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Noted in Passing: Elizabeth Wurtzel, Author, Prozac Nation

Elizabeth Wurtzel (1967–2020) died at the age of 52 on January 7th in New York City of metastatic breast cancer. Wurtzel became a notorious “bad girl,” with a wicked sense of black humor, sparing few, least of all herself, and a disarming “tell all” candor in her break through memoir Prozac Nation.

Full disclosure: I am catching up on my reading. Triggered by Wurtzel’s passing

Elizabeth Wurtzel (her young self): Cover Art: Prozac Nation

Elizabeth Wurtzel (her young self): Cover Art: Prozac Nation

away, I had not read her best selling Prozac Nation until earlier this week (01/14/2020). I acknowledge I need to get out more.

Now I am familiar with pathographies – autobiographies and biographies of mental pathology – having read Kay Redfield Jamison’s An Unquiet Mind, Jamison’s “Robert Lowell: Setting the River on Fire: A Study of Genius, Mani, and Character,” and Elyn Saks’ The Center Will Not Hold, all worth reading – as is Prozac Nation. Thus, I bring an innocent reading – and eye – to a work that is anything but innocent.

Wurtzel is credited with putting the funny but self-lacerating memoir on the literary map, with its account of her emotional struggles against the Black Wave of depression, volatile internal conflicts, and acting out in the form of cutting, starting at age eleven. Subsequent attempts to attain emotional equilibrium through substance abuse and volatile relationships with members of the opposite sex, the narrative actually turns into a coming of age story. Some coming; some aging.

Not quite stream of consciousness, but definitely a rapid fire, back-and-forth conversation of Wurtzel with herself, it puts me in mind of the cliché: your mind can be a bad neighborhood; if you go there, you are going to get mugged, albeit in a comical way; mugged by negative self-talk, devaluing self assessments, and rage at the narcissistic slights inflicted by intimates, strangers, and intimate-strangers alike.

Wurtzel’s writing is shot from a cannon. The character sketches are wickedly funny and just as cutting as her own practices of self-injury. One example: “If Archer weren’t so good-looking, I’m not sure he’d exist at all, since he lacks most vital signs [….][H]e is the best opportunity to hang out with a gorgeous man and be certain that there will be no sexual tension whatsoever” (p. 224).

Wurtzel literally calls out the elephant in her family’s living room early in the narrative (p. 58): her parents are fighting, from the time Elizabeth is two years old, when her mom divorces her dad. The parents continue to fight (including in court) throughout her childhood, adolescence, and emerging adulthood, all the while “telling me that their [hostile] feelings for one another shouldn’t affect me,” blaming the victim if she feels affected, making the child an unwitting pawn.

Usually an emotion will shift after a few hours and a depression will shift after a few months, even if no intervention is undertaken other than good rest and good nourishment. To keep the disorder in place, active measure must be undertaken by the person, environment or both. The ongoing family situation is a significant contributor to the extraordinary duration of the distress.

It gets worse. The dad has access to health benefits through a good, albeit low level, corporate job; but it seems that every time the growing Wurtzel gets into an emotional crisis (chronic emergency would be more like it), the dad stops paying for psychotherapy, telling her its nothing personal. The real reason is usually a dust up with the mom.

Queue up the late rock-and-roller Stevie Ray Vaughn: Caught in the cross fire. Elizabeth is. She cannot help but internalize the conflict. Any kid would. This is the way it is. It starts so early and continues so unremittingly, that one must be positively as blind as the parents not to see it: this is an invalidating environment.

Another example of invalidation that might be straight out of Heinz Kohut, MD: “For instance, I’ll walk into her [mom’s] apartment and she’ll just blurt out, Those shoes are so ugly! And I never asked her. And I like my shoes […] The concept of Who asked you? does not exist in my family […] We’re all meshed together” (p. 231). Unremitting, serial breakdowns in empathy, resulting in emotional contagion, conflict, and enmeshment with the toxic self-object and hostile introject. Ouch!

Abandonment comes up early and often. In year-after-year of being sent off to a different camp, depending on which one offers a discount to her and her mom, who are living in a kind of genteel poverty. It induces a real panic about abandonment in the young Wurtzel, resulting in dozens of calls requesting rescue. Having been dutifully rehearsed during latency, this fear takes on a life of its own. “[…] [B]eing alone turns into a terrible fear that I will have no friends” (p. 89).

In several relationships with college BFs (at Harvard College) Wurtzel cries and cries sad tears, angry tears, at the prospect of separation such that the behavior creates the dreaded self-fulfilling prophecy. She goes well beyond “high maintenance” into the land of continuous confrontation, just plain crazy shit, and the bottomless pit of infinite upset all the time. Meanwhile, the guy wants a friend with whom he can go to the movies and party, maybe perform some consensual sex acts between reading about Derrida and Marxism. Enough.

Years later it comes out. The man Elizabeth thought was her dad, who was divorced after two years by the mom, and who also thought he was the dad, is not the biological father. Even though he did not have the DNA data, somehow he was never able to relate to Elizabeth in quite the proper parental way. (See the article by Wurtzel entitled Bastard, cited at the bottom of this post.)

Wurtzel has a gift for zingy one-liners, coming out of the blue, and yet creating their own context instantaneously. As regards the above-cited elephant, “We went to Alaska and we froze to death” (58) – emotionally. More like the abandoning, ice box father and the bonfire mother. Things heat up, especially with her mom: “I come from a family of screamers” (p. 185). Balance is hard to find.

The subtitle is “Young and depressed in America,” and one can sees Wurtzel’s editor’s skillful hand in connecting the dots between individual suffering, of which there is an abundance, and the breakdown of communities, ongoing, whether due to globalization, an opioid epidemic, or the malling / mauling of America.

The reader learns the difference between sadness and negative self-talk and what we might call existential depression: “I’d been expelled from the place where possibility still existed” (p. 60). Depression is the loss of the possibility of possibility. It is not just that I lose love and long for love; I lose the possibility of the possibility of love. This is gonna be tough going.

This is definitely a page-turner. Hard to put down. However, there are also some loose ends. I mean in the narrative, looser than Wurtzel herself. 

The title is premised on the interpretation that Wurtzel suffered between the ages of eleven and twenty one from a hard to treat Black Wave. Tons of talk therapy – finally she can’t stop crying for days – and not for the first time – and her shrink prescribes an anti-psychotic – Mellaril [thioridazine] – and its anticholinergic effects promptly dry up her mucus membranes, allowing her “to get a grip on it.” She is able to stop crying.

I am reading this passage and scratching my head. This is an emergency measure, right? Wurtzel is a lot of things, but her reality testing of the everyday is good enough. I know nothing, really, and am not a prescriber. However, I have been know to echo Lou Marinoff’s saying, “Plato, not Prozac!” And yet: An actual antidepressant such as imipramine or disiprimine would have had the same anticholinergic effects, have dried up the tears physiologically, and it might actually also operate as an antidepressant, would it not?!

Perhaps it was because of the unremitting of suicidal ideation that Wurtzel endorsed and expressed that no medical doctor recommended a tricyclic antidepressant. A person can actually hurt themselves with the tricyclic antidepressants, as with any powerful drug, which can cause a fatal heart arrhythmia if consumed contrary to proper guidance and in volume. But if this is supposed to be an emergency measure, a small number of pills in small dosages, closely supervised, would also have been possible would it not? Was Wurtzel getting adequate medical treatment even by advanced 1994 care standards? We may never know.

I am not one noted to value psychiatric labels, seeing them as getting in the way of being fully present with the other person as a possibility. Yet Wurtzel has a breakthrough towards the end of her narrative when she gets one – a label – along with the newly available fluoxetine (Prozac). Her psychiatrist gives her a diagnosis of atypical depression. I would add, demonstrably treatment resistant. “Atypical” because years of talk therapy and first line antipsychotics have barely made a dent in her unremitting self-abuse, inclination to self-medicate with weed, alcohol, and acting out with a series of boy friends, a couple of whom are the target of an intense romantic idealization combined with a neediness calculated eventually to drive them all away. However, at this point, the Prozac seems to work – except that about two weeks after starting to take it, she is feeling a tad better, and her only serious suicide attempt reported in the book occurs. Hold that thought.

One thing lifted Wurtzel’s work head and shoulders above your average narrative of suffering and redemption for me. Wurtzel is working through her invalidating environment and she gets it: “…[M]y addiction to depression …involved the same mental mechanism as someone else’s alcoholism” (p. 23).

Suffering is sticky. The risk of suffering is that it becomes an uncomfortable comfort zone. The body and the mind adapt to chronic pain and chronic stress. Even when the result is still pain, not numbness, the entire messy complex takes on a life of its own and becomes: suffering. If you water the tree of your sorrows, the tree grows. It grows until the suffering becomes the man-eating plant in the back of the Broadway play Little Shop of Horrors. That seems to have been going on here.

Empathy lessons occur in abundance in Prozac Nation, but they are mostly in a privative mode – that is, empathy is conspicuously missing.

Wurtzel is hungry for someone to respond to her as a whole person, writing: “I love you and I support you just the way you are because you’re wonderful just the way you are. They don’t understand that I don’t remember anyone ever saying that to me” (p. 231).

Wurtzel’s mother “loves” her as long as (if) she is brilliant, gets into Harvard, and they can continue intermittently to tear at one another’s guts on special occasions. He dad “loves” her as long as she does not make herself too needy, will pose for his photos, and otherwise leave him alone. Her friends “love” her as long she as is funny and amazing and the life of the party. Her boy friends “love” her as long as she continues to put out, which she does all too casually, leaving her feeling cheap. The impingements come fast and thick; here “love” means acknowledging someone as a whole human being, i.e., empathy; but no one gets her as a possibility.  

My take on it? If, at any point, someone would have given her a good sustained listening, something important would have shifted. Nor is it quite so simple. Her suffering would not have been magically disappeared; but it would have been decisively reduced. Once again, we will never know for sure.

Page after page of this page-turner, Wurtzel is explicitly crying out for “love,” and people are trying to love this individual, who seemingly inevitably gets caustically cutting towards others or becomes a needy emotional sponge, an unlovable rag of self-pity, albeit with a sense of humor, driving them away. Thus, Wurtzel’s ultimate test of love: love me even when I am deep down unlovable. It doesn’t work that well.

One can have empathy with the loveable but loving the unlovable is a high bar, by definition impossible. This person needs the firm boundaries of a rigorous and critical empathy. But instead Wurtzel’s friends and counselors efforts are lost in translation and become emotional contagion, projection, and inconsistent efforts to force compliance and conformity.

Finally, Wurtzel does get some empathy from the shrink disguised in the narrative as “Dr Sterling.” She was. Wurtzel writes: “Dr Sterling knew that somewhere in my personality there was a giggly girl who just wanted to have fun, and she thought it was important that I be allowed to express that aspect of myself (pp. 211–212). Predictably the breakdowns and out-of-attunements are frequent. The cutting remits but the acting out – street drugs, sexual misadventures (including the “accidental blow job”), and repetitive, endless phone calls – ramp up.

So what happens? Along comes Prozac [fluoxetine] and Dr Sterling gives it to her. Wurtzel is feeling better as a result of the medicine. But “better” is relative. Wurtzel gets into it with her psychiatrist, and she locks herself in the bathroom and takes the whole bottle of Mellaril [thioridazine], knowing that her shrink is waiting outside the door for her. As Wurtzel feels herself going under from the effects of the drug and she hears her shrink shouting outside the door, she unlocks it.

Now never say that someone who threatens suicide or actually swallows the pills is not suicidal. Never. People have been known to be all-too-unlucky in such situations and succeed where they are using a bad method to try and solve the problem of their suffering. I suggest this was one of those, and arguably as a result of the un-inhibiting effects of the Prozac.

Those are such facts as reported in the narrative. Throughout the book, Wurtzel is plagued by suicidal thoughts, she cuts herself and engages in taking street drugs and crazy sex, but not until she gets the Prozac does she actually take action and make a serious attempt at suicide. Hmmm.

I am not making this up. It is in the book. Has anyone read it since 1994? This is the book entitled “Prozac Nation” and is regarded as some kind of strange endorsement for Prozac. Wurtzel subsequently and consistently denied it was an endorsement of fluoxetine [Prozac], emphasizing her commitment to being self-expressed. That she succeeds in doing in spades. Definitely. What some authors won’t do to move some copy!

I read Wurtzel’s memoir for the first time ever upon learning of her passing on January 7, 2020. We can measure the distance between the publication in 1994 and today in that of all the reviews between then and now no one – not one – mentioned that the fear of abandonment, the invalidating early environment and ongoing invalidating entanglement with the warring parents, the volatile emotions (especially atypical depression), volatile relationships, volatile self-identity, and para suicidal behavior are the check list for borderline personality disorder.  I hasten to add checklists are overrated, and I acknowledge I might have missed something.

However, it does put me in mind of a quotation from Marsha Linehan, innovator in Dialectical Behavioral Therapy (DBT), and who, in the  video cited below, is talking on camera with permission with an avowedly suicidal patient. Linehan says: “I think it is good that you see it as a problem that you feel suicidal and want to fix that; but suicide is not so much a problem as a solution.” Pause for jaw dropping effect. “People’s lives are so messed up that they want to check out as away of solving the problem. What our program does is help you find a better solution – so it is not really a suicide prevention program so much as a life worth living program.”

Elizabeth Wurtzel succeeded in having one of those lives worth living, even without a formal program and in spite of all the challenges put in her path by accidents of biology, early experience, and her own demons. She had gifts aplenty and she managed to use them to attain a good measure of power, freedom, and full self-expression. Above all, self-expression. We are enriched by Wurtzel’s comet-like trajectory through our post-modern modernity and diminished by her passing. It is truly an ask-not-for-whom-the-bell-tolls moment.

REFERENCES

Elizabeth Wurtzel, (1994) Prozac Nation: Young and Depressed in America, New York: Mariner Books (Houghton Mifflin Harcourt (paperback edition), pp. 339, $16.99.

‘I believe in love’: Elizabeth’s Wurtzel’s final year, in her own words by Elizabeth Wurtzel, https://gen.medium.com/i-believe-in-love-elizabeth-wurtzel-s-final-year-in-her-own-words-e34320e41ee0 

Bastard Neither of my parents was exactly who I thought they were by Elizabeth Wurtzel, https://www.thecut.com/2018/12/elizabeth-wurtzel-on-discovering-the-truth-about-her-parents.html

Elizabeth Wurtzel by Liz Phair, June 16, 2017, https://www.interviewmagazine.com/culture/elizabeth-wurtzel

Lou Agosta, (2018), Empathy Lessons, Chicago: Two Pears Press: https://www.amazon.com/Lou-Agosta/e/B07Q4XX6PF/ref=dp_byline_cont_book_1

Marsha Linehan talks with a patient about borderline personality disorder and dialectical behavioral therapy: https://www.youtube.com/watch?v=tgzw50SbokM

© Lou Agosta, PhD and the Chicago Empathy Project

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