Working with depression
Healthcare Counselling and Psychotherapy Journal, April 2022

People who report chronic low mood or depression, sometimes known as dysthymia, can be challenging to the therapist. The depressed person might initially be met with the sympathy of others. But that sympathy might soon wear thin, to be replaced by irritation and withdrawal,¹ a process that might easily play itself out in the therapy room. The patient might also see their depression as an innate aspect of their personality, and therefore untreatable.

Interpersonal psychotherapy is recommended as a treatment for depression. In my experience, it is also effective in the treatment of dysthymia.

So, how is dysthymic disorder identified – and how is it different from a severe depressive episode without psychotic symptoms?² Severe depression is often easier to recognise, due to its acute nature. Dysthymic disorder tends to be less obvious. It is described as depressed mood for most of the day, more days than not, as indicated by the sufferer’s subjective account or observation by others, for at least two years.³ As with many mood disorders, comorbidities are likely to occur with dysthymia. Markowitz⁴ cites severe depression, as well as anxiety disorders, substance abuse and personality disorders.

Dysthymia is a chronic condition, but the patient might well be presenting for therapy as a response to a recent life event, such as a job loss or bereavement, which has made their mood worse.

Dysthymic patients are more likely to conceal their difficulties, perhaps as a result of the chronicity of the condition. The chronicity often leads to adaptations, which can appear both at home and in the workplace.⁴

To compensate for their lack of self-esteem,³ dysthymic patients often expend what little energy they have striving at work to appear outwardly ‘normal’; indeed, they tend to be hard and loyal workers.⁵

Personal and social interactions can also prove difficult, due to the unpredictability and emotional risk involved.⁴

Dysthymic patients often experience difficulties in asserting themselves, expressing anger and taking risks in social and intimate relationships. They can therefore experience isolation, which can contribute to the emergence of depressive symptoms.

Of course, counsellors and psychotherapists are not usually qualified medical practitioners, so are not authorised to offer a formal diagnosis. However, a therapist and their patient can agree dysthymia to be the likely difficulty, and plan treatment accordingly.

If their dysthymic symptoms have been lifelong, the patient might never have learnt interpersonal skills, such as the forming and sustaining of close and intimate relationships. They can consequently view their dysthymia as an aspect of their personality, rather than an illness. The therapist then has the daunting task of not only helping the patient to gain symptomatic relief, but also to learn the interpersonal skills they did not acquire at the appropriate time in their development.

Patients suffering from severe depression can usually recall times of remission from symptoms, when they have been able to enjoy life. Dysthymic patients do not have the luxury of such memories,⁴ which makes it more of a challenge for the therapist to instil the hope and optimism in the patient that they will get better.

The therapist must therefore help the patient to distinguish between ‘trait’ and ‘state’, so the patient can more clearly see their depression as an illness. They can then better understand it and believe it to be treatable.

Before 1980, dysthymic symptoms were considered to be indicative of a depressive personality disorder. Dysthymic disorder was reclassified as a mood disorder with the publication of DSM-3 in 1980. Previously, long-term psychodynamic psychotherapy and psychoanalysis were the talking therapies of choice, although there was little research evidence to support their efficacy.

Interpersonal psychotherapy

The origins of interpersonal psychotherapy (IPT) go back to the 1970s, when Gerald Klerman and his colleagues worked collaboratively to develop a targeted system of talking therapy to treat depression. The group was made up of psychiatrists, psychotherapists, social workers and researchers, who were interested in how the social, biological and psychological aspects of depression intersect, and how they could be used together in treatment.⁶

There is a large body of research into the effectiveness of IPT as a treatment for depression. Consequently, it is now an evidence-based intervention, recommended as a treatment for depressive disorders by NICE guidelines, and is widely used in Improving Access to Psychological Therapies (IAPT) services in the UK.

IPT is a brief, structured, present-centred therapy that is usually delivered over 16 sessions, made up of three phases: early, middle and end. It is designed to disturb or disrupt depressive symptoms and gives the patient experience of fluctuations in their depression, creating the space to bring about change.

IPT is an active therapy that requires the patient to increase their engagement with others and with pleasurable activity, in order to reduce isolation. The therapist is not a neutral party or passive observer, but an active participant in the process.⁷

An integral part of the model is the symptom review that takes place every session. The review is designed to help the patient to track their depressive symptoms and to better identify variations. The aim is to enable the patient to become the expert on their own depression and to understand that their depression is fluid, not static. For example, changes in mood, sleep, appetite and libido can all be indicators of improvement. In IAPT services, questionnaires are also used in each session to identify and track the patient’s symptoms of depression and their overall functioning.

In IPT, we encourage our patients to engage with other people and pleasurable activities. So, we enquire about the patient’s activities since our last session. The dysthymic patient might not have participated in an interest or hobby in many years. But the therapist should not give up. Encouraging the patient to become engaged in hobbies and activities increases their chances of making social contacts, which can open the door to the use of strategies, such as communication analysis and role play.

In session one, the tasks are to outline the IPT structure, pinpoint the patient’s key difficulty, deliver psycho-education and draw up an initial therapy contract. I would also begin to help the patient identify their depressive symptoms and recognise fluctuations, so introducing the concept of their condition as an illness.

When delivering psycho-education, I normally start by asking the patient about their understanding and experience of depression. In my experience, the dysthymic patient is likely to talk about the chronicity of their depression, which they view as part of their personality. At this point, the therapist can find out how long the person thinks they have been depressed and the effects of the depression on their relationships.

If dysthymia is identified, it is helpful to put forward the ‘trait’ versus ‘state’ argument, to encourage the patient to accept that they are unwell, so they can start to experience their depressive symptoms as ego-dystonic, as opposed to innate. They can then develop mastery over their symptoms and engage with supportive others and pleasurable activities.

Initially, a dysthymic patient is unlikely to be convinced. It is, therefore, the therapist’s task continually to reiterate this point throughout the therapy, in a spirit of hope and optimism. It should be clear to the patient that their mood disorder is an illness, which is treatable. The therapist can also explain that IPT has a solid evidence base for effective treatment of such conditions.

In the second session, I would take a history of the patient’s episodes of depression. The history tends to be presented as a timeline, showing triggers, any previous treatment and any changes that influenced the depressive symptoms. It can be challenging, as the dysthymic patient is unlikely easily to recognise triggers or factors that change the state of their depression. It can also be useful to identifyperiods that were free from depression. They are likely to be few and far between, but they will support the argument
that the depression is fluid and hence more treatable.

We would take an interpersonal inventory in session three, which is often a diagram, representing the people and relationships in the patient’s life. It is typically presented in the form of a constellation, showing how the patient perceives their distance from those around them. The constellation helps to identify the patient’s degree of isolation and possible sources of support.⁷ Particular attention should be given to current, close, supportive relationships, and what the patient expects and gets from them. Unsatisfying relationships in the past and present are of interest and underlying patterns noteworthy.

The final session of the early phase of therapy (session four) is used to refine the therapeutic contract and to set goals. It can be challenging to set goals with dysthymic patients, who have little experience of anything other than their chronic state. A dysthymic patient could well find it difficult to conceptualise a goal, as it might be something they have not previously experienced – a caring and satisfying relationship, for example. The therapist and patient can agree sub goals, such as joining a club or society, where there are the opportunities to meet people, as staging posts towards a meaningful relationship. But these markers need to be concrete and achievable.

In the fourth session, a formulation is also presented to the patient, informed by what has been learnt so far, primarily from the timeline and interpersonal inventory. The formulation is crucial in reinforcing to the dysthymic patient that they are suffering from an identifiable illness that is treatable. The use of a definition for dysthymic disorder could also prove helpful, in that the patient can better see their condition as treatable. The formulation influences the choice of focal area for the middle and end phases of the therapy.

The focal area is a pivotal feature of IPT.⁷ It serves two main functions: first, it determines the current issue(s) contributing to the patient’s interpersonal difficulties that caused and/or are driving their depression; second, it provides a set of treatment strategies for use in the middle and end phases of therapy. There is a choice of four focal areas: complicated bereavement, transitions, interpersonal role dispute and sensitivities.

Complicated bereavement

We talk of complicated bereavement when the patient has recently lost someone significant, but the grieving process has either not taken place or has been arrested in some way. The death of someone close can elicit great distress in the dysthymic patient, perhaps because they tend to have few, intimate relationships.⁴ But it can provide the therapist with the opportunity to elicit affect and help the patient to process their loss. It could also alleviate their depressive symptoms, by allowing them to access feelings of sadness and anger, which are often difficult to express. If the patient can free up the grieving process, it could enable them to explore possibilities for initiating and developing new relationships.

Transitions

We would consider a transition to be a major change in the patient’s life, such as redundancy, divorce or leaving home for university. A novel feature of IPT for dysthymia is to regard the dysthymic disorder as a transition in itself, the transition from illness to health. The patient is likely to have been depressed for a long period, often stretching into decades. The work might therefore involve helping the patient to understand what it’s like to be well. The new possibilities of a life of wellness can be explored, along with the potential for new relationships, the development of new interests and a greater engagement by the patient in the world around them.

Interpersonal role dispute

People with dysthymic disorder tend to have unequal relationships of limited intimacy.⁴ Feelings of unworthiness, inferiority and inadequacy can stifle their abilities to assert and express themselves, leading to the pent-up emotions that can feed their depressive symptoms. Interpersonal difficulties are common and can result in tensions or disputes, which can become ‘stuck’. Work is then needed to free up the sticking points and resolve the dispute.

Dysthymic patients are more likely to settle for any relationship rather than none, often due to the sparseness of their network.⁴ Therefore, therapist and patient need to explore and decide whether a relationship is genuinely satisfying. It is likely to be a challenge for both therapist and patient to define what would be a satisfying and fulfilling relationship for the patient. But once these needs and desires are uncovered, therapist and patient can explore available options.

Dysthymic individuals often suppress anger, due to a fear of ‘rocking the boat’ and losing the overvalued partner or friend.³ The patient might not even be aware that they are feeling anger, substituting it for guilt or self-criticism.^8–10 The internal rage can result in masochistic relationships, where the patient’s  unwillingness to set boundaries means they suffer the other person’s hurtful behaviours. Helping the patient to recognise the connection between their depressive symptoms and the behaviours of others around them can herald a new understanding, clearing the way to employ new strategies within their relationships. It might be the first time they experience their own power to control events and alter their lives.

Interpersonal deficits (sensitivities)

Due to the chronicity of dysthymic disorder, patients might not have acquired the skills necessary to establish and maintain satisfying social interactions. For example, they might not have learnt how to reciprocate people’s interest in them. Indeed, it’s possible that these deficits predispose the patient to depression. Consequently, the sensitivities focal area is the most difficult to treat using IPT. However, the therapist can help the patient to reduce their depressive symptoms by encouraging them to increase their engagement with their network and pleasurable activities. Challenging the thoughts and feelings the patient carries about themselves can also help to modify the behaviours they use in their interactions with others.

In the middle phase, the therapist would link any symptoms and difficult interpersonal events, such as an argument, to the agreed focal area(s).¹ For example, let’s say the focal area is dispute. The therapist could explore with the patient strategies for moving the dispute on. As always, it’s crucial to maintain a present-centred framework, to discourage the patient’s ruminations on past losses and failures. It can also help to mobilise their energy to manage their current symptoms and use their network of supporters to aid recovery.

Ending therapy

IPT, like many therapies, attaches a great deal of importance to therapeutic endings. As IPT is a time-limited therapy, it is essential to prepare the patient for when therapy ends.

Dysthymic patients tend to overvalue relationships, so it’s important to allow the patient to express their feelings around ending therapy, which might include anger towards the therapist. The feelings need to be accepted and acknowledged.

It’s important to show the patient how far they have come and how they are ready to transform their dependence into healthy independence. A review of the therapy is carried out, which involves the therapist and patient accounting for the progress the patient has made and what they did to reduce their depressive symptoms. The strategies and techniques the patient has learnt through IPT will help them to be their own therapist, keeping themselves well in the future.

If continuation or maintenance sessions are decided upon, the therapist needs to step back, dilute their own input and place more emphasis on the patient’s new-found skills in maintaining their depression-free state. The entire IPT treatment needs to be considered a transition in itself, from being depressed to being healthy.⁴

The IPT stance that dysthymia is an illness, and that it’s treatable, is paramount, as is the continual instilling of hope.