IPT for Women with Trauma Histories in Community Mental Health Care
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- Talbot, N.L. & Gamble, S.A. J Contemp Psychother (2008) 38: 35. doi:10.1007/s10879-007-9066-9
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Many women in community mental health care have interpersonal trauma histories and chronic, complex depression. Despite the profound treatment needs of this population, there are few treatment studies or descriptions to guide effective practice. In this paper, we describe an adaptation of Interpersonal Psychotherapy (IPT) that we have tested among depressed women with sexual abuse histories. IPT-Trauma in Community Settings (IPT-TCS) is IPT with modifications specifically designed for its transport to depressed patients with interpersonal trauma histories in community settings. Modifications include an expanded treatment duration, engagement analysis, sociocultural formulation, and interpersonal-patterns problem area. IPT-TCS modifications are described with case examples.
Depressed women with childhood trauma histories comprise a large population within community mental health centers (U.S. Department of Health & Human Services 2001). Their mood disorders are often chronic and accompanied by other mental disorders (Kendler et al. 2000; Molnar et al. 2001b), heightened risk of deliberate self-harm (Molnar et al. 2001a), and comorbid physical illness (Walker et al. 1999). Complicating the clinical picture further, these women frequently experience pervasive interpersonal difficulties, including sexual assault and domestic violence, and socioeconomic adversities (DiLillo 2001; DiLillo et al. 2001; Kendler et al. 2000; McCauley et al. 1997). The persistent and often treatment-refractory mood disorders (Andrews 1995; Gladstone et al. 2004; Hayden and Klein 2001; Zlotnick et al. 2001; Zlotnick et al. 1995) observed in many women with histories of childhood trauma exact tremendous social and economic costs (Murray and Lopez 1996). Despite the disproportionate burden of serious mental illness among depressed women with sexual abuse histories, treatment research aimed at this population is exceedingly scarce (Price et al. 2001). Moreover, depression treatment research in general has been highly focused on white, comparatively affluent patients, and has paid relatively little attention to the applicability of efficacious treatments to poor and ethnic minority patients (U.S. Department of Health & Human Services 2001). In this paper, we describe a modification of Interpersonal Psychotherapy (IPT) that we have tested among depressed women with histories of childhood sexual abuse. IPT-Trauma in Community Settings (IPT-TCS) is IPT with modifications specifically designed for its transport to depressed patients with interpersonal trauma histories in community settings.
Our experiences in treating depressed women with sexual abuse histories in a community mental health center (CMHC) have guided the development of IPT-TCS. The four modifications within IPT-TCS were developed in response to observations we made during an uncontrolled pilot study (Talbot et al. 2005) and in a small randomized trial of IPT-TCS compared to usual care in a CMHC. First, we realized that patients did not conform to the expectation of weekly therapy appointments, and perceived that a more flexible meeting schedule was needed. Second, we learned that patients experienced significant treatment barriers, often citing stigma-related obstacles that interfered with initial treatment engagement and persistence in therapy. Treatment adherence in this mostly poor and predominantly minority patient population did not match adherence rates reported in typical psychotherapy efficacy trials. In our pilot study, less than half (40%) of participants completed all 16 sessions and, on average, women completed approximately 11 sessions over a 32-week period (Talbot et al. 2005). Third, we found that the sociocultural histories and milieus of our patients heavily influenced the initial treatment formulations and the development of the problem focus. Fourth, we observed that severe, cumulative trauma had a pervasive impact on women’s ways of forming and being in relationships. Using enhancements of traditional IPT therapeutic strategies, IPT-TCS addresses each of these four areas.
We will briefly review the rationale for using IPT in treating women with sexual abuse histories, and discuss the IPT-TCS approach to obtaining and addressing a woman’s trauma history. With that background, we then describe each of the four IPT-TCS modifications and offer case examples.
Rationale for IPT with Women with Sexual Abuse Histories
Women with severe childhood trauma histories commonly experience significant interpersonal distress that extends into adulthood. In choosing IPT for this patient population, we reasoned that an efficacious treatment for major depression that targets interpersonal functioning and social support would be well matched to the presenting concerns and interpersonal patterns of depressed women with histories of childhood sexual abuse. The theoretical roots of IPT in attachment theory, which emphasizes the formative influence of early interpersonal relationships on development and adult interpersonal patterns, also made it a good fit to women who had suffered developmental trauma. Attachment theory describes characteristic patterns of need fulfillment in interpersonal relationships that are initiated in early childhood and typically persist into adulthood. When these needs are left unmet and caregivers are unresponsive during childhood, insecure attachment patterns are likely to develop. Adults with insecure attachments are hard-pressed to create stable relationships. When their early experiences are abuse-filled, adults may expect similar mistreatment in relationships. IPT has the theoretical and practical flexibility to acknowledge the effects of past trauma on patients’ current interpersonal functioning. At the same time, the therapeutic focus in IPT on current (not past) interpersonal difficulties and their link to depression seemed to fit the presenting ‘here and now’ concerns of this patient population. Our pilot study strongly suggested that IPT is likely to be beneficial (Talbot et al. 2005). Study participants became less depressed and had improved psychological functioning following a 16-session course of IPT. Modifications were added to enhance IPT’s fit to the patients’ developmental trauma history and the clinical setting.
Overview of IPT-TCS
Other researchers have adapted IPT to particular study populations (Markowitz 1998; Mufson et al. 2004a; Mufson et al., 2004b; Swartz et al. 2004; Stuart et al. 2006). Likewise, we added four components to IPT to address the needs of depressed women with trauma histories seen in community settings: we expanded the duration of treatment, and added an engagement analysis, a sociocultural formulation, and an interpersonal-patterns problem area. We use the term “IPT-Trauma in Community Settings” (IPT-TCS) to refer to Interpersonal Psychotherapy with these four modifications. The expanded treatment duration matches the realities of attendance patterns in a CMHC. We found in our pilot studies and accumulated clinical experience that poor treatment participation was strongly influenced by social barriers in particular, including the stigma of mental health care and shame associated with trauma histories. The engagement analysis uses enhanced IPT strategies in initial sessions to help patients overcome social and practical barriers to treatment participation. We also recognized the need to explicitly include cultural factors in treatment formulations with low-income and minority women. The sociocultural formulation is an elaboration of IPT’s Interpersonal Formulation (Stuart and Robertson 2003), and is focused on cultural influences on patients’ interpersonal problems and depression. Finally, the interpersonal-patterns problem area is a trauma-specific modification of one of the IPT problem areas to target interpersonal patterns associated with interpersonal trauma. IPT-TCS is based on standard, manualized IPT and uses conventional IPT intervention practices. In the case examples of IPT-TCS modifications, we note in italicized brackets the techniques used by the therapists.
Assessing and Addressing the Trauma History
IPT-TCS is not trauma-focused therapy. Rather, it explicitly assesses and addresses traumatic experiences in a manner that is consistent with the focus on current interpersonal concerns of usual IPT practice. IPT-TCS therapists provide education about major depression and, when appropriate, may also provide information about PTSD symptoms. Exposure-focused strategies are not a part of IPT-TCS. Patients with comorbid PTSD have significant interpersonal functioning deficits that can exacerbate post-traumatic symptoms (Schumm et al. 2004). As interpersonal functioning improves, post-traumatic symptoms may decline with IPT (Bleiberg and Markowitz 2005).
Histories of trauma and abuse are obtained during the Interpersonal Inventory, a central feature of IPT designed to identify key current relationships, as well as past relationships and interpersonal events that bear on current functioning. Because the therapy is time-limited, a complete history may not be possible, nor is it necessary. The goal of IPT-TCS is to work with the patient to identify those traumatic experiences and relationships in childhood and/or adulthood that have had an enduring impact, and to identify their effects on current interpersonal behaviors and relationships. In our experience, patients are willing and able to reflect on their traumatic experiences and to describe the ways in which those experiences have influenced them. The Interpersonal Inventory is conducted in the initial stage of treatment and in creating a ‘relational map’ naturally leads to the Interpersonal Formulation. Here, the therapist and patient articulate how the dominant interpersonal theme(s) in the patient’s life have informed the patient’s current depression and distress. This shared understanding of the relationship between the patient’s interpersonal experience and mood disorder sets the stage for the selection of the Interpersonal Problem Area(s). In IPT-TCS, the problem area of Interpersonal Patterns reflects the impact of interpersonal trauma on interpersonal-behavioral patterns across the lifespan. The Interpersonal Patterns problem area is commonly used in conjunction with one of the present-focused problem areas (i.e. interpersonal conflict, role transition, or grief).
Expansion of Treatment Duration
This modification matches the realities of attendance patterns in a CMHC. “Standard” IPT has typically been described as being delivered in weekly sessions during acute-phase treatment. This weekly treatment, however, has largely been confined to research protocols, with more flexible scheduling of sessions occurring in community settings. This reflects the competing demands in the lives of patients who face the multiple challenges of childcare responsibilities, unreliable transportation, uncertain work schedules, poor social support for mental health treatment, and limited financial resources. In IPT-TCS, we encourage regular session attendance and help patients actively problem-solve to overcome barriers to care. At the same time, the real constraints on weekly attendance are acknowledged and respected. In our pilot studies, patients and therapists were given up to 32 weeks to complete the 16-session course of IPT-TCS.
Expanding treatment duration is also responsive to the attachment difficulties that are pervasive among women with extensive trauma histories (Mickelson et al. 1997). The insecure attachment styles that predominate in this population can pose significant challenges to treatment adherence. Patients with insecure attachments do not expect reliable support from others and may have difficulty forging satisfying, sustained relationships, including therapeutic relationships with their therapists. As a result, cancelled appointments and no-shows can occur. The expanded treatment frame allows women to receive a full-dose of IPT with due consideration of these social and psychological realities.
Treatment duration may be extended beyond the planned 16-session course of IPT-TCS. Decisions about continued treatment are made in the last phase of treatment (sessions 12–16) based on therapist and patient evaluations of clinical progress and need. Our expectation is that some women will choose to end treatment after 16 sessions. For others, however, treatment will continue, although often on a less frequent basis. Given the chronic, recurrent nature of depression in this patient population, and the high comorbid burden, we believe that continued therapy is a desirable outcome. Furthermore, women with sexual abuse histories may be more likely to become distressed in the face of stressful life events (Kendler et al. 2004). Continued treatment contact may have a prophylactic effect in such cases (Harkness et al. 2002).
Ms. A was a 28-year-old Hispanic woman who lived with her children, ages 6 and 3, and the children’s father. She was employed full-time as a nurse’s aide and taking college classes towards a nursing degree. When she came to treatment, Ms. A was exhausted by her busy schedule, depressed and demoralized, and angry at her partner who “only lifts a finger to play his video games.” Ms. A’s childhood history was riddled with abuse and neglect, multiple foster care placements, truancy, and polysubstance abuse. At age 18, she met her current partner and the two began a lucrative business in dealing drugs. Eventually, the couple went into drug treatment and decided to go straight. Ms. A suspected that her partner had recently gone back to dealing.
In their first session, when her therapist asked Ms. A how she would fit therapy into her very busy schedule, she replied that she could leave the children with their father during sessions. Minutes before the second session, Ms. A called to cancel with the explanation that her partner would not give her a ride to the clinic. The session was rescheduled. Ms. A did not attend that session or call to cancel. When the therapist reached Ms. A on the phone, she explained that she had a fight with her partner who had complained about watching the children while she was in therapy. Ms. A came to the next two sessions, although she arrived late. With the therapist’s encouragement, she talked openly and emotionally about the serious conflicts in her relationship. She told her therapist about a loving foster care family who still tried to keep in touch with her, and her ambivalence about spending time with the family, as they were “churchgoing folks who might judge me.” [Example of “Use of Affect” technique] Aware of Ms. A’s interpersonal sensitivities, the therapist was careful to convey an accepting, respectful attitude about her struggles and choices.
Ms. A’s attendance became more consistent during the middle phase of therapy. By session 11 (week 18), Ms. A once again began to cancel and no-show to appointments. Her therapist continued to call following missed sessions. Ms. A explained, on different occasions, that her work schedule, lack of transportation, and childcare difficulties conflicted with session times. The therapist conveyed her understanding of the multiple roles and responsibilities that Ms. A juggled, while also working with her to problem-solve the scheduling conflicts. [Example of “Problem-Solving” technique] At session 14 (week 28), Ms. A confided that she was dismayed about treatment coming to an end. Although she was less depressed and had renewed energy, Ms. A worried that her mood could worsen again. After discussing options for ongoing treatment, the therapist and Ms. A agreed to meet every other week following the 16th session.
Summary: An expanded treatment duration was sufficiently flexible to allow the patient to complete 16 sessions of IPT-TCS. In IPT-TCS, therapists make an active outreach to patients to inquire about missed sessions and encourage regular participation.
Common barriers to care
Barriers to care
Stigma or lack of support for mental health care
“I don’t want to be seen as a crazy person.”
“If my husband finds out that I’m coming, he’ll think we’re talking about him, and we’ll fight.”
“My family knows about my abuse, but they say I should just get over it.”
“My boyfriend says this is the nut house.”
Religious or spiritual objections by the patient or significant others to mental health care
“My pastor says that all I have to do is follow Jesus to feel better.”
Demoralization or lack of hope that change is possible
“I can’t imagine what it would be like to not be depressed. I’ve always been this way.”
“Every time I thought things were going to get better or trusted somebody, I got let down.”
Therapist gender or ethnicity
“How can I feel safe with a male therapist?”
“How can a white therapist understand my experience as a black woman?”
Shame or embarrassment about revealing personal details in therapy
“I’ve never told anyone about some of the things that have happened to me. I don’t know if I can face my therapist if she knows about those things.”
“I don’t know if I can say out loud what is going on in my relationship. I think I’ll be too upset and get overwhelmed if I face it.”
Costly or unreliable transportation or childcare
“I can’t afford the parking lot at the clinic.”
“My friend said she would watch the kids, but she didn’t show up.”
“Paying for babysitting during therapy is just too much money for me.”
Treatment site objections or discomforts
“Being in the waiting room with so many people makes me uncomfortable.”
“The hospital is too big and impersonal. I wish that I could go to therapy in my neighborhood.”
Including an assessment of barriers in the initial sessions provides the patient with an opportunity to identify potential obstacles to treatment as well as possible solutions. Therapeutic attention to interpersonal barriers could include: providing psychoeducation about depression and the effectiveness of treatments in order to reduce stigma and instill hope; improving patients’ abilities to communicate with family members about their depression to reduce family members’ objections to care; and, in the case of intractable family objections, empathizing and reinforcing the patient’s desire to continue treatment even in the face of family opposition. Addressing practical barriers could include: role-playing effective ways of asking family members for childcare assistance during sessions; and, problem-solving how to negotiate public transportation to sessions. Ambivalence about treatment is noted in a nonconfrontative, nonjudgmental manner. The IPT strategy of Clarification is particularly useful in addressing ambivalence. Throughout treatment, therapists discuss missed sessions and tardiness as an interpersonal communication.
Engagement analysis is also an important opportunity for therapists to learn about their patients’ cultural perspectives on what it means to seek mental health treatment, both to the patient and to the significant others in the patient’s life. Social barriers to care may be culturally influenced. Some patients say that participating in psychotherapy is in conflict with their culturally held values of maintaining family privacy and seeking informal social support. Others have expressed concerns that their spiritual or religious values could come into conflict with the goals of therapy. Ethnic-minority patients may question their white therapists’ ability to appreciate their values and attitudes, social patterns, and experiences of racism and marginalization.
Ms. B, a 40-year-old, single, white mother of three children ages 15–22, presented for treatment for her depression after being fired from her job as a mental health aide. According to her report, she was terminated from her position due to repeated absences and frequent conflicts with her co-workers and supervisor. When Ms. B entered treatment, she reported feeling like a failure after losing her job. She had virtually no energy, no job prospects, and felt helpless about her current situation. In the first session, Ms. B stated that one of her goals was to “communicate better with others.” She indicated that others often “misread” her as being “cold and hard” and “never really got to know the real me.” The therapist began engagement analysis by asking whether Ms. B could think of any potential obstacles to maintaining treatment participation. Having worked in the mental health field for 3 years, Ms. B recognized that therapy could be beneficial to others, yet she had doubts about whether treatment could actually help her. She remarked, “I should know this stuff myself, I shouldn’t need anyone to tell me.” In addition, Ms. B informed her therapist that she was afraid she would run into her former co-workers and patients in the waiting room. Ms. B’s therapist responded empathically and used reflective listening to ensure that Ms. B’s concerns were fully understood.
Therapist: “So, it sounds like there’s a part of you that wants some help and knows that what you are currently going through might be more than you can handle on your own; yet, there’s another part of you that is feeling a little embarrassed and like you would really like to be able to solve this by yourself. Tell me more about these feelings.” [Clarification]
Ms. B: “Yeah, ever since I was little I’ve had to get myself out of messes. This should be no different. But it is. It’s just too big. I need help, I really do.”
The therapist and Ms. B then problem-solved a solution to her fears of being seen in the waiting area by scheduling appointment times that were “off-shift” for her co-workers. [Problem-Solving] Recognizing that this solution might not be fully effective, the therapist and Ms. B also planned and role-played what Ms. B could say if she ran into familiar people in the waiting area. [Role Play] Ms. B also shared her doubts that her teenage children could understand her depression and need for treatment. Ms. B said that she felt ashamed and was convinced that word would get out that she was “nuts.” The therapist empathized with Ms. B’s feelings of shame and stigma. [Use of Affect] With the therapist’s assistance, Ms. B planned and practiced effective ways to discuss her depression treatment with her children. [Communication Analysis; Role Play]
During the first half of her treatment (sessions 1–8), Ms. B regularly attended sessions. At session 10 (week 13), however, Ms. B began to cancel and no-show to appointments. Her therapist called following each missed session to reschedule her appointment and to inquire about the absence. During session 12 (week 18), the therapist addressed the repeated cancellations and invited Ms. B to discuss what was interfering with her ability to attend her therapy appointments. Ms. B explained that she “just hadn’t felt like coming [to sessions] anymore,” and questioned whether she really needed to see a “head doctor.” The therapist noted Ms. B’s ambivalence and asked how she thought therapy was going. [Clarification] Ms. B appeared relieved that she was able to discuss her concerns related to mental health stigma. In subsequent sessions, Ms. B’s interpersonal patterns of avoidance or conflict when shamed were identified. Alternative strategies, such as assertive communication, were discussed and practiced.
Summary: Through engagement analysis, the therapist and patient were able to identify potential social barriers to care. IPT strategies of clarification, communication analysis, role play, and use of affect were used to assist the patient in identifying barriers and using interpersonal strategies to overcome them.
Culture can be “broadly defined as a common heritage or set of beliefs, norms, and values, and as referring to the shared, and largely learned, attributes of a group of people” (U.S. Department of Health & Human Services 2001). Although an individual’s culture is often thought of as being a function of her membership in a particular racial or ethnic group, individuals may in fact have strong cultural ties to other types of groups defined by religion, geographic locale, age group, or sexual preference, for example. Most observers would agree that psychotherapies are built upon implicit cultural values and biases, both in terms of their content and structure. Take, for example, an individual psychotherapy where the therapeutic goal is directed at the patient’s individuation-separation. The structure and content of that therapy depends in part on a cultural emphasis on the individual and autonomy, as opposed to other cultural values emphasizing the group and communality. Because psychotherapy research has, in great part, been conducted with white, relatively affluent patients, corresponding cultural values have been largely assumed and implicit in the structure and content of therapy. We acknowledge that IPT-TCS rests upon cultural assumptions about illness and normality, expert-patient models of helping relationships, and Western developmental theory. We have not attempted to develop a wholly new model of psychotherapy from a culturally specific perspective. At the same time, we are purposely moving away from cultural universalism, which would assert that an efficacious psychotherapy for depression is applicable to people of all cultural backgrounds without modification or adaptation (Bernal and Scharrón-del-Río 2001; Sue 1998; Sue 2004).
In IPT, the initial phase of treatment includes an Interpersonal Formulation. Here, drawing from the biopsychosocial model, the biological, psychological, and social factors that have combined to produce current interpersonal distress are reviewed by the therapist and patient (Stuart and Robertson 2003). The Interpersonal Formulation directly informs the selection of the problem focus. It is critical that sociocultural factors be integrated into the Interpersonal Formulation. IPT-TCS therapists must assess the social conditions and cultural-group identifications of their patients. Culturally informed, shared understandings of the causes of depression and treatment goals are likely to improve treatment adherence among minority women (Brown et al. 2003; Lewis-Fernández and Díaz 2002). Attitudes towards psychotherapy and medications, including stigma associated with mental health care, may be strongly influenced by the individual’s cultural and religious experience (Brown et al. 2003; Brown et al. 1996; Klonoff et al. 1999; McLeod and Kessler 1990). Examples of sociocultural factors that may be pertinent include:
the contribution of discrimination and racism to distress
personal identification with cultural groups and subcultures
culture-group attitudes towards mental health care
effects of immigration or migration
somatically based expressions of emotional distress
the presence and functioning of kinship networks
the role of spirituality and religious involvement
individuation-autonomy values versus group-communality values
the impact of poverty, community violence, and neighborhood conditions
Sociocultural factors are assessed during the initial history-taking and, in particular, the Interpersonal Inventory. IPT-TCS therapists do not have a checklist approach to assessing culture. Rather, they are attentive and responsive to cultural elements in patients’ narratives. In addition, therapists must consider how their own cultural background may influence the patient–therapist relationship and the patient’s experience with them in therapy.
Ms. D was a 54-year-old African American woman who had been married for 30 years and had five adult children. She had been depressed periodically throughout her adult life and now sought treatment for a new episode of depression. Ms. D described her husband as a kind man who “worried about me a lot because he thinks I’m too emotional.” Several months prior, her youngest child had left home to live with her boyfriend, became pregnant, and had an abortion. Ms. D tearfully said that these events in her daughter’s life had been devastating to her, both because she missed having her daughter at home and because she had deep moral objections to abortion.
To assess potential treatment barriers, the therapist asked Ms. D what might get in the way of coming to or staying in therapy. Ms. D replied that she wanted to know if the therapist was a Christian. When asked, she explained that she doubted whether she could feel comfortable in therapy with someone who could not share or at least accept her Christian beliefs. The therapist candidly replied that he was raised in a Catholic faith tradition, and that Christian values remained deeply important to him, as did spiritual growth and development. When the therapist inquired about Ms. D’s thoughts about his disclosure, she replied, “It sounds like we don’t have the same exact faith, but you are a person who believes in God, and that’s good.” [Clarification; Use of the Therapeutic Relationship]
Constructing the Interpersonal Inventory, the therapist learned that Ms. D had been raised in the rural South in a family of seven children headed by parents who worked hard to provide the bare necessities for their family. Ms. D had recurring, disturbing thoughts of the sexual abuse she suffered from an uncle. She was comforted by memories of her grandmother, a strong woman who was dedicated to helping others and to her religious faith. When Ms. D met her husband, the couple moved to a large city in the Northeast. The culture shift was almost overwhelming to Ms. D. She described herself as a “naïve country girl” who was shocked by the social mores, was terrified by community violence and drug activity, and was upset by the prejudice she encountered. The therapist asked Ms. D about possible concerns or misgivings about being in therapy with a white man, given her experiences with racism. [Clarification] She answered directly with a bit of a smile, “Well, I’m willing to give you a chance, so we’ll see.”
The Interpersonal Formulation integrated sociocultural factors and emphasized three core themes in Ms. D’s life: the chronic anxiety, mistrust, and shame that she suffered as a result of the sexual abuse and severe economic deprivation in her childhood; the role of caregiver that had sustained her and the resilience she attributed both to the powerful example of her grandmother and to her religious faith; and, the cultural challenges she had encountered throughout her life, including the shock of transplanting to the urban North and racism, which had heightened her sense of being different and vulnerable.
Summary: During the Interpersonal Inventory, the therapist assessed the cultural and social conditions that strongly influenced the patient. The patient’s culturally-mediated experiences and values were fully integrated into the Interpersonal Formulation. As well, the therapist carefully attended to religious values that affected the patient’s willingness to engage in therapy and was prepared to respond to the patient’s inquiries about particular sociocultural issues that the patient viewed as being important to the therapeutic relationship. We do not advocate any one approach for responding to patients’ direct inquires about therapists’ cultural beliefs, attitudes, and experiences. Instead, we encourage IPT-TCS therapists to be (1) familiar with sociocultural issues, (2) open to engaging in a dialogue with patients about these issues, and (3) prepared to respond to patients’ questions in an open, honest manner with attention to the therapeutic alliance.
Reformulation of the Fourth Problem Area: Interpersonal Patterns
Three of the four IPT foci emphasize current interpersonal problems: interpersonal conflict, role transitions, and grief and loss. In contrast, the fourth problem area, ‘interpersonal deficits’ (Weissman et al. 2000) or ‘interpersonal sensitivity’ (Stuart and Robertson 2003) reflects an enduring interpersonal style. For this reason, some have advised that it is not a preferred treatment focus (Weissman et al. 2000), presumably because it might not be amenable to short-term treatment. More recently, it has been argued that the deficit/sensitivity problem area is more accurately conceptualized as an attachment style, and as such is a moderator of treatment rather than a true problem area in IPT (see Stuart this issue).
In IPT-TCS, this problem area is reformulated and renamed ‘interpersonal patterns.’ This problem area is designed to reflect the developmental nature of persistent interpersonal patterns in patients’ lives. The Interpersonal Patterns problem area helps women to recognize long-standing, trauma-related patterns of behavior and emotion in relating to others that undermine relationship satisfaction. Most women readily perceive persistent interpersonal patterns that undermine or strengthen their interpersonal effectiveness. Explaining those patterns within a developmental framework is experienced as removing blame and consequently helps women construct a coherent narrative emphasizing their resilience. Cultural influences on persistent interpersonal difficulties can be a factor in shaping interpersonal patterns. During the Interpersonal Inventory, the therapist notes persistent emotion states and interpersonal behaviors that may signal an interpersonal pattern problem. These include:
Chronic social withdrawal and attachment avoidance
Chronic neediness or reassurance-seeking in close relationships
Persistent interpersonal mistrust
Recurrent, severe interpersonal conflicts (e.g., intimate partner violence)
Repeated and abrupt terminations of close relationships
By combining ‘interpersonal patterns’ with one of the present-focused problem areas (interpersonal conflict, role transition, or grief), therapists maintain a focus on current problems while conveying a developmentally informed view of the pattern of the problem over time. A few examples of interpersonal difficulties that could be treated within a combined problem focus framework are: dissatisfactions and fears about sexual activity; involvements in sexually exploitative, emotionally abusive, or physically battering relationships; and, fears about being able to protect and care for a child. As treatment progresses and the work on the present-focused problem area proceeds, patients almost inevitably experience setbacks when their attempts to make interpersonal changes are unsuccessful. These ‘failure’ experiences can be tremendously discouraging. The Interpersonal Patterns problem area anticipates that such difficulties will arise, and provides the patients with a way of explaining how these setbacks occur that minimizes self-blame.
Ms. C was a 34-year-old African American woman who had three children ages 14, 12 and 7. Ms. C came to treatment in acute distress about her own health concerns and about her 14-year-old son’s recent school suspensions for truancy and physical confrontations with other students.
During the Interpersonal Inventory, the therapist identified a chronic interpersonal pattern. Ms. C had been raised in a harsh family environment where neediness and vulnerability were met with physical abuse and ridicule. Her stepfather used threats of violence to enforce her silence about his sexual abuse. To protect herself, Ms. C learned to ‘hold her tongue’ and keep her feelings hidden. She confided in no one about the situation at home. As she grew older, this pattern continued in Ms. C’s relationships. She described herself as usually unassertive, passive, and placating. On occasion, however, she would aggressively lash out when her anxiety or anger overcame her. [Communication Analysis] At treatment outset, she was neglecting the medical care that she needed for a chronic illness. On occasion, she would become so anxious about her health that she would phone her doctor’s office, demand an immediate appointment and threaten the office staff. When her son was suspended from school, she confronted the principal, threatened physical violence, and had to be escorted from the building.
The therapist framed the Interpersonal Patterns problem focus in this way: “From what you’ve told me, it seems that you want to protect and stand up for yourself and your children. It’s important to you that you not be taken advantage of. Because of what you experienced growing up though—that standing up for yourself would hurt you—you’ve learned to take a lot of hard knocks without complaining. Still, sometimes, it’s just too much. You feel that it’s not fair and you strike out. This pattern of going back and forth between just taking it, on the one hand, and striking out, on the other hand, has caused you some trouble in your life. You think you may have driven some good people away with your anger, and you get lonely at times. In therapy we could talk about how to find a middle ground, a way to really let other people know what you think and want without hitting them over the head with it. Does that way of understanding things make sense to you, and does this sound like an approach that you think could be helpful?”
Ms. C stated that the therapist’s description was a good summary of what she had disclosed about her life. Ms. C then went on to admit, in evident pain, that she was deeply ashamed of the confrontation with the principal, a man whom she respected a great deal. The therapist empathized with her experience, while reinforcing the idea that Ms. C had learned these patterns to protect herself. [Use of Affect] Ms. C and the therapist made a plan to keep the Interpersonal Patterns problem in mind as they focused their work on the Interpersonal Conflicts that she was having with her son, school officials, and health care personnel. As the therapy progressed, Ms. C and the therapist examined incidents, in detail, where Ms. C came into conflict with others as well as other episodes where she suppressed her needs and wishes and then felt disappointed and frustrated. [Interpersonal Incident Analysis] It became increasingly clear to Ms. C that she often felt fear and shame when asking for help or expressing needs because she anticipated rejection. As setbacks occurred and Ms. C despaired of being able to make or maintain interpersonal changes, the therapist used the Interpersonal Patterns problem area to remind Ms. C about the developmental origins of her interpersonal fear and shame, and to bolster Ms. C’s resiliency in standing up for herself and her children.
Summary: The Interpersonal Patterns problem area supplemented the Interpersonal Conflicts problem focus. The treatment was focused on assisting the patient to improve her communications of interpersonal needs and thereby reduce her current interpersonal conflicts. Adding the Interpersonal Patterns considerations helped the therapist and patient to understand the developmental origins of her communication difficulties. With that understanding, the patient was better able to minimize self-blame and to construct a coherent narrative that emphasized her resilience.
For clinicians in community mental health centers, the treatment of depressed women with childhood trauma histories poses a significant set of challenges. Engaging these patients in treatment is hindered by the patients’ inadequate social supports, the stigma that often accompanies mental health and trauma, and socioeconomic adversity that limits access to care. The mood disorders of women with trauma histories can be chronic, complicated, and highly resistant to treatment. Findings from our clinical trials conducted in a CMHC setting with diverse, financially disadvantaged women suggest that depressed women with trauma histories can be successfully engaged and treated by providing an interpersonally-focused treatment for depression (IPT). To maximize the effectiveness of IPT in this population and setting, we have adapted basic IPT techniques to address four specific domains that are highly relevant for this population. IPT-TCS involves: (1) an expansion of the duration of treatment to accommodate more flexible scheduling of appointments, (2) an engagement analysis conducted at the onset of treatment to assess barriers to care, (3) a sociocultural formulation within the Interpersonal Formulation to specify patients’ sociocultural context and backgrounds, and (4) an interpersonal-patterns problem area that reflects the developmental nature of persistent interpersonal patterns in these patients’ lives.
It is important to note that IPT-TCS is not a new treatment. Rather, IPT-TCS is wholly based on the theoretical underpinnings, interpersonal focus, and therapeutic methods of traditional IPT. In making the ‘Trauma in Community Settings’ designation, we do not intend to imply that this is a unique therapy. Our goal is the effective dissemination of IPT to community settings where low-income and minority patients—many with trauma histories—seek care. To assist that process, we have presented four modifications of IPT designed to improve its fit to this patient population’s developmental-interpersonal histories and sociocultural contexts. In our view, these modifications have better suited patients’ needs, helped to alleviate their depressive symptoms, and have allowed the CMHC staff therapists in our studies to readily adopt IPT within their clinical practices.
Future research is needed to examine whether initial improvements in depressive symptoms can be maintained following IPT-TCS treatment among depressed patients with trauma histories. The long-term post-treatment functioning of these patients across multiple domains, including interpersonal, work, and co-morbid physical and mental health, needs to be assessed. Although the primary treatment target of IPT-TCS is major depression, depressed patients with trauma histories are likely to have comorbid disorders, including PTSD and substance use disorders (Molnar et al. 2001b). More research is needed to evaluate IPT’s applicability for these complicated patients, as comorbid disorders represent the rule rather than the exception in community mental health practices. Future research may reveal that a combination of interpersonal and cognitive behavioral methods is better suited to concurrent depression and PTSD, for example, than IPT alone (Robertson, Rushton, Bartrum and Ray 2004). In such a case, a multifaceted treatment may need to be developed. We believe that the best interests of depressed patients with trauma histories will be ensured by the availability of a range of treatment modalities whose effectiveness has been established in community-based clinical trials.