Interpersonal Psychotherapy Informed Treatment for Avoidant Personality Disorder With Subsequent Depression

Abstract

This is a single-case study of a young woman with avoidant personality disorder (APD) and subsequent depression, worry, lack of motivation, feelings of inadequacy, and nonassertive behaviors in her romantic relationship and professional career. Treatment was informed by interpersonal psychotherapy (IPT) for depression and also utilized assertiveness skills training. The client’s self-confidence was tracked daily, using a subjective self-report measure, and the completion of personality and symptom assessment measures before treatment (Phase A) and during the termination stage of treatment. Simulation Modeling Analysis for Time Series evaluated the change in levels of self-confidence across baseline, active treatment (Phase B), and termination (Phase C). In addition, reliable change was assessed using a comparison of Minnesota Multiphasic Personality Inventory 2–Restructured Form and Symptom Checklist-90–Revised results from baseline and Phase C. The patient experienced symptom improvement in self-confidence, somatic complaints, stress and worry, anxiety, and depression, suggesting that IPT techniques may be useful in the treatment of APD.

Keywords

time series major depressive disorder avoidant personality disorder interpersonal psychotherapy assertiveness training

1 Theoretical and Research Basis

Description of Avoidant Personality Disorder (APD) and Major Depressive Disorder (MDD)

APD is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and extreme levels of sensitivity to negative evaluation beginning in early adulthood. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000), all personality disorders are grouped into one of three clusters based on symptom similarities, and APD, along with dependent and obsessive-compulsive personality disorders, are categorized as Cluster C disorders and conceptualized as anxious or fearful personality structures. A diagnosis of APD requires at least four of the following symptoms: (a) avoidance of occupational activities involving interpersonal contact for fear of criticism, disapproval, or rejection; (b) unwillingness to be involved with others unless certain of being liked; (c) restraint in intimate relationships for fear of being shamed; (d) preoccupation with social criticism or rejection; (e) inhibition in social situations due to feelings of inadequacy; (f) views self as social inept, unappealing, or inferior to others; or (g) highly reluctant to take risks or engage in new activities for fear they may be embarrassing (APA, 2000). According to the DSM-IV-TR (APA, 2000), onset of APD, which is sometimes considered an alternate conceptualization of social phobia, may “abruptly follow a stressful or humiliating experience, or it may be insidious” (p. 453). The primary difference between APD and social phobia is that individuals with APD have more severe and long-standing symptoms that are present throughout most social experiences. Not only does this character structure inhibit one’s social functioning, but there are also high rates of comorbidity between APD and depressive disorders, and avoidant symptoms are exacerbated when a depressive disorder is present (e.g., Alpert et al., 1997). According to the DSM-IV-TR, approximately between 0.5% and 1.0% of the general population suffers from APD, and no significant differences have been found across genders (APA, 2000).

MDD is characterized by one or more episodes of depressed mood or loss of interest accompanied by at least four additional symptoms (i.e., anhedonia, significant weight loss or gain, disturbed sleep patterns, psychomotor agitation, loss of energy, feelings of worthlessness, difficulty with concentration, and thoughts of or attempts at self-harm). In addition, the symptoms must interfere with occupational, social, and/or other important areas of functioning, or at least require significant effort to maintain a normal level of functioning (APA, 2000). Major depressive episodes often are precipitated by a variety of factors, including low self-esteem (Roberts, Gotlib, & Kassel, 1996) or major life events such as an unhealthy relationship or the loss of a family member or job. MDD is more commonly experienced by women than men and has a high lifetime risk for females in the general population (between 10% and 25%), regardless of ethnicity, education, income, or marital status (APA, 2000).

Treating APD and Depression

The importance of a therapeutic alliance

Numerous researchers have shown the therapeutic alliance to be of utmost importance to the progress of treatment (e.g., Klein et al., 2003). In fact, one study found that therapeutic alliance predicted patient outcome beyond in-treatment change in depressed symptoms in clients with chronic depression, generalized anxiety disorder, or APD (Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000). This finding underscores the importance of a genuine and strong therapeutic relationship. More specifically, it is primarily the patient’s contribution to the therapeutic alliance that had a positive influence on the outcome of treatment, which indicates that the client’s comfort and investment in the therapy significantly impacts treatment outcome (Krupnick et al., 1996).

Treating APD

Unfortunately, there is little research assessing the effectiveness of specific treatments for APD (Alden, Laposa, Taylor, & Ryder, 2002). Overall, researchers have examined two main treatment modalities: cognitive-behavioral therapy (CBT) and brief dynamic therapy. One study compared cognitive and brief dynamic therapies to treat cluster C disorders and found both to be effective, with more symptom relief found in those who received the dynamic treatment (Svartberg, Stiles, & Seltzer, 2004). This same study found that 2 years after treatment, 54% of the dynamic psychotherapy patients and 42% of the cognitive therapy patients had recovered symptomatically. Additional research indicates that behavioral strategies can be effective in treating patients with APD (e.g., Alden & Cappe, 1986). Finally, a recent study compared short-term dynamic psychotherapy and CBT for APD, specifically, and found that CBT was more efficacious than brief dynamic therapy (Emmelkamp et al., 2006). Despite this last finding, to the best knowledge of these author, there have been no further treatment outcome studies examining effective treatments for this disorder. Whereas previous studies have found evidence to support the use of both a dynamic approach and a cognitive-behavioral approach, it is clear that more research is needed. Given that both psychodynamic and cognitive-behavioral approaches have been effective, this article explored how a treatment that incorporates key principles from both cognitive-behavioral and dynamic theories might be a novel and successful treatment for this disorder.

Interpersonal psychotherapy for depression

Evaluating treatments for MDD has received extensive empirical attention; thus, there are many distinct psychotherapy approaches that are considered efficacious in the treatment of adult MDD, such as CBT, supportive therapy, behavioral activation therapy, interpersonal psychotherapy (IPT), and problem-solving therapy (e.g., Cuijpers, Andersson, Donker, & van Straten, 2011). However, when considering treatment options for a depressed individual who also has significant interpersonal struggles, IPT for depression might be particularly effective. IPT is an eclectic psychotherapy approach that includes aspects of the medical illness model, utilizes a supportive therapy mindset, employs some traditional CBT practices, and recognizes the benefits of certain psychodynamic techniques. Specifically, the aspects of CBT that IPT shares include the emphasis on the “here-and-now,” using a directive therapeutic approach, and encouraging social functioning change, rather than character change (Bleiberg & Markowitz, 2008). However, similarly to psychodynamic psychotherapy, IPT also emphasizes raising awareness of affect and feelings that previously may not have been in the client’s awareness (Weissman, Markowitz, & Klerman, 2000).

IPT for depression has two main principles: The first is conceptualizing depression as a medical illness that is not due to a weakness in the client and the second is that the depression is linked to a recent negative or stressful life event (Bleiberg & Markowitz, 2008). As such, it can be a helpful treatment option for clients whose depression seems to be related to current interpersonal difficulties. IPT may be particularly beneficial for individuals who are struggling with “role disputes,” such as a conflict with a romantic partner. Depressed clients tend to put the needs of others ahead of their own and often “have difficulty asserting themselves, confronting others, or getting angry effectively, which makes it difficult to manage interpersonal conflicts” (Bleiberg & Markowitz, 2008). Thus, it is the goal of IPT to validate these difficulties and help the client conceive ways to have more effective communication with others. Research on the efficacy of IPT has similar impacts on depression as the use of pharmacotherapy (Schulberg et al., 1996) and CBT in the treatment of mild and moderate depression (Luty et al., 2007). Although pharmacotherapy may produce more rapid improvement of depressive symptoms, IPT may produce lasting emotional and behavior change after IPT has ended.

IPT-informed treatment for APD and subsequent depression

IPT previously has not been indicated for the treatment of APD, which is considered to be a more stable characterological issue. However, due to the high comorbidity of the two disorders, it is likely that patients could benefit from evaluating interventions that aim to treat both APD and subsequent depression. Although IPT is not usually indicated for characterological change, the roots of APD lie in the client’s interpersonal worry, passivity, and avoidance, all of which fit the core theme of IPT regarding social functioning change. As such, IPT-informed treatment may not only be helpful in treating depression but also may be helpful in treating the underlying socially avoidant and anxious personality structure. In addition, the behavioral techniques of IPT may be indicated for the treatment of APD, as behavioral strategies are helpful in treating this characterological disorder. In sum, it is possible that using some of the basic themes of IPT not only may help lift the experienced depression, but also improve a client’s interpersonal and social behaviors and relationships, thus changing the underlying and deep-rooted characterological patterns. A few researchers have examined the use of IPT to treat MDD with avoidant or obsessive personality traits; one study found IPT to be generally effective in reducing symptoms in this population (Barber & Muenz, 1996), and one case study highlighted changes in obsessive-compulsive and avoidant personality traits through the use of metacognitive interpersonal therapy (MIT), a treatment designed to help patients understand mental states and reduce problematic interpersonal representations and build new more effective ones (Fiore, Dimaggio, Nicolo, Semerari, & Carcione, 2008).

It should be noted that one of the main principles of IPT is that it is a short-term treatment. Brief CBT has been helpful in the treatment of long-term interpersonal avoidance in a randomized controlled trial (Emmelkamp et al., 2006) and in a case study (Hyman & Schneider, 2004); however, personality disorders are stable in nature and thus usually entail relatively long-term treatment (e.g., Bateman & Fonagy, 2000). Therefore, an IPT-informed treatment for APD would likely necessitate more sessions than the typical time-limited treatment of depression alone. Furthermore, successful treatment of APD using an IPT-informed intervention may require greater than usual emphasis on behavioral strategies (e.g., assertiveness training), which, as previously mentioned, has been helpful in treating APD (Alden & Cappe, 1986).

Assertiveness training

Both clients with APD and MDD often experience feelings of inadequacy and regularly do not feel entitled to asserting themselves. In fact, extensive research shows that feelings of inadequacy, low self-esteem, social anxiety, and even APD can often lead to overly submissive behaviors (e.g., Leising, Sporberg, & Rehbein, 2006). These nonassertive and passive behaviors can set the stage for an individual to continuously have their rights and feelings violated by others (Jakubowski-Spector, 1973), a common experience for individuals with APD (Alden & Capreol, 1993). As such, many clients find it helpful to learn assertiveness skills in therapy both through modeling and encouraging assertive behaviors in the therapeutic relationship and encouraging practice of assertive behaviors outside of the therapeutic relationship.

Being assertive does not always mean that individuals get what they want; rather, assertive behaviors are honest, clear, and respectful communication efforts. Many of the first assertiveness trainings stem from Manual Smith’s “Bill of Assertive Rights,” which reminds readers of their personal rights during communication (Smith, 1985). This is particularly important for both depressed and APD individuals, who often put others’ needs before their own and find it difficult to stand up for themselves. According to research, assertiveness training increases assertive behaviors and also reduces stress long term (e.g., Lee & Swanson Crockett, 1994). Furthermore, one study found assertion training to be more effective in reducing depression and increasing assertive behaviors than traditional psychotherapy (Sanchez, Lewinsohn, & Larson, 2012). Finally, some studies have examined the efficacy of adding social skills training (including emphasizing the importance of setting clear expectations and of others) and found these approaches to help treat avoidant tendencies (e.g., Herbert et al., 2005).

Integrated approach to treating APD and depression

As previously mentioned, there is little empirical data comparing different treatments for APD, a personality pattern characterized by social inhibition, feelings of inadequacy, and social sensitivity; however, initial studies suggest that using behavioral strategies may be beneficial for this population. IPT for depression may prove to help individuals struggling with APD and depression, as IPT focuses on improving the client’s current interpersonal difficulties, while maintaining a supportive stance. In addition, this approach may be improved by the addition of assertiveness skill training and practice. As such, a treatment plan informed by IPT principles, which also recognizes the long-term necessity of treating a personality disorder, and includes assertiveness skills, may be innovative and advantageous for this population and for individuals specifically struggling with interpersonal conflicts (i.e., role disputes). It is the goal of this case study to evaluate such a treatment in a single-case-study format.

Assessing the effectiveness of single-case studies

Whereas most research on the process and outcome of psychotherapy are randomized controlled studies, some have argued that case-based research studies conducted in clinical settings may offer new and important insights into treatment evaluations (Westen & Bradley, 2005). Furthermore, psychotherapy process and outcome research has recognized the utility of patient-rated symptom monitoring in single-case (N = 1) designs (e.g., Borckardt & Nash, 2008). In particular, an advantage of time-series design is that it addresses effectiveness of the treatment (reduction of symptoms) and the manner in which change occurs over time (Borckardt et al., 2008). Moreover, time-series design allows the clinician to measure target symptoms for each patient, on a daily level, reflecting meaningful, personalized changes. These analyses may provide new insight into the treatment of APD.

Another method of examining significant change is to determine whether the changes in functioning, as a result of therapy, are statistically significant (Jacobson & Truax, 1991). Determining significant change involves calculating a reliable change index (RCI); a formula for this method will be provided in the results section of this paper. Both the time-series design and the measure of significant change will help to demonstrate the utility of IPT-informed long-term treatment with assertiveness training for an individual with APD and depression.

2 Case Introduction

Ms. K was a 24-year-old Caucasian female graduate student at a southern state university pursuing a degree as a nurse practitioner. Ms. K came to the clinic on her own accord to address symptoms of depression and interpersonal passivity.

3 Presenting Complaints

Ms. K presented at intake with symptoms of depression (i.e., low self-esteem, loss of energy and fatigue, feelings of stress, worry, tearfulness, and overall low motivation), which negatively affected her efficacy in her academics and romantic relationships. In addition, she reported a lifetime of significant interpersonal passivity, which historically affected her work, academics, peer relationships, and romantic relationship. Whereas Ms. K reported feeling low positive mood throughout her adolescence and young adult life, the presenting episode was most severe. At the time of intake, she had received no prior diagnoses, counseling, or psychotherapy.

In addition, Ms. K reported somatic complaints, in the form of gastrointestinal problems, which were exacerbated when she was feeling particularly overworked and worried. Her feelings of inadequacy were present in multiple aspects of her life, including in her romantic relationship and in her professional career. For example, Ms. K often found it difficult to “speak her mind” in her relationship with her boyfriend and was often afraid to share with him her feelings and concerns. Moreover, at time of intake, Ms. K’s graduate school graduation date was 8 months away and she feared she would be unable to find a job. At intake, she presented with a minor depressive episode and was given an initial diagnosis of depressive disorder–not otherwise specified (APA, 2000); her Global Assessment of Functioning (GAF) was 65.

Although Ms. K was initially diagnosed with a depressive disorder at intake, it became clear early in the treatment that her lifelong interpersonal passivity and avoidance were persistent and caused her to frequently feel trapped and depressed. Because personality features are typically ego-syntonic and involve characteristics that the client has come to accept, many patients do not self-report their potentially problematic Axis II issues; rather, they may find Axis I symptoms to be more distressing and thus more readily report those complaints (e.g., Widiger, 2003). Consequently, it is understandable that a clinician may first identify the presence of Axis I disorders and later identify Axis II disorders as the assessment phase of treatment unfolds. Thus, during the initial sessions, her diagnosis evolved and she was conceptualized as having APD along with moderate and recurrent MDD, given her history of her untreated negative affect. Per the differential diagnosis recommendations in the DSM-IV-TR (APA, 2000), it was determined that her avoidant behaviors were best explained by a characterological issue, rather than a phobia, given that individuals with APD have more severe and long-standing symptoms that are present throughout most social experiences. Ms. K’s avoidant tendencies had been present her entire life and affected all areas of functioning. Specifically, she met criteria for the personality disorder diagnosis in the following ways: (a) persistent and pervasive feelings of tension and apprehension; (b) excessive preoccupation with being criticized or rejected in social situations; (c) belief that one is socially inept, personally unappealing, or inferior to others; and (d) avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection. These symptoms were met with hypersensitivity to criticism and rejection.

4 History

Ms. K grew up in an intact family of middle socioeconomic status in a suburb outside of a moderately large southern city. She had one younger sister who lived with her at the time of intake and two older half sisters who lived in different states. Her mother and father were high-school educated; her father was a mechanic and her mother worked part-time in human resources. Ms. K’s mother had breast cancer twice during Ms. K’s childhood and was in remission since 2005. Ms. K’s mother and father suffered from financial strain and depressed mood; her mother had been on antidepressants since before Ms. K was born and her father had struggled with depressed mood throughout his adulthood without receiving a formal diagnosis.

To best cope with the family difficulties and subsequent inconsistencies during her childhood, Ms. K worked to reduce the burden on her parents by avoiding all conflict. According to Ms. K, for as long as she can remember, she avoided sharing negative feelings or addressing conflicts directly to protect others and prevent the occurrence of an uncomfortable interpersonal interaction. Ms. K was conceptualized as having an ambivalent/resistant childhood attachment as a result of her parents’ preoccupation and emotional inconsistencies during her childhood. Given the financial and medical stress faced by her parents during Ms. K’s childhood, it is understandable that her parents may have been inconsistent in the type of support they were able to provide; however, insecure attachments are related to maladaptive interpersonal patterns later in life (Ravitz, Maunder, & McBride, 2008). Specifically, the self-silencing associated with the fear of burdening close others is the type of avoidance associated with individuals who fearfully avoid intimacy, viewing themselves as undeserving of love and support from others (Bartholomew, 1990). Furthermore, children with anxious attachments tend to develop internalizing disorders, such as MDD (Berlin, Cassidy, & Appleyard, 2008).

At the time of intake, Ms. K had been dating her first romantic partner (Mr. J) for approximately 5 months. The two had been friends for years, and Ms. K helped him through his separation from his wife, which led the two to becoming close and intimate friends. During his separation, Ms. K and Mr. J became romantically involved; however, Mr. J did not want to define the nature of their relationship and instead kept the terms of the relationship vague. Ms. K reported that Mr. J had not yet filed for divorce at the time of intake and that she felt trapped in the relationship, wanting to better understand what she meant to Mr. J and their future, while at the same time not wanting to “push him too much.” She worried that having a serious conversation with Mr. J about the future of their relationship would cause him to criticize and leave her. This concern was a major reason for Ms. K seeking therapy.

At intake, Ms. K was living in an apartment with her younger sister, who was an undergraduate student, and was carrying the majority of the financial responsibility by working a night shift at the hospital in addition to being a full-time graduate student. Ms. K reports having a handful of close friends, many of whom were also close to Mr. J. It was hard for Ms. K to find motivation to complete coursework during the evenings after school and work because the majority of her social network worked from 9 a.m. to 5 p.m. Although Ms. K reported a close adult relationship with her mother, to whom she turned for emotional support regarding her romantic relationship, it was unclear the extent to which Ms. K had family and friends who expressed their feelings of pride and offered encouragement and support of her pursuit of a graduate degree. She was the first in her family to pursue such an advanced degree and feeling like an “outsider” in her own family likely contributed to her feelings of inadequacy. As such, Ms. K continued to keep her feelings to herself, not sharing them with others, for fear of burdening others or receiving criticism. This became a problem in her relationship with Mr. J, as she often felt criticized and silenced in her interactions with him.

5 Assessment

Daily Measures

The client completed an intake interview in which she specified a major symptom of complaint (self-confidence) that she would track on a daily basis. The client was asked to rate how she was feeling about this symptom using a 9-point Likert-type scale (e.g., 1 = none/not at all bothered by this problem and 9 = extreme/extremely bothered by this problem). She completed a daily measure of her self-confidence level for 1 week prior to treatment and then the first 12 weeks of therapy; however, it became an added stressor as she was trying to finish her postgraduate degree. She and her therapist agreed that she should stop the daily measures at that time. For the purpose of assessing her posttreatment status, after 24 months of treatment, the client completed 3 weeks of daily measures, when she and the therapist were in the process of termination.

Personality Measures

In addition, the client completed the Minnesota Multiphasic Personality Inventory 2–Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008) at intake. When interpreting the MMPI-2-RF, one should consider that T-scores of 55 and below are considered to be average or low, T-scores of 56 to 65 are considered moderately high, T-scores of 66 to 75 are considered high, and anything above a 76 is considered very high, and is present in only 1% of the population (Ben-Porath & Tellegen, 2008). On interpretation of Ms. K’s MMPI-2-RF results, she showed moderate-to-high peaks in emotional/internalizing dysfunction (T = 65), demoralization (T = 71), and dysfunctional negative emotions (T = 60). All of these are consistent with an individual presenting with low positive mood. In addition, she showed a moderately elevated score on Gastrointestinal Complaints (T = 64), and high levels of self-doubt (T = 76), stress/worry (T = 73), and anxiety (T = 70). Similarly, these somatic and internalizing complaints are often indicative of an individual who is socially anxious or avoidant and depressed. Finally, interpersonally, Ms. K had a highly elevated score on the Interpersonal Passivity scale (T = 68), which was consistent with her self-report of nonassertive behaviors and generally avoidant interpersonal style. It was hypothesized that if the treatment was successful, Ms. K would show significant decreases in the above dimensions.

In addition, Ms. K was administered the Symptom Checklist-90–Revised (SCL-90-R; Derogatis, 1992) at intake. The clinical threshold for this scale is T ≥ 60. She self-reported clinically elevated symptoms of depression (T = 61), but no other clinically significant scores were noted on this test. Overall, Ms. K’s self-report at intake suggested that she struggled with low self-esteem, low positive mood, stress and worry, interpersonal passivity, and somatic complaints. It was hypothesized that if the treatment were successful, Ms. K would show significant decreases on the Depression scale of the SCL-90-R.

6 Case Conceptualization

Ms. K was conceptualized as a highly intelligent young woman, experiencing social stress and worry, depressed mood, and low motivation to complete her academic requirements. She was struggling to understand her romantic relationship and having difficulties asserting herself in her work and in her romantic relationship. Ms. K explained that this was her first “real” romantic relationship, and thus she found herself idealizing Mr. J. This idealization, paired with her difficulty with assertiveness, contributed to the vague status of her relationship with Mr. J. Consequently, she found herself in the middle of a relationship that she was unable to define, which caused her to worry about the future. She could not hold Mr. J accountable for noticing or respecting her feelings, and Ms. K became increasingly nervous about speaking up and asking for what she wanted, for fear of losing a relationship that she worked so hard to achieve. In sum, one of Ms. K’s chief complaints involved “role disputes,” which IPT defines as conflicts with a significant other; in this case, it was Mr. J. According to IPT, experiencing role disputes is a common interpersonal problem faced by many depressed individuals (Bleiberg & Markowitz, 2008).

The majority of Ms. K’s energy was put into resolving the role dispute by maintaining a steady romantic relationship with Mr. J, and thus she was often too exhausted to tackle major academic tasks and put assignments off until the last minute, finding herself even more overwhelmed. These problems likely were compounded by her underlying feelings of inadequacy and worries about competency; these deep-rooted concerns about competency and fear of criticism by her professors or supervisors often led her to procrastinate and avoid completing her schoolwork. This often led to increased levels of anxiety when deadlines or evaluations approached. Despite awareness of this problem, Ms. K had difficulties stopping this cycle.

Therapy was designed using IPT principles in hopes of reducing Ms. K’s feelings of inadequacy in her academics and in her romantic relationship, and increasing her ability to communicate effectively with others. It was expected that by increasing her feelings of self-confidence, Ms. K would not only be able to see the ways in which Mr. J often mistreated her, but also learn how to assert her needs by demanding more respect and openness. Furthermore, by reducing her fear of criticism, Ms. K would similarly reduce her procrastination. In theory, this would have a cyclical effect, such that the more assertive Ms. K became, the more comfortable she would feel with these new behaviors, thus making them easier to continue in the future. Toward this goal, assertiveness training also was included in this treatment, beginning with less challenging tasks, working up to more challenging tasks, such as asserting herself in her romantic relationship, and with a boss or supervisor.

7 Course of Treatment and Assessment of Progress

Overview

Ms. K participated in twice-monthly individual therapy for 24 months, for a total of 44 sessions to date. The treatment integrated supportive therapy with IPT principles and periods of assertiveness skills training. Whereas traditional IPT is a short-term treatment, a longer-term structure was indicated given the client’s avoidant personality patterns and lack of social and emotional support outside of the therapeutic relationship. Ms. K tracked her symptoms for a week before treatment began, then daily for the first 12 weeks of therapy, and stopped due to the high demands of graduate school. She completed 3 weeks of daily follow-up data during the termination period and also completed the MMPI-2-RF and SCL-90-R during this time.

Clinical Intervention

The content of therapy sessions centered around the “here and now” principles of low self-esteem, inadequacy, insecurity, and feeling unable to “speak up” in relationships; all of these are central principles in IPT treatment. The treatment consisted of approaches guided by IPT strategies for the “initial phase,” “middle phase,” and “termination phase” of treatment. According to IPT, a client’s interpersonal problem areas are related to the onset or maintenance of the client’s depressive episode; as such, IPT uses strategies to address each problem area (Bleiberg & Markowitz, 2008).

Initial phase of treatment

The initial goal of treatment was to create a safe space and a strong therapeutic alliance with Ms. K so that she could feel safe to explore and express herself. This goal was accomplished by the therapist exhibiting an understanding of her presenting problems, expressing genuine concern and support, and providing a safe and consistent environment for her to work through her interpersonal problems. It became clear in the initial phase of treatment that Ms. K experienced a role dispute in her relationship with Mr. J, and the therapist helped her explore this relationship, the nature of the conflict, and her options to resolve it. Initially, the therapist followed strategies used to treat role disputes in IPT by validating Ms. K’s frustration and feelings of forced silence in her relationship, and helped to reduce her self-blame for these feelings.

Middle phase of treatment

During the middle phase of treatment, the client and the therapist worked together to connect her feelings of insecurity and avoidance with her current romantic relationship, her body image, and her worries about completing graduate school and finding a job. Ms. K was reinforced and encouraged to be assertive in the therapeutic relationship throughout treatment. For example, the therapist agreed when she eventually requested to meet twice monthly, as opposed to weekly, which was the standard of care in the clinic, because independence from the therapist is an emphasis in the middle phase of IPT treatment (Bleiberg & Markowitz, 2008).

After a few months of treatment, Ms. K expressed interest in practicing her assertive behaviors outside of the therapeutic relationship and began to do so in her romantic relationship in small ways (e.g., asking for clarification during a discussion, sharing her feelings toward Mr. J). Encouraging clients to express their negative feelings related to the role dispute in a healthy and constructive way is an essential strategy used by IPT therapists in treating conflicts with significant others. During this phase, the therapist focused on empowering the client to communicate effectively through role-plays and guided communication with the therapist. Ms. K and the therapist spent multiple sessions discussing assertive behaviors and the difference between passive inaction and choosing not to act. Specifically, Smith’s (1985) “Bill of Assertive Rights” was introduced, and Ms. K was given a handout about this topic. Each of the 10 rights was discussed at length and Ms. K engaged with the handout, identifying which points were more difficult for her than others. She began using the handout to help guide her preparation for assertive communication.

Slowly, Ms. K began to assert herself more and more in her romantic relationship, working toward the ultimate goal of having a serious conversation with Mr. J about the future of their relationship. She was aware that by asserting herself and discussing the future she was putting herself at risk of being disappointed by Mr. J. In fact, after Ms. K initiated a few separate conversations with Mr. J about their relationship, Mr. J was finally able to face Ms. K and tell her his reasons for being so vague and keeping an emotional distance from her. Mr. J decided to end the relationship (about 6 months after treatment began), explaining that he did not have strong enough romantic feelings toward her and that he viewed her more as a close friend than a romantic partner. As expected, at this time, Ms. K became more depressed and experienced increased rumination, tearfulness, and sadness. She sought medical management of her symptoms and began taking the lowest dose of Prozac and found it to be helpful in reducing tearfulness and increasing motivation. Despite her depressed feelings following the end of this relationship, Ms. K remained proud of herself for seeking the answers that she now knew she deserved. Soon after the break-up, Ms. K struggled to “move on” from the relationship with Mr. J, who remained in her life for the next few months. Their relationship was mostly platonic; however, at times Mr. J would emotionally rely on Ms. K, asking for comfort or support that was atypical of a platonic friend. Whereas this interaction felt good to Ms. K initially, she began to resent his efforts and started to set boundaries for the relationship. She eventually stopped returning his phone calls, text messages, and at this time has not seen him in over a year.

Termination phase of treatment

At the end of treatment, Ms. K did not idealize Mr. J the way she used to, and she was better able to notice the ways in which he mistreated her. The therapist reinforced Ms. K’s growing self-esteem by noting how her improved communication in interpersonal relationships led to positive changes in her mood, which is a typical strategy used in the termination phase of IPT (Bleiberg & Markowitz, 2008). About 6 months post-break-up, Ms. K reported feeling more self-confident and began online dating and entered into a few different dating relationships with men she met on the dating site. After 3 months of dating one of these men, she decided to terminate the relationship, as she realized she was not feeling as strongly for him as he was for her. She noted that this was something she wished Mr. J had said to her from the beginning, rather than leading her on for so long. On occasions such as this one, the therapist echoed Ms. K’s insights and emphasized the progress she had made, an important strategy used in the termination phase of IPT (Bleiberg & Markowitz, 2008).

In addition, Ms. K graduated and earned her degree about 8 months after treatment began. After graduation, she held two different jobs using her degree, one of which she quit after a few months, because she had moral and ethical concerns about the practice. She quit the job and quickly found another that she preferred. These efforts demonstrated the increased value she began to see in herself and her professional abilities. She also exhibited increased assertive behaviors at work by negotiating her salary, standing up for what she believed in, and pushing herself to learn new skills. This pattern of assertive behavior was a clear departure from her presenting pattern of avoidance and was suggestive of potential characterological change.

After 20 months of treatment, Ms. K came into a therapy session and explained that her mother was very ill and had just been diagnosed with Leukemia, which the doctors believed was caused by her earlier radiation/chemotherapy treatments for breast cancer. Ms. K was appropriately concerned for her mother’s well-being and was able to play a critical role for her family during this time, as she was the only one with medical knowledge. Not only was Ms. K helpful by translating complicated medical terminology to her family, but it also seemed as though they truly saw her impressive professional accomplishments and achievements. This recognition made Ms. K feel much more confident and proud of her professional work.

At the time of this article, Ms. K is going through the process of terminating the therapeutic relationship. Not only does Ms. K self-report reduced negative symptoms related to her depression and former avoidance patterns, but she also reports more confidence in her skills and abilities to succeed professionally and interpersonally. She and the therapist are discussing how to use the skills she has gained in treatment to avoid depression “relapses,” another critical aspect of the termination phase of IPT (Bleiberg & Markowitz, 2008). Currently, Ms. K and the therapist meet once each month and use the session as a “check-in” which is often indicated for patients post-IPT and is called Maintenance IPT (IPT-M). Results suggest that IPT-M may prolong time to relapse in depression (Frank et al., 1990).

Assessment of Progress During Treatment

Level-change analysis

To assess for therapeutic change, Ms. K’s daily-symptom ratings were analyzed. Time-series level-change analyses were conducted using Simulation Modeling Analysis (SMA; Borckardt, 2006), a bootstrapping approach used to assess the shorter data streams typically encountered in intervention research (Borckardt et al., 2008). In addition, SMA accounts for the autocorrelation, or nonindependence of sequential observations, in the data stream. This program calculates an effect size (Pearson’s r), along with the probability of obtaining that effect size, given the length of data stream, and its level of autocorrelation. Level-change analysis compares the mean scores of the two data streams, and significant effect sizes for level change indicate significant improvement in the severity of the reported variable.

To test Ms. K’s data for self-confidence improvement, and efficacy of treatment approach, pretreatment baseline data (Phase A) were compared with the data collected during the first 12 weeks of her treatment (Phase B), using SMA. From Phase A to Phase B, Ms. K’s self-confidence had not significantly improved or worsened (R = −.15, p > .05).

To assess Ms. K’s data for self-confidence improvement (which she tracked daily) and efficacy of treatment approach, pretreatment baseline data (Phase A) were compared with the data collected during her termination phase/follow-up (Phase C), using SMA. From baseline to follow-up, Ms. K reported being less bothered by her self-confidence level (i.e., she reported significant improvement in her level of self-confidence; R = −.43, p < .05). See Figure 1 for a graphical representation of changes in problems with self-confidence over all three phases.

Figure 1.

Changes in problems with self-confidence over time

Reliable change in symptomatology analyses

To test for significant change across specific dimensions (self-confidence and personality and symptom change), Jacobson and colleagues’ method of assessing reliable change was utilized. This method involves using the formula [c = (M¹ + M²) / 2], where M¹ is the mean of healthy controls and M² is the score of the patient at post-treatment. If the score of the patient at post-treatment is less than c, clinically significant change can be inferred. To determine whether this is a statistically significant change, the RCI is calculated, which involves subtracting the patient’s posttreatment score(s) from the pretreatment score(s), divided by the standard error of the estimate (Jacobson & Truax, 1991). This score is then multiplied by 1.96, and a c-score greater than the RCI estimate indicates a significant change.

To assess for personality and diagnostic change, results from Ms. K’s MMPI-2-RF and SCL-90-R at baseline was compared with her MMPI-2-RF and SCL-90-R at termination/follow-up. Per self-report, Ms. K showed reductions in many of the symptoms of depression, low positive mood, stress and worry, and somatic complaints, as measured by comparisons of her MMPI-2-RF and SCL-90-R at baseline and termination phase/follow-up. Ms. K reported reductions on the MMPI-2-RF in levels of emotional/internalizing dysfunction, demoralization, and dysfunctional negative emotions, gastrointestinal complaints, stress/worry, anxiety, and interpersonal passivity, but not self-doubt. In addition, she reported a reduction on the Depression scale of the SCL-90-R. Overall, it appeared that Ms. K experienced a reduction in the majority of her presenting symptoms.

Whether these findings demonstrated reliable change was examined using the recommendations of Jacobson and Truax (1991) where applicable. Ms. K’s scores for RCI on the MMPI-2-RF were examined. Results suggest that Ms. K achieved reliable change from baseline to termination phase/follow-up in the areas of somatic complaints (RCI = −2.50, p < .05), stress and worry (RCI = −3.61, p < .05), and anxiety (RCI = −3.61, p < .05). Contrary to hypotheses, although she did achieve decreases, she did not achieve reliable change in the areas of emotional/internalizing dysfunction, demoralization, dysfunctional negative emotions, self-doubt, or interpersonal passivity.

Next, Ms. K’s scores for reliable change on the SCL-90-R were examined, using a comparison of clinical and nonclinical sample norms (e.g., Holi, 2003). She showed a decrease in the Depression scale, and results of analyses suggest that Ms. K achieved reliable change from baseline to termination phase/follow-up on this dimension (RCI = −2.06, p < .05). Taken together, Ms. K showed statistically significant increases in self-confidence, as measured by her daily report, as well as decreases in somatic complaints, stress and worry, and anxiety, as measured by the MMPI-2-RF, and depression, as measured by the SCL-90-R.

8 Complicating Factors

After 12 weeks of treatment and daily assessment of symptoms, Ms. K and her therapist agreed that continuing to track symptoms daily was becoming an added stressor and thus she stopped completing these measures at this time. Twelve weeks of daily measures were collected during her treatment, which is sufficient for reliable analysis (Borckardt et al., 2008). Although the data reported above do not reflect any significant change from baseline to 12 weeks into treatment, Ms. K was given follow-up measures to complete during the treatment termination phases, to examine her overall progress throughout the 2-year treatment.

In addition, as previously noted, Ms. K began taking a low-dose of Prozac 6 months into treatment, following the termination of her relationship with Mr. J. She reported that this medication helped manage her increased tearfulness and motivation to complete schoolwork, and she continued to take the low-dose selective serotonin reuptake inhibitors (SSRI) for 10 months. She decided to stop taking the medication when she began to feel sufficiently comfortable after the end of her relationship; she followed appropriate methods for tapering off of SSRI’s and reported no negative side effects. Whereas it would have been ideal to track her progress during this time, her follow-up/termination phase assessment was given 5 months after she stopped taking the antidepressant, and thus, posttreatment effects are unlikely related to the presence of this drug.

9 Access and Barriers to Care

There were no issues with access to treatment or barriers to care in this case.

10 Follow-Up

Because Ms. K is still in the termination phase of treatment, no official posttreatment data have been collected.

11 Treatment Implications of the Case

During the first 12 weeks of treatment, Ms. K reported no significant changes in her daily measure of self-confidence; however, a significant improvement was found in her feelings of self-confidence, depression, stress and worry, and somatic complaints over the course of the 24-month treatment, as measured by a comparison of baseline and follow-up levels of her daily measures, the MMPI-2-RF, and the SCL-90-R. Looking back, there are two likely reasons that Ms. K did not show significant daily improvements during the first 12-weeks of treatment. First, treating APD, or any personality disorder, takes significant time, and it is quite rare to see characterological change over such a short period of time. Second, much of the initial IPT-informed treatment was spent (a) developing a therapeutic alliance; (b) offering social and emotional support that she was not receiving elsewhere; (c) helping to reduce the self-blame and shame she experienced about her depression, social avoidance, and passivity; (d) identifying factors and triggers related to her low positive mood, stress and worry; and (e) discussing assertiveness skills. One of the key goals of IPT is social functioning change, and the early therapeutic work was intended to help prepare Ms. K to take these new steps toward social change. As a result, it took a few months before she felt confident to seek change in her personal and professional life by practicing her newly acquired assertiveness skills.

Much of Ms. K’s therapeutic growth and change could be attributed to the time directly leading up to, during, and following her break-up with Mr. J. During this time, Ms. K was able to not only apply the assertiveness and social skills that she had honed in therapy to situations outside of the therapeutic relationship, but she also was able to see the positive results of standing up for herself and demanding respect from Mr. J, which was reinforcing of her new assertive behaviors. It is likely that these experiences helped her to feel more confident and increased her self-worth, which in turn allowed her to withstand the pain of the break-up better than she would have when she began treatment. Furthermore, these reinforcing experiences also allowed her to practice these skills in her professional career. Finally, by working hard to behave in ways that contradicted her avoidant impulses and tendencies, Ms. K actively challenged and restructured her pattern of social interactions, which resulted in more deep-rooted characterological change. This new pattern of behaviors may, in time, lead to continued symptom reduction and internalization of a more positive self-image.

Despite significant improvements in many areas, there were some symptoms and personality patterns that did not achieve significant improvement during treatment, such as her tendency to internalize, demoralization, self-doubt, dysfunctional negative emotions, and interpersonal passivity, as measured by the MMPI-2-RF. Although not all target areas of treatment were significantly improved, the treatment was not unsuccessful. Rather, tendencies toward internalization, demoralization, self-doubt, and interpersonal passivity are often long-standing character patterns; it is possible that achieving statistically significant changes in these areas would require more time and/or treatment. In addition, the MMPI-2-RF is primarily aimed at understanding the test-taker’s personality, which by definition is stable over time. As such, the wording of the MMPI-2-RF is intended to assess traits, rather than emotional or psychological states; therefore, the test has high test–retest reliability and any change should be considered significant and important. Perhaps future studies should include more state or behavioral measures of symptomatology to assess change that is occurring at the time of testing instead of items that require the client to respond in light of her history and past tendencies.

Retrospectively, Ms. K might have benefitted from further exploration of her past, which may have allowed for a deeper understanding of when, how, and why her avoidant tendencies began and were maintained. For the most part, therapy involved dealing with the “here-and-now” which is a key principle of IPT; however, as IPT is interpersonal in nature, spending more time focusing on early social interactions (i.e., a more long-term psychodynamic approach) may have brought out awareness of the nature of her avoidance patterns and could have increased the speed at which Ms. K experienced changes in her personality structure and, as a result, created more improvement in her presenting symptoms.

12 Recommendations to Clinicians and Students

This single-case research allowed for the in-depth exploration of a long-term supportive therapy that utilized themes of IPT for the treatment of APD and subsequent depression, with the addition of assertiveness training. Time-series design offered a more in-depth examination of Ms. K’s change over time in self-identified symptoms and issues, and could be useful in tracking progress in all psychotherapy patients. In addition, significant change was assessed on the MMPI-2-RF and SCL-90-R from baseline to follow-up, and allowed the therapist to see broader personality and symptom changes over the 2-year treatment. Furthermore, this type of study helps to bridge the gap between laboratory science and clinical practice. Both of these techniques are cost-effective and take relatively little time for both the patient and the therapist to manage and can be beneficial for psychotherapy effectiveness research.

Results of this study suggest that many symptoms improved over the course of this 2-year IPT-informed treatment, including self-confidence, somatic complaints, stress and worry, anxiety, and depression. These are promising findings and suggest further exploration of the efficacy of IPT-informed treatments for APD and social anxiety and avoidance might be useful, and future research should test the efficacy of this approach in a randomized controlled trial.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Bios

Sarah E. Gilbert is a graduate student in the Clinical Psychology Ph.D. program at the University of Tennessee. Her research interests focus on the effects of interpersonal relationships on mental health and the ways in which awareness and compassion can improve general functioning.

Kristina C. Gordon is a professor and licensed clinical psychologist in the Psychology Department at the University of Tennessee. She has been an active researcher and clinician for nearly 20 years and has published numerous journal articles, book chapters, and books in areas related to romantic relationships, couple therapy, forgiveness, and compassion.

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