Clinical vignette

Clara is a 27-year-old single white woman, a physician who graduated from medical school but experienced psychotic mania during her first year of surgical training. After recovering from the manic episode, she transferred to a less stressful residency in pathology. She was able to complete her pathology residency but became severely depressed as she attempted to find a job afterwards. In therapy, Clara focused initially on the IPSRT-specific strategy of mourning for the lost healthy self. She discussed her early career aspirations, including plans to become a trauma surgeon. She felt defeated by her illness, choosing pathology because "I had no other options". Clara and the therapist also explored the toll that the illness had taken on relationships, leaving Clara feeling incapable of sustaining a relationship or confiding in others about her illness. Through the mourning process, Clara came to accept the limitations of her illness, while recognizing that there were still many options open to her. The next part of treatment helped Clara make the transition from pathology resident to working physician. The therapist helped Clara explore the importance of finding a career that was intellectually challenging but not too pressured. They also discussed the importance of selecting a job that enabled her to maintain a regular schedule. After exploring several options, Clara decided that she did not wish to pursue an academic career in pathology, but should consider a less time-intensive job in the pharmaceutical industry. Clara's mood improved as she began to pursue new career options that were compatible with both her illness and her modified career aspirations.

Although built on the principles of IPT, IPSRT differs from IPT in several respects (Swartz et al., 2002). Firstly, IPT focuses on the links between life events and mood. In IPSRT, life events are viewed not only as sources of mood dysregulation but also as potential triggers of rhythm disruption. Thus, IPSRT addresses interpersonal problems using both IPT strategies and behavioral strategies designed to regulate the social rhythm disruptions associated with the interpersonal problem. In addition, IPT for unipolar depression is a therapy of interpersonal change. The therapist actively encourages depressed patients to take interpersonal risks and make relatively large changes in their interpersonal circumstances in a brief period of time. By contrast, patients who suffer from bipolar disorder may destabilize in the face of relatively minor change (Frank et al., 1999), and are likely to deteriorate in the setting of very stimulating shifts in their interpersonal lives. Therefore, in IPSRT, the therapist helps the patient adapt to change and find a healthy balance between spontaneity and stability. Changes are made gradually, and both therapist and patient remain alert to signs of clinical deterioration in the face of change.

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