemingly reflecting his increasing comfort with his feelings and in taking more active roles in relationships, Matthew applied more aggressively for work and spoke more hopefully about the future. He reported doing so for his own benefit, wanting to establish his own future without feeling subjugated by his stepfather. By session 12, Matthew had secured a job, ended his stepfather’s financial assistance, and reconnected with friends. He felt much better.

The final two sessions focused on consolidating gains and furthering progress. Matthew reported great improvement, which was reflected in symptom measures: his CAPS-5 score had dropped from 46 to 24, and his HAM-D score from 23 to 9. PTSD symptoms remained significant but had decreased from severe to moderate; his depressive scores were minimal. He reported drinking less. Feeling more confident and capable, Matthew talked enthusiastically about pursuing a new romantic relationship he intended to handle differently by asserting his needs and setting appropriate limits. Reflecting on treatment, Matthew said: “I think I thought, not that I deserved what happened to me exactly, but that I shouldn’t expect anything better. I like helping other people, but I don’t think I understood I can be a nice person without being taken advantage of.” The therapist responded that Matthew had perforce acted agreeable and compliant as a mistreated and abandoned child, a coping strategy that had helped him avoid danger, but that as an adult he had broader options. Matthew agreed, saying he planned to continue practicing everything he had learned. Before an emotional, engaged goodbye, Matthew reported feeling much less guilty about the past and optimistic about the future.

Table 1 shows Matthew’s progress on symptom scales, RF, SSRF, and the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), which measures childhood and adult separation anxiety: total score ≥8 indicates separation anxiety disorder (25). Matthew’s SSRF improvement (at week 4), which eventually normalized, anticipated subsequent (at weeks 7 and 14) CAPS-5 and HAM-D improvement, as hypothesized. (The rating schedule in this underfunded study, however, could not preclude that clinical improvement may have already occurred by week 4). Matthew’s RF improved, as did his separation anxiety score, although it remained elevated. The improved scores appeared clinically meaningful, reflecting the broadened emotional understanding and interpersonal changes Matthew made during treatment. Whether, as in this case, change in SSRF score generally predicts PTSD outcome in IPT will be clarified in the results of our larger trial.