Interpersonal Psychotherapy for Depressed Adolescents: Advanced Workshop

Laura Mufson, Ph.D. Jami Young, Ph.D. ISIPT Meeting June 10, 2015

Conflict of Interest

❑ Laura Mufson, Ph.D. receives royalties from book: Interpersonal Psychotherapy for Depressed Adolescents, second edition, 2004. Guilford Publications.

❑ Jami Young, Ph.D. has no conflicts of interest.

Overview of Workshop (1)

1. Focus on interpersonal formulation ! How to decide between different problem areas? ! How to make the formulation reflect what the adolescent has

told you about her relationships? ! How to share the formulation with the adolescent and make sure

she understands and agrees?

Overview of Workshop (2)

2. Focus on the middle phase ! Using the two most common problem areas (role disputes and

role transitions), what does the middle phase look like? ! How are the problem area specific strategies and general

techniques (i.e., communication analysis, decision analysis, role play, work at home) applied in the middle phase?

! How do you decide which direction to take in a session? ! How are parents involved in the middle phase of IPT-A? ! How to deal with challenging situations?

3. IPT-A adaptations

INITIAL PHASE

Goals of Initial Phase

❑ Identify and diagnose symptoms ❑ Educate about depression ❑ Assign limited sick role ❑ Explain theory of IPT-A ❑ Conduct interpersonal inventory ❑ Identify the problem area ❑ Set treatment contract

Problem Area Formulation

❑ A hypothesis to address several questions: ❑ How did the patient come to be the way he or she is? ❑ What factors are maintaining the problem? ❑ What can be done about it?

❑ Should validate the patient’s experience and way of understanding the problem

❑ Results in a mutually determined focus for treatment ❑ Provides a plausible rationale for the use of IPT-A for

the problem

Giving the Formulation (1)

❑ The formulation should be brief and should focus on the interpersonal issues most directly related to the depression

❑ Structure: ❑ Summarize depression symptoms and when they started ❑ Identify what relationship they seem most related to ❑ Discuss how that relationship appears to impact on mood from

information gathered during inventory ❑ Share hope that you can help the teen to learn new strategies for

communicating and problem-solving that will likely improve the situation and then the mood will improve

❑ Stress the link between the identified difficulties and the mood

Giving the Formulation (2)

❑ Ask for feedback about the formulation ❑ Does it make sense to her? ❑ Did something get left out? ❑ Does she feel it will be helpful to focus on this relationship?

❑ Discuss any disagreements about what the focus of treatment should be

FORMULATION PRACTICE

TaraMom

DadEric (boyfriend)

April (friend)

Lisa (sister)

James (Sue’s son)

Tom (Sue’s son)

Sue (Dad’s GF)

Gabby (friend)

Tara’s Closeness Circle

These past few weeks we have discussed the important relationships in your life. It sounds like the two relationships most closely linked to your depression are your boyfriend, Eric, and your dad. From what you have been saying, it sounds like your depression really started this year when you began 11th grade on your own for the first time in that school since Eric graduated in June. During the past two years you spent almost all your time with Eric and therefore didn’t have other close friendships in school when he left, making you feel isolated and alone. It sounds like your feelings of depression are also affecting how you behave towards Eric which increases the conflict between the two of you, which further worsens your mood. !While you describe the start of school as the time of your depression getting worse, it sounds like you have been struggling a bit in your relationship with your father and his girlfriend for several years and that this relationship has gotten increasingly more difficult in the past year. As you’ve started to feel more depressed and irritable, you’ve found it harder to get along with your dad. You don’t want to go to his house anymore and when you are there you withdraw to your room. You’ve stopped talking to him and mainly communicate through your sister.

Case Formulation: Tara

You are having trouble communicating your feelings in these important relationships which prevents you from getting the understanding and support you need, and your irritability is further impacting these relationships. Does that make sense to you and sound right? Can you tell me it in your own words?   What we want to do in here is help you adjust to the recent changes in your life and to help you resolve the conflict with your dad which is having a large impact on your mood. We will work on helping you communicate your feelings more openly and effectively so that you can feel supported and be able to negotiate and problem-solve situations you would like to change, in particular with your dad and Eric. I think these changes will make you feel less depressed and more understood. Let’s figure out which relationship to focus on first.

Case Formulation: Tara

Depression Circle

�

Precipitating Event ■ Problems in relationship with

boyfriend- started school without him there

■ Having difficulty with father

Feelings ■ Sad ■ Irritable ■ Angry

Relationships ■ Have more conflict with boyfriend ■ Have conflict with father and

mother

Feelings ■ Feel more depressed – grades

declining, ■ Feel bad about yourself ■ Feel guilty and self-critical

Relationships ■ Stop spending time with friends

and going out on the weekends ■ Intermittent break-ups with

boyfriend ■ More fighting with Dad ■ Stop talking to Dad

Feelings ■ Hopeless and helpless ■ Irritable and sad ■ Very tired

Tara’s Depression

Circle

Jennifer’s Closeness Circle

Jennifer

Mark(half-brother)

Susan (older sister)

MomRay (brother)

Step-dad

John (half-brother)

Eric (half-brother)

Elena (niece)

Michael (nephew)

Karen (friend)

Jill (friend)

Randy (male friend)

Case Formulation: Jennifer

Your depression is happening at the same time as many transitions in your life. In addition to starting high school, you are in the process of figuring out how to have romantic relationships, and what kind of person you want to be. Given your family cultural background, the process of separating from your family and the values that they have tried to ingrain in you, figuring out who you want to be is very complicated. Your mother grew up in a rural town in Mexico and began working at a very young age. Her experience as a teenager is very different from yours as a teenager in New York City. Your mother is also very invested in your future and your education. She was unable to complete high school herself and she wants you to have a better life than she’s had. Because she is worried about you, she tries to control you by setting very strict rules on what you can do, for example she doesn’t’ want to allow you to date or participate in extracurricular activities at school. When your mom sets these restrictions, you feel like she doesn’t understand you and as though she isn’t on your side. This leads you to feeling more hurt and misunderstood and you respond by arguing back and rebelling even more against her restrictions.

Case Formulation: Jennifer

This causes even more arguments between you and Mom and then she places even more restrictions on you. After the arguments, you described feeling guilty and you start to isolate from your family both by hiding your feelings from them and staying in your room. Sometimes, the arguments are so tense that you get a headache that lasts until the next day or you notice your appetite has gone away and you can’t concentrate at school. Your mother doesn’t seem to know how to help you with this transition to being an adolescent or how to support you during this time.

One of the things I’d like to work on with you in treatment is to help you communicate more effectively with your mom so she can understand what you are feeling more clearly which might help you get the opportunity to show her you can be more independent, and at the same time reassure her that you are being responsible and safe. Communicating more with Mom about your feelings about the rules she has made and your desire to participate in normal school activities will likely improve your relationship with her, increase her trust in you and result in a decrease in your depressed mood.

Depression Circle

�

Precipitating Event ■ Conflict with mother about

wanting to have more independence

Feelings ■ Sad ■ Irritable ■ Angry

Relationships ■ More heated arguments with Mom ■ Refusing to obey rules at home

Feelings ■ Feel more depressed – grades

declining, poor concentration ■ Feel guilty and self-critical ■ Somatic symptoms ■

Relationships ■ More intense arguments with

Mom ■ More fighting with female

friends

Feelings ■ Hopeless that things will get

better ■ Irritable and sad ■ Very angry

Jennifer’s Depression

Circle

MIDDLE PHASE

Middle Phase Sessions

❑ Begin each session with review of depression symptoms and mood rating

❑ Work collaboratively with adolescent to clarify the problem

❑ Work on interpersonal communication ❑ Identify effective strategies ❑ Assist in development of skills for negotiating

relationships

PROBLEM AREA SPECIFIC STRATEGIES

Role Disputes

❑ Strategies

❑ Relate depressive symptoms to the overt or covert dispute ❑ Explore unrealistic or mismatched expectations and their

contribution to the dispute ❑ Assess and modify maladaptive communication strategies ❑ Teach the art of negotiation

Role Transitions

❑ Strategies ❑ To understand what the change means to the

adolescent ❑ To identify what is demanded by the new situation

which is problematic ❑ To assess what will be gained and lost ❑ To master new interpersonal skills that will ease the

transition ❑ Facilitate negotiation between adolescent and parent

around transition

MIDDLE PHASE TECHNIQUES: APPLICATION TO PROBLEM AREAS

Communication Analysis

❑ Goals are to help the adolescent understand: ❑ The impact of his/her words on others ❑ The feelings he/she conveys with verbal and

nonverbal communications ❑ The feelings that generated the verbal/nonverbal

exchange ❑ The cyclical nature of communication ❑ The ability to modify these exchanges and then

the affect associated with the relationship

Specific Questions

❑ What did you say? ❑ What did s/he say? ❑ Then what happened? ❑ How did you feel? ❑ Was that the message you wanted to convey? ❑ How do you think it made ______ feel? ❑ How could you have said it differently? ❑ How do you think ______ would have felt? ❑ How would you have felt differently?

Decision Analysis

❑ Select an interpersonal situation that is causing conflict ❑ Encourage the teen to generate possible solutions to the

conflict ❑ Evaluate the pros and cons of each solution ❑ Select one solution to try first ❑ Rehearse the interaction needed for the first solution ❑ Review the interaction the following week examining

either its success or where it didn’t work and possible reasons why

New Communication Techniques

❑ Following communication analysis and decision analysis, the work focuses on how the adolescent can effectively communicate to address the interpersonal problem

❑ It may be helpful to teach and label specific interpersonal techniques that are appropriate to a given situation

Specific Communication Strategies

❑ Aim for good timing ❑ Use “I” statements ❑ Give to get – start off with a positive statement that

shows you understand how the other person feels ❑ Have several solutions in mind for negotiating ❑ Don’t give up

Role Playing

❑ Goals ❑ To give the adolescent a SAFE place to practice new

interpersonal skills (e.g., expression of affect) ❑ To give the adolescent the opportunity for rehearsal

and to receive feedback on skills and strategies prior to trying to apply it outside of therapy

❑ To improve the teen’s social confidence

Guidelines for Role Playing

❑ Role playing is an active technique – just don’t talk about what it would be like to do it – act it out

❑ Be prepared to initially have to coax some adolescents to do it

❑ For anxious teens – lead them to it gradually ❑ Talk through it first ❑ Structure it for them ❑ Allow them to play the role they are more comfortable

with initially and then switch roles with them

Importance of “Scripting”

❑ Before role playing, ask: ❑ What is the goal of the conversation? Without worrying about

how to say it, what would you want to convey? ❑ How can we say this in a way that is most likely to have a

positive outcome? Might the skills be helpful? ❑ How might you start the conversation? What might be the

person’s response? What can you say next? ❑ This allows you to come up with a script of the first few

statements to prepare the teen for the role play (and to give you a sense how to play the other person)

Homework

❑ Really “work at home” ❑ Explain to teens that they will be experimenting with new

skills at home between sessions ❑ To be created as needed to support the therapeutic work ❑ Developed as an outgrowth of work on a particular

problem ❑ Tailored to the individual patient and not necessarily

strictly prescribed

“Work at Home”

❑ Often comes out of a discussion or role play in session ❑ Or is assigned to address a particular symptom or issue

that continues to be problematic (e.g., being socially withdrawn)

❑ Goals: ❑ Help the teens own and internalize the new skills ❑ Gain a sense of mastery independent of therapist ❑ Improve important relationships

Middle Phase Implementation

What does the middle phase look like in a role transition or role dispute case in adolescents? How would you use these techniques in the cases of Tara and Jennifer? How do you decide what to focus on in a given session? ! General transition work around losses and gains in the new role vs.

targeted work on a specific relationship

How do you decide which relationship to target when there are multiple relationships related to problem area? What would be appropriate work at home assignments?

Dealing with SI/NSSI in Middle Phase

Jennifer and her mother had an argument in which her mother attempted to grab her phone and scratched Jennifer Upset from the fight, later that night in her room Jennifer scratched her wrist with a nail ! She had a history of superficially cutting her leg and wrist since

age 13 but had not engaged in NSSI since initiating current treatment.

Treatment Options: ! Work on communication of feelings individually with teen ! How much parent involvement – meet individually? ! Dyadic session?

Parent Involvement

Purpose of Teen-Parent Session

❑ The purpose of the middle phase dyadic session differs depending on the problem area

❑ If the problem area does not involve the parent, purpose can be to update parent on progress and to engage parent’s support of middle phase work

❑ If the problem area involves the parent, purpose is to help the teen and parent communicate in a new way ❑ Goal is not necessarily to resolve a problem or reach a solution

but to improve the process of communication

Preparing for Teen-Parent Session

❑ Need to prepare teenager in session before dyadic session

❑ Pick a low intensity topic to discuss ❑ Discuss techniques that would be useful ❑ Script conversation ❑ Role play conversation ❑ Discuss who will invite the parent in for session

Therapist in Teen-Parent Session

❑ Provides an introduction to parent about the purpose of the session

❑ Acts as a coach to the teen ❑ Encourages the teen and parent to talk to each other,

rather than talking through the therapist ❑ Intervenes if the conversation gets too hot and reminds teen

and parent of the techniques that may be useful ❑ Observes the interaction and uses this information to guide

future interventions

Structure of Teen-Parent Session

❑ Meet with the teen alone to conduct symptom review and mood rating and to review the main points that will be discussed (15 minutes) ❑ May also meet with the parent alone to prepare them for the

session (this is useful if you anticipate resistance) ❑ Meet with the parent and adolescent together (25 minutes) ❑ Meet with the adolescent after to debrief (10 minutes)

Session with Parent Alone

Occurs when therapist has concerns about the ability for the parent to be supportive in the dyadic session Engage parent in supporting the teen’s work in the sessions and to be open to change Specific Goals: ! Assess parent’s understanding of the problem and provide more

psychoeducation when necessary ! Assess whether teen’s goals are feasible with the parent or

whether the goals need to be revised

Teen-Parent Session Implementation

How might parents be involved in the case of Tara? Jennifer? What would you choose to focus on in the session? When is the opportune time for having a parent session? ! Need to think about this in advance as need at least one session

to plan for teen-parent session When would you consider meeting with parent alone?

IPT-A ADAPTATIONS

IPT Adults

IPT- for Adolescents (IPT-A)

Efficacy

IPT-A in Schools

Prevention of Weight Gain in Adolescent Girls

MCI + IPT-A for Black Teens in Schools

IPSRT for Bipolar Adolescents

UTALK Prevention Program

Delivery of IPT-A in the Schools

❑ IPT-A delivered by school-based clinicians ❑ More flexible ❑ First 8 sessions weekly ❑ Last 4 sessions anytime in remaining 8 weeks ❑ Clinical trial showed that IPT-A was more effective than TAU

in reducing depression symptoms and improving social functioning

Stepped Care Model in Primary Care (SCIPT-A): Phase I

8 Sessions of IPT-A Modifications from the pilot study ! 8 rather than 6 sessions ! Added parent involvement in session 5 or 6 ! Allowed for additional parent session if needed Delivered by the clinic social worker SCIPT-A Training ! 1 day of didactics ! One hour of weekly group supervision - 4 clinicians ! Audiotape every session: 1st 3 cases – every session reviewed and

rated and then 3 tapes per case after that

Phase II: Combined IPT-A and Medication Visits and Consultation

Continue with 8 more weekly IPT-A sessions Pediatrician visits ! Medication dispensation and management ■ 10-15 minute patient visits at Weeks 1, 2, 4, 6, and 8

! Child Psychiatrist - phone check-ins with pediatrician for consultation ■ At least 3 times during Phase II ■ Also done as needed

Group IPT-A

❑ 6-8 adolescents with depressive disorders ❑ Two individual pre-group sessions to conduct initial tasks (e.g.,

psychoeducation, interpersonal inventory) ❑ Twelve group sessions – 90 minutes each ❑ Mid-group parent-adolescent session ❑ Post-group parent-adolescent session ❑ Typically don’t include kids with the grief problem area

Interpersonal Psychotherapy – Adolescent Skills Training

❑ A school-based prevention group for adolescents with elevated depression symptoms

❑ 2 pre-group sessions ❑ 8 group sessions – 90 minutes each ❑ Focus is more on psychoeducation and interpersonal skill-

building that can be applied to different relationships

Other Adaptations

❑ IPSRT-A: IPT for bipolar adolescents – prevention and intervention

❑ IPT-WG: IPT for prevention of excess weight gain for at-risk adolescent girls

❑ IPT-FB: IPT for prepubertal depression ❑ IPT-MBD: IPT for mood and behavior dysregulation

SAMSHA National Registry for Evidence-Based Programs list of Legacy Programs

Adolescent Coping With Depression (CWD-A)

Attachment-Based Family Therapy (ABFT)

Brief Strategic Family Therapy

Cognitive Behavioral Therapy for Adolescent Depression

Coping Cat

Family Intervention for Suicide Prevention (FISP)

HOMEBUILDERS

Interpersonal Psychotherapy for Depressed Adolescents (IPT-A)

Mindfulness-Based Stress Reduction (MBSR)

Multisystemic Therapy (MST) for Juvenile Offenders

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)