Interpersonal Psychotherapy With Expressive Art for Depression in a Psycho-Oncology Context

Abstract

The following case outlines the use of interpersonal psychotherapy (IPT) with integrated expressive art practices over 10 sessions in treatment of AF, a 62-year-old Caucasian female presenting with depression as a psycho-oncology outpatient. AF’s presentation was in the context of a history of diagnosis and treatment of melanoma, several family losses to cancer, long-standing dysthymia and recurrent major depressive episodes, and relocation from interstate following marriage separation. IPT was delivered to address AF’s identified core problem area of interpersonal sensitivities, while expressive art exercises played a role of creative self-reflection and exploration. At the conclusion of therapy, AF demonstrated not only elimination of clinical symptoms of depression and anxiety but also growth as a newly resilient and enlivened individual. Theoretical, research, and intervention implications for treatment of depression in broad and specific to psycho-oncology contexts are discussed.

Keywords

interpersonal psychotherapy art depression cancer

1 Theoretical and Research Basis for Treatment

Depressive presentations are common in the psycho-oncology context, with a predicted prevalence of up to 24% to 60% of cancer patients (Caruso et al., 2017; Krebber et al., 2014). Such presentations may be preexisting diagnoses that become comorbid to independent issues associated with cancer diagnosis, treatment, prognosis and outcomes, or secondary to such issues. Regardless, such presentations are comprised of unique factors for formulation and intervention, restricting the generalizability of clinical depression efficacy trials drawn from non-psycho-oncology populations. Although preliminary research supports the value of psychological intervention for cancer management in general (Osborn, Demoncada, & Feuerstein, 2006; Tavakolpour, Daneshpazhooh, & Mahmoudi, 2017), clear guidelines for specific therapy models are not established.

Existing Cochrane reviews have shown that cognitive behavioral therapy (CBT) may be effective for short-term reduction of cancer-related psychological distress, but that effects do not apparently remain at 12-month follow-up (Galway et al., 2012; Mustafa, Carson, Stevens, Gillespie, & Edwards, 2013). Importantly, the authors of these reviews emphasize the lack of generalizability of findings for different forms and stages of cancer and respective medical treatment. Compounded complexity of potential various psychiatric disorders and social conditions also requires consideration. Furthermore, as addressed in the current case study, it is not uncommon for cancer patients to also present with complicating factors such as bereavement over the loss of family or friends who also had cancer and/or adjustments of adapting to life during and after treatment, including ongoing cancer recurrence anxiety (Sarkar et al., 2015).

Depression in a psycho-oncology context lacks a reliable evidence base. A meta-analysis suggested generally limited evidence of efficacy of CBT, though also raised possible methodological contributions to these findings (Williams & Dale, 2006). Case studies have shown potential value in problem-solving therapy (Carvalho & Hopko, 2009) and behavioral activation (Armento & Hopko, 2009) as treatments. Overall, there are no established standards and guidelines for practice. Thus, the current standings leave little available guidance and much potential for exploration.

Interpersonal psychotherapy (IPT) is a model of therapy that has growing support as a first-line treatment modality for depressive disorders in general (Cuijpers, Donker, Weissman, Ravitz, & Cristea, 2016). In its current form, IPT has a primary theoretical base of attachment theory (Stuart, 2008; see Ainsworth, 1978; Bowlby, 1977; Bretherton, 1992). The model identifies social support and interpersonal relationships as essential to psychological well-being and targets these factors with the assumption that depressive psychiatric symptoms subsequently resolve once addressed. The model includes a biopsychosocial individual-centered approach and emphasizes present-focused and collaborative therapy. Four problem areas are identified for addressing: grief/loss, interpersonal disputes, role transitions, and interpersonal sensitivities. The latter of these has been recommended to differ from the other three areas, reflecting attachment issues and requiring individualized extensions from the classical IPT model (Stuart, 2008). Core techniques include interpersonal incidents, communication analysis, use of content and process affect, and role-playing (elaborated in the treatment section; Stuart & Robertson, 2012).

As elaborated below, IPT was selected as the treatment modality given an apparent core theme of lack of social connectedness to the client’s presenting issues. Indeed, linking of depressive symptoms to an underlying cause of social disconnection is congruent with modern neuro-evolutionary models for etiology and intervention, which propose depression as protraction/dysfunction of an innate affective-biological system of separation distress (see Watt & Panksepp, 2009). Despite complex psychobiological underpinnings, the base IPT framework is easily accessible for clients using the four core problems areas for mapping difficulties. These problem areas offer useful mappings for many of the issues experienced by cancer patients, survivors, carers, and bereaved.

Interpersonal relationships have for some time been known to be an important factor in managing cancer-related distress (Wortman, Dunkel, & Schetter, 1979). However, although two phone-based adaptations of IPT for cancer show encouraging results for reduction of depressive symptoms (Badger et al., 2005; Donnelly et al., 2000), there are currently no available research studies that have explored efficacy of face-to-face IPT for depression in a psycho-oncology context. This case study is intended to further support the potential clinical value of IPT. It is also intended to demonstrate the adaptability of IPT with integrative novel therapeutic adjuncts; in this instance, the role of personal exploration through expressive art.

A critique of contemporary IPT practice has been its rigid manualization in treatment approach and narrowed focus on reduction of symptoms from diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013; see Stuart, 2008). Indeed, as identified by Stuart and Robertson (2012), the primary targets of IPT are increased social support and interpersonal relationships, with reduced depressive symptoms seen as secondary outcomes to these gains. Stuart (2008) has encouraged increased appreciation of the value of use of clinical observation for individualized formulation of the client’s presenting difficulties and subsequent appropriate intervention. The author emphasizes innovation and creativity in the practice of IPT with depression diagnostic subgroups, such as those with history of dysthymia. This emphasis on use of clinical observation and innovation is being increasingly supported by many other current leading figures in clinical practice (see Wampold & Imel, 2015).

In the present case, expressive art was included in the therapy as the client had previously effectively used art as a means of coping with cancer-related grief. Art-based therapies have some supporting literature for use with cancer patients yet carry particular limitations toward effective operationalization and standardization of therapeutic factors (Geue et al., 2010). Despite lack of standardized-practice evidence, the integration of art in this case aligned with the recommendations of Stuart and Robertson (2012) to include the unique contributions of clinician and client characteristics for optimal IPT practice.

Practicing in psycho-oncology (like many other contemporary settings) often entails complex presentations for which no solid generalized evidence base exists. However, effective use of both inductive with deductive reasoning for treatment formulation can make optimal use of neighboring objective evidence-based practice guidelines, as well as unique subjective client–clinician contributions, without necessarily sacrificing either. The current case study is presented as an example of effective integration of the science and art of psychotherapy for the treatment of a unique presentation of depression in a psycho-oncology context.

2 Case Introduction

The following case outlines the implementation of IPT with integrated expressive art exercises in treatment of AF, a 62-year-old Caucasian female. AF was referred by her cancer care coordinator for outpatient psycho-oncology services regarding depression in the context of fear of cancer recurrence involving core themes of isolation and death. Therapy procedures were outlined at intake. The limits of confidentiality in psychological services were discussed in the initial appointment. Permission for this case study was obtained verbally in Session 9 (offering AF time to consider if needed) and recorded in her clinical file; ethics clearance was provided by the local health district ethics advisor.

3 Presenting Complaints

Prior to attending therapy, AF had attended a melanoma check-up where she was informed that a previously treated skin cancer had been riskier in prognosis than she was previously aware. Her current medical prognosis reportedly remained positive, with no signs of cancer recurrence. Despite the good prognosis, AF disclosed that her physician’s parting word “good luck” onset an experience of depression and fear that markedly impaired her daily functioning. AF described that these words although intellectually understandable as benign created a felt sense that her skin cancer was an imminent threat, battle, and defeat for her. AF was referred to the psycho-oncology service by her cancer care coordinator following this onset.

AF presented to the initial appointment on time, appearing clean and tidy in grooming and wearing casual attire that reflected effort of appearance. She was evidently alert, oriented, and showed unremarkable thought form, perception, and thought content. AF engaged cooperatively yet appeared uncomfortable, anxious, and mildly affectively blunted. The therapist observed unusual effort on AF’s behalf to be pleasant and polite and hypothesized this to be her way of “not being a bother.” Speech was also unremarkable in pace and volume, and she was an overall good historian. However, the therapist noted that AF tended to curb emotional content and descriptiveness with prominent use of object pronouns and externalizing. For example, rather than say “my fear of cancer and thoughts of dying upset me,” phrases such as “it just gets to you, that stuff” were prominent. AF was mostly congruent in affect though tended to blunt grief-related emotions through self-deprecating humor, or situation-minimizing comments. This further affirmed AF’s reluctance to be a “bother,” but also indicated an avoidance of experiencing or acknowledging unpleasant internal events.

AF was evidently ambivalent toward her attendance. She made apologetic comments about “taking up [the therapist’s] time . . . going on and on.” When asked about her thoughts for a follow-up session, she immediately sought the therapist’s opinion as to whether it was worthwhile, and then agreed when the therapist suggested it may well be. With the other noted presentation factors, the therapist therefore hypothesized a “people-pleasing” pattern might be typical for AF (Catarino, Gilbert, McEwan, & Baião, 2014; Neborsky & ten Have-de Labije, 2012).

Throughout the session, AF reported complaints of spending a week of feeling “wasted”—referring to a state of marked distress and functional incapacity (i.e., not alcohol related; AF reported no substance use). Despite continued good prognosis, the appointment onset a period of marked depressed mood, anhedonia, tearfulness, indecisiveness, fatigue, and excessive guilt. These symptoms had reportedly been present since AF’s initial diagnosis nearly a year ago but notably increased in severity following the check-up consultation. Suicidality was not disclosed and did not emerge in risk assessments conducted throughout. Recurrent ruminative thinking surrounding death was experienced, but with logical association to cancer. This rumination was accompanied with feelings of fear, uneasiness, hopelessness, fragility, and loneliness.

4 History

AF reported growing up in Western Australia (WA) with a strict father who limited her opportunities for socializing. AF described that although she had some acquaintances, she considered herself to “not really have any friends” throughout high school. She disclosed a self-diagnosed onset of depressive symptoms at age 17 due to these factors. AF reportedly experienced a number of depressive episodes since, often in alignment with life events such as the divorce of her first husband, the death of her son, and relocating from WA to rural New South Wales (NSW) with her second and current husband. The only professional treatment experienced was in nearly 20 years prior using what she reported as emotion freedom technique with a therapist of unknown qualification. AF was an early childhood school teacher. She completed her qualifications as a mature-aged student in her 40s. She reportedly had to retire early to care for her second husband and could not return due to her cancer diagnosis and subsequent mood disturbance. AF stated a considerable loss of identity and meaningful occupation without this role.

AF was diagnosed with a melanoma and successfully treated with excision nearly 1 year prior to therapy. At the time, she was living on a property in a rural NSW town with her husband. She reportedly felt isolated there, knowing only her husband’s family locally, whom she described as distancing and inconsiderate. AF stated that she did not believe her husband could be supportive of her in the event of medical illness, mentioning that he was a person who experienced significant alcohol use and chronic depression. She described “feeling terrified” at the time and overwhelmed with concerns of being alone and reexperiencing cancer.

AF separated from her second husband and moved to the local region in roughly 2 months after her diagnosis and treatment to temporarily live with her daughter and teenage granddaughter in the hopes of relieving her isolation and medical/death anxiety. She also had two other daughters living in the nearby region, though was reportedly not as close with them. Her son died 17 years beforehand from melanoma, when he was aged 23 years. She also had lost her mother recently to breast cancer, and an uncle and nephew to melanoma some years ago. She communicated very little with her husband over the year following separation, fearful of the outcomes of her conversation and self-doubting of her capacity to assert herself. AF reported a generally good dynamic with her daughter but described issues of feeling disrespected and not being able to assert herself during disagreements. It was 10 months after relocation that AF underwent the routine check-up for her melanoma from which her referral followed.

5 Assessment

Assessment Measures

Mainstream-structured psychological measures have a limited evidence base of reliability and validity in psycho-oncology (Grassi & Riba, 2012). However, assessment did include the Kessler Psychological Distress Scale (K-10; Kessler et al., 2003) and Depression Anxiety Stress Scales–21 (DASS-21; Lovibond & Lovibond, 1995). These measures were chosen as they have supporting evidence for measuring psychological distress in outpatient oncology contexts (Banks et al., 2010; Fox, Lillis, Gerhart, Hoerger, & Duberstein, 2018; Johnson et al., 2015) and were familiar to the supporting oncology medical and nursing team of AF. The K-10 is commonly used in Australian hospital inpatient and outpatient settings to screen for depression and anxiety symptoms occurring over the past month. The DASS-21 is likewise common in general Australian health care settings, assessing indications of depression, anxiety, and stress over a period of 2 weeks. The DASS-21 has shown superior factor separation of depression and anxiety when compared with other common measures in non-oncology populations (Lovibond & Lovibond, 1995). Thus, the therapist was hopeful for clearer distinction of depression symptoms from cancer-related stress and anxiety. However, cautious interpretation of the anxiety factor in psycho-oncology has been previously recommended (Johnson et al., 2015).

Reactive reporting was evident in the structured measures. Both the K-10 and DASS-21 were completed by AF at the beginning of the initial session (with the therapist present). As shown in Table 1, AF’s responses indicated mild to no clinical impairment on the DASS-21. A score of 23 on the K-10 screener suggested “likely presence of a mild mental disorder.” This contrasted the moderate clinical distress and impairment reported by AF’s cancer care coordinator in the referral and observed by the therapist in the initial interview. At the beginning of the next session, AF was asked for reflections on the first session. She volunteered a comment that after the session she had reflected that she underreported when completing the measures (the therapist had intended to discuss this with AF, but she broached the topic first). When prompted for reasoning, AF suggested that many of the symptoms had become “normal” for her. The therapist offered that she again complete the DASS-21: results this time reached the extremely severe range for depression, anxiety, and stress. These responses again seemed reactive and potentially unreliable as presentation indicated moderate range severity for each. The following session, AF again proactively shared that she believed her responses had been exaggerated due to focusing on the previous few difficult days rather than prior 2 weeks. An average of the two reports, which were completed within the span of a week, is included in table and indicates moderate levels for each factor. Given the potential unreliability of the structured measures, clinician observation and verbal self-report of mood, behavioral changes, and interpersonal situation were emphasized as the primary means of assessing progress.

Table 1.

Scores on the DASS-21 at Pre (Average of Sessions 1 and 2) and Post (Session 10) Intervention.

	Pre-1	Pre-2	Pre-Average	Post
Depression	12 (Mild)	28 (Extremely severe)	20 (Moderate)	8 (Normal) difference = 12
Anxiety	7 (Normal)	21 (Extremely severe)	13.5 (Moderate)	6 (Normal) difference = 7.5
Stress	15 (Mild)	35 (Extremely severe)	25 (Moderate)	12 (Normal) difference = 13

Note. RC critical values (Christensen & Mendoza, 1986; difference value greater than RC = significant change): depression = 5.44, anxiety = 5.84, stress = 6.38. RC = reliable change; DASS-21 = Depression, Anxiety, and Stress Scales, 21-item (Lovibond & Lovibond, 1995).

6 Case Conceptualization

AF’s depressed mood, anhedonia, tearfulness, indecisiveness, fatigue, and excessive guilt had produced impairment in daily functioning (particularly social and occupational) for a period of over 2 weeks. This affirmed diagnosis of a major depressive episode in accordance with Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) criteria. The therapist formulated this depression as the primary presenting problem and hypothesized social isolation as the predominant precipitating and perpetuating factor. AF’s anxiety regarding her health was hypothesized to be a sense of vulnerability linked to this lack of social support and compounded by her depressive symptoms. Indeed, a generalized anxiety disorder was not sufficiently supported in the context of AF’s medical issues.

AF affirmed that since being a young child she felt disconnected from peers and described relationships with a group of girls throughout high school that sounded like friendships though she stated that she perceived them not to be: that “they were a group” and she was “always just on the outside.” AF felt alone during her first divorce and university studies, with only her two eldest children supporting her emotionally. She felt some sense of connection in her role as a teacher yet lost that upon retiring also. AF described herself as shy, introverted, and an ineffective socializer. She disclosed always feeling disheartened by a lack of social inclusion. Indeed, AF would become slightly yet visibly more distressed when describing the strong sense of loneliness she experienced when living in rural NSW.

The therapist enquired about AF’s son’s melanoma diagnosis and death. She described that he had been mostly alone during his decline of health. He had originally not been considered high risk, and therefore the family had not been as attentive as they otherwise would have been. Close to the time of his death he had divorced from his wife. AF commuted over 8 hr by bus to visit him as possible but was unable to visit as regularly as she would have liked. Despite diagnosis, his death had been unforeseen. The therapist noted (but did not verbalize) striking parallels of AF’s son’s death with the fears she described upon receiving her own diagnosis, particularly the theme of isolation.

When asked about her experience of her son’s death, AF reported that many described her response as “taking it well . . . being strong” due to a relative lack of demonstrated grief and proactive approach to funeral arrangements and such. This along with AF’s apparent people-pleasing demeanor in interview suggested that she viewed showing unpleasant emotions was weak and unlikable. In further discussion, AF explained that she painted a large memorial banner of her son as the core part of her grieving process.

Overall, from the initial interview it was apparent that AF had experienced depression in relation to experiences of social isolation across her adult life. Her presenting issues of fear of cancer recurrence were not necessarily completely attributable to this, yet certainly showed association with lack of social support and interpersonal relationships. Again, the therapist believed that physical unwellness amplified her sense of aloneness, which reciprocally made her feel more physically vulnerable.

IPT is a first-line psychological intervention for both acute and dysthymic depression (Cuijpers et al., 2016; National Institute for Clinical Excellence, 2009), and provided a useful framework for AF’s profile. That is, the model principally emphasizes the role of social relationships in moderating psychological well-being (Stuart & Robertson, 2012). As well as aetiological suitability, the therapist had also attended an advanced training program in the model, therefore affirming competent practice.

Stuart (2008) identifies an avoidant attachment style as often contributing to long-standing patterns of social disconnection and subsequent repeated episodes of depression. Indeed, AF indicated avoidant attachment style features with excessive self-dependence, reliance on autoregulatory behaviors, and a tendency to avoid emotional experience and disclosure (Tatkin, 2011). Indeed, rather than co-regulating by communicating emotional distress to others, she would distract herself with activities such as watching television or cleaning. Grief was evident with the death of her son, mother, and other family members to cancer. Interpersonal conflicts were evident with the separation of her husband, as well as in the dynamic of living with her daughter. Role transitions were evident in her relocating to the local city region as a separated-spouse, as well as being a cancer survivor. Finally, interpersonal sensitivities were indicated in AF’s lack of friendships throughout her life. Indeed, the core of AF’s presenting problems seemed to be lack of interpersonal relatedness. Addressing interpersonal problems in therapy was affirmed in that AF relocating to live with her daughter had reportedly improved her depression following her original melanoma experience and death/isolation anxiety. IPT was discussed with AF, who affirmed its suitability.

7 Course of Treatment and Assessment of Progress

Initial Sessions (1-3)

Early sessions involved establishing a baseline of AF’s level of psychological distress, interpersonal inventory, core problem area, and provision of psychoeducation about depression and anxiety. Introduction of art in therapy was also included. The initial session was an intake during which AF’s history was taken and structured assessment measures were administered. AF was oriented to IPT at the conclusion including discussion on the four problem areas. AF was provided with an information sheet on them for further reading and was encouraged to consider a core problem area as a path for therapy.

In Session 2, AF chose interpersonal sensitivities as the focus problem area (though acknowledged identifying with all four problem areas). She reported that a lack of social connection over her life had been a persistent burden on her quality of living and insightfully recognized increased interpersonal connections would improve her depressive state and sense of safety/support should she experience medical illness. Furthermore, AF reported that she did not believe herself competent to resolve interpersonal conflicts with her current status of self-worth. Incidentally, role transition and interpersonal conflicts were also addressed as practicing interpersonal skills came to require engagement in the local region and transition to being a newly sociable and self-asserting person. Indeed, as mentioned previously, interpersonal sensitivities has been proposed to reflect an individual’s general character and attachment style and therefore likely improve other interpersonal problems (Stuart, 2008).

Aligning with the biopsychosocial framework of IPT (Stuart & Robertson, 2012), psychoeducation drew upon an interpersonal neurobiology model (Cozolino, 2014), with emphasis on the evolutionary roots of grief/depression and the role of neuroplasticity through behavioral actions in achieving change (Brunoni, Lopes, & Fregni, 2008). That is, depression was explained to AF (in lay terms) as distress and behavioral deactivation resulting from protracted activation of the biologically imprinted separation distress affect system (see Eisenberger, 2011; Panksepp, 2015; Watt & Panksepp, 2009). The importance of behavioral change and social engagement in moderating this separation distress mechanism was emphasized. Such a psychoeducation model of biogenic drives, yet psychosocial interpersonal interventions for difficulties, has grown in popularity from compassion-focused approaches (Gilbert, 2009). Indeed, socio-epidemiological research indicates that the approach minimizes stigma and family-expressed emotion, while increasing belief in self-efficacy and internal locus for change (Fosha, Siegel, & Solomon, 2009; Haslam & Kvaale, 2015; Rüsch, Angermeyer, & Corrigan, 2005).

Use of closeness circles mapped out that AF only considered her daughter and granddaughter as close, with other meaningful people (e.g., her husband and other daughters) placed in the outside circle. A second “therapy goals” set of closeness circles was also completed to indicate how AF would like to see her social support network after successful intervention. The primary difference was the inclusion of friends and acquaintances in the middle and outer rings of the circle. The mapping of AF’s biological, social, psychological, cultural, and spiritual formulation of herself was discussed in Session 2 and agreed to be completed in the following session. Being unable to attend the third session due to illness, AF was asked and agreed via phone to complete the mapping at home. AF returned with only negative aspects (e.g., cancer history, divorced, depressed, etc.). This negative view of herself was reflected as characteristic of depression.

Homework usually involves interpersonal experiments and challenges in the middle sessions of IPT, rather than diaries and record keeping kept throughout as with CBT. However, AF had already been keeping four such diaries after adopting the technique from her daughter (currently receiving CBT). These diaries were reportedly “not helping” and becoming a “chore.” Although AF had not engaged in art for nearly 20 years, with consideration of the role that it had played in her grief process for her son, in the third session the therapist suggested that she substitute one diary entry instead with an artwork that conveyed the same content in an emotional–visual way. Instructions included dedicating only a short period of time to the task and with minimum planning, with the aim of evoking free association in the portrayal.

Middle Sessions (4-8)

The use of expressive art introduced in Session 3 proved effective, as AF returned the next session visibly enlivened. She stated that she had been “inspired” and that after completing the task had retired her other diaries and furthermore attended an art event—a rare outing in the 10 months since her relocation. In interpreting the artwork, AF began to describe meaningful and positive facets to her life. These included being an artist, mother, animal lover, survivor, and interestingly, therapy client. Incidentally, explicitly describing herself showed stark negativity, while AF’s implicit exploration indicated some sense of self-love buried underneath and facilitated a holistic view of herself. This was then maintained for the remaining sessions, with the therapist providing a single word summarizing some key aspect of the session and AF creating a work around that word.

Middle sessions focused on the IPT techniques of communication analysis, interpersonal incident analysis, use of content and process affect, and role-playing (see Stuart & Robertson, 2012). AF’s relationship with her daughter provided much of the initial material. For example, AF raised an interpersonal incident of her daughter speaking for her in a public situation. AF reported that this was common and expressed frustration that her daughter did not respect her boundaries. Applying communication analysis, AF came to realize that she only indirectly communicated that she believed her boundaries were not respected and tended to use a soft and passive voice. Indeed, indirect language was identified as a common factor of AF’s communication style. AF and the therapist formulated ways of including more direct and assertive language for this situation, practiced in session and then set its use as homework. AF reported marked changes after the first few applications. Immediacy was also used to practice communication and interpersonal incident analysis in session. AF was regularly asked to express her belief about the therapist’s perception of, and emotional reactions to, in-session interactions. Frequent mismatches occurred, regularly with AF assuming a negative experience on the therapist’s behalf, particularly whenever she expressed unpleasant internal events. This was used to manage AF’s resistance to experiencing and expressing unpleasant emotion, with the therapist modeling the healthy and rewarding benefits of AF sharing her affective state with others. As well as this use of process affect, content affect (affect associated with historical incidents outside of therapy) was also a primary focus. For example, AF held apparent shame for experiencing anger toward others. In exploring the functions of appropriate anger, that is, for effectively asserting oneself, AF became more accepting of her internal experiences.

AF keenly took the metaphor of the different “lenses” that any two people will bring into an interaction. Applying this perspective, she began to increasingly reconsider in-session interactions, those at home, as well as historical relationships. Importantly, she recognized that the peers in high school had considered her a friend, yet she had distanced herself due to her own perception of being an outsider. Indeed, reconnection via social media later revealed that one of the school girls had considered her a close friend and still cherished the relationship to the present day.

A pivotal point in therapy was when AF attended following an episode of pneumonia. She presented highly distraught with relapsed marked depression and death/isolation anxiety. AF avoided any discussion regarding physical unwellness, becoming tearful and briefly mentioning feeling “old and weak,” before apologizing for her emotional display and changing topic. AF repeatedly made phrases such as “I need to get over this . . . I just need to get on top of it.” This was unusual as her use of indirect language and affect avoidance had reduced. AF could not clarify what she meant by “it” and this was therefore set as her session artwork. The following week, AF produced an incredibly insightful artwork that depicted “it” as not “a thing” to be “gotten over.” Rather “it” resembled a path. AF interpreted her work as meaning her life was not a problem to be solved but a process to be lived. Indeed, she stated that she had originally planned to draw a foot on the path, but that this would appear to be “squashing it . . . being on top of it,” which would halt the process and prevent progress. Fascinatingly, the path was intentionally drawn in a way that could be viewed to look cellular or geographical (i.e., like a histological stain or map). When asked of the purpose, AF stated that it captured the scale of life, and all facets as important for meaningful living. It was reflected to AF that it was a cellular (i.e., melanoma) and geographical (i.e., relocation) problem that brought her to therapy. She stated that this had not been a conscious intention, but that the interpretation struck home. This demonstration of insight through AF’s artworks of reflection on core session themes was a prominent feature for each middle and late session.

AF’s increasing confidence and improved mood and lowered anhedonia resulted in ambitions and actions toward longer term meaningful occupation. AF began researching opportunities to return to university for further study in arts and/or education. She also began to seek out and engage in artistic recreational groups and explore employment options. Pottery and textile classes and neighborhood gatherings began to increasingly fill discussions of how AF had been occupied throughout the week.

As AF’s awareness and skills in communication developed alongside an increase in social activity, opportunities for further development became available. As well as the lenses of the participating individuals, broader contextual factors in interactions were also evaluated. For example, AF reported an interpersonal incident of “being ignored” during a nonreciprocal conversation at another art event. Exploring the situation, the person had been an instructor who was busy seeing to many people at once and was not holding long conversations with anyone. In a later session, she described being ignored at party, identifying no contextual explanations, feeling mildly upset, but believing it reflected another person being rude rather than herself being unlikable.

Final Sessions (9-10)

Given that follow-up would be unavailable (see below), the final sessions solely focused on relapse prevention and improvement maintenance. Reflection on therapeutic gains (see below) were reflected upon emphasizing AF’s agency in their achievement. Means of appropriately continuing benefits of therapy using social support were discussed. AF’s reluctance to demonstrate vulnerability as an obstacle to this was clearly changed; she mentioned sharing some experiences of her therapy with newfound friends from an art class. AF had also improved emotional communication with her daughter and granddaughter. She furthermore mentioned the idea of continuing her art-journal work by requesting that close family and friends be the ones to offer topic words/phrases. Discussion was held regarding access and use of psychological services in the future if needed.

Therapy outcomes

Readministration of the DASS-21 at the end of Session 10 indicated no clinical symptoms of depression, anxiety, or stress. Applying the reliable change statistical analysis method (Christensen & Mendoza, 1986), therefore, showed significant change from the average of the measures from Sessions 1 and 2. As noted, caution is required for interpretation of these results (also see “Complicating Factors” section). Regardless, improved psychological well-being and achievement of AF’s therapy goals was evidenced by changes in her in-session presentation and reported increased social support and occupational engagement. A usual routine of sedentary activities in the home had been supplanted with weekly art classes, attendance to art events, and participation in social gatherings with newly formed friends (e.g., parties and going for coffee). Revisiting the closeness circles affirmed that AF had achieved her therapy goal for social support and interpersonal relationships by filling her middle and outers rings with friends and acquaintances.

After 10 months of procrastination, AF had begun exploring and acting on initiatives to engage in further tertiary studies and return to work as a teacher. AF reflected improved relationships at home with her daughter, with increased self-confidence to assert herself. She had also begun to contact her husband via phone and arranged a date to return and finalize the separation/divorce. This conversation was rehearsed using the empty chair technique and reflected another gain as AF unapologetically wept in session. Indeed, AF had shown increased comfortability in experiencing and expressing emotion with lowered concern of “being a bother.” This reportedly occurred outside of session also, demonstrated in AF sharing sadness with some members of her art-group about the upcoming close of therapy. Improvement regarding AF’s fears of medical illness was shown in that although the ninth session followed another bout of medical illness, she uncharacteristically did not fall into depression: “I felt upset and down for a while, but it didn’t take grip . . . somehow, I just kept moving.” Furthermore, AF attended another medical check-up just prior to the 10th session without any undue distress. Overall, AF had transitioned from describing herself as “boring . . . socially off . . . weak and old” to “interesting . . . strong . . . creative . . . not-that-old.” Indeed, AF’s final artwork affirmed this shift (as did clinical observation). The artwork was to address the words “good luck.” That is, the precipitating event as spoken by the physician, which even in early sessions elicited observable distress. The returned drawing depicted that it was AF’s future problems that would need “good luck” in dealing with her.

8 Complicating Factors

Attachment and Relational Style of Both Client and Therapist

AF’s avoidant attachment style and related depressive style were evident influencing factors of therapy from the initial session. Her self-dependence contributed to ambivalence toward engaging in therapy and difficulty showing vulnerability while engaged. Indeed, this had been the first time that she had been willing to trial psychological services due to a lifelong pattern of “managing things [her]self.” Self-criticism likewise perpetuated these complications, with a sense of unworthiness for professional help and guilt for burdening the therapist. This pattern is not uncommon in depression, particularly for individuals who experience repeated episodes over a lifetime (Blatt, Quinlan, Chevron, McDonald, & Zuroff, 1982; Lynch et al., 2015; Zuroff & Fitzpatrick, 1995), and can have meaningful implications for transference (Daniel, 2006).

Stuart and Robertson (2012) describe IPT as a psychodynamic-informed rather than psychodynamic-focused therapy. The authors explain that transference is not something to be explicitly explored with clients but is important for the therapist to have an awareness of for facilitating accurate empathy. In particular, elicited responses (i.e., co-transference)—reactions that the client would induce in most people—are distinguished from countertransference—reactions induced due to the therapist’s personal temperament and attachment style. Indeed, AF’s attachment and relational style elicited unusual moments of self-doubt in the therapist. This elicited response of doubt was addressed in supervision, with the open reflective exchange prompting consideration of the therapist’s own attachment and relational style. Interpersonal analysis for the therapist revealed some “blind spot” avoidant tendencies in an otherwise secure style. Therefore, evidence of potential countertransference obstructing empathy was raised. Awareness of these previously hidden tendencies was not explicitly explored in the therapy but allowed for deeper attunement and effective relating in subsequent sessions all the same.

Reactive Reporting on Structured Assessment Measures

AF’s reactive reporting in structured assessment was a notable complicating factor that detracts from validity of structured outcome measures at conclusion and indicates potential distortion of verbal reports. As mentioned, AF attributed her underreporting to habituation to many of the listed symptoms. Her explanation for overreporting following that was stated to be reflecting only on the previous few days, which had been particularly difficult. Another important consideration was AF’s people-pleasing relational style and efforts to not burden the therapist. These factors indeed may compromise interpretation of AF’s posttherapy outcomes. However, clear discrepancies affirm clinical changes from pre- and post-evaluation. First, AF was more comfortable in expressing emotional distress and therefore less constrained by attempts to “not be a bother.” This does not discount some contribution of this factor however, and it is possible that underreporting occurred for both verbal and structured assessment at conclusion (a consideration for all clinical cases). Second, AF had achieved increased quantity and quality of social support and interpersonal relationships. Again, these are in fact the primary targets of IPT, and a reduction of psychiatric symptoms following achievement of meeting these targets is core to the model. Finally, AF’s functional capacity was clearly improved as indicated by the marked increase in motivation toward and engagement in social and occupational activities. After nearly 10 months of apparent stagnation, spending her majority of time at home but wanting to reengage with employment or study, AF’s immediate and long-term schedule had markedly filled with meaningful events and plans.

9 Access and Barriers to Care

AF’s access to therapy was not broadly limited in session numbers, with psycho-oncology services being available as needed as a part of the broader oncology (medically oriented) care provisions. However, the treating therapist was a clinical psychology trainee, whose placement was due to end in 12 weeks upon commencing with AF. These limitations were addressed from the initial session, and AF was advised of continued availability of services with another clinician if needed. At the end of the 10 sessions, both AF and the therapist agreed no further sessions were required.

10 Follow-Up

The therapist provided psychological services as part of a clinical psychology placement, which ended before follow-up could be conducted. This is unfortunate given the importance placed on follow-up in IPT, and the approach that therapy is never completely “terminated.” However, 10 session limits are the reality for the majority of psychological service provisions under the current Australian Medicare scheme, thereby making adherence to the optimal IPT model of follow-up difficult in general.

11 Treatment Implications of the Case

Validity of IPT for Depression in a Psycho-Oncology Context

IPT is an empirically supported first-line treatment modality for depressive disorders (Cuijpers et al., 2016). Although depressive features are common in cancer patients/survivors and carers/bereaved, the generalizability of mainstream clinical efficacy trials for depression is questionable for psycho-oncology contexts (Holland, 2010). However, the problem areas outlined in IPT (grief/loss, interpersonal sensitivities, role disputes, and role transitions) offer a robust framework for mapping many of the experiences of psycho-oncology clients. The model is also flexible to accommodate use of unique subjective client–clinician qualities, without sacrificing core practice elements.

Balancing Quantitative Assessment Measures With Clinical Observation

Response to structured measures in early sessions was reactive (underreported/low–mild 1 week then highly severe the next). Clinician observation affirmed considerable distress and dysfunction, yet at a moderate level. AF herself addressed her reactive reporting proactively. Structured clinical assessments are unquestionably in general valuable. However, they require balancing with clinician and client-observed changes in mood and cognitive state as well as behavioral and social patterns. Both structured and observation-based assessment after 10 sessions conjunctively indicated no evident clinical symptoms of depression, anxiety, or stress remained. Improvement was most clearly supported by a perceived sense of confidence and self-efficacy that AF had not previously held as observed by herself, her daughter, and the therapist, as well as the marked change in her social and occupational engagement.

Balancing Standardized Therapy Techniques With Unique Client–Therapist Resources

As discussed above, use of immediacy in therapy played a role in practicing interpersonal skills and awareness to address AF’s identified interpersonal sensitivities. AF clearly internalized many of these skills, often implicitly describing their use in social situations between sessions. The use of artistic expression to reflect upon and further explore session content was also a likely important (in the opinion of AF and the therapist essential) contributor to clinical gains. It demonstrated apparent preconscious insights that AF did not express (and at times contradicted) in explicit verbal communications during sessions, insights that seemed to create a shift in the way AF viewed herself and her situation. Psychobiological research has begun to offer increasing support for the concept of implicit resources that are inaccessible through conventional talk-therapy; often emphasized by the role of metaphoric/creative “right-brain” processing (e.g., see McGilchrist, 2013; Meares, 2005; Schore, 2011; Van der Kolk, 2015).

AF increasingly began to occupy her time with social events involving art and used these events to further develop her interpersonal skills. Neuro-evolutionary models (Watt & Panksepp, 2009) congruent to the IPT theory of depression propose depression as essentially behavioral deactivation following protracted separation distress. Therefore, the confluence of social engagement with occupational engagement in producing reduction of depressive symptoms is expected and was an outcome for AF. AF’s art exercises gave motivation and opportunity to engage in new social situations and for AF to explore herself with less rigidity. The co-occurring direct work on interpersonal sensitivities gave her the confidence to address the unresolved situation with her separated husband and created new relationships that facilitated her role transition as being no longer married and living in a new location. AF’s progress was solidified when medical appointments and issues—which induced crippling despair and anxiety at intake—produced no remarkable distress. Indeed, AF expressed both explicitly (verbally) and implicitly (artistically–metaphorically and behaviorally) that she now had the internal and social resources to endure future challenges.

12 Recommendations to Clinicians and Students

Contemporary psychological practice has seen emphasis on standardization in therapeutic modalities, with evidence that it contributes to clinical outcomes in general (Addis, Cardemil, Duncan, & Miller, 2006) and specifically for IPT (Rounsaville, Malley, Foley, & Weissman, 1988). A primary critique, however, is that clients presenting for treatment do not likewise fit neatly into manualized standards, particularly outside of research trials that efficacy literature is drawn from, and certainly in complex contexts such as psycho-oncology practice (Krug, 2009; Thyer, 2015; Wakefield, 1992). Further criticism includes that therapy becomes mechanistic rather than organic, with a loss of person-centered focus in the therapy, and detraction from the therapeutic alliance. Both of these factors likewise are well-supported contributors to therapeutic efficacy in general (Wampold & Imel, 2015) and specifically for IPT (Stuart, 2008).

As demonstrated in the current case study, objective evidence-based practices and unique subjective client–clinician resources can be effectively integrated. In this instance, IPT was used to address issues of interpersonal disconnection while expressive art addressed existential issues of intrapersonal disconnection in the treatment of depression in a psycho-oncology context. These two streams of approach worked not in parallel but in confluence, creating a holistic approach greater than the sum of its parts. We recommend fellow clinicians and students consider and explore how novel adjuncts can be included with standardized clinical practices for their own unique clients. We encourage reflection that not only is there a science and art of psychotherapy but also a science and psychotherapy of art.

Footnotes

Acknowledgements

Jesse D. Bourke would like to acknowledge and dedicate this case report to Professor Trevor Waring, his friend and first clinical mentor. Although Trevor’s own life was lost too soon to cancer, his love of science, art, psychotherapy, and their blending clearly lives on in Jesse’s clinical practice.

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.

ORCID iD

Jesse D. Bourke

Author Biographies

Jesse D. Bourke is a clinical psychology registrar currently completing his PhD thesis on the psychobiology of brain asymmetries at the University of Newcastle, Australia. He has special interests in trauma, personality disorders, and chronic depression, as well as biological psychiatry, psychodynamics, and transpersonal/existential psychology.

Camille Plant is a clinical psychologist in psycho-oncology and also works as a clinical advisor at The Way Back Support Service, Hunter Primary Care, in suicide prevention. She is a University of Newcastle conjoint lecturer, provides supervision to clinical psychology placement students, has co-lectured to undergraduate psychology students, and educated fifth-year medical students about psycho-oncology.

Sophia Wooldridge is a clinical psychologist working in psycho-oncology, who has experience in a range of health-related settings including traumatic brain injury recovery. She is a conjoint lecturer at University of Newcastle and an Australian Health Practitioner Regulation Agency (AHPRA) board approved supervisor in clinical psychology.

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