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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 attention 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
Virtual reality (VR) is coming to psychotherapy. Based on a briefing on July 08, 2016, a company named “Psious” provides VR technology. Psious’ collaboration agreement, available temporarily to Chicago-area mental health professionals, includes training forthe therapist on how to use the VR technology. Online manuals integrating the simulated scenarios provide step-by-step guidance from psychologists on how to help patients shift out of fear, expanding positive responses to a variety of stress-laden situations that people find confronting such as fear of heights, flying in airplanes, insects, and more (to be detailed momentarily).
The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all its own – even without goggles. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversations with a past or future person or reality. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationship work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and fear – are generated in the mind of the beholder.
Positioning an intervention that exploits VR in any psychotherapy clinical practice raises numerous issues that must be engaged, and the economics of virtual reality mean the time is now. Flight simulators in which airplane pilots train still cost millions of dollars. The initial “one off” VR goggles used to cost hundreds of thousands of dollars. Psious brings the goggles, plus the necessary software subscription for a compelling price of $1299 a year not including the hardware (Samsung Gear VR goggles and Samsung Galaxy smartphone), the platform on which the software operates). Hardware bought on Amazon for about $700 is discounted to $259 with an annual subscription. The total cost is about $1558 a year for access and ownership of the hardware. At current rates for psychotherapy that is about ten session to break even.
The therapist has a display on his computer of what is being presented in the Goggles to the client. For example, in the scenario in which the patient is dealing with fear of public speaking, one is presented with a “speaker’s eye view” of an audience. Controls allow the therapist to incorporate the patient’s expectations and feedback on what he is ready to confront. The therapist controls different scenarios – a member of the audience gets up and walks out, members of the audience are audibly talking with one another and not listening to the speaker, applause, booing, questions are shouted out (e.g.) “What is the weakness in your proposal?” The list goes on. Close coordination is required between the therapist operating the controls and the subject of the therapy in order for this simulated speaking experience not to become re-traumatizing. Of course, even the latter could become a therapeutic opportunity if the patient is flooded but is enabled to recover his equilibrium thanks to an empowering conversation with the therapist at the moment of the upset.
Modules are currently available for fear of flying, needles, heights, public speaking, animals/insects, driving, claustrophobia, agoraphobia, social anxiety, and generalized anxiety. Given that as soon as one is confronted with fear the intervention also involves imagining or activating a “safe place” from which to function in the face of fear, positive modules are available that provide coaching in breathing exercise, mindfulness, and Jacobsen Relaxation (progressive muscle relaxation).
While the VR technology is innovative and disruptive in many ways, a moment’s reflection suggestion continuity between VR technology and the “virtual reality” of the transference in classic psychodynamic therapy. There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used in a conversation is English or other natural language. For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of his father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him, Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection), Hans was afraid of being punished by his father for being naughty – so the hostility was displaced onto a symbolic object. Hans’ symptoms (themselves a kind of indirect, virtual expression of suffering) actually gave Hans power, since the whole family was now literally running around trying to help and consulting The Professor (Freud) about what was going on. In short, the virtual reality made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity. So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone.
Psious was founded in 2013 in Barcelona, Spain. It has operations in Barcelona, and is opening a branch in Chicago, which is where I met with Scott Lowe. Psious has about 50 employees worldwide and some 400 clients using the technology in a clinical or closely related setting.
Psious’ claim is that virtual reality based therapy (VRBT) is superior to CBT alone, when the latter uses merely the patient’s imagination [see references to peer-reviewed articles at the end]. For example, if one is so afraid of flying that one is unable to do one’s job because it requires travelling on an airplane for business, one is sitting there in the therapist’s office imagining boarding an airplane and taxiing towards the runway for takeoff. Instead of closing one’s eyes and imaging a trip to the airport, put on the VRBT goggles and find oneself sitting in a seat in coach. For someone seriously stressed by such a situation, the person’s pulse is accelerating, sweat is breaking out, fear is escalating faster than the airplane, and comfort is in free fall until one wants to jump up and run screaming down the aisle and try to open the emergency exit. Not good.
Presumably one would work with the therapist to adjust, adapt, and accommodate to the environment in small steps during which the client’s comfort level is monitored in an on-going conversation with the therapist (and the available biofeedback tool, a galvanic skin sensor). First, are you willing to put on the headset and sit in the airplane seat? Close the cabin door? Taxi towards the runway. Rev up the engines? Start rolling down the runway? Picking up speed? Nose wheel off the ground? Wheels up? Vibration in the cabin as the plane gains altitude? Shaking from side-to-side as the plane ascends through turbulence? Big bump as the plane picks up and enters the jet stream? While the headset provides compelling visual and sound clues, the seat does not vibrate. Still, up until now, if one wanted to confront one’s fear of flying (in an airplane), one had to charter an airplane, time in a flight simulator, or use one’s imagination. It’s a whole new world with Psious.
Let me say up front that I have gone to the demo for the fear of heights, heard the presentation, put on the headset, and I am inclined to say that this technology has legs. At the risk of paradox, virtual reality therapy is the real deal. However, as the Psious people make clear, it is not a replacement for a therapist, it is a tool that can augment the process of confronting and engaging one’s fears under the guidance of a therapist. Why? Because the virtual reality goggles put the client back in a simulated situation that is most calculated to arouse the anxiety that requires treatment. The conventional wisdom is that one cannot overcome one’s fear without engaging with it. However, the engagement must find a stretch to the client’s comfort zone, no matter how narrow, that does not result in retraumatization. In short, the kid gloves are on. The head set should not cause the patient to run screaming from the room as he or she did from the spider or public bathroom. This scenario motivates the need for fine-grained controls as well as training the therapist in how to use them and how to talk the client through an empowering – or at least survivable – experience with the fearful.
The knock against individual dynamic psychotherapy has been that it does not scale. It is highly individual, one size definitely does not fit all, and a third of the population would have to be therapists in order to treat all the members of the armed forces who are suffering from some significant measure of PTSD. If one could define a process that enabled the wounded warrior to bring CBT tips and techniques such as interrupting the pathogenic thought and going to his or her “safe place” while confronting the trauma, perhaps initially in a diminished presentation, then it just might make a scalable difference in treating significant numbers of clients using a method that really works (presumably as opposed to medications with substances that may be addictive).
The fear of horses that manifest itself in Little Hans’ fear of going out onto the street (due, in turn, to fear of encountering a horse) was actual fear. Hans was not faking. He was really terrified. However, his fear was inauthentic in that it masked his unexpressed hostility and ambivalence toward his father and his new baby sister. He was not afraid of horses; he was afraid of being punished for wishing to do away with his new sister. “The stork should take it back.” “Throw it down the drain (that is, the sister).” Remember has was only four years old. However, it is in the nature of an emotion such as fear to glom (“adhere”) onto an available object. This binds the fear to a specific target that may be able to be avoided or otherwise managed in a survival drill rather than have free-floating fear paralyze the entire organism, endangering the survival of the whole. There may even some objects such as spiders, snakes, and thorns that we humans are biologically and evolutionarily predisposed to experience as automatically and inevitably arouse fear. What then of the technology?
The Psious technology is still relevant to address the delta between one’s ordinary uneasiness towards a spider that allows one to take a napkin and remove it from the kitchen and someone else extreme distress that causes them to hyperventilate and, as noted, run screaming from the room. True, they may just have an intensified biological disposition, but they may also be adding expanded meaning based on their individual experience. As far as I can tell, the scenarios are useful in evoking the feared object regardless of the cause, but the therapy still has to intervene with a narrative to shift the fear in the direction of a manageable de-escalation of the fear. Whether the narrative is a CBT one that send the individual to his “safe place by the calming waters” or one that deconstructs the fear as a transference displacement from one’s reaction to one’s father’s scary masculinity, is independent of the technology. It remains a function of the therapeutic intervention.
I am excited by these developments for three reasons. First, the scenarios presented in the goggles are compelling. I have climbed mountains and I regularly fly on airplanes, but I still have a lurking fear of heights. When I put on the goggles and found myself near the glass bottomed sky deck, I was literally unable to step forward over the visual cliff. Amazingly enough, it did not even help when I closed my eyes – since I still vividly imagined being in the scenario. However, taking off the goggles worked just fine in interrupting the process. I do not know if the other scenarios are as compelling. However, I do not have a fear of any of the other things quite as visceral as my fear of heights, or more properly speaking, the visual cliff.
Second and more importantly, this technology may enable individuals who are unable to be helped any other way (“treatment resistant”) to get the treatment they require. We can debate whether or not it is the best treatment; but I am persuaded that if someone is suffering, then a treatment that works is one worth engaging. If a person is so confronted that they are unwilling or unable to imagine a scenario in which they encounter their fear, this technology gives the client an opportunity, with his permission, to puts himself in the fear arousing situation – which, if I am any judge, can be “tuned down” to a significant degree such that a gradual “on ramp” is available to client with the encounter.
Third, some individuals who need help but do not value a conversation for possibility with another person (such as a therapist) may be persuaded to engage by using the goggles as a kind of lever to open up access to their upset. The same people who are fascinated by the technology of the functional magnetic imaging (fMRI) apparatus that shows what area of the brain lights up as they are empathizing with the pain of another will be able to engage in a conversation with the therapist while in the process of using the goggles. Some may say it is a “gimmick”; but I say if this be gimmickry, make the most of it. The provisioning of a virtual reality platform provides an “on ramp” to the virtual reality of a transference conversation in which displacement, symbolization, and interpretation can be marshaled above and beyond the VR scenarios.
Frankly, the most engaging scenario is one that Psious does not have available. As the result of the wars in Afghanistan and Iraq, the US and its allies has many soldiers suffering from diverse forms of post traumatic stress disorder. Worse yet, the diagnosis of PTSD does not even encompass the forms of moral trauma (see further the work of John Mundt, Ph.D., Jesse Brown, VA Center, Chicago) from which many service men and women are suffering. For example, In Iraq a car with four occupants is speeding towards a check point containing multiple passage, ignoring warnings to stop, zig sagging around the barriers. A suicide bomber? The sergeant orders the gunner to fire. The family was rushing to the hospital with a pregnant woman giving birth. One of the now orphaned children survives. The gunner cannot forgive himself, but this does not qualify as PTSD under current rules unless all the criteria are satisfied. The VR technology offers rich possibilities for reenacting the scenario with diverse outcomes, enabling an empowering conversation about what the soldier experienced, what it meant to him, and how to work through his suffering and guilt. Note at this point this is all “brain storming” and “blue sky,” but the possibilities are significant and deserve the urgent attention of software innovators, Veteran Affairs decision makers, politicians, psychotherapists, and survivors alike.
Issues include whether in what sense the hardware is a medical device. What sense, if any, does it make to certify it as health insurance compliant? There are so many rules and regulations around health care that I am not even clear that I know how to ask the right questions. Does a therapist using this device as an adjunct or augmenter to CBT or dynamic psychotherapy need to call it out in her or his coding of the insurance claim, and what sense would it make to try to do so? Presumably Psious will be engaging with these issues over the next year.
References: A selection of publications:
Chapman, L. K., & DeLapp, R. C. (2013). Nine session treatment of a blood–injection–injury phobia with manualized cognitive behavioural therapy: An adult case example. Clinical Case Studies. Retrieved October 26, 2014, from http://ccs.sagepub.com/content/early/2013/10/28/1534650113509304
Wiederhold, B.K., Mendoza, M., Nakatani, T. Bulinger, A.H. & Wiederhold, M.D. (2005). VR for blood-injection-injury phobia. Annual Review of CyberTherapy and Telemedicine, 3, 109-116.
Botella, C., Osma, J., García-Palacios, A., Quero, S. & Baños, R.M. (2004). Treatment of Flying Phobia using Virtual Reality: Data from a 1-Year Follow-up using a Multiple Baseline Design. Clinical Psychology & Psychotherapy, 11(5), 311-323.
Da Costa, R.T., Sardinha, A. & Nardi, A.E. (2008). Virtual reality exposure in the treatment of fear of flying. Aviation, Space, and Environmental Medicine, 79(9), 899-903.
Wallach, H.S. & Bar-Zvi, M. (2007). Virtual-reality-assisted treatment of flight phobia. Israel Journal of Psychiatry and Related Sciences, 44(1), 29-32.
Emmelkamp, P., Krijn, M., Hulsbosch, A. M., De Vries, S., Schuemie, M. J. & Van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: A comparative evaluation in acrophobia. Behaviour Research and Therapy. Vol. 40, 509-516.
Botella, C., García-Palacios, A., Villa, H., Baños, R., Quero, S., Alcañiz, M., & Riva, G. (n.d.). Virtual Reality Exposure In The Treatment Of Panic Disorder And Agoraphobia: A Controlled Study. Clinical Psychology & Psychotherapy, 164-175.
Cárdenas, G., Muñoz, S., González, M., & Uribarren, G. (n.d.). Virtual Reality Applications to Agoraphobia: A Protocol. CyberPsychology & Behavior, 248-250.
J., C. (n.d.). A Randomized Controlled Study of Virtual Reality Exposure Therapy and Cognitive-Behaviour Therapy in Panic Disorder with Agoraphobia. Frontiers in Neuroengineering.
Anderson, P.L., Price, M., Edwards, S.M., Obasaju, M.A., Mayowa, A., Schmertz, S.K., Zimand, E. & Calamaras, M.R. (2013). Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 81(5), 751.760.
Moldovan, R. & David, D. (2014). One session treatment of cognitive and behavioral therapy and virtual reality for social and specific phobias. Preliminary results from a randomized clinical trial. Journal of Evidence-Based Psychotherapies, 14(1), 67-83.
Safir, M.P., Wallach, H.S. & Bar-Zvi, M. (2012). Virtual reality cognitive-behavior therapy for public speaking anxiety: One-year follow-Up. Behavior Modification, 36(2), 235-246.
Da Costa, R.T., de Carvalho, M.R. & Nardi, A.E. (2010). Virtual reality exposure therapy in the treatment of driving phobia. Psicologia: Teoria e Pesquisa, 26(1), 131-137.
Wald, J. & Taylor, S. (2000). Efficacy of virtual reality exposure therapy to treat driving phobia: A case study. Journal of Behaviour Therapy and Experimental Psychiatry, 31(3-4), 249-257.
Wald, J. & Taylor, S. (2003). Preliminary research on the efficacy of virtual reality exposure therapy to treat driving phobia. CyberPsychology & Behaviour, 6(5), 459-465.
Wald, J. (2004). Efficacy of virtual reality exposure therapy for driving phobia: A multiple baseline across-subjects design. Behaviour Therapy, 35(3), 621-635.
Botella, C.M., Juan, M.C., Baños, R.M., Alcañiz, M., Guillén, V. y Rey, B. (2005) Mixing Realities? An Application of Augmented Reality for the Treatment of Cockroach Phobia. Cyberpsychology and Behaviour, 8(2), 162-171.
Spira, J.L., Pyne, J.M., Wiederhold, B., Wiederhold, M., Graap, K. & Rizzo, A. (2006). Virtual reality and other experiential therapies for combat-related posttraumatic stress disorder. Primary Psychiatry, 13(3), 58-64. http://www.researchgate.net/profile/James_Spira/publication/228387636_Virtual_reality_and_other_experiential_therapies_for_combat-related_posttraumatic_stress_disorder/links/00463518c81d4ac9d1000000.pdf
(c) Lou Agosta, PhD