Sensitivities/Deficits the greatest missed opportunity in IPT?

Transcription

1 27 th January, 2017 Sensitivities/Deficits the greatest missed opportunity in IPT? Dr Roslyn Law Deputy Director, CYP IAPT Chair IPTUK

2 Roslyn Law 2 Why have four focal areas if we are only going to use three?

3 Roslyn Law 3 The classic view Interpersonal deficits or sensitivity is the most difficult problem are 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 tolerating relationships, which puts them at risk for depression and complicates the therapeutic alliance. Markowitz & Weissman (2000) Casebook of Interpersonal Psychotherapy

4 Roslyn Law 4 Alternative View Ability to maintain a focus on the interpersonal context of the symptoms ERG, 2010 The insidious and incremental effect of daily rejection, disappointment and exclusion is a viable focus as well as the attention grabbing effect of a significant change, loss or conflict Translating depression into the interpersonal context does not necessarily require that the event is entirely new, only that it has a meaningful and primary role in maintaining current depressive symptoms

5 Roslyn Law 5 Thinking around the edges The interpersonal deficits seen in patients with bipolar disorder typically falls into the category of the chronically dissatisfied type, who often have disputes with almost every important person in their lives or who find themselves in self-imposed isolation following a mania that has made them wary of social contact Often, this leads to work that consists of what might be thought of as a whole series of individual role disputes, in which you try to help the patient to see the thread or threads connecting the multiple disputes in his or her life. Frank (2005) Treating Bipolar Disorder. A Clinician s Guide to Interpersonal and Social Rhythm Therapy

6 Roslyn Law 6 Interpersonal Patterns (Talbolt & Gamble, 2008) Interpersonal Psychotherapy for Depressed Women With Sexual Abuse Histories Talbot et al (2005, 2008, 2011) The Sensitivities focal area has been extended to reflect the developmental nature of persistent interpersonal patterns and to recognize longstanding, trauma-related patterns of behavior and emotion in relating to others that undermine current relationship satisfaction. Using a developmental framework aims to reduce self-blame and helps women construct a coherent interpersonal narrative emphasizing their resilience By combining interpersonal patterns with one of the present-focused problem areas therapists maintain a focus on current problems while conveying a developmentally informed view of the pattern of the problem over time Inevitable setbacks in making interpersonal changes are anticipated and collaboratively examined in detail. The developmental framework is used to minimizes self-blame while working towards change This is used to promote mind mindedness mentalization begets mentalization

7 Roslyn Law 7 Expanding our vision of sensitivities a broad spectrum Repetition of a painful pattern is at the heart of the formulation rather than the most recent example

8 Roslyn Law 8 Nature of Sensitivity in UK cases: 198/2000 Character of Sensitivity Isolated few relationships 30% Superficial relationships 26% Abusive relationships 7% Recurrent conflict across relationships Repeated relationship breakdown 19% 14% Attendance Response No response 4% > 12 sessions > 16 sessions PHQ-9 (below cut off) PHQ-9 (mild) PHQ-9 (moderate-severe) 89% 24% 50% 29% 15%

9 Roslyn Law 9 IAPT outcome data

10 Roslyn Law 10 Comparative outcome among the problem areas of Interpersonal Psychotherapy for depression Levenson et al (2010) Interpersonal deficits becomes the focus of treatment with patients who lack sufficient satisfying interpersonal relationships, who have difficulty maintaining the relationships that might exist, or who have unresolved symptoms that interfere with current relationships. Interpersonal deficits was used as a primary or secondary focal area. 14 of 182 participants. Contrary to our prediction that patients whose treatment was focused on interpersonal deficits would take longer to remit, survival analyses indicated that patients receiving treatment focused on each of the four problem areas did not differ in their times to remission. Nor were patients in the interpersonal deficits group more likely to have an Axis II diagnosis. Grief Deficits Disputes Transitions Remitted 88.2% 78.6% 86.7% 80.2% Mean time to remission (days) (53) 69 63

11 Roslyn Law 11 With young people Examples of interpersonal deficits include inability to initiate relationships, inability to maintain relationships, inability to express one s feelings verbally, and/or difficulty eliciting information from others to establish communication. The area of interpersonal deficits is selected as the problem area for IPT-A when the deficits either contribute to or result from the adolescent s depression Interpersonal deficits also may be identified as a problem area when it appears that a depression has caused the adolescent to withdraw socially. The social withdrawal may result in a developmental lag in interpersonal skills that further perpetuates the depression by impairing social relationships. Mufson et al (2004) Interpersonal Psychotherapy for Depressed Adolescents

12 Roslyn Law 12 Einstein once said: "If you can t explain it simply you don t understand it well enough. Working with young people is a wonderful opportunity to operationalize what we are doing The same is true of explaining something to a 14 year old

13 Roslyn Law 13

14 Anna Freud National Centre for Children and Families Transitions Sensitivities 14 Roslyn Law Disputes Grief

15 Focal Areas in CYP IAPT ( ) Change Conflict Isolation Grief

16 Roslyn Law 16 Gathering information and formulating the target difficulties

17 Roslyn Law 17 Story of important relationships: family and peers develop? most difficult? start? best about it? end?

18 Roslyn Law 18 Take time to review several relationships looking for patterns develop? most difficult? develop? most difficult? develop? most difficult? start? best about it? end? start? best about it? end? start? best about it? end? develop? most difficult? develop? most difficult? start? best about it? end? start? best about it? end? develop? most difficult? develop? most difficult? develop? most difficult? start? best about it? end? start? best about it? end? start? best about it? end?

19 Roslyn Law 19 Map out target problems and possible solutions Notice when depression tries to make me give up and don t Worry people won t like me so go along with others plans Practice making one suggestion before agreeing to a plan Confirms other don t like me so withdraw even more and feel even more sad Do things I don t want to do and feel resentful Practice talking about my feelings and saying no Put myself in others shoes and ask how they are feeling Others get confused or angry Start to withdraw rather than saying no. Feel sad. Ask for help when I notice that I am starting to withdraw

20 Roslyn Law 20 Use of therapeutic relationship in Sensitivities

21 Roslyn Law 21 Explicit modelling to facilitate network change Re-establish social learning through collaborative interpersonal problem solving

22 Roslyn Law 22 Depressed Brain: Decreased dialogue Fischer-Kern et al (2013) Mentalizing in female inpatients with major depressive disorder. Journal of Nervous & Mental Disease, Mar; 201(3):202-7 o Female inpatients with depression showed a severe impairment in their ability to identify and interpret mental states of the self and others compared with the healthy controls o Mentalization deficits were not restricted to depression-specific topics o Deficits in mentalizing capacity were related to illness duration, number of admissions, and cognitive impairment suggesting that a chronic course of depression results in further mentalizing impairments

23 Roslyn Law 23 The P Factor Recent studies have examined the P Factor as a measure of overall psychopathology or impairment - the vulnerability an individual carries with them This has x10 greater capacity to predict future outcome than internalizing diagnoses Meta structure of mental disorder has two aspects: Diagnosis Impairment better predictor of future outcome P factor: pathology or persistence - the absence of resilience Resilience reflects core executive functioning the capacity of the cortex to control itself. This capacity correlates very highly with the P Factor The P factor represents a severely restricted capacity for social learning a core feature of the sensitivity focus and a core target for IPT

24 Roslyn Law 24 Fundamental task of IPT is to (re-)establishing social learning

25 Roslyn Law 25 Conclusions Collaborative formulation is central helping the person to feel his or her dilemma and distress is perceived accurately understood A Sensitivity formulation is fundamentally hopeful and aims to re-establish trust in social learning Evidence on comparative outcomes across focal areas is limited but the UK experience does not support the view that Sensitivity should be reserved as a last resort Neither avoidance nor embracing the Sensitivity focus is currently a well evidenced choice