Can Interpersonal Psychotherapy prevent or treat depression among people with Autism Spectrum Disorder?
Malin Bäck, Emil Johansson (relatera@me.com)
Interpersonal Psychotherapy (IPT), with its focus on negative stress related to human relationships, has proven effective across various conditions. These positive outcomes also include improved relational functioning, enhanced mentalization abilities, and increased quality of life. Individuals on the autism spectrum often experience comorbid depression, social stress, and difficulties in relating to themselves and others. While IPT has not been extensively studied for autism spectrum conditions, many clinicians report its usefulness in practice. Pending larger studies, we share the following case study, with the consent of those involved.
INTRODUCTION
Background, Aim and Method
Autism spectrum disorder (ASD) is a neurodevelopmental disorder, characterized by social communication difficulties and restricted repetitive thinking and behavior (Battle, 2013). ASD is also associated with difficulties regulating emotions and coping with stress. Further, up to 85% of individuals with ASD present with alexithymia as well as a general tendency to intellectualize rather than experience and process emotions. ASD is also associated with difficulties with central coherence, a disability that costs a lot of energy in the person’s daily life. Individuals with ASD possess difficulties in self-understanding or theory of own mind as well as theory of mind about others (Robinson, 2018). It is well established that ASD is linked to difficulties with an ability what Peter Fonagy and colleagues call mentalizing; a cognitive and emotional understanding of human behaviours. Mentalization is an imaginative activity about others or one self, intentional mental states of needs, desires, feelings, beliefs, goals, purposes and reasons (Channon, Crawford, Orlowska, Parikh, & Thoma, 2014; Fonagy & Bateman, 2006). The ability to mentalize is a fundamental capacity required in our social environment and impairments may utilise a risk for clinical psychiatric disorders (A. Bateman & Fonagy, 2008). Interpersonal functioning in general is a predictor for psychological well- beeing and positive social relationships exert a strong influence on people ́s physical and psychological health. One important factor for successful engagement in the social world is the ability to mentalize toward mental states of own and others. Some researchers state that difficulties in mentalizing are one of the key impairment in individuals with ASD (Stichter et al., 2010). For individuals with ASD the awareness of the physical and concrete details in a life event is available but the existents of mental states from others or one self may be blind spots, which often cause an interpersonal deficit, confusion and relational stress. Not caring for or being aware of basic attachment needs in the interaction with others is probably a high risk factor for depression and other mental illnesses. A German study about mentalization among depressed patients, presented a significantly lower capacity for mentalization among the depressed participants compared with the healthy controls. The results indicated severe impairment in the ability to identify and interpret mental states of the self and others. Correlations with illness duration, cognitive impairment and number of admissions suggested that a chronic course of depression may result in further mentalizing impairments (Fischer- Kern et al., 2013). Meet the criteria of ASD and also suffer from major depression will probably decrease the individual ́s possibility to mentalize even more. This comorbid condition is over time a growing threat for social learning, life quality and the ability to develop a self-supportive life in agency and healthy relationships.
Interpersonal psychotherapy (IPT) is an evidence based treatment, developed to treat depression (Klerman, Dimascio, Weissman, Prusoff, & Paykel, 1974). Ever since 1970 ́s when the treatment was invented it has shown more or less evidence for several conditions such as eating disorders (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012), bipolar disorders (Swartz, Frank, & Frankel, 2008), PTSD (Markowitz et al., 2015) and borderline personality disorder (A. W. Bateman, 2012). One of several focus areas that are taken into consideration in IPT is how interpersonal deficits/interpersonal sensitivity affects the person’s vulnerability to develop or maintain depressive symptoms or other psychiatric illnesses. Interpersonal theory, given from Harry Stuck Sullivan states that human behaviours are driven by two fundamental relational needs; 1.) to feel safe and avoid insecurity/threats and 2.) to experience intimacy/tenderness and satisfaction in close relationships. In our ambition to meet these needs we develop interpersonal patterns which we are carrying with us and stage out in our relationship with others. For people with a secure attachment these needs are fulfilled together with others (Lipsitz & Markowitz, 2013). The strategies in IPT have focus on current mental problems on what in DSM-IV were found under axis 1: current mood e.g. major depression and axis IV: current psychosocial life events (APA, 1994). IPT actively links these two on-going issues together in an explicit and exploratory way in a strategy called “mood-event”. By activating existing social support and to deal with current interpersonal problems IPT will maintain symptom reduction. This is based on the idea that it is normal and secure for the individual to come close and lean on others when s/he is not depressed and that interpersonal interaction has been undermined due to the current depression or psychosocial life circumstances, encountered in the individuals life (Brakemeier & Frase, 2012). When it comes to individuals with an insecure attachment, people with cumulative negative relational experiences or persons in the spectra of ASD, the formulation of how to feel safe together with others, or how to get the attachment needs fulfilled, may need to be more individualised. A person with an avoidant relational style or who get perceptually overwhelmed in social interactions may in IPT formulate goals like “How to communicate need of distance” for example (A. W. Bateman, 2012; Bellino, Rinaldi, & Bogetto, 2010).
The aim in this paper is to reflect upon weather Interpersonal Psychotherapy; an indirectly mentalizing and affect focused treatment with focus on social interaction, would be a suitable intervention to treat current depressive symptoms and prevent further relapses among people with ASD.
Methodologically I have made a literature search in the field and will share my reflections in this topic, based on a few articles and my own clinical experience. Since 1995 I work in a psychiatric clinic for adults. I mostly meet young people with ASD, that haven’t received their ASD-diagnosis until they ́ve come to us, mostly for whole other reasons. That means that they often met the criteria of so called high functioning ASD/HFA/Asperger syndrome. That also means that they have an interpersonal history, gathered by relational misunderstandings, bullying, sense of massive social skill deficits, relational failures and a comorbid mental illness during a long period of time. The literature review is followed by a case study based on a certain therapy, with some modifications drawn from other therapies to highlight recurring themes and with respect for personal integrity. All involved have provided both verbal and written consent.
RESULTS
Autism Spectrum Disorder and co-morbid depression
Consequently, people with ASD experience higher levels of emotional distress and additional mental health difficulties compared to a typically developing (TD) peers. Research indicates that 74% of young people with ASD had clinically significant emotional difficulties, such as anger, sadness or anxiety, compared to 18% of TD peers (Totsika, Hastings, Emerson, Lancaster, & Berridge, 2011). Psychiatric illness like depression and anxiety is common among ASD. From early childhood and further on, the prevalence of psychiatric illness is more frequent than in the normal population and the risk of developing depressive symptoms or anxiety tends to evolve over time. In the dissertation “Asperger syndrome in males over two decades”, Adam Helles reports that almost all participants (94%) had at least one comorbid psychiatric or neurodevelopmental disorder during their lifetime and 54% had at least one current comorbid disorder. Having a current comorbid psychiatric disorder was associated with low subjective quality of life, but not with general functioning or objective quality of life (Helles, Gillberg, Gillberg, & Billstedt, 2017). ASD people have a higher risk for suicide, especially women (Hirvikoski et al., 2016) and reports a higher (70%) degree of suicidal thoughts (Cassidy, Bradley, Bowen, Wigham, & Rodgers, 2018). Another salient issue is the importance of psychiatric comorbidity on subjective quality of life. Treatment of the comorbid disorders for individuals with ASD will probably be important in attempts to increase the meaning of everyday life of these individuals (Helles et al., 2017).
Autism Spectrum Disorder – a social disability
Individuals with high functioning ASD exhibit difficulties in the knowledge or correct performance of social skills. This subgroup’s social difficulties appear to be associated with deficits in three social cognition processes: 1.) Theory of mind, 2.) Emotion recognition and 3.)Executive functioning. These three constructs are what comprise so-called social competence. (Stichter et al., 2010). Deficits related to theory of mind result in an inability to understand the thoughts intentions and feelings of others. According to theory of mind and the ability to interpret an interpersonal situation, Channon et.al (2014) present research about mentalizing and social problem-solving in adults with ASD. Those with ASD were found to differentiate more markedly between intentional and unintentional human actions than controls in assigning blame for negative outcomes also examined intentionality, and concluded that individuals with ASD relied more on outcome information than on characters’ intentions when judging the moral permissibility of actions described in a series of vignettes. Taken together, these findings suggest that, when coping with difficult social situations, social reasoning in individuals with ASD may be more rigid and rule based, compensating for inadequate social abilities through reliance on deliberate reasoning strategies drawn from social knowledge and conventions they have been explicitly taught or acquired through experience in the social world. This could explain why those with ASD seem to have a more ‘‘black- and-white’’ approach to complex social situations requiring sophisticated emotional and social skills (Channon et al., 2014). Emotion recognition involves the ability to distinguish the various affective expressions (facial, gestural, and verbal) in one self and others and to understand the social-contextual meaning of these expressions. According to mentalizing, an acceptable level of feelings are guiding markers of important emotional and relational needs that ought to be communicated or taken care of. People with ASD report painful experiences through emotional misunderstandings with others in the environment (Robinson, 2018). A recent study in the field of affective neuroscience and tracking social motivation system deficits, the authors presented that people with ASD reported a higher emotional recognition of negative feelings/motivational signals such as fear, anger and sadness and significant low consciousness of playfulness, caring and seeking behvior. One conclusion was that playfulness could be at the root of social bonding impairments in ASD (Carre et al., 2015). There are limited treatment options for individuals with ASD on the impact of emotional and relational vulnerabilities and how to work with social skill deficits and resulting interpersonal traumas of enduring painful feelings, such as loneliness, shame, fear and alienation (Robinson, 2018). Accomplish social development, Robinson suggest therapy to create so-called “experience sharing (ES)” in the relationships. ES is described to develop in a matter of different from attachment and instrumental interaction. Lack of ES is suggested as the primary factor in limiting the social development of individuals with ASD (Robinson, 2018).
Interpersonal Psychotherapy
IPT views the relationship between psychiatric disorders and interpersonal problems as reciprocal. Although acute life events are most obvious, enduring social conditions also matter. Chronic stressful life conditions in the form of lack of interpersonal skills or other adversity can also be linked to depression. Social support also considered positive, potentially protective features of social connections and the negative impact of their absence. Conversely, lack of social connection or loneliness and social exclusion constitute powerful sources of stress. Loneliness is a risk factor for depression and other psychiatric disorders, findings that are consistent with the lifelong needs for intimacy and attachment, described by Sullivan and Bowlby (Lipsitz & Markowitz, 2013). IPT suggests that interpersonal problems affect symptoms through the following change mechanisms: 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills (Lipsitz & Markowitz, 2013). In IPT, the patient and therapist together define a central interpersonal problem area that serves as the primary treatment focus, that falls into one of four categories: complicated grief, role transition, role dispute or interpersonal deficits, also called interpersonal sensitivity. The sensitivity focus is typically chosen when a problem in one of the first three categories cannot be identified as a previous onset or when general relational problems are maintaining the depression or seems to be the onset for current mood. When working with this focus, patient and therapist look at interpersonal patterns over time, looking for possibilities for social support and are using the therapeutic relationship as a modelling social scene as a place to practice interpersonal skills, to communicate and cope with feelings that arises when interacting with others. IPT has three phases. The initial phase includes: a) evaluation – diagnosing the syndrome and any comorbid conditions and conducting the interpersonal inventory – a thorough review of current and past relationships; b) providing the case formulation, which defines the target diagnosis within the medical model, providing the patient with the transitional sick role — intended to alleviate responsibility for current difficulties and linking the diagnosis to a focal interpersonal problem; and c) agreeing on the treatment plan. The formulation provides the interpersonal problem focus through which the proposed change mechanisms are activated. The middle phase comprises the main work of resolving the interpersonal problem with the expected result of reducing symptoms. The final phase involves direct discussion of termination, reviewing improvement, consolidating gains, and anticipating future problems (Markowitz & Weissman, 2004).
Case – Eric
Eric came to therapy just after he turned 18. He then had tried to commit his third suicide attempt in a few years. The GP had diagnosed him with major depression measured 34 of MADRS-S. He was supposed to go to school; an IT-programme at high school but he hadn’t been there more than a few days this semester. It turned out that hadn’t been much at school at all since he was nine years old and the parents had difficulty to force him to go. He tells me that he don’t have problems to be in school when he actually is there but he hates to interrupt what he’s busy with and he feel uncomfortable to leave home. – “When I’m in school its ok but then I don’t wont to go home. I don’t like transitions from one situation to another”. He was reported to be an anxious child. When his elder brother introduced him to the computer game Tibia at the age of six, he didn’t want to do anything else. Instead of school, he stayed at home and played Tibia. He also started to programme early. The school once coordinated a contact at Bup, since he was diagnosed with social phobia. He still stayed at home mostly but even though received grades over average. –“I guess I’m an easy learner”, he replied. When I asked him about his current mood and how he felt, he first got quiet and soon he panicked and started to “freeze”. Shaking, crying, tensed. Later in therapy we named this state “turn into a rock” or “the statue feeling”. Eric is miserably and don’t think life has any meaning at all. He doesn’t have any dreams towards the future and gets scared when I ask about it. Every time I ask how he feels or what he can experience in his body, he panics and says that he likes to kill himself. I get this sense that he doesn’t understand inner states and that feelings, needs and thoughts in an abstract or existentially way, puts him in an extreme dysregulated position. I consult a psychologist at my clinic about Eric, since I get this sense that he doesn’t avoid to feel or mentalize. I get a sense that he has no idea what I’m talking about. Soon Eric received the diagnosis Asperger Syndrome/ High functioning ASD. During the thoroughly conducted psychology tests, Eric for the first time felt that he felt understood and got curious to know more about himself. The psychologist “regave” her assessment to me and Eric, wrote down strengtnesses and weaknesses she had identified. Eric had major problems with coherence and theory of mind. He also presented minimal affect consciousness and low executive functions. Doing things he didn’t feel confortable with and to interact with others made him easily exhausted. In some way he had already understood this and didn’t even want to think about the future since he didn’t think that this life was possible for him. When he played Tibia the rules of how to live was more understandable and he wanted to go there all the time. Just after Eric received the ASD diagnosis I suggested that we would try to work together with IPT. I said that I could see; that becoming a young adult seemed to be a difficult transition for him since the ASD causes him an interpersonal deficit/sensitivity. Although he doesn’t really ask for socializing “of board” (in real life), he cant totally avoid social interactions with others. Thus relational events are confusing and cost him a lot of energy. By explore and try to understand how different interpersonal events in his life affect his sense of feeling exhausted, bored, restless and uncomfortable and how this may affect his vulnerability for depressive symptoms, alienation, freezing panic and suicidal behaviour, Eric hopefully can develop a sense of agency, an understanding of whom he is and what he needs. From this he can make plans and communicate better with others. This may decrease his depressive symptoms and prepare him better for his role transition becoming a young man. Eric accepted my offer. Since it’s the policy in our suicide prevention programme to follow patients after a suicide attempt at least one year, we decided to meet weekly at least a year and then negotiate a new contract.
Topics during treatment
Eric came to me at 11:00-11:50 pm every Tuesday. He never missed an appointment. He arrived at the same time and waited for me in the same chair every week. He was quiet, still- faced, serious and polite. I did most of the talking; suggesting different options people may would ́ve answer on my questions. Underlined that there’s no right answers but it is a way to be curios and to fantasise about how it might feel inside when things happen. We met every week for one and a half year. Eventually he started to talk more and more. Today he has a collage degree, has his own apartment, works as a successful programmer and “earns more than the double than I do”. Here follows a few vignettes that might be helpful when working with ASD in IPT.
Linking “Mood-event” – but first design a language for it
In IPT a central strategy in every session is to link the interaction between current mood/feelings/symptoms to current events and explore how they affect one another. Eric had extremely hard to see how things affected him at all and he easily got overwhelmed trying to explore inner states and got terrified. In an ambition to work low affectively and concrete, I compared him with a car with a gas tank (he liked to drive cars) or a computer game – that we needed to understand what takes energy and possibly generates power. Every week we made a very detailed work in small every day events and identified new words for inner states and on-going events that seemed to be important to understand his opportunities and challenges. For example, he could not do several things that took energy the same week. Then he stayed in bed a few days later and it ended up with suicidal thoughts. This helped him to plan the week and we involved his network to help them to understand his needs accorded to the ASD. On the other hand, feeling bored activated an emptiness he couldn’t cope with and it triggered suicidal behaviours. To find a balance in social interaction, activities that felt meaningful and recovery was so to speak a work on life and death.
Structure and planning – the understandable secure base
Eric realised that he needed a very detailed plan for different occasions. To not get anxious or exhausted (and then passive and suicidal) it was important with long-term planning; what to do, where, when, how, for how long and with whom? The details were important and to find out what was expecting from him. This job included communication whit his parents and his gaming friend with ADHD. They were all impulsive, creative and flexible people and that stressed Eric a lot. He needed to have a precise, transparent and concrete plan. We worked a lot with communication analysis, decision analysis and role-play.
The sick-role in IPT; Acknowledge, responsibility and recourses
Through use of the medical model, IPT seeks to create a new narrative for the patient, demystifying and externalizing the current problem and mood as something the patient has rather than a defining aspect of who s/he is. Through use of the sick role, IPT seeks to decrease demoralization and guilt due to past social failures and the burden of current expectations, increase motivation for change and emphatically validate the patient’s current distress. The sick-role offer an externalising self-observing position that indirectly facilitates mentalization.
The difference between “be the depression” and have symptoms of depression….
“Before.. All the time I tried not to think about how I was feeling, definitely not when I felt depressed. If I felt bad it was so overwhelming, I couldn ́t get out of bed. You know ”the rock” or the freezing statue”… Now it ́s more like I can feel miserable without ”shutting down” immediately. It is even that I can feel some pleasure to know that I feel bad… Yes, in a strange way …You know… I can feel that I’m feeling in a certain way and be in that feeling… to feel and in a way… to KNOW something about ME, something is going on inside me. It feels good in a way even though, it’s all about, that I might feel bad … Do you get it? ERIC
With Eric, I frequently used validating psycho-education about, ASD, depression, affects and how to be self-observant and perspective taking. Eric used the medical model to understand himself. He started to talk about ASD as a sensitivity he and his environment needed to understand and taking care of; to prevent mood disorders and to create conditions for a functional adulthood. Important strategies he targeted was *how to use limited social energy in a healthy way, *to taught himself to “think out loud” to be understood * communicate needs to others *have a plan for the next day before go to bed and *to write diary to remind himself how things had been and what’s going on inside and out (He told me that otherwise he would forget to observe thoughts and feelings). Using the sick-role also included acceptance and mourning. In end of therapy, talking about how well things worked for him, Eric became sad when we talked about the past, empathizing with himself as a confused miserable kid. This was an important and tearful moment for both of us.
Different social arenas – Who am I in this social setting – sense of self
Eric didn’t really express any need to socialize with others but he frequently met people in different settings and we used these occasions to understand what in different social situations was more energy taking than others. Eric didn’t like to meet many people at the same time, and he hated to talk with relatives about things that didn’t interested him. E.g. we learned that he didn’t like to go to his grandma since his father expected him to wear a white shirt. He panicked. It wasn’t only uncomfortable, he didn’t know who he was, felt dressed out. After communicating this, he was allowed to use his worn out Iron maiden t-hirt and then it was okay to go. Though he choosed not to talk with his football-loving cousins. In stead he helped his grandma to make coffee and talked about computers with his uncle.
Making plans for the new role without therapy – termination
Eric came to me weekly for one and a half year. He then started folk-high school and we planed to have a maintenance treatment by email monthly and IRL-sessions twice a year. He then had not been depressed for a long time. Still Eric didn’t se when or how to ask for social support and he had hard to imagine early warning signs on depression. We made several written plans for different possible occasions and invited his parents to be informed. * When do you know? *When do others recon depressive signals? *When to contact the psychiatry? Even if Eric couldn’t really imagine how it would be, we created a supportive team, just in case.
”I still don’t think my life has a meaning, I need important change in life before I can feel that, but it’s not so pointless that I like to kill myself. I can be happy for small things in my life. I understand myself better now and in the future maybe I can live a normal life as grown-ups do… and in 10 years or so maybe I have a girlfriend ” ERIC
A few times I was asked to supervise the teachers at Erics new school after a few crisis but quite soon he felt safe in his new role as a student. Two years later he went to college, studying programming and web-design. He was headhunted already at college by a well- reputed programming company and he also started his own firm. He still came to me twice a year for a few years. “Its like going to the dentist, he said. It keeps remind me of thinking, feeling and to call my family”. Besides working a lot he had made many friends and dated a girl that lived abroad. -“I’m not afraid to stick from the plan anymore. I know that I can deal with the situation whatever comes up”. He smiled and told me that he even wore a striped shirt at a business conference – with a fly;
“It looked stupid but we all had to look the same. I didn’t panicked though, but I really hate shirts, honestly. And don’t even mention the fly.”
DISCUSSION
Eric was my first patient with ASD whit whom I had the opportunity to work with IPT. I have had several patients with ASD ever since in both short-term and long-term format. Yet it’s no evidence for this treatment what we would call IPT-ASD. Research need to be done. Working with ASD in IPT includes both a.) outgoing interventions e.g. working with structure, interpersonal skills, practicing role-play, communication and decision analysis – and b.) an internal focus being a human being with self and others. Some individuals with ASD have a strong sense of their inner world but lack of flexibility and no awareness of theory of mind toward others. For others, both the inner and the outer world are incomprehensible and frightening. In some therapies IPT needs to motivate the patient to involve with others at all and for some IPT need to focus not to take all the place, learn how to stop a conversation and so on.
The treatment needs to be individualized. Below follows a few suggestions, based on my own experience;
- Make things concrete.
- Include psycho education about feelings, social needs, the brain and so on; it will facilitate curiosity and exploration.
- To understand own and others feeling – find a personal way to relate; freezing statue- feeling terrified, bored and need to kill myself -emptiness, cravings for programming –
- Design a common language that fits this unique person.
- Individuals with ASD have a perception deficit. It affects all social occasions and costs a lot of energy – explore how to deal with that.
- Use special interest – How can it help?
IPT may help ASD to improve social skills and improve communication, social functioning and prevent loneliness/isolation. For many with ASD, social interaction is a way to understand difficult events that are exhaustive and that trigger the sensitivity for depression and anxiety. My personal interpretation of IPT is that the primary goal using IPT-events as a focal area is not social problem solving. It is an arena to understand where symptoms take place and by understand how the interpersonal interaction affect the mood of the person, the patient eventually gets a better understanding of the psychiatric stress, in this case ASD and depressive symptoms.
Addition: From a patient perspective, we recommend a Swedish radio interview that sheds light on a young man’s experience of deep depression, his journey out of it, the importance of understanding his diagnosis, and how psychotherapy contributed to his recovery (Heldmark 2020).
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Linköping University Advanced Psychology 2019 Final examination
Malin Bäck
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