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Interpersonal Therapy (IPT) Gets Traction: Dynamic Therapy “Lite”?

Review of: The Guide to Interpersonal Psychotherapy: Updated and Expanded Edition (2007/2018), Myrna M. Weissman, John C. Markowitz, Gerald L. Klerman; Oxford, UK: Oxford University Press, 283 pp. ($34.10 (US$)).

Interpersonal therapy (IPT) is a promising, evidence-based, talk therapy. IPT is the innovative brainchild of Gerald L. Klerman, Myrna M. Weissman, John C. Markowitz, and a team of dedicated professionals. IPT has received expanding CoverArtGuideToInterpersonalPsychotherapyattention since the mid- and late 2000s.

This book is an IPT manual and it emphasizes:  It is important to keep IPT grounded in affect. Therapy feels meaningful to the patient when it comes alive with emotions related to important issues in the patient’s life. The IPT sessions focus each meeting on a recent, affectively charged event in the patient’s life. In short, the therapist encourages the patient to talk about what happened in their life during the past week. Sounds familiar?

The novice practitioner – perhaps a resident in psychiatry who has been concentrating on psychopharmacology, because that is the prevailing paradigm – is given helpful scripts (what to say to the patient):  “In interpersonal psychotherapy, we work on the connection between your feelings and your life situation. In the next X weeks, we will work on unfulfilled wishes and problematic relationships that are contributing to your depression. You should begin to become more comfortable with your feelings in problematic close relationships and decide how to use them to change the relationship/situation you’re in”  (p. 106).

Originally developed as an intervention for depression, IPT has been progressively extended to other disorders including anxiety, trauma, and personality disorders including borderline personality disorder. Also of note, IPT demonstrably does not work for substance abuse, including alcohol.

IPT draws on the insight of dynamic psychotherapy that events in the patient’s life evoke strong feelings (or not) and that the processing of those feelings (or not) contributes to the patient’s behavior in the community. The “deep history” of the work invokes the tradition of Harry Stack Sullivan (1842 – 1949) and the William Alanson White Institute, acknowledging the interaction of the cultural dynamics between the self and the community.

IPT acknowledges that sadness and depressed mood are part of the human condition. Low mood is a nearly universal response to disruption of close interpersonal relations. John Bowlby argued that attachment bonds [key term: attachment] are necessary to survival: the attachment of the helpless infant to the mother helps to preserve the infant’s life and well-being (p. 10).

However, the resemblance between IPT and the anti-psychiatry sometimes characteristic of the Neo-Freudians such as Sullivan or Bowlby is soon dispelled. IPT embraces the medical model, asserting that (e.g.) depression is an illness such as the flu or even an appendicitis. IPT proudly embraces the common factor – something shared by all [or most] forms of psychotherapy – that the role of doctor and patient are essential to the process.

 The IPT doctor is active in educating the patient about what to expect and what to do, along with more subtle forms of inspirational guidance and suggestion. While the patient may usefully learn directly from experience as redescribed in the process of therapy, he or she had better do so promptly – as the process is time-limited to some sixteen sessions.

The time-limit is an essential part of IPT, acting as a “forcing function” to cause both patient and doctor – but mostly the patient – to “cut to the chase,” say what is bothering her, and take action to do something about it. Hence, IPT’s strengths – the cost is relatively predictable and insurance payers love that – it is relatively easy to define a comparative process test (say, against CBT or psychopharm) – and grant writers and approvers like that – and its weaknesses – it is time-limited.

One clarification upfront. When the trainers of interpersonal therapy say that it is “interpersonal,” they do not mean that the therapy targets the relationship between the patient and the therapist. “Interpersonal” means that it is about the interpersonal relationships in the patient’s life.

The powerful insight of IPT is that the way the person feels about what is going on in her or his life results in behavior, including symptomatic behavior such as depression and anxiety, that remits if one connects the dots between the two, i.e., between the feelings as called forth in the therapy and the dysfunctional symptoms.  IPT is unconcerned about transference or the deep past of childhood and it tries to identify the focal interpersonal problem area in the patient’s current life. “IPT does not interpret the transference, but rather helps the patient to relate emotions to interpersonal interactions in the here and now” (p. 74) – otherwise known as interpreting the transference.

Basically, with some conditions and qualifications, the patient is allowed one problem area, though each of the area is potentially vast and overlapping: grief (e.g., death, loss), role disputes (interpersonal conflict), role transitions (e.g., divorce), and interpersonal deficits of attachment (aloneness, isolation) (p. 11). 

According to Weissman and Markowitz, more than 100 clinical trials of IPT (Barth et al., 2013; Cuijpers et al., 2008, 2011, 2016) are available (p. 12). That is what makes IPT so attractive as “dynamic therapy lite”, especially to psychiatrics who find prescribing insufficient to produce wellbeing in their patients.

The meta analysis by Cuijpers et al. (2016 / see the excellent and extensive bibliography in the book), based on eight randomized trials, suggests efficacy for anxiety disorders: “In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT.” No less effective, but perhaps also no more. [P. 187] However, for those entry level therapists who are not comfortable with the over-intellectualizations of CPT, IPT can have an advantage of validating an approach that empathically gets one in touch with emotions and feelings.

A recurring theme in this approach is that IPT talks to patients about how they feel about what is happening or has happened in their lives and invites patients to make the crucial recognition that their interpersonal encounters evoke strong feelings. Then the IPT mantra (at least in this text):  that, rather than being “bad” or “dangerous,” feelings provide interpersonal information (e.g., anger means someone is bothering you) they can reflect upon and use to handle their environment.

The instructions to the IPT psychiatrist in training? “Your aim will be to link the patient’s interpersonal situation (a spouse’s affair, a mother’s death, a move to a different city) to the onset of symptoms in a brief contextualizing narrative that makes sense to both the patient and you. [….] Use the initial sessions to ensure that you have focused on a pivotal, emotionally meaningful area for the patient and that you have ruled out surprises that might otherwise arise later in treatment” (p. 36).

So, for example, IPT points out that patients with panic disorder experience their paralyzing physical attacks as coming “out of the blue,” yet most talk therapies, including IPT, suggest that panic is a response to interpersonal events: one study found that three-quarters of panic patients had had an interpersonal loss within six weeks of panic onset (p. 191).

 So what happens when, for example, a woman who presents saying, “My children are my big problem” later, as she gets to know you, calls out the more pressing area of distress: her spouse’s extramarital affair? Given the time-limited name of the treatment, what to say? Well, IPT tries to address this typical situation, allowing for “maintenance,” typically once a month extensions. Twice a month? However, somehow extended the duration of the sessions by means of maintenance seems not  to be the right answer. A new contract and a new engagement is needed.

IPT is quite explicit about giving patients the Sick Role. This does indeed relieve patients of blame. It is not your fault – you are sick. “The sick role excuses patients from what their illness precludes them from doing, but it carries the responsibility to work as a patient to get better” (p. 115). Definitely. A sensible trade-off.

However, the therapist is then left with the difficulty that the illness in question – depression, anxiety, trauma, personality disorder, and so on – is significantly unlike most other diseases in the world of medicine. Yes, there is an underlying molecular process; but it is just that, in most cases, science has not identified the biomarkers.

The IPT role-playing script (p. 39) suggests telling the patient that depression is no different the appendicitis or the flu. Wow. Don’t call Carl Rogers – page the surgeon! We can cure an appendicitis even if the patient is unconscious. Indeed at a certain point in the treatment it is required. However, that is not the case with a significant mental disorder. You cannot cure an unconscious psychiatric patient. More to the point, today the patient’s intentional participation in the process is required.

I can’t resist. The history of the heroic age of psychiatry does present “the sleep cure.” Stay in bed for about three months, highly sedated, with the doctor on call fulltime, waking the person once every twenty four hours for nourishment and bowel movement, and at the end of three months – voila! – something significant has shifted – the individual no longer feels depressed. This is the reduction to absurdity of the medical model – yet, in its day, it worked!

For example, in the case of complicated grief, treatment is not a sign of disrespect for the deceased – but that respect is the way treatment shows up – LIVES– for the patient. Complicated grief is a form of depression (p. 45). The doctor must truly have a magisterial authority in order to overcome the patient’s commitment to her or his suffering. You see the problem? It says right there in the manual: your grief is really depression. But the patient’s experience is that they cannot live without the other person. Yes, it violates the IPT contract that the person seems unwilling or unable to try. That is the therapy – you are in violation of your therapeutic contract?

Whereas in CBT, a therapist might ask a patient to look at the evidence about an anxious thought, an IPT therapist lets the patient sit with the feelings, pointing out at an opportune moment that guilt is a actually a symptom of the depression. What is the evidence that when your friend does not answer your text message, it is because she or he is cheating on you? Are there any facts here? In IPT rather, let’s talk about your feelings about the relationship: have you ever had any feelings of temptation towards cheating? In short, in IPT the therapy is to talk about the temptation (loss, fear, anger, and so on) and bring forth a catharsis – yes, it says it right there in the manual – catharsis makes you better.

IPT acknowledges the need to manage magical thinking, but IPT does not call it that]: The bereaved person fears that if they recover from the grief (i.e., the depressive episode), it means they did not love the deceased as much as they had believed. To their way of thinking, if they really loved the person, the loss would be so great that they could never recover. The treatment? Acknowledge, validate, and work through the loss by talking about it. In that sense, IPT is a talking cure.

The guidance for those practicing IPT (p. 57)?  Ask for the details of the interaction. Often, the patient will come in with in interpretation: “He is a jerk.” Okay, got it; but what did he actually say? : “What did you say? What did he say? How did you feel then? Then what did you say?” and so on. Get in touch with facts and feelings. The reconstruction of interpersonal encounters provides a sense of how the patient functions interpersonally, what may be going wrong in the relationship, and where the patient ignores or suppresses emotional responses to the other party

It is a strong point of IPT’s approach to treatment – get the facts. Freud pointed out long ago – the patient comes in and cannot give a coherent account of his or her life. Freud noted the gaps – repression – but equally important are the distorted communications, interpretations, and positions. “The boss is a jerk.” “Okay – I got that – what did he actually say?”

For those curious as to what is a “role transition”:  Moving one’s household, taking a new career or job, leaving home after school or divorce, being diagnosed with a serious medical condition, taking on new responsibilities due to the illness of a family member, or a change (decline) in economic status, are other examples of life role transitions. Refugee status has become a transition problems for significant populations in many countries.

Unlike many descriptions of cognitive behavioral therapy (CBT), IPT focuses on discussing feelings, normalizing them as responses to interpersonal interactions and as useful interpersonal information, and using them to take action to change the patient’s interactions in order to resolve the identified problem area (p. 88). That a person feels angry about a perceived or actual interaction contains valuable information for the person, which is usually overlooked due to over-intellectualization or being overwhelmed by emotions (under-intellectualization).

IPT emphasizes, “depression is a medical vulnerability, sort of like having an ulcer. If you should get depressed in the future, the important thing to remember is that it’s a treatable illness, it’s not your fault, and you just need to return for treatment, the way you would for any other medical problem” (p. 113).

IPT is a sensible, practical approach. The take away is that whatever the intervention one should actively try to solve the problem – working on solving the problem = x drives the therapy. The hidden / confounding variable is that the problem seems to be = x but is actually = y or = (x & y). In that case, the openness of psychodynamic therapy will surface an issue of which IPT remains unaware. Of course, the process will require more time.

There are many applications of IPT – to postpartum depression, depression in adolescents, depression in children of tender age (recommendation: treat the parent(s), depression in senior citizen, – here we go into the weed, there are many studies, and the results are generally favorable – the guidance? If one tries, one gets better.

Since this is not a softball review, the most critical thing I can think to say is that it is not really treating what the DSM describes as depression – it is treating stress – and there is nothing wrong with that – the cytokine theory of depression makes the case that “depression” is “sickness behavior” – this aligns well with the repetition (nearly ad nauseam) to the patient that “depression” is a sickness like the flu or [incredibly] enough an appendicitis. Okay, let’s take this seriously. This is supposed to be a common factor – but you would not hear Carl Rogers say it. You would not hear CBT practitioners say it – rather they would say, “you have a skills deficit – and while that is not your fault, no one ever taught you the skill, we are not “blaming” biology, we are blaming the parent or the early environment

At times and at risk of over-simplification, CBT is committed to how thinking causes, brings forth, determines one’s feelings. IPT emphasizes how one’s emotional experiences cause, bring forth, and determine one’s thinking. “Therapists work hard with […] patients to identify emotions— and particularly negative affect and feelings of competitiveness, anger, and sadness— that arise in everyday situations. The therapist and patient discuss whether such feelings are understandable and warranted. The idea of a transgression— that there are some behaviors that break expected social conduct, warrant anger, and deserve at the least an apology— may be helpful in normalizing such feelings for patients” (see p. 164).

I call out some statements that, strictly speaking, make no sense: “Klerman advocated for research standards in psychotherapy that were comparable to those in pharmacotherapy research” (p. 12). Okay, but: The authors cannot be referring to double blind testing where neither the patient nor the doctor knows what treatment he is delivering. I am giving you CBT versus IPT versus psychopharm, but neither of us knows what it is. Notwithstanding the many useful results provided by IPT practitioners, this points to a significant blind spot.

A silly statement by the authors, in which the authors get carried away with their own greatness: “No other psychotherapies explicitly focus on the IPT problem areas” (p. 106). Really? Counter-examples? Freud’s “Mourning and melancholia”? Life transitions in DBT? Lack of skills in CBT? Role disputes and discrepancies (all of the above)?

Another thing that seems just plain crazy to this author is the approach to trauma, though, once again, trauma survivors have benefited from IPT in evidence-based studies. IPT acknowledges accurately: The trauma explains why the patient is struggling interpersonally, but receives no further direct discussion (p. 195). However, a time occurs in most conversations with trauma survivors (with or without a bit of nudging) when the trauma seems to erupt – spontaneously comes up – and IPT ties the therapist’s hands because she or he cannot engage with it. Why not? It is not part of the definition of IPT? The researchers are doing an evidence-based study and to do so would “confuse” the modality with exposure focused treatments? So much the worse for the evidence ( am inclined to say). If the patient brings up the trauma and is willing – indeed wants and give every evidence of wanting to talk about it – then it would be unethical not to do so. Did anyone think of that?

The ultimate true but trivial statement, apparently now required to be fully buzzword compliant: “Neuroimaging studies have shown that psychotherapy changes your brain chemistry [Brody et al., 2001; Martin et al., 2001 9see the excellent bibliography in the book itself for details)]: it’s a biological treatment” (p. 110). Hey, studying French will change your brain and brain chemistry. Studying French is now a biological treatment?

Time-limits are essential to IPT and are a kind of “good news,” “bad news” sort of practice. Freud himself made use of setting a time limit in the case of Sergei Pankejeff (“the Wolf Man”) when Freud felt, after months and months of work, the treatment was stalled, the patient was living in genteel poverty, burring through his modest fortune, couldn’t pay, and it was time to fish or cut bait (my expression, not Freud’s). It seemed to have worked, or at least worked well enough, as a “forcing function.” However, this parameter on Freud’s part was used on an exception basis. IPT takes the “forcing function” and makes it the rule. In fact, traditional Freudians may see IPT as a case collection of parameters (exceptional practices that are employed in the face of contingencies in treatment) that try to add up to “psychoanalysis lite.”

The risk is that while a medical molecular process may not aware of the clock, the blind spots, self-deceptions, and self-serving behaviors by which people afflict themselves unwittingly are acutely aware of the passage time. Therefore, the “disorder” goes under ground until the time is up. In a telling analogy, the process is like announcing to the local armed insurgency, freedom fighters, or your opponent of choice that the UN expeditionary force is going to pull out in sixteen weeks. The opponent’s strategy strategy going forward is clear. Lay low until the powers-that-be pull out. Then it is back to business as usual.

Meanwhile, once feelings are identified and normalized, role playing is needed to help patients become comfortable with self-assertion or confrontation. “They may never have expressed a wish and almost never have said “no” to anyone. Yet if a patient has a successful experience in one of these situations (e.g., asking for and receiving a raise, confronting a spouse), the patient will have learned a new skill, discover some sense of control over the local environment, and likely feel better” (p. 164).

The IPT text and training repeatedly emphasize that “feelings are powerful, but not dangerous—and in fact, you need them [feelings] to decide whom you can trust. Expressing your feelings to another person may seem risky, but it provides a test of whether the other person is trustworthy or not. If you feel angry and voice it to another person, the other person has the chance either to apologize and change behavior, or to confirm that he or she is uncaring or untrustworthy” (pp. 194 – 195).

Agree – but there is a big “but.” The thing is that for some people feelings ARE dangerous if the feelings threaten to fragment the coherence and integrity of the sense of self. This is especially the case with survivors of trauma. There is it not just an over-feeling, but a feeling “I am gonna die!” One can dismiss this as a “personality disorder,” but I do not believe such dismissal would be fair or accurate. If subjected to strong enough feelings, just about anyone is capable of being shaken to their core. Therefore, methods are for strengthening the person’s self’s sense of stability and equilibrium in the face of strong feelings. Expanded distress tolerance? Expanded emotional regulation? Self-soothing? Working through? Exposure? Transmuting internalization? Suggestion? Encouragement? All of the above?

Having gotten in touch with emotions, patients can proceed to more usual IPT maneuvers, such as solving a role transition. As patients gain comfort with their feelings, they engage interpersonal situations with expanded competence, life feels safer, and they begin spontaneously—without IPT therapist encouragement—to face the situations and traumatic reminders they have been avoiding. In the vast majority of instances, the authors assume the patient is out of touch with his or her feelings. The therapy consists in invoking the feeling so that the patient can get in touch with it. But what about being over-whelmed by one’s feelings? Yes, one can also lose touch with one’s feelings if one is overwhelmed, but it is significantly different mode of losing touch. What about that?

We end on a positive note. IPT is demonstrably effective with borderline personality disorder, though the time-limited aspect is “finessed” by [apparently] doubling the number of sessions to distinguish between establishing trust with the therapist and actually doing the work.

We give the last word to the authors of this engaging, practical text: “The therapist presents BPD to the patient as a poorly named syndrome that has a significant depressive component. A major difference between MDD [major depressive disorder] and BPD [borderline personality disorder] is that while depressed patients often have difficulty expressing any anger, patients with BPD often do the same much of the time but then periodically explode with excessive anger, which reinforces their tendency to avoid expressing anger whenever possible. The goals of treatment are, as is usually the case in IPT, to link mood (including anger) to interpersonal situations, to find better ways of handling such situations, and to build better social supports and skills.” (p. 201).  

(c) Lou Agosta, PhD and the Chicago Empathy Project



Real Hallucinations by Matthew Ratcliffe [book review] – Okay, so what would FAKE hallucinations be?

“Reality testing” is a distinction that is in the background of Matthew Ratcliffe’s penetrating and incisive book Real Hallucinations: Psychiatric Illness,

Cover art: Real Hallucinations by Matthew Ratcliffe - so what are fake hallucinations?

Cover art: Real Hallucinations by Matthew Ratcliffe – so what are fake hallucinations? Find out here

Intentionality, and the Interpersonal World(Cambridge, MA: MIT Press, 2017, 290 pp.). Disturbances of the sense of reality are among the key phenomena that cause people who suffer from hallucinations or delusions to be referred to psychiatrist professionals.

 Ratcliffe takes pains to work through the various senses of reality that confront one as soon as one wishes to assert that something = x is not real. For example: “Illness or jet lag can involve an all-enveloping and lingering sense of one’s perceptual experience as somehow lack, not quite right” (p. 44). But that is just the beginning.

 The memoires of psychiatric patients, who have survived psychosis – as well as thought experiments invented by philosophers and Ratcliffe’s own survey research – are full of examples where the distinctions between perceiving, imagining, remembering, anticipating, and experiencing, begin to break down and actually do break down. All these are engaged in the narratives of those who have survived psychosis such as Elyn Saks, M. Sechehaye, or reports from a survey collected by Ratcliffe.

 Ratcliffe collects extensive evidence of the intermittent flexibility of the boundary between imagining that something happened and remembering that something happened; between intending to fill up the gas tank of the car and remembering that I did so (but did not); between perceiving the bear at the window of the cabin and imagining the bear at the window, and so on. I look into the mirror and see a face that does not look anything like my own (my example, not Ratcliffe’s). The face is so different that I realize I must be dreaming, and wake up. If I do not wake up, and the face still looks frighteningly different, then modes perception and imagination have gotten mixed up, I am having a psychotic breakdown and need help.

 These considerations result in Ratcliffe’s innovative account of hallucinations and delusions. Ratcliffe’s nuances, conditions, and qualifications are many, but they boil down to: in hallucinating, content is framed using an intentional mode at variance with what it might be anticipated to be. Thus, a voice that is remembered or imagined is misconstrued as being actually perceived in the here and now; in delusions such as thought insertion, a thought that is imaginary or remembered or otherwise fictional is misframed as an occurring belief. The misframing, slippage, or “going off the rails,” occurs because of an anxious anticipation of something = x, including the possibility that what the individual is fearing is fear itself.

 This account finds strong support in the works of R. Bentall, L. Sass, and the reports of survivors of psychosis, distinguishing between hallucinations as having an experience versus having a sense of an experience. (The reader may usefully consult the book itself for the excellent bibliography.) In hallucinating, one is having a “sense of an experience.” And, notwithstanding the insistence of the psychotically disturbed that they are really experiencing what they are experiencing – which is what makes it so frightening – a moment often comes in which the [psychotic] individual acknowledges he or she can distinguish the voices or anomalous beliefs from everyday, standard situations, places, and practices.

 This leads to what is sometimes described as “double bookkeeping” – the psychotic person seems to inhabit two worlds – the standard, shared world and his own special, different one. Or the psychotic person may feel that the standard world has been completely annihilated and he is the only survivor or feel that he is already dead. In either case, the individuals looks carefully both ways before crossing the street. Curious. Yet this is the disorder itself.

 Ratcliffe also finds support in the work of Marius Romme and Sandra Escher, who are credited with giving rise to the Hearing Voices Movement (p. 30 – 33). This is not just a theory or collection of data, but a normative position about how those who have anomalous experiences such as hearing voices should engage with their voices and engage with the medical community. In so far as I understand it, Ratcliffe is a fellow traveler with the view that voices with distressing content are socially embedded and events such as trauma, neglect, abuse, adult social isolation, and so on, are important determinants of the anomalous experience.

Often the disordered individual’s sense of reality is demonstrably in breakdown, but differences and variations in the degree of disorder are of the essence in description, diagnosis, and treatment.

 You and I – as average ordinary everyday citizens – have trouble communicating with psychotic individuals because we no longer share the same methods or procedures for reality testing. The psychotic’s reality testing is producing a different result than yours and mine. The result may be so vastly different that we say the psychotic has no sense of reality at all. None. The individual is banging his head against the wall. However, fortunately, that is rarely the case. Most often a form of “double bookkeeping” is occurring, and sense can be made out of the seemingly senseless.

 This is where Ratcliffe’s powerful contribution comes into its own and makes a difference. Inquiring minds want to know: what the heck is going on with hallucinations and delusions such as thought insertion?

 Ratcliffe’s contribution is an important, even outstanding one; but this reviewer is at pains to create a context for a review that will connect with the prospective readers.

Yet another digression must be bracketed before one can engage the book in context and on its own merits.

 To be sure, the biological explanation of hallucinations and delusions looms large. But Ratcliffe does not go there, and the reader will find none in this text, though their appropriate applicability is acknowledged. The conventional wisdom is: dopamine up, hallucinations up. Take a bunch of cocaine. Do this enough (or sometimes only once) and the brain is flooded with dopamine (and related, activating neurotransmitters). The person is hearing and seeing all sorts of stuff that is not really there. We call this stuff = x “hallucinations and delusions.”

 This neurotransmitter imbalance explanation is evidence-based and pharmacological interventions that reduce the ratio of available dopamine to dopamine-receptors really do seem to restore equilibrium to the brain.

 However, something seems to be missing from the neurological discussion – an account that puts the suffering, struggling human being in a personal world that is able to support and sustain his recovery and return to humanity. Hence the need for Ratcliffe’s contribution, which lays the foundations for such a conversation (without, however, actually completing the journey).

 Ratcliffe’s account begins by taking issue, cautiously, with Dan Zahavi’s (and other’s) approach to the minimal self. Key term: minimal self. At the risk of oversimplification, psychosis is then hypothesized to be a disorder of the integrating and synthesizing capabilities of the minimal self. Ratcliffe generally endorses what Zahavi has to say but is at pains to include the requirement that the minimal self emerges out of a social matrix: “Our most basic sense of self is developmentally dependent on interactions with other people” (p. 16). Thus, when the social milieu is disrupted – through trauma, adverse childhood experiences, metabolic disorders, or addiction – the minimal self and its meaning making and integration capabilities also break down. Viola! Psychosis.

 How minimal is the minimal self, asks Ratcliffe? He answers that it includes the sense that the individual is having a pre-reflective sense of “mineness” in perceiving, imagining, engaging in inner speech, moving around in the space, and remembering.

These immediate prereflexive, unproblematic acts of seeing, imagining, verbal thinking, moving, and remembering are called “modalities of intentionality” in the phenomenology of Edmund Husserl. These acts of intentionality have a temporal form. Anticipation is one of the fundamental forms of intentionality along with retention (recollection) and being present. (Note this material is technical and not for the faint of heart, but will be of interest to many readers.)

 This analysis of intentionality opens up deep philosophical issues at this point, and Ratcliffe engages with them. The bottom line for Ratcliffe is that an intentional analysis of consciousness is on the critical path to providing an account of hallucinations and delusions. 

For example, is the intentional act of seeing distinct from the content of consciousness? Can an individual disentangle the sense of seeing a tree from the shape, color, location in space, and so on, of the experience, leaving us with access to an act of perceiving in itself? Is the form separable from the content? It seems that it is, though their togetherness is such that one can only get access to the form through and by means of the content.

 Since this is not a softball review, one may ask: So what? Hard working, dedicated, committed psychiatrists are taking arms against a seeming epidemic of psychotic disorders using the tools with which they have been trained – second generation anti-psychotic drugs. If a person comes in claiming to hear things that are not there and the person does not have a metabolic disorder, then the doctor is probably going to err on the side of caution and start him on a low does of one of those anti-psychotic medications. So why do we need a phenomenological analysis of real hallucinations – and “real hallucinations” as opposed to what? Fake hallucinations? 

It turns out that, for the most part (and absent a study such as Ratcliffe’s and a few others like it), we do NOT know what hallucinations are. Even more problematically, we think we know, but we do not. We may usefully take a step back here to put the matter in context. 

 The average person, for example, thinks of hallucinations the way they occur in the Hollywood movie A Beautiful Mind (my example, not Ratcliffe’s). In the movie, the Nobel Prize winning mathematician and economist John Nash is having a conversation with his roommate. The audience sees the roommate, hears him and Nash talking together, and the scene is portrayed as if Nash sees and relates to the roommate the way we, the audience, see and relate to him.

Ratcliffe does not mention the Nash movie, and I bring it up to relate Ratcliffe’s contribution to the average, everyday misunderstanding of hallucinations. This academy award-winning movie about Nash contains many compelling performances, much engaging narrative, a good example of an elaborate, delusional system, but what it does NOT contain is an example of a real hallucination. (By the way as regards Hollywood fictions, The Black Swan (2010) with Natalie Portman does a much better job of capturing what psychotic hallucination are like as the lace of a ballet costume seems to grow like a malevolent fungus.)

Nash’s roommate does not exist – the audience eventually learns (to their astonishment) that the roommate is a hallucination. The roommate is part of Nash’s elaborate delusional network, resulting in Nash’s being given a diagnosis of paranoid schizophrenia – along with electroshock therapy and first generation antipsychotics (but that is another story). Meanwhile, if one gets inside the experience of the person who is having conversation with someone who is not really there, the experience is nothing like an ordinary experience. Okay, so what is it like? Hollywood gives us examples of fake hallucinations. Hence, the need for Ratcliffe’s Real Hallucinations.

(c) Lou Agosta, PhD and the Chicago Empathy Project

Radical Empathy Disrupts Depression: Review of Ratcliffe’s Experiences of Depression

Over the summer I have been catching up on my reading. Matthew Ratcliffe’s Experiences of Depression: A Study in Phenomenology (Oxford University

Cover art: Matthew Ratcliffe: Experiences of Depression: A Study in Phenomenology

Cover art: Matthew Ratcliffe: Experiences of Depression: A Study in Phenomenology

Press, 2015, 318 pp, (44.09 $US)) is an important and eye-opening book for anyone who engages with depression or who wants a deep dive into phenomenological method.

The strength of this book is that Ratcliffe begins by listening to what the first person accounts have to say. Though Ratcliffe does not even use the word “empathy” until late in the work, and then in a debate that leaves much to be clarified, Ratcliffe’s method is a highly empathic one. What does he get out of listening to what the diversity of first person accounts have to say?

What is going on when the depressed person complains that getting out of bed requires enormous effort, and brushing one’s teeth seem impossible because the tooth brush seems to weigh twenty pounds? What is possible for the ordinary person is not possible for the depressed person.

This is a simple-minded, though accurate, example. Now extend it to loss of energy (lethargy) for daily and professional projects, the breakdowns in relations to other people and to oneself, including rampant self-reproaches, physical symptoms such as disturbances of appetite, sleep, consciousness (inability to concentrate). What goes missing from the experience of the depressed person?

Where you and I see possibility – tomorrow is another (and better!) day – the depressed person does not see possibility. The depressed person’s tomorrow is going to be the same miserable day as today. This is not just a belief (though it may be that too); this is the depressed person’s way of being – his experience of the world. This is not just the loss of one possible project or even a series of projects. This is the loss of possibility itself. This is Ratcliffe’s fundamental idea: depression is the loss of the very possibility of possibility.

This idea – the loss of the possibility of possibility – open up the flood gates for the description and appropriation of the diversity (“heterogeneity”) of depressive symptoms. The depressed person does not experience the possible – does not experience the possible as possible. That is the disorder itself.

The disorder is that it is not possible to conceive that things will get better. One is left without hope. Hope is itself openness to a possible future that is better. One is left demoralized. One is left without a future. Guilt is the impossibility of undoing faults or mistakes in the past. One’s crime is irrevocable, impossible to fix or make reparations (or reinterpret). No possibility of forgiveness.

Meanwhile, the depressed person often gets influenza like symptoms – no energy, inability to concentrate, headaches, stomach distress – one takes to one’s bed. However, unlike the case of the flu, in which one feels miserable but knows if one just hangs in there one will get better in a few days, the depressed person cannot imagine things being otherwise. No possibility period.

The phenomenology? Backing up for a high level view based on the phenomenological methods of Husserl and Heidegger, the world is not a thing in the world. The world is the context for things in the world. The world is the space of possibilities. The world of the depressed person is different than the world of the ordinary person. The los of possibility has a domino effect, “taking down” practical significance, hope, and interpersonal connection. Nothing matters anymore. Lethargy, detachment, self-reproach, and flu like symptoms are pervasive.

Given that the audiences for this book, including psychiatrists and many analytic philosophers, have not read Husserl and Heidegger, Ratcliffe devotes significant time and effort providing background, marshaling evidence, and arguing “depression is the loss of possibility – not just one or a series of possibilities – the very possibility of possibility – the depress person cannot even conceive of [the] possibility [of taking action].”

This is as it should be, and the book contains many technical distinctions – e.g., noetic and noematic – and, in that respect, is not for the faint of heart. Still, I was persuaded, and I believe, you will be too. This is a powerful and important contribution, which should be, required study for anyone proposing to engage with persons who one customarily describes as depressed. It changes one’s listening and in a powerful and positive way.  

Since this is not a softball review, this leads to the two-ton elephant in the room. So what? What is the guidance in overcoming depression? As I am a person who performs empathy consulting and psychotherapy, this reviewer asks: what are the action items or recommendations? How does one access the possibility of possibility, given that possibilities always present themselves as specific projects in the world? How does one jump-start the possibility of possibility when nothing seems possible?

In all fairness, addressing this may not be Ratcliffe’s job since he is doing phenomenological research, not clinical practice; but the question is almost unavoidable. Therefore, I am so bold as to engage in some “reading between the lines.”

Ratcliffe’s short answer to jump starting possibility is “radical empathy.” Radical empathy – unlike ordinary empathy (according to Ratcliffe) – does not presume that the two people trying to relate share the same space of possibilities (p. 242). Radical empathy is a kind of lever to open a space of possibilities of difference.

My take on radical empathy? Radical empathy consists in the would-be empathizer being committed enough to relating that he continues to try to do so even though logical reasons exist that empathy should fail. In this case, the depressed person is overwhelmed, experiencing being cut off from human relatedness, isolated, and disconnected. That is the disorder itself – along with the other symptoms.

Yet the would-be empathizer persists in his attempts to relate, vicariously experiencing the isolation and disconnectedness (or not) as a privative form of relatedness. The depressed person, even in his isolation, “gets it” that the empathizer is committed to the possibility of relating, even though the depressed person is frustrating the efforts. That’s it. That’s the moment something starts shifting.

Voila! The possibility of possibility is back in play. The depressed person’s “getting it” that the other is committed to the possibility of relating provides an Ariadne’s thread out of the labyrinth. That’s the empathic breakthrough.

This does not guarantee that radical empathy will succeed. Nor is there any guarantee that after trying ten times, the 11th try will be enough to do the trick. The depressed person may still be so cut off from possibility that suicide starts to look like a solution; but if one can acknowledge the possibility of a bad – very bad – solution (e.g., suicide), then one may be able to find a better solution – whether pharmacological, cognitive behavioral or empathy-based. 

To cut to the chase, I am so bold as to suggest that all empathy is radical empathy (in Ratcliffe’s sense). Contrary to Ratcliffe’s assertion, ordinary empathy does notrequire a space of shared possibilities. Shared possibilities are a “nice to have,” but often a high bar. Possibilities might be shared, but often they are not. Given the state of the world, such a space of shared possibilities is rarer than any of us might wish. I assert: All empathy is a risk undertaken to create a space of shared possibilities when there was no shared context.

All the other would-be empathic mechanisms such as simulation, mindedness, sympathy, altruism, are examples of incomplete empathy or breakdowns of empathy into projection, emotional contagion, or conformity. If the breakdowns were clarified, then empathic connection would emerge out of the misunderstanding, restoring the integrity of the relationship.

Meanwhile, Ratcliffe acknowledges the usefulness of the Diagnostic and Statistical Manual (DSM) for aligning the conversation and assuring us that the researchers are talking about the same phenomena. He is respectful of the professional sensibilities of the medical and psychiatric establishment – perhaps too respectful in my opinion. Yet, then again, if one is going to speak truth to power, it is best to start with an agreeable word. The barber lathers a man before he shaves him.

Though not a contribution to the growing body of anti-DSM literature, Ratcliffe’s work is an antidote to the pervasive tendency to under-describe depression (and other psychiatric disorders). The DSM is a starting point. However, Ratcliffe’s work makes clear that the DSM, especially as regards depression, is a pragmatic conglomeration of overlapping traits, not a natural kind.

Arguably melancholy is a natural kind; mania is a natural kind; paranoia is a natural kind; inflammation is a natural kind (and here the cytokine theory of depression is called out); but major depressive order as defined by the DSM? Nope. Ratcliffe does not spend much time or effort on the matter of the social construction of the categories of mental illness, and if one had to summarize Ratcliffe’s approach it aligns with the genealogical approach of Ian Hacking (e.g., see Ian Hacking, (2002), Historical Ontology, Cambridge, MA: Harvard University Press), who was himself inspired by Foucault (in turn, inspired by Nietzsche). 

In spite of his commitment to sustained phenomenological description of the things themselves, Ratcliffe quickly discovers that the phenomena bring forth a deep structure and background separable from any specific first person report. As usual, the way the researcher gets access to the phenomena significantly influences one’s description of the phenomena.

The data? The phenomena? Ratcliffe collects some 150 free form depression questionnaires in which sufferers and survivors of depression try to express and describe their experiences. Many of these contain lengthy feedback from the survivors on their experiences of depression. Ratcliffe also reviews many memoires of suicide and depression survivors, who try to express the ineffable nature of their experiences, such as Styron’s Darkness Visible. Many conditions and qualifications regarding the data are argued, limitations defined, and the richness of the experience plumbed for an expansive encounter with the enemy – depression.

Several things come out in the first person accounts that are not emphasized or are outright overlooked in the DSM. These include: the intimate relationship between depression and anxiety (“anxious distress” is called out in DSM-5, but unrelated to the whole); loss of hope and changes in bodily experience are briefly acknowledged in the DSM-5, but are critical path in the treatment; the altered experience of time is not mentioned at all (but the future seems to disappear as a positive, possible horizon); impaired social function is mentioned as a consequence whereas such loss of function is integral to the phenomena itself. This list goes on.

One of the first things that occurred to me as I sat down to read this book was: Am I going to get depressed – not necessarily in the full clinical sense; but is it going to cause an upset? My experience was that such a negative outcome was not the case. I suspect that was because, as an author who “gets” and uses empathy, Ratcliffe knows how to regulate the empathy in the space of possibilities to prevent empathic distress.

However, before turning to Ratcliffe’s breakthrough notion of radical empathy, the text engages with the issue of how empathy maps to the theory of mind debate in which empathy as simulation is arrayed against a theory of mindedness that enable persons to perceive others as sources of intentionality. The details of this debate are technical and at times Ratcliffe seems to forget the insight with which he began the book: “I argue that human experience incorporates an ordinarily pre-reflective sense of belonging to a shared world’, which is altered in depression” (p. 2). 

Once one disconnects the subject from its environment – the subject’s belonging to a shared world of people, neither simulation theory nor theory of mindedness can ever quite connect them again. It is a myth that we human beings are unrelated. We are all related. Human beings are already related to one another – biologically, psychologically, and in our very way of being (ontologically). Ratcliffe gets this. There is nothing wrong. Yet there is something missing.

Ratcliffe conceptualizes empathy as an attitude that does not include the communication of affect. Therefore, he overlooks several breakdowns in empathy – such as emotional contagion, projection, conformity – that if clarified provide the breakthrough to “radical empathy” (Ratcliffe’s key term) that is need to give traction to treatment options. There is indeed such a thing as an empathic attitude; but I disagree with Ratcliffe that a congruence of feeling (whether partial or complete) is to be ruled-out.

Ratcliffe (and his argument) are troubled by the notion that if one empathizes with a depressed person, then one may end up feeling quite depressed. This seems to be an invalidation of empathy and an obstacle to using it in treatment. Neither needs to be the case. First, in an admittedly extreme case, if one talks to eight depressed people in a row in the course of a treatment day, then one is very likely going to feel down – at least sub-clinically depressed – by the end of the day, regardless of the quality of one’s empathy. Is this empathy or a breakdown of empathy?

Look at the phenomena. Phenomenologically, there is no other plausible way to describe this than to say that the feelings and emotions have been communicated from one person to another. Once again, is this empathy? No – according to Ratcliffe, empathy is an attitude, not a congruence of feelings.

I suggest this answer is incomplete. It is not an “either or” choice. One must integrate empathic receptivity (openness), empathic understanding, empathic interpretation, and empathic responsiveness.

The answer is still “No,” but because the communication of feeling, the congruence of feeling – one paradigm case of which is vicarious experience – is not complete empathy. It is merely phase one of empathy.

If one stops with the mere communication of feeling, then one gets emotional contagion (as Ratcliffe properly notes). This is a breakdown of empathy, but Ratcliffe does not describe it in such a way. However, do not be so hasty to dismiss empathy. That empathy breaks down does notmean empathy is invalid or must be abandoned.

The would-be empathizer may [must?] take this vicarious experience of the other’s distress and process it further through empathic understanding, empathic interpretation, and empathic responsiveness in order to make it useable in relating to the other person as a possibility or a breakdown of possibility.

Likewise with compassion fatigue, which is likely in the background of Ratcliffe’s insistence that empathy is an attitude, not a congruence of feeling. Though compassion fatigue is not an issue Ratcliffe engages, it is common to acknowledge that the helping professions are at risk of burn out, empathic distress, and compassion fatigue. (Note that burn out itself is a kind of loss of the possibility of possibility. “Depression”?)

Those who engage with depressed people are particularly at risk of such an outcome. Empathy reportedly peaks in the third year of medical school, and, unless specific interventions such as further training are undertaken, it is downhill from thereon (see Hojat, Mohammadreza, et al. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school, Academic Medicine84 (9): 1182–1191). What to do about it?

Once again, Ratcliffe may not see this as his job – and the book is already over 300 pages of dense descriptions of depression – but one may offer a couple of thoughts. We usually think of empathy as an “on off” switch. Turn it on for the “in group” – patients, clients, friends, family – turn it off for the competition, the opposing team, people who talk foreign languages or have unfamiliar customs or the “out group.” Rather, the training is to regard empathy as more like a dial or tuner – dial empathy up or down by regulating one’s receptivity – one’s openness (Ratcliffe’s term) – to the experiences of other persons.

If one is over-whelmed by the other person’s depression one is doing it wrong. Properly deployed by experienced practitioners, empathy is a method of providing a sample or trace of the other person’s experience. Max Scheler (who Ratcliffe approvingly cites) calls this a “vicarious experience” (Nacherlebnis) – rather like an after image of another person’s feeling. As noted, this trace or sample of the other’s experience has to be further processed by the understanding of possibilities to be useful in shifting out of stuckness. (See Max Scheler, (1913/1922).  The Nature of Sympathy, tr. Peter Heath. Hamden: CN: Archon Books, 1970)).

Of course, expanding one’s empathy does not come naturally to most people, which is why training and practice are needed. But experience shows that if one works at it, one can expand one’s empathic capabilities and the results one gets in trying to be empathic. (See Zaki, Jamil and Mina Ciskara. (2015). Addressing empathic failures, Current Directions in Psychological Science,December 2015, Vol. 24, No. 6: 471–476. DOI: 10.1177/0963721415599978).

The antidote? A radical proposal – in addition to radical empathy. If one is experiencing compassion fatigue, maybe one is being too compassionate. Now compassion is different from empathy. In compassion, one’s strong feeling – passion – motivates one to get involved, take action, and intervene to help the other. (Nor is anyone saying be hard-hearted or indifferent, but know when to dial it down a bit.) In contract, empathy in the full sense of the term, of which Ratcliffe’s radical empathy is a subset, is a method of data gathering about the experience of the other person. It consists in being open to the experiences of the other person, having a vicarious experience of the other’s experience, and further processing it in empathic understanding, empathic interpretation, and empathic responsiveness.

It is ironic that the phenomenology of depression misses the key phenomenological distinction – vicarious experience – in the account of trying to empathize with depression. In relating to a depressed person, I can be open to a vicarious experience of melancholy or stress or anger or irritability or discordant mood or whatever the other person is experiencing – without succumbing to a merger with them. This vicarious experience gets processed further in understanding who the person is, where he is at, what he “gets” as possible for himself in the moment. Through interpretation and responsiveness, this may open up other possibilities. Now we are back in the realm of jump-starting the possibility of possibility.

Ratcliffe finds inspiration in, but puts his own definitive spin on, Jonathan Lear’s Radical Hope, a narrative of the struggles of the Native American Crow people. After the buffalo went away (were killed off), the indigenous Crow people, experienced world collapse. Hunting ceased. Demonstrating courage in tribal warfare became impossible. Culture and customs lost significance and ceased to make a difference. Nothing changed – i.e., in effect, time stopped. All hope was lost and – at the risk of a caricature – the only possibilities were the self-destructive non-possibilities of alcoholism and inadequate, dignity-destroying government handouts.

However, even amid this world collapse – analogous to the depressive person’s loss of the possibility of possibility – a wise Crow elder put forth a prophecy that an event, something = x, would happen that would enable a the rebirth of possibility of the true people. This was radical hope – “to hope against hope until hope creates from its own wreck the thing it contemplates” as the poet Shelley put it.

The prophesized event turned out to be World War II, a conflict in which the Crow were able to draw on their warrior tradition and make a contribution to the defeat of the enemy.

Ratcliffe’s radical empathy is analogous to radical hope here. The therapist keeps alive the possibility of possibility and gives expression to it while the depressed person is unable to do so for himself. The therapist keeps blowing on the embers – and may indeed get short of breath doing so – until the spark rekindles the fire of neuronal activity in the depressed person’s consciousness.

In conclusion, Ratcliffe “gets it” – while simulation and theory of mindedness go round-and-round about whether feelings are congruent or perspective interchangeable, psychiatric disorders across the spectrum, from mood disorders to thought disorder, are especially challenging to anyone’s empathy. Most psychiatric disorders – not just autism or psychopathy – involve a breakdown of empathy (as Ratcliffe points out elsewhere), leaving the person feeling disconnected, isolated, not “gotten.” Ordinary empathy is already radical in so far as one person is able to understand another in his or her humanity. Such a commitment – call it an “attitude” or a “method” – is not easy or trivial. Yet the commitment to relating to the other’s humanity is what calls forth the humanity back into possibility.

(c) Lou Agosta, PhD and the Chicago Empathy Project