Clinical vignette

Bob is a 52-year-old married man with bipolar disorder who began treatment with IP-SRT because of a 6-month history of depression that was unresponsive to sequential trials of mood stabilizers plus antidepressants. He had been a successful businessman, but several devastating manic episodes had left him bankrupt and estranged from his family. After he completed 3 weeks of SRMs, it became apparent that Bob consistently reversed his days and nights, spent hours on the Internet from midnight to 5 a.m., and slept routinely during the daytime. He was also very isolated, with few social contacts. Bob acknowledged that he felt lonely and disconnected from "the rest of the world". The therapist helped the patient see that his sleep schedule was contributing to his isolation and perhaps his depression. Together, they worked out a plan to shift his bedtime gradually from 6 a.m. to 2 a.m. over a period of several weeks. Bob agreed to participate in some regular activities during daytime hours, such as a daily walk to buy the newspaper at a neighborhood store, and at least one phone call to a friend or relative around the conventional dinner hour. Although progress was slow, the patient noted some improvement in his mood as he began the process of reconnecting with his social network. The social rhythm therapy component of IPSRT helped provide opportunities for social interactions; IPT strategies were then used to help Bob develop new skills to manage these interactions.

INTERPERSONAL PSYCHOTHERAPY (IPT)

IPT is thoroughly described elsewhere in this text (Chapter 9) and will be described very briefly in this chapter. The initial phase of IPT begins with an in-depth psychiatric evaluation. The therapist conceptualizes the patient's "problem" as a medical illness characterized by specific symptoms linked to biological processes, equating bipolar disorder with medical illnesses such as diabetes or heart disease. The therapist educates the patient, making direct statements about diagnosis, the heritability of the disorder, and treatment options. This approach, in addition to ensuring an accurate diagnosis, relieves the patient of the guilt associated with this syndrome. During the initial phase of treatment, the therapist also gives patients the sick role (Parsons, 1951), a role that encourages patients to participate actively in treatment, helps them accept that symptoms are manifestations of a medical condition, and relieves them of unmanageable social obligations. The therapist conceptualizes the sick role as a temporary status for the patient, who is expected to work in treatment toward resuming the healthy role.

During the initial phase, the therapist conducts the interpersonal inventory, a systematic exploration of the important individuals in the patient's past and present life. When inquiring about these significant relationships, the therapist explores the quality of the relationships including the fulfilling and unsatisfying aspects of the relationships. In addition, the therapist investigates seemingly important relationships the patient does not mention. A good understanding of the patient's interpersonal difficulties will then allow the therapist to see connections between interpersonal events and symptom exacerbation.

The centerpiece of IPT is the interpersonal case formulation (Markowitz & Swartz, 1997), a summary statement that reiterates the patient's diagnosis and links it to one (or at most two) interpersonal problem areas. In the formulation, the therapist explicitly links the onset and maintenance of the mood episode to a specific interpersonal problem area. A salient problem area is chosen, based on information collected during the psychiatric interview and interpersonal inventory. In IPT, there are four possible interpersonal problem areas: grief, role transition, interpersonal role dispute, and interpersonal deficits. These four problem areas are discussed below, with a specific focus on their relevance in the treatment of bipolar disorder.

Grief

The patient and therapist will choose grief or complicated bereavement as the focal problem area when the current affective episode is linked to the death of an important person in the patient's life. Treatment focuses on facilitation of the mourning process. The therapist reviews in detail the relationship with the deceased person, encourages the expression of previously suppressed affect in order to facilitate catharsis, and helps the patient recognize distorted (either overly positive or overly negative) memories of the relationship with the deceased. In standard IPT, the problem area of grief is selected only when an important person in the patient's life has died. Individuals with bipolar disorder, however, often experience the symbolic loss of the person they would have become were they not afflicted with bipolar disorder. In IPSRT, this is referred to as grieving for the lost healthy self. Subsumed under the broader category of grief, grieving for the lost healthy self involves encouraging patients to talk about the limits placed on their life by the illness, lost hopes, and missed opportunities. After mourning these losses, the patient is helped to recognize his or her strengths (rather than focusing on the losses), and gently encouraged to set new, realistic goals.

Role transition

A role transition is defined as a major life change. Examples of a role change include moving to a new city, starting a new job, becoming a parent, graduating from college, etc. Although role transitions are a normal part of the human experience, for individuals who are vulnerable to mood disorders, these changes may provoke an episode. Patients with bipolar disorder are especially vulnerable to change, even of the face of relatively minor perturbations of their environment (Frank et al., 1999). IPT strategies for addressing a role transition include helping the patient develop more realistic views of both the old and new roles (patients tend to idealize the old role and devalue the new one) and acquiring new interpersonal skills to master the new role.

It is important to keep in mind that bipolar illness itself may bring about role transitions. For instance, mania-driven, inappropriate behavior may lead to job loss; depression-associated social isolation may lead to failed relationships. Paradoxically, the process of achieving mood stability may represent a role transition for many patients. In particular, many patients miss the pleasurable hypomanic episodes associated with more variable mood states. It is important that the therapist help the patient mourn the loss of these episodes, identify their negative consequences, and help the patient find pleasures associated with new-found mood stability.

Interpersonal role dispute

An interpersonal role dispute occurs when nonreciprocal expectations are present in intimate relationships. The goals of treatment include identification of the dispute, alteration of role expectations and communication patterns, and development of a change plan. Therapeutic strategies include role-play, investigation of realistic options, and communication analysis. Role disputes are common sequelae of bipolar disorder. Irritability associated with both depression and mania can contribute to the erosion of close interpersonal relationships. Similarly, protracted social withdrawal associated with bipolar depression can destroy close relationships. Friends and family members may be perplexed and ultimately vexed by the patient's wild swings in mood and energy states, leading to misunderstandings and ultimately entrenched role disputes.

Interpersonal deficits

Patients with interpersonal deficits have long histories of unsuccessful relationships. Typically, the therapist is not able to identify a clear interpersonal event associated with episode onset. Thus, this problem area is used as a "default" category, applied only when the three other categories do not capture the patient's circumstances. Patients with long-standing bipolar disorder who have destroyed virtually all close relationships may be best characterized as experiencing interpersonal deficits. This problem area is the least well conceptualized of the four and is associated with poorer outcomes (Weissman et al., 2000).

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