Dealing with Post-Catastrophe—Resilience

This final chapter discusses the complex phenomenon of resilience: how some people weather the storm of crisis. It also describes the limitations of resilience and the importance of treating individuals who lack or lose it. A discussion of attachment as a factor relevant to IPT and to resilience suggests one mechanism through which IPT may benefit patients and impart resilience. Brief IPT may actually repair long-standing attachment difficulties, thus improving interpersonal comfort and functioning. The chapter also reviews the concept of post-traumatic growth in the context of the pandemic. Finally, it documents the uncertain situation in which we find ourselves at this juncture in the pandemic.

Posttraumatic Stress

This chapter describes the adaptations of IPT for treating PTSD, the DSM-5 diagnostic criteria for PTSD, and the research supporting the use of IPT as a non-exposure treatment for this disorder. This research includes a National Institute of Mental Health randomized trial conducted by the author comparing IPT to prolonged exposure therapy and to relaxation therapy, with quite positive results for IPT. Adaptation includes the importance of affective attunement to counter traumatic numbness. There follow three detailed case examples of IPT treatment of complicated grief, role dispute, and role transition associated with PTSD during the Covid-19 pandemic.

In the Aftermath of Upheaval

This chapter provides recent historical background for the book: a brief recounting of the onset of the pandemic and its medical and social consequences. It describes in detail some of the losses due to Covid-19, including the loss of sense of safety and health; loss of income and employment; and, too often, the loss of loved ones. The lockdown disrupted social rhythms, a disorienting and anxiety-generating experience for many. With social distancing comes the potential loss of social supports, a risk factor for psychopathology. Excessive social media use is another related psychological risk. Part of the problem for people lies in gauging: how much upset is normal and appropriate in an upsetting time, and how much is excessive and symptomatic? In this destructive context, we anticipate, and are already seeing, a wave of psychiatric disorders following the surge(s) of the virus.

Interpersonal Psychotherapy

This chapter introduces the basic principles, structure, and techniques of IPT: a brief treatment manual for the (tele-)clinician. IPT is a time-limited, affect- and life event–based psychotherapy that helps patients master a life crisis, often by mobilizing social support and learning to use feelings to understand and manage interpersonal encounters. The basic paradigm is that feelings and symptoms arise in an interpersonal context: feeling and situation are connected. The IPT framework includes making a diagnosis, taking an interpersonal inventory to explore the patient’s relationships and current life crises, giving patients the no-fault, medical model “sick role,” setting a time limit, and providing a formulation linking the patient’s diagnosis to a focal problem area on which the therapy will thereafter focus. The problem areas are grief (complicated bereavement following the death of a significant other), role dispute (a struggle with someone), or a role transition (any major life change). The chapter also stresses the importance of affect tolerance and building a treatment alliance and provides a Social Rhythm Metric and a Covid Behavioral Checklist.

Termination

This chapter elaborates on the termination phase of acute IPT, already briefly discussed in Chapter 3 of this book. It describes the need to consolidate and reinforce treatment gains; to ask the patient why he or she is feeling better; and to acknowledge feelings associated with the role transition of ending treatment. Patients who have not improved in brief IPT should be offered alternative effective treatment. The chapter also addresses indications for and utilization of making a new therapeutic contract for continuation and maintenance IPT and the likelihood that extending treatment will be beneficial in the setting of ongoing disaster.

Anxiety and Other Distressing Symptoms

This omnibus chapter covers anxiety disorders and other psychiatric disorders that may arise or be aggravated by the pandemic. Some anxiety is of course warranted in the midst of a crisis of ongoing risk and uncertainty; therapist and patient must try to separate appropriate from symptomatic anxiety. The chapter includes a discussion of prior IPT research for these disorders, appropriate IPT adaptations, and extended, detailed case examples illustrating the application of IPT to panic disorder, generalized anxiety disorder, and social anxiety disorder. It also addresses how the pandemic may trigger or exacerbate other diagnoses for which IPT has shown benefit.

Major Depression

Utilizing the elements described in the previous chapters, this one applies the IPT approach to patients with major depressive disorder in the setting of the Covid-19 pandemic. Major depression is a common sequela of disaster. Major depression is also the disorder for which IPT was first tested and has been most frequently evaluated, and for which it is considered a first line, practice guideline-recommended treatment. Four extended, detailed Covid-19 related case examples cover the three focal IPT problem areas of grief (complicated bereavement), role dispute, and role transition. These cases also underscore the importance of cultural issues in personalizing IPT to the treatment of individuals.

How the Pandemic Has Transformed Psychotherapy

Based on a recent article by the author and his colleagues published in the American Journal of Psychiatry, this chapter describes the overnight conversion of outpatient psychiatry from in-person treatment to remote tele-therapy. The chapter details the relatively small research base supporting tele-therapy and the limitations of that research. It describes both the advantages of tele-therapy, namely access to ongoing care, and its numerous limitations and distractions. These include issues of the treatment setting, transmission difficulties, electronic intrusions, physical discomfort, and emotional distancing. Nonetheless, at a time when many people need psychiatric treatment, tele-therapy can be invaluable.

Life Crises

This chapter details the process of the IPT therapeutic treatment approach in the three focal problem areas: grief (complicated bereavement), role dispute, and role transition. (The potential fourth IPT problem area is unneeded in the setting of disaster.) Each involves a basic treatment paradigm spread across the three phases of treatment, including an opening question to determine recent affectively charged events; communication analysis, to help patients understand their feelings in a recent interpersonal situation; exploring options, to resolve interpersonal difficulties; and role play, to help patients practice those options. IPT assigns no homework but uses the time limit to press treatment forward. Although the three problem areas differ thematically, all involve solving an interpersonal crisis by interpersonal means.

Introduction

The introduction sets the stage for the book to follow: it describes the 2020 Covid-19 pandemic; the losses, risks, and life changes it is entailing; and their psychological consequences. A crisis evokes strong, distressing feelings and symptoms. The introduction presents interpersonal psychotherapy (IPT), a proven, time-limited treatment for mood, anxiety, and posttraumatic disorders, as likely to be a helpful response to this crisis. IPT is a life event–based therapy for symptoms due to an overwhelming global series of life events. The brief introduction alerts the reader to the main psychiatric consequences of major life disruption and trauma: anxiety, depression, and posttraumatic stress, which succeeding chapters will cover. It describes the forced switch to tele-psychotherapy and provides a rationale for why interpersonal therapy is likely to benefit many people sustaining these losses.